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PRACTICAL  TREATISE 


PHYSICAL  EXPLORATION 


a>«mi 


CHEST, 


DIAGNOSIS   OP   DISBASBS 


RESPIRaWiIT  ORGANS. 


AUSTIN    FLINT,    M.D., 

IUI>li:41-  muUt,  AHL>  19  Till  UII4  IfUSTt  01LI,tal»  UltmiAL; 

nufin  er  mt  iir*  tint  lunm  nr  amicin^  nc. 


8ECOKO  EDITION,  BEVI3BD. 


PHILADELPHIA: 

HENRY    0.    LEA. 
186  6. 


•     ■ 


>-ii  i  ''H^iA.. 


KhUnd  ftTAiirillnf  lo  Art  i«f  CoiiffrsHi  Id  tbt  ^ir  IRAd^ 
UT    IIItHHT    C.    LKA, 

In  Ibi  Clirk'i  OfllH  of  (1h  Dlililst  Cusrt  Ar  tlu  Euteni  IHiUiet  of  I^unajlinDl* 


ISBHAM     k     CO.,     PKIHTIKII, 


PREFACE. 


Tqk  first  edition  of  this  tr<-atise  was  pablislied  in  IS36,  and  the 
work  has  for  some  time  been  out  of  print.  During  the  ten  j-cars 
which  bsve  elapsed,  the  author  has  continued  to  gire  special  atten- 
tion  to  the  diagnosis  of  diseases  affecting  the  reepiratorj  organs; 
and  daring  tnost  of  this  period  he  bas  given  dail^'  lessons  in  auscul- 
tation and  percussion  at  the  bedside.  Daring  been  connected  for 
three  jears  with  the  Nen  Orleans  Charitv  Hospital,  and  for  the 
last  six  vears  with  Bellevue  IIoBpita)  and  the  filackwell's  Island 
Charity  llnspital  of  \cw  York,  and  with  the  Long  Inland  College 
noH]>ital,  of  Brooblrn,  hia  opporlimilivii  for  the  clinical  atwly  and 
practical  teaching  of  phrsical  exploration  have  been  e-Vlcnsive.  Id 
preparing,  therefore,  *  second  edition  of  tho  work,  he  has  felt  that 
he  might  assume  a  degree  of  assurance  whidi  would  have  been  less 
wnrrantable  when  the  first  edition  was  written. 

A  comparison  of  the  present  with  the  former  edition,  will  show 
that  the  work  has  undergone  considerable  modification.  While  its 
plan  and  vs«ential  features  arc  unchanged,  numerous  important 
alterations  have  been  made;  much  has  hecn  added,  while,  bjr  suh- 
stituling  brief  statements  for  certain  statistical  details  relating 
especially  to  the  healthy  chest,  the  volume,  instead  of  being  en- 
larged, has  been  somewhat  reduced  in  eixe.  The  aim  of  the  author 
hae  been  to  prewnl  to  the  student  and  practilioRer  of  mnlieinc, 
clearly  and  comprehensively,  an  exposition  of  the  physical  explora- 
tion of  the  chest,  and  of  the  diagnosis  of  diseases  aifecting  the  re- 
spiratory organs,  striving  to  divest  these  enbjecte  of  comp)exi,ty 
and  nccillcss  refinements.  Recognizing  the  fact  that  physical  ex- 
ploration, to  be  made  generally  availuMc  in  medical  practice,  must 
Ira  8impli6ed  as  much  as  possible  without  cotnproDiising  its  capabili- 
ties, he  has  studied  to  facilitnt«  the  acquUition  of  an   adequate 


iV  PREFACE. 

knowledge  of  signs  bj  avoiding  an  unnecessary  mnlti plication  of 
them,  by  adopting  a  convenient  classification,  by  pointing  out  dis- 
tinctly their  differential  characters,  and  by  the  Introduction  of  a  few 
new  names  which  are  In  themselves  descriptive. 

The  experience  of  the  author  having  led  to  certain  resalts  which 
he  ventures  to  believe  enlarge  somewhat  the  scope  of  physical  ex- 
ploration, increasing,  also,  the  facility  and  accuracy  with  which 
different  signs  are  discriminated,  it  may  not  be  considered  amiss  to 
enumerate  here  certain  points  to  which  the  attention  of  the  reader 
of  the  work  is  especially  invited.  The  distinctive  characters  of  the 
signs  obtained  by  auscultation  and  percussion  are  derived  almost 
exclusively  from  differences  relating  to  intensity,  pitch,  and  quality 
of  sounds.  An  acquaintance  with  the  acoustic  signs,  to  be  precise  and 
accurate,  must,  in  the  opinion  of  the  author,  be  based  on  characters 
thus  derived ;  whereas,  withont  an  appreciation  of  distinctiona  re- 
lating to  intensity,  pitch,  and  quality,  the  knowledge  of  these  signs 
is  comparatively  indefinite  and  unreliable.  The  studies  of  the  author 
have  been  directed  especially  to  characters  relating  to  the  pitch,  in 
conjunction  with  those  relating  to  the  quality,  of  acoustic  signs,  and 
from  differences  in  pitch,  hitherto  but  little  considered,  he  has  de- 
rived distinctions  which  he  believes  to  be  of  much  practical  value. 
By  means  of  differences  in  pitch,  conjoined  with  those  of  quality, 
the  respiratory  sign  called  l)ronchial  or  tubular  breathing,  may  be 
readily  distinguished  from  the  cavernous  respiration ;  a  prolonged 
expiratory  sound  proceeding  either  from  vesicular  emphysema  or 
an  abnormal  exaggeration  of  the  vesicular  murmur,  that  is,  not  denot- 
ing solidification  of  lung,  need  never  be  confounded  with  the  pro- 
longed expiration  which  denotes  a  tuberculous  or  some  other  solidi- 
fying deposit ;  exaggerated  or  puerile  breathing  is  easily  recognized 
as  distinct  from  what  has  been  called  rude  respiration ;  the  vocal 
sign  called  bronchophony  is  distinguished  from  a  simple  increase  of 
the  resonance  of  the  voice,  and  the  pectoriloquy  arising  From  solidi* 
Sed  lung  is  discriminated  from  the  pectoriloquy  which  signifies  a 
pulmonary  cavity.  Attention  to  the  pitch  of  the  resonance  ob- 
tained by  percussion,  renders  sometimes  apparent  a  slight  degree 
of  dulness  which  would  otherwise  not  be  perceived;  and  it  enables 
the  observer  to  perceive,  in  certain  cases,  that  a  morbid  disparity 
between  the  two  Bides,  as  regards  intensity  of  resonance,  is  due  to 
an  exaggerated,  or  as  the  author  prefers  to  call  it,  a  veaiculo-tympa- 
nitic  resonance  on  the  side  most  resonant,  and  not  to  dulness  on  the 


PREPACB. 


I 
I 


BJde  iri«lding  the  lesser  degree  of  resoDtnco.  The  pitch  of  the  mu- 
coais  the  euhcropiinnU  uiid  tho  crtpilant  rale  furniehes  a  reliable 
criterion  of  the  condition  of  the  lung  a»  regiirda  the  exiMonce  or  the 
absence  of  solidiGcution.  To  thcso  points  may  I>e  uddesl  a  norel  mode 
of  auscaltatorj  p«rcniwion,  riz.,  applying  Cammann's  stethoscope 
near  the  open  month  of  the  patient,  while  percussion  is  made.  In 
this  vty  the  amphoric  and  the  cracked  metal  intonation  may  often 
be  obtained  in  cases  in  which  they  are  not  otherwise  appreciable. 

Under  the  name  hronn/io-vtsicular,  or  veticulo-tubular  natpiration, 
are  described  certain  modi6catioDs  of  respiratory  sounds  rcprcMtnt- 
ing  all  the  degrees  of  solidification  of  lung  which  fall  short  of  an 
amount  sufficient  to  yield  purely  bronchial  or  tabular  brcslliing. 
These  modifications  have  heretofore  been  loosely  embraced  under 
the  names  rude  and  rotigli  respiration.  The  names  broncho- vesicular 
and  vesioulo-tubular  express  the  diiiliuciive  cbaraoteni  of  the  sign, 
and  are  ibua  in  themselves  di-wriptive.  By  the  diB«t«nl  grades  of 
modification  as  regards  the  pitch  and  quality  of  tlic  inspiratory  and 
the  expiratory  xound,  the  amount,  as  wdl  as  the  extent,  of  the  .solidi- 
fication  maybe  ascertained.  This  sign  is  of  much  value,  especially 
in  the  diagnosis  of  tuberculous  disease  in  its  early  stoge.  The  name 
broncho-eaivmouB  is  also  introduced  as  expressing  the  characters  of  a 
sign  which  represents  solidification  of  lung  and  a  cavity  conjoined. 

An  original  feature  of  the  work  is  the  introduction  of  several 
signs  produced  by  the  whispered  voice.  These  signs,  as  representing 
certain  physical  conditions,  are  generally  available,  and  their  char- 
acters relating  to  pitch  and  quality  are  highly  significant.  The 
names  exaggerated  bronchial  whuper,  whispering  bronchophony  or 
brtmehophvHu:  %chi»ptr,  and  cai-emout  tehinprr,  although,  perhaps, 
not,  intrinsically,  tho  bc4t  which  might  have  hcon  devised,  have  the 
advantage  of  corresponding  with  the  names  commonly  applied  to 
correlative  signs  produced  by  the  load  voice. 

The  author  would  slate,  aa  a  feuturc  of  the  work,  the  recognition 
of  the  pnnoipic  that  the  constancy  of  association  of  certain  ab- 
normal sounds  with  certain  -physical  coifditions  constitutes  the  only 
reliable  proof  of  the  validity  of  the  former  as  representing  the  Utter. 
It  ia  inconsititent  with  this  principle  to  undertake  to  determined 
priori  signs  to  which  e<Ttain  physical  conditions  should  give  rise, 
and  still  more,  on  the  other  hand,  to  infer  the  existence  of  certain 
physical  conditions  from  certain  abnormal  sounds.  Aa  stated  in 
tbe  preface  to  the  first  edition,  "  To  the  mechanism  of  physical  phe- 


Tl 


IFACB. 


nomcna,  relatively  smnll  space  is  nccordcd,  rccogoizing,  as  the  only 
safe  basis  of  our  kiiowli'ilgo  of  thrir  tiignificaiin:  an<l  pntliologicnl 
relations,  clinicul  facts  tiiki-ii  in  conticction  witli  morbiJ  anatomy, 
ai)d  Wlieviug  that  deductions  from  the  Inns  of  physic;:,  or  analogicsl 
inferences  from  cxperimonis  made  out  of  the  body  and  even  with 
th«  liwid  subject,  are  to  be  received  with  great  circumspeciion." 

Having  now  for  several  years  devoted  considerable  pains  to  teach- 
ing tlic  ]>riu<;i)iles  and  practice  of  auscultniion  and  pprons^ioD  to 
priviite  classes,  the  author  is  induced  to  conclude  this  preface  with 
a  iiketch  of  the  plan  which  he  hsii  pursued,  hoping  thus  to  make  his 
experience  of  service  to  some  of  his  renders  who  may  he  led  to 
engage  in  this  branch  of  clinical  instruction.  Instruction  in  phys* 
ical  exploration  to  be  effective  tntist  be  in  the  form  of  familiar  lce»ons 
in  the  wards  of  a  hospital  large  enough  to  furnish  a  suflicivut  nwniber 
of  examples  of  all  the  physical  signs.  The  classes  must  be  stnull,  in 
onler  that  it  may  not  be  tedious  for  the  diifcrcnt  members  u>  listen 
in  8ucc«Hsian,  and  also  that  patients  shall  n;it  be  fatigued.  The 
neoKs«ity  of  limiting  the  number  composing  a  class  relates  only  to 
teaching  tbn  auscultatory  signs ;  tlie  signs  obtained  by  percussion 
can,  of  course,  he  illustrated  to  a  large  class.  The  author  is  accu- 
tomed  to  limit  classes  in  au^'ciillntioo  to,  at  most,  fifteen  members. 
After  explaining  and  illustrating  the  acoustic  distinctions  exprc^sixl 
by  the  terms  intensity,  pitch,  and  4]uulity,  together  with  sAne  pre* 
liminary  considerations,  the  study  of  pcrciissioii  is  cnten-d  upon. 
The  first  objects  for  the  members  of  the  class,  arc  to  uiidcriitand  and 
become  practically  acquainted  with  the  normal  vesicular  resonance 
as  regards  the  characters  relating  to  inlenfiiy,  pilch,  and  qtiality, 
and  with  the  nonnsl  variations  which  pertain  to  tlic  chest  in  dif- 
ferent persons  and  indifferent  parts  of  the  chest  in  the  same  person. 
Then  the  four  morbid  signs  obtained  by  percussion  are  explained 
by  comparison,  as  regards  the  distinctive  characters  of  each,  with 
those  of  the  normal  resicular  resonance,  and  they  are  afterward 
illustrated  by  means  of  different  cases  of  disease.  Entering  next  upon 
the  study  of  auseollation,  the  characters  of  the  normal  respiratory 
and  vocal  sounds  are  first  explained,  compared,  and  illustrated  by  ex- 
aminations of  persons  free  from  any  disease  of  the  respiratory  system; 
afterward  the  morbid  auscultatory  signs  are  severally  explained, 
compared  with  each  other,  and  with  the  normal  sounds,  as  regards - 
their  distinctive  characters,  and  illustrated  practically  by  oases  of 
diseaM.     Taking  up  at  each  lesson  a  few  signs,  their  distinctive 


PREFACB. 


VU 


^ 


eharaciers.  eercrally,  as  regards  in(cQsit<r,  j>itch,  and  qnality,  are, 
first,  to  he  rendered  clear  and  familiar,  and,  s<cond,  they  are  lo  bo 
verified  by  each  mcmWr  of  the  class,  cases  exetnplifjitg  the  signa 
haring  b«eti  previously  selected  for  the  purpose  of  atndy.  After  a 
practical  knowledge  of  all  the  signs  fiirnislied  by  percussion  and 
suscoltation  has  been  acquired,  several  lessons  are  devoted  to  the 
Blaily  of  cases  of  diflfereni  diseases  of  the  cheat,  with  reference  to 
the  manner  of  obtaining  and  combining  signs  derived  frotn  all  the 
metlioits  of  physical  exploration,  and  arriving  at  the  diagnosis.  By 
pnraaing  this  plan,  an  acqaaintance  with  the  signs,  and  the  princi- 
plea  of  diagnoisis  sufficient  for  engaging  in  the  practice  of  physical 
cjploralion  may,  with  due  capacity  and  attention  on  the  part  of  the 
Stndent,  be  obtained  in  a  few  lessons;  the  author's  course  of  prac- 
tical instruction,  embracing  the  physical  diagnosis  of  diseases  of  the 
heart,  conMHts  of  twenty  lessons,  from  one  lo  two  hours  being  devoted 
to  each  lc»tton.  It  is  not  to  be  expected  that  after  a  course  of  twenty 
lessons  the  members  of  »  class  will  be  at  once  qccomplished  auscul- 
tatora;  but,  with  the  knowledge  acqaired  in  such  a  course,  provided 
the  teacher  be  able  to  command  b  sufficient  number  of  cases  to  illus- 
trate the  different  signs,  the  pupil  is  prepared  to  go  on  and  tnake 
rapid  pro^rexit  wilhoiit  further  aid,  gmilunlly  ohinining  by  experi- 
ence that  Mlf-confiilcace  which  is  desirable,  and  which  iii  only  to  be 
obtained  by  practice. 

Plij'sical  exploration  may  be  mastered  by  means  of  books  and 
U-ctuTcs  together  with  such  clinical  opportunities  as  are  offered  in 
any  ho«pitnl  of  considerable  size,  but  the  saving  of  time  and  labor 
cfrccti-<l  by  syMcmutic  bed-side  instruction  in  large  hospitals  ie  iin- 
meiMte ;  the  amount  of  progress  made  In  a  few  weeks  is  greater  than 
it  pomiblv  during  muuy  months  or  even  years  without  these  advan- 
tages. It  would  con<luco  much  tovard  a  more  general  diffusion  of 
the  practical  knowloilge  of  auscultation  and  percussion,  were  a  larger 
number  of  competent  physicians  connected  with  large  hospitals  to 
become  engaged  in  forming  classes  for  private  iostroction  in  theae 
mttbod*  of  physical  cxploralioo — a  department  of  medicine  whid) 
tfoameaiU  itself  as  not  Ichb  attractive  than  important. 


If  nr  TOKK,  Aagiut,  isee. 


CONTENTS. 


INTKODUCTION. 

SiiTFioN  I.  Preliminary  Points   pertaining  to  the  Anatomy 

and  Physiology  of  the  Respiratory  Apparatus,  17 

I.  The  Thoracic  Parietea,     ....  18 

II.  Pulmonary  Organs, 34 

III.  Trachea,  Bronchi,  and  Larynx,                .  46 

Skction  II.  Topographicat  Divisions  of  the  Chest,         .  54 

I.  Anterior  Regions, 66 

II.  Posterior  Regions, 69 

III.  Lateral  Regions, 60 

PART  L 

Chapter  I.  Definitions — Different  Methods  of  Exploration — 
Sources  of  the  Distinctive  Characters  of  Dif- 
ferent Sounds — General  Remarks,         ,        .  65 

II.  Percuraion, 76 

Percussion  in  Health, 79 

Percussion  in  Disease, 97 

History, 116 

III.  Anscultation, 117 

Auscultation  in  Health,          ....  128 

Auscultation  in  Disease, 154 

IT.  Inspection, 275 

Summary 289 

History, 291 

a 


'■"i 


(trw*. 3£* 

Xmot  &rwu».-j:l«; 323 

f'M^.JMn-  Err^oMiftiK.  ....  331 

frArrMJt  Br'AftfaitM. 340 

?t*v/6il»7  BroadiiUfi.       ....  US 
f  f    t/.ltfJiH^M  vA  Omtnai/ia  of  tbe  Bronchi:^ 

T»i-.«M — P«ruiMU — Aaihma-        .  346 

tfilumtif/n  tA  tbft  BronchUI  Tabes.  .  346 

'>'Atr»':ti'A  of  the  Broocbial  Tnb«s.  S5d 

f'<!rtnMri*^Wboopuig-CoBgfa,    .  361 

A-tKm», 363 

\\\.  f'fiAriio'fnitiH — Inperfect  ExpansioD  (Atelec- 

tMin^  and  CoIUpM,      ....  368 

A/.'mUt  rj'i^/«r  Pneainonitis,  .  368 

frri|iftrf<r:(:t  ExpatiHion  sod  CoUapee  of  Pol- 

moiiarjr  l>jbale8,  ....  398 

(''lir'iNiu  I'Deamonitu,        ....  403 

rV-  K(«i.l.y<M.m« 406 

VtwIiiiiUr  KmphyBoma,     ....  406 

liiKirlobular  Kinphjaoma,  .  418 


COHTBNTB. 


XI 


PAOK 

Chapteb  Y.  Pulmonary  TuborcaloBis — Bronchial  PhthiBis,   .      421 

Acute  Phthisis, 466 

Betrospective  DiagnoBiB  of  Tuberculoats,    .      468 

Bronchial  Fhthiaig, 471 

'    YI.  Pnlmonary    (Edema — Gangrene  of  the  Lungs 

— Pnlmonarj  Apoplexy — Cancer  of  the 

Langs — Cancer  in  the  MediaBtinnm, 

Pnlmonary  (Edema, 

Gangrene  of  the  Lnngs, 

Pnlmonary  Apoplexy,  . 

Cancer  of  the  Lnngs,    . 

Cancer  in  the  Mediastinum, 

YIL  Acute    Plenritia  —  Chronic    Plenritis  —  Empy 

ema  —  Hydrotborax — Pneumothorax — 

Pnenmo-Hydrothorax  —  Pleuralgia  — 

Diaphragmatic  Hernia 

Acnte  Pleuritls, 601 

Chronic  Pleuritis, 527 

Empyema, 641 

CircumBcribed  Plenritis  with  Liquid  Effu- 
sion,      

Hydrothorax, 

P  neum  othorax — P  d  cum  o-Hy  droth  orax , 
Intercostal  I^enrslgia  and  Pleurodynia, 
Diaphragmatic  Hernia, 
YIII.  DiBcases  affecting  the  Trachea  and  Larynx, 
Foreign  Bodies  in  the  Air-Passagee,    . 


474 
474 
477 
483 
487 
494 


501 


546 
549 
561 
561 
665 
672 
682 


PHYSICAL   EXPLORATION. 


INTRODUCTION. 


SECTION  I. 


PRELIMINARY  POINTS  PERTAINING  TO  TUE  ANATOMY  AND 
PHYSIOLOGY  Of  THE  RESPIKATOKY  APPARATUS. 


Tbk  study  of  diaeases  affecting  the  respiratory  npparutus  involrcs, 
iw  a  point  of  departure,  acquaintaDce  with  the  several  HlruvlureK, 
organs,  and  functions  which  ihU  apparatus  erabraci-n.  To  thi«  pre- 
paratory linonlcdge  it  is  presumed,  of  course,  the  reader  has  already 
giTcn  more  or  tess  attention ;  but  it  will  be  useful  to  review  oertaia 
points  pertaining  to  the  anatomy  and  physiology  of  this  portion  of 
the  organism,  which  irill  be  found  to  have  direct  and  intimate  path(>> 
logical  relaliotis.  To  these  points  this  section  will  be  mainly  limited, 
omitting  dctailrt  oth^r  than  those  of  special  importance  in  their  bear- 
ioge  on  the  subjects  to  be  subset]uently  considered. 

The  respiratory  apparatus  comprises  1st,  the  thoraeie  parictee, 
inclosiYC  of  the  diajihragm;  2d,  the  pulmonary  organs  contained 
vithin  the  thoracic  cavity ;  8d,  the  canal  or  tube  leading  from  the 
langs  to  the  pharynx,  consisting  of  the  primary  bronchi  and  their 
Bubdivisions,  (lie  trachi;a,  and  larynx.  The  throat,  moulh,  and  nasal 
paasages,  although  involved  in  respiration,  arc  rather  ui^unctD  of 
the  respiratory  opparatufl  than  constituent*  of  it,  their  constructJ<Mi 
|^_   having  more  direct  reference  to  other  functions. 


r 


18  ANATOHT    AND    FHVBIOLOOY. 


I.  The  TfiOBACic  Parietbs. 


The  portion  of  the  skeleton  called  the  thorax  ie  composed  of  the 
dorsal  vertebrse,  the  ribs,  and  the  bones  of  the  sternnm,  forming  by 
their  union,  together  with  their  intervening  cartilages,  a  truncated 
cone,  designed  to  protect  the  organs  which  it  contains,  and  to  be 
subservient  to  certain  movements  concerned  in  respiration.  The 
bony  arches,  the  ribs,  exclusive  of  the  two  last  on  each  side  (reckon- 
ing, as  is  usual,  from  the  summit  of  the  cone  downward),  are  joined, 
either  to  the  sternum,  or  to  each  other,  by  cartilages  to  which  the 
walls  of  the  chest  are  in  a  great  measure  indebted  for  their  elasticity 
and  mobility.  The  superior  seven  ribs  joined  to  the  sternnm  are 
called  the  true  ribs,  and  the  remaining  five  on  each  side  are  dis- 
tinguished as  tlie/alie  ribs.  The  two  lowest  on  each  side,  from  the 
fact  that  their  anterior  extremities  are  disconnected  from  those 
situated  above  them,  as  well  as  from  each  other,  are  known  as  the 
floating  ribs.  The  elasticity  of  the  costal  cartilages  is  greatest  in 
early  life;  it  becomes  impaired,  as  a  general  rule,  in  proportion  to 
age,  and  with  advanced  years  may  be  nearly  lost  in  consequence  of 
ossification.  Under  these  circumstances  the  alternate  increase  and 
diminution  of  the  thoracic  capacity  with  the  two  acts  of  respiration, 
80  far  aa  the  successive  expansion  and  contraction  of  the  thoracic 
walls  are  therein  involved,  must  of  necessity  be  in  some  measure 
restrained. 

The  direction  of  the  first  rib  is  nearly  horizontal.  The  remainder 
have  an  oblique  direction  downward,  the  obliquity  increasing  with 
each  inferior  rib.  Below  the  third  rib  the  costal  cartilages  also  have 
an  oblique  direction,  but  not  corresponding  to  that  of  the  ribs.  At 
a  short  distance  from  the  point  of  their  attachment  to  the  ends  of 
the  ribs,  they  pursue  an  upward  direction  to  their  sternal  connections. 
Hence  a  line  coincident  with  the  axis  of  these  ribs,  forms  with  a  line 
passing  through  the  axis  of  their  cartilages,  an  angle  which  is  less 
obtuse  with  each  inferior  rib.  The  length  of  the  costal  cartilages 
also  increases  successively  with  the  three  lowest  of  the  true  ribs. 
These  anatomical  points,  viz.,  the  oblique  downward  direction  of  the 
ribs  and  the  oblique  upward  direction  of  the  costal  cartilages,  are 
provisions  for  the  respiratory  muvements,  so  far  as  these  movements 
relate  to  the  anterior  and  lateral  portions  of  the  chest.  With  the 
act  of  inspiration,  more  especially  when  its  force  is  voluntarily 


THB   THOBACIC    PABISTBS. 


19 


niigmentcd,  the  lateral  nnd  anU'ro-postcrior  dintDcUm  arc  incr«a8e<l. 
This  is  effecle<J  clttcllr  by  the  clovntton  of  the  ribg,  by  wliicb  tlieir 
'obliquity  is  dim  i  Dished,  cu)i»itig  them  to  approxiiDatc  and  even  attain 
Bto  a  borixontal  directiou,  tending  tbiia  to  bring  tbo  ribs  and  the  costal 
cartilage!!  on  a  continuous  line,  diminishing  or  abolishing  the  angle 
^  formed  by  (he  union  of  the  ribs  and  cartilages.     After  the  ccsisation 
^  of  the  motive  power  which  effects  these  ehangeR,  in  other  words, 
i«ith  the  act  of  expiration,  the  elasticity  of  the  cartilages  suffices  to 
restore  the  costal  angle  which  exists  in  a  passive  condition  of  tlio 
chest.     These  movements  are  abnormally  increased  and  diminished 
is  coDseqncnce  of  diSerent  forms  of  disease.     A  change,  also,  as 
regards  the  oblique  direction  of  the  riba  is  attendant  on  certain 
thoracic  affections,  viz.,  pleurisy  with  a  large  accumulation  of  ]ii{iiid 
in  the  pleural  sac;  the  presence  of  liquid  and  gus  in  pneiiino-hyd re- 
thorax,  and  in  some  cases  of  dilatation  of  tbe  air-cells  or  vesicular 
enpbjBema.     In  connection  with  these  affections  the  same  changes 
■  are  tnechaoically  produced  which  arc  effected  by  a  forcible  act  of  in- 
^iration,  with  the  important  difference,  that  while  the  eiilargeinent 
of  tlve  chest  in  tbo  latter  case  is  but  for  an  instant,  in  the  former 
case  it  persists  so  long  as  the  morbid  conditions  which  have  mduced 

■  it  continue. 
Tbe  margins  of  tbe  ribs  are  not  in  contact,  but  separated,  leaving 
what  are  termed  tbe  intercotlal »pace».  In  coDsequence  of  the  pro- 
grcireivcly  increasing  obliquity  in  the  direction  of  the  ribs  the  inter- 
costal spaces  are  broader  in  front  than  behind.  Under  different 
morbid  conditions  these  spaces  arc  increased  and  diminished  in 
width.  The  former  is  incident  to  the  accnmulation  of  a  large  quan- 
tity of  liquid  in  the  chest,  tbe  latter  to  contraction  of  the  chest 
following  the  removal  of  this  liquid  by  ahiorplion  or  otherwise.  In 
the  female  skeleton  the  upper  ribs  are  more  widely  separated  than 
in  the  male,  and  tbey  possess  also,  relatively,  a  great«r  degree  of 

I,     mobility.     This  anatomical  diffwenci'  in  the  two  sexes  has  relation 

Bto  the  greater  part  which  tbe  summit  of  tlio  cheat  takes  in  the 

Hrespiratory  movements  in  the  ftimale. 

B  "^^^  intercostal  spaces,  when  tbe  thorax  is  investci]  with  the  soft 
parts,  are  filled  with  muscular  substance,  which  is  concerned  is 
carrying  on  the  respiratory  morements.  The  intervening  muscular 
layers  are  depressed  hdow  the  level  of  the  ribs,  causing  furrows, 
which  are  called  the  inlermstal  d«pre$»iont.  In  persons  with  small 
or  moderate  adipose  deposit,  these   depressions  are   apparent   on 


so  AMATOHT    AND    PHYSIOLOQT. 

the  surface,  being  observable  especially  in  front  and  laterally,  at 
the  lower  part  of  the  chest.  They  are  everywhere  visible,  except 
in  the  portions  covered  by  the  scapnlee.  in  cases  of  great  ema- 
ciation. A  change  as  respects  this  anatomical  point  occurs  in  cer- 
tain morbid  conditions,  viz.,  when  there  is  an  accumulation  of  a 
large  quantity  of  liquid  in  certain  cases  of  pleuritis,  or  an  accumu- 
lation of  liquid  and  air  in  pneumo-hydrothora:!.  Under  these  cir- 
cumstances the  intercostal  depressions  are  abolished,  and  the  inter- 
vening integument  may  even  project  beyond  the  level  of  the  ribs 
when  a  very  large  quantity  of  liquid  or  air  is  contained  in  the  pleural 
sac. 

The  scapulae  and  clavicles,  with  the  soft  parts,  give  to  the  thorax 
a  shape  quite  different' from  that  which  it  presents  divested  of  these 
appendages.  Compared  to  a  truncated  cone,  the  base  is  now  above. 
These  superadded  bones,  certain  muscles  investing  portions  of  the 
thoracic  walls,  and,  in  the  female,  the  mammary  gland,  offer  obstacles 
in  the  way  of  exploring  the  chest  for  the  physical  signs  of  disease, 
which  will  be  noticed  hereafter  in  connection  with  the  consideration 
of  these  signs. 

The  partition  wall  sepcu'ating  the  chest  from  the  abdomen  is  the 
tendino-muscular  septum,  the  diaphragm,  springing  from  the  lumbar 
vertebrae,  from  the  first  to  the  fourth  inclusive,  and  attached  to  the 
six  inferior  ribs.  Examined  from  below  it  forms  a  vaulted  or  arched 
roof  of  the  abdominal  cavity,  its  upper  surface  having  a  correspond- 
ing convexity  extending  into  the  thoracic  cavity  on  each  side.  The 
height  to  which  this  convexity  rises  in  the  two  sides  is  not  equal, 
being  greater  in  the  right  than  in  the  left  side.  In  the  former  it 
rises  as  high  as  the  fourth  intercostal  space;  in  the  latter  to  a  level 
with  the  fifth  rib.  Thus  the  right  chest  has  a  vertical  diameter 
somewhat  less  than  that  of  the  left.  Accumulation  of  liquid  within 
the  pleural  sac,  and  dilatation  of  the  air-cells  in  some  cases  of  emphy- 
sema, may  cause,  mechanically,  depression  of  the  diaphragmatic  arch ; 
and,  on  the  other  hand,  enlargement  of  the  liver  on  the  right  side, 
and,  on  the  left  side,  enlargement  of  the  spleen,  or  distension  of  the 
stomach,  will  produce  an  elevation  above  the  normal  height. 

The  contraction  of  the  muscular  portion  of  the  diaphragm  di- 
minishes its  vaulted  form,  depressing  it  to  a  plane,  thereby  extend- 
ing the  vertical  diameter  of  the  thoracic  space.  In  this  way  it 
becomes  the  moat  important  agent  in  the  act  of  inspiration,  resuming 
its  convexity  with  the  act  of  expiration.    These  movements  are  liable 


TITF  THORACIC    TAHIBTES. 


SI 


k 


I 


t«  be  restrained,  or  DiTV8t(td  by  variouH  kffections  which  will  be 
presently  mentioned. 

Considered  a«  divided  into  lateral  fanlreo,  the  thoracic  (Mrietea  on 
the  two  sides,  not  only  as  rcspcvts  the  skeleton,  but  when  invested 
with  the  soft  parts,  should  he  nearly  symmetricnl,  so  that  any  con- 
siderable deviation  in  this  point  of  view  denotes  either  present 
diseast-,  or  deformity.  An  exception  relates  to  ibe  semicircular 
measurement  at  the  middle  and  inferior  portion  of  the  chest.  The 
right  side  usually,  but  not  invariably,  measures  somewhat  more  than 
the  left,  the  average  difference  being  about  half  an  inch.  Of  138 
cases  of  persons  in  good  health  in  which  measurements  were  made 
by  Woillea,  the  right  semi-circumfercucc  eicce*ied  the  left  in  97; 
the  left  exceeded  llii-  right  in  9,  and  both  sides  were  equal  in  21. 
The  greater  siso  of  the  right  side,  as  determined  by  measurement, 
is  usually  attributed  to  the  presence  of  the  liver  on  that  xido.  Tlic 
facts  presented  by  the  author  just  named,  however,  scera  to  »how 
that  it  depends,  in  a  measure  at  least,  on  the  greater  use  of  the  right 
npper  extremity,  which  is  habilunl  with  most  persons.  In  no  instance 
in  which  the  persons  were  right-handed  did  the  left  cxceud  the  right 
side  in  measurement;  on  the  other  hand,  of  five  cases  in  which  the 
personii  were  left-handed,  in  three  the  left  side  exceeded  the  right, 
and  in  the  remaining  two  cases  both  sides  were  equal.  In  a  per- 
fectly symmetrical  chest  the  shoulders  should  be  on  the  same  level ; 
and  in  the  male  the  nipples,  situated  on  the  fourth  rib  or  in  ibe 

■    fourth  intercostal  space,  should  be  on  the  same  transverse  line  and 
equidiiitanl  from  the  centre  of  the  sternum.     The  general  law  of  sym- 
metry aa  regards  correspondence  in  similar  portions  of  the  cbest  on 
the  two  sides  is  of  importance  in  determining  the  existence  of  intra- 
thoracic diseases;  and,  with  reference  to  the  application  of  thb  Uw, 
H    it  is  to  be  borne  in  mind  that  certain  p«st  affections  are  liable  to  leave 
devintionit  more  or  le&s  permanent.   The  most  common  cause  of  defor- 
mity is  itpinal  curvature,  which  may  be  sufficient  to  disturb  the  sym- 
metry of  the  two  sides  without  existing  to  a  degree  to  bo  noticed  unless 
a  careful  compari.4on  be  instituted.    Cases  of  sligbt  lutcrnl  curvature 
depressing  the  shoulder  and  nipple  of  one  side  (oftener  the  right  than 
H    tlM!  left  Hide),  approximating  the  margins  of  the  ribs,  and  diminishing 
ttie  semi.circumfer<;nce,  are  very  frequent,  and  liable,  without  special 
^_     attention,  to  he  overlooked.     Certain  diseases  within  the  cheat  lead 
H    to  markcl  alterations  in  the  eonfonnation  on  one  side.     This  is  true 
^B  especially,  as  will  bo  seen  hereafter,  of  chronic  picuritis.    The  chetit 


S2 


AKATOMT    AKD    PBTSIOLOeT. 


on  one  or  both  sidos  mar  l>c  deformed  in  ranous  injt  irrespective 
of  epinal  corvature.  TIiiih  the  Htcrnum  may  project  unnaturall^r, 
causing  tJic  "chicken"  or  "pif;cun  hrc4ut,"  or  it  ma;  be  more  or 
less  (leprcttsed;-lhcrc  miiy  he  Battening  on  one  side,  produced  per- 
haps bj  pressure  from  the  uriu  of  the  nurse  in  curly  infancy:  cod- 
traetion  at  the  lower  part  of  ttie  chest  in  frmales,  occasioned  by 
tight  lacing ;  di:<lortious  from  frnctures  or  other  injuries,  etc  These 
dcriiiiions  from  syiiiinctry  iire  sufficiently  obvious,  and  will  not  there- 
fore escnpu  notice.  Practioally  tlicy  are  of  great  importance  in  de- 
terniiniiig  certain  of  the  physical  signs  of  existing  disease.  The 
greater  portion  of  these  signs,  aa  will  tie  seen  hereafter,  being  based 
on  the  assumption  that,  irrespective  of  present  disease,  the  two  sides 
of  the  chest  arc  symmetrical,  it  is  obviously  important  to  dclcraiinc, 
in  individual  cases,  to  what  extent  the  law  of  symmetry  holds  good. 
The  rcM'arehea  of  Woillex'  show  that  chests  presenting  in  all  par- 
ticulars complete  regularity  of  conformation  arc  found  in  only  the 
proportion  of  about  twenty  of  every  hundred  persons.  I>cviations 
from  symmetry,  either  disconnected  from  disease  (physiological),  or 
rcijuliing  from  prcrioua  morbid  conditions  (pathological),  therefore, 
citist  to  a  greater  or  less  extent,  in  a  large  proportion  of  individuals. 
This  fact  would  impair  very  materially  the  value  of  physical  ex- 
ploration were  it  not  practicable,  as  it  generally  is,  to  determine 
whether  deviations  which  may  be  discovered  are  due  to  present 
disease,  or  existed  previously. 

The  rfgpiratory  movements  involve  certain  points  important  to  be 
premised  in  addition  to  those  already  noticed. 

A  complete  respiration,  as  is  well  known,  comprises  two  acts,  via., 
an  act  of  insyiratioH,  and  an  act  of  expiration.  In  health,  after 
adult  age,  the  respirations  are  repeated  from  14  to  20  times  per 
minute,  the  habilual  fretjuency  varying  considerably  within  healthy 
limits  in  different  individuals.  The  frt^quency  U  somewhat  greater 
in  feiriulc8  than  In  males,  and  i^tiil  greater  in  children.  Deviations 
as  regards  the  frequency  of  the  respirations,  exceeding  the  limits  of 
health,  lire  importnnt  symptoms  of  disease.  In  various  affections 
compromising  the  function  of  hwmiitosis,  the  frequency  of  the  res- 
pirations is  considenihly  increased,  rising  for  example  in  bronchitis 
aficcting  the  smaller  tubes,  to  30,  40,  50,  60,  or  even  a  still  greater 

'  "J TVthpreln*  )>rHt)'|u<-«  tur  I'mipwlion  ot  Is  uji-niiirstion  di'  la  pyilrini?,  oofi- 
■iddr^  cotoinc  moycui  dingnoiiiqueii  com]ilAnic!nlairni  iln  Is  pnrcustion  i-t  da 
I'suMTultstloii."  Parts,  1887.  ArcliivM  Uju^mIm  ie  UMvdoa,  Staie  Sirie, 
Ivme  i,  ]i.  TS. 


TBB   THORACIC   fABIBTM. 


S8 


I 


r.  per  minute.  On  tho  otbcr  hand,  sn  »bnorm»l  (liminntion 
in  jrcqucocy  sc-compnoicii  certain  morbid  eoBdJtiona  of  the  nervous 
sjrBtrin  wliicli  ftlTcct  imlircctl;  the  respiration.  ThuK,  the  rctipirutions 
are  morLidly  infrciucnt,  or  slow,  in  mpoplcxy,  and  in  coma  however 
indnced.  The  immediate  object  of  the  act  of  infiralitm  is  the 
enUrgenient  of  the  thoracic  space,  the  air  rushing  in  to  611  the 
vacuntn  thus  created  within  the  air-ce11s  and  tubes  of  the  lungs. 
This  enlargement  is  effected  hy  means  of  mu»clos  attached  to  the 
thoracic  walls,  on  the  one  hand,  and,  on  the  other  hand,  by  the 
depression  of  the  diaphragm.  Tho  initnetlinlc  object  of  expiration 
b  to  restore  the  chest  to  the  diinensioD^  it  nntnnilly  assamos  when 
not  acted  on  by  the  dilating;  uiuaclci^,  and  to  contrnct  it  eometimee 
beyond  that  point,  thus  causing  expnlvion  of  the  nir  received  by  the 
act  of  inspiration.  The  simple  restoration  of  llie  chest  is  due  mainly 
lo  the  elasticity  of  the  dilated  parUi,  but  contructjoii  beyond  the 
dimeDsions  which  it  naturally  atiHumes.,  \»  elT«ctcd  by  expiratory 
nuscles.  The  movements  incident  lo  the  two  aot4,  respcetircly,  in 
ordinary  or  tranquil  rcspiralioti;  the  modifications  exhibited  when 
the  breathing  is  exaggerated  or  forced ;  the  normal  differences  to  be 
ob»erTed  in  different  persons;  the  variations  due  to  age,  eex,  etc., 
are  physiological  points,  not  only  interesting  in  themselves,  but  of 
ntility  in  order  to  appreciate  the  aberrations  assuciutcd  with  diseasce 
of  the  respiratory  apparatus.  In  bestowing  some  consideration  on 
these  points  I  shall  not  detain  the  reader  with  minute  descriptions, 
atill  less  engage  in  discussions  relative  to  the  mechanism  of  respira* 
tion,  which,  however  much  of  interest  they  may  possess  for  one 
desirous  of  investi^ting  the  subject  fully,  are  not  of  special  im- 
portance as  preparatory  to  entering  on  the  study  of  the  physical 
exploration  of  the  chest. 

lo  ordinary  breathing,  m  the  mole,  the  diaphragm  is  usually  the 
more  imporiHnt,  and  indeed  sometimes  almost  the  sole  efficient 
agent.  The  diaphragmatic  movements  are  indicated  by  a  percep- 
tible, rising  and  falling  of  the  abdomen.  Bat  in  certain  diseases 
these  movements  are  to  a  greater  or  less  extent  restrained,  and 
they  may  even  he  completely  arrested.  They  are  notably  diminished 
in  acute  peritonitis,  being  unconsciously  repressed  in  consequence 
of  the  pain  which  they  occasion ;  and  they  are  mechanically  pre- 
vented  by  a  great  <)uantity  of  li([Did  within  the  peritoneal  sac,  by 
enormous  distension  of  the  stomach  or  inteatine«  with  gas,  by  ah- 
domina)  tumors,  and  by  pregnancy.     Under  these  ciroumslanoNi 


24 


AVatOMT   AltD    PHTSIOLOflT. 


the  thoracic  mitMlcM  ukc  oo  »  sapplemeiitarj  actiritjr,  which  is 
rendered  iiufficicnlly  obvious  by  tb«  increased  moveinents  of  tbi 
thoracic  vbII«.  The  breathing  is  then  said  to  be  thoraeie  oreaiaV 
Oil  the  other  hand,  the  moreinenta  of  the  ribs  are  volantarily  re- 
pre»i«vd  in  t'on»cqui>iic«of  the  pain  incident  thereto  in  acute  pi euri^, 
or  in  intercostal  neuralgia,  and  they  are  mechanically  limited  by 
rigidity  and  otieificalion  of  the  costal  cartilages.  The  diaphragm, 
in  thiM  c«M>,  takes  on  an  increased  action.  The  breathing  is  then 
distinguished  as  diaphragmatic  or  abdominal,  the  Latter  term  de- 
DOting  the  fact  that  this  supplementary  activity  is  manifested  by  a 
corresponding  incresBe  in  the  mible  rising  and  falling  of  the  ab- 
dominal walls.  The  deviations  from  normal  respiration  knoira  as 
tittracit  or  eottal,  and  diaphragmatie  or  abdominal,  thns  not  only 
indicate  the  existence  of  diwa«e,  but  point  to  its  situation. 

By  certain  intra-thoracic  affections  the  morements  of  the  chc^t  art 
diminished  or  suspended  on  one  side,  and,  by  way  of  compensati' 
abnormally  increased  on  the  other  side.  This  obtains  in  ciu»ck  of 
eopiouH  liquid  effusion  within  one  of  the  pleural  sac«.  Panilysis  of 
the  mu.«clr«  of  a  lateral  half  of  the  body  {hemiplegia)  may  also  be 
attended  by  diminished  thoracic  movements  of  the  affected  »ide. 

Ajialrsis  of  th<>  movements  of  the  thoracic  nails  derclops  other 
eircuiDAftanecs  which  are  to  be  noted.  The  enlargement  of  the  cbcit, 
exclusive  of  the  diaphragm,  in  inspiration,  is  effected  by  the  action 
of  the  thoracic  muscles  elevating  the  ribs,  the  latter,  as  hnM  bccD 
aeen,  pursuing  an  oblique  ilireciion  and  forming  an  angular  con- 
nection vritli  the  costal  cartilages.  In  propoition  as  tlie  nbs  are 
thus  raised,  the  costal  angles  become  more  obtuse,  and  the  ribs  ap- 
proach to  a  horizontal  direction,  the  ribs  and  cartibges  together 
approximating  to  a  continuous  line.  At  the  same  time  the  stcmam 
is  raided  upward  end  projected  forward.  The  ribn,  also,  are  rota 
backwanl  at  their  spinal  junction.  The  result  \a,  the  cavity  of 
chest  becomes  enlarged  in  every  direction.  Owing  to  the  gre: 
length  of  the  lower  trve  ribs  as  well  as  of  their  cartilagea,  and  the 
lean  degree  of  obtuscnesa  of  the  angle  formed  by  the  union  of  the 
fomter  with  the  latter,  the-te  clcTatton  and  expansion  moremcnta, 
IN  ihe  malt,  are  much  more  marked  in  the  lower,  than  the  upper 
part  of  the  chest;  and  thrv  are  greater  during  ihe  middle,  tbaa 
either  at  tltc  beginning  or  the  end  of  the  inspiratory  act.  In  ordi- 
nary breathing,  the  ribs  at  the  summit  of  the  male  chest  appear  to 
have  little  or  no  part  in  the  thoracic  movemctita.    Accurate  measare- 


nnm 


25 

roent  shows  that  lh«y  do  not  rcraain  quiescent,  but  tlie  motion  is 
oenally  so  slight  as  scarcely  to  be  perceived.  The  morenienta  «re 
tnaioly  confines!  to  the  lower  part  of  the  cbcvt  anil  tfac  abdomen, 
rre<]uently  appearing  to  be  limited  to  the  bitter.  Thii<,  it  ia  to  be 
bomo  in  mind,  ii)  true  of  ordiitartf  brt'iitbiiig  in  the  male  itox.  In 
exaggerated  or  forcvd  breathing,  and  in  the  f«ninle,  the  respirntorjr 
moTemcnla  present  important  modification*,  ll  will  fncilitatc  iho 
description  of  thcac  modifications  to  adopt  a  subdivision  of  the 
thoracic  movements  made  by  Beau  and  Miiinmt,'  which  I  am 
Mti«fied  from  my  own  obvervalionH  ie  founded  in  nature.  From  an 
examination  of  a  Inrpe  number  of  indiridunis  these  observers  resolve 
normal  difTcreiiccK  of  broitlhiiig  in  the  two  itexcs,  ns  denoted  by  obvious 
movements,  into  three  kinds,  or  a«  styled  by  them,  typet.  In  many 
persons,  as  already  vtuted,  ordinnry  brnlhing  is  carried  on  almost 
exclusively  by  the  dispbrngin.  In  these  persons  the  chief  visible 
evidences  "f  ullernute  enlargement  nnd  diminution  of  the  thoracic 
space,  with  the  two  rettpiratory  acts,  consist  in  the  rising  and  fall- 
ing  of  the  abdomen.  This  i»  eallcil  the  ahdommal  type  of  respira- 
tion. In  other  persons,  of  the  male  sex,  movements  of  the  lower 
part  of  tlic  chest,  from  the  seventh  rib,  inclusive,  are  involved  in  a 
greater  or  le«  de;;rrPO.  The  type,  then,  is  called  inferior  co$tal. 
This  type  is  very  rarely,  if  ever,  presented  alone.  It  is  associated 
with  the  abdominal.  Both  typc«,  in  oilier  words,  are  represented 
frequently  in  the  male  Nex,  different  pers<fns  differing  considerably 
M  respects  the  predominance  of  one  or  the  other  type.  The  third 
type  is  called  auprrior  costal,  and,  as  the  title  signifies,  is  character- 
ized by  the  respiratory  movements  being  especially  manifest  at  the 
sammit  of  the  ehc«t.  This  type,  as  will  be  seen  presently,  is  peculiar 
to  females.  Now,  a  change  in  the  type  of  respintioti  generally 
characten^es  exaggerated  or  forced,  as  contrasted  with  onlinary, 
breathing.  The  abdominal  type  becomes  less  marked,  and  tlio 
it^ferior  efMai  appears  to  take  its  place.  This  is  demonstrated  by 
the  ingenious  researches  of  John  Hutchinson,*  the  correctness  of 
which  may  be  easily  verified  by  an  examination  of  the  nude  chest 
in  a  living  male  subject.  The  respiratory  movements,  examined 
when  the  respiration  is  lrnni|ml,  and,  afterward,  when  voluntarily 
inereaaed,  present,  in  the  first  instance,  an  abdominal  mntJon  more 


■  R<Thi>rrhM  iiir  1#  roManlame  Am  nxiiiveinHiU  nwplralolrra. 
<r»l«>  ilv  )I«(]<<cUic.  Dic«nit>r«.  1842. 
*  J£*dici>4^lmrglcHt  Tranwclloa*,  vol.  xilx,  1946. 


ArcliiTtB  G<iv- 


(;r  l*Mi  m*AA^  -ra.  or  -vmran:  »  vs-aic  n^nc  if  .iiifcrtiir  Bual 
tii'Aion ;  »ui.  A  "S^  •Kvjui.  astnm^..  -znk  uioiibiibm.  moaoiL  iMttctai 
of  ix-ihir  i(j<T**w^  »  csEiniMiKt-  vale  me  mfe^iir  bskiJ  noMB  > 
ti'ttuMy  twrrvut^^  k  mt^artir  ^jifat  niiruut  bemc  wmKimeE  s^o'- 
K'J'1<!'I.     H'jvri^^M'A  vbt  i^  11  'Uimc  -iia.-!.  ns.  "dia  mtuc^  tlK 

fiM!l,  iM  kV/«&  vja^lw-'e-T  "tT-  It.  r.  StMm-  IS*  nymtimtm  rf 
Llin  iiiftri'/r  ri^>t,  vz^A  m  iiri»mr»t>rr  on*  ^t  "mt  fii^jdm-pm,  pn- 
vt'ntN  tl>«  ri<i/j;r  u^d  £kT:i^  uf  ^iit  HvdgmimZ  vmk  fnoB  Wmg  af- 
pHrt^iit.  N*rT«rtiM:kH.  h  t««.»  jiik%.  u  mar  Ite  ■nidicwrily 
|tr<jvi-il  hjr  yt^vihkiv^  xktt  Wwa  ytn  vS  fiit  aKS  l^fm  ud  after  » 

Tim  irit^rciftt*!  eiraoM*  u  di«  lw«r  psa-i  ff  dkt  fhest  are  en»e 
wliNt  wi'|(-iii;i]  wjtL  tlM'  Mrt  (^ iiicpb-a.i30iL,  and  coiitukJt  eonttvcted 
Willi  4'x;iir«ti<>n,  At  tl^  ctosiDit  of  tlte  ciicEt.  ItovfTcr.  ibe  ktctk 
(if  LliiN  in  tlie  e%Mt.  Th«  rit/t  approximaie  tctt  eU^iIt  in  in^irar- 
lion,  ill  (;'tiiN«(|(iAhc«  of  ««cb  rib  being  raised  sligbilj  more  than  tte 
tlllK  (tltHVH  it. 

Tint  iiititrcoNUl  difpreMi'/M  which  are  apparent  at  the  inferioT 
liortioii  i>f  tli«  eiifM  latvrally  and  aoteriorlr,  in  thin  persons,  are 
liHiHt  i'iiiia|ii(tmfuii  i»  tli«  set  «f  ioHpiratioo,  and  are  increased  in  pro- 
)i<irl|(iii  lit  tlin  (mUriit  of  the  inspiratory  morements.  This  is  the 
riil«,  lull,  ni'i!oriliiJ|f  Ui  lieau  and  Maiesiat,  exceptions  are  occauon- 
•tll^V  <<>  '"<  iiWirvd, 

'I'lin  r<'i|tli'ntiiry  iii'ivi!in«iilM  in  the  adnlt  female  differ  in  a  re- 
nin rltiilili>  iiintiiii>r  Tntm  iIi'ink  which  have  been  described  as  belong- 
lli|I  In  lliit  iiinlti  Mfx.  It)  llio  adult  female  the  anperior  portion  of 
llii>  olii>iil  proHKiila,  ill  thi*  net  of  iuHpiration,  an  expansion  notably 
|[i'i<ii(iir  (liitii  111  iiinltiN,  ihii  muvomcntH  of  the  inferior  portion  of  the 
t'lti'Mli  Mini  of  til"  iiliiliiitK'Ti,  li«iii((  proportion  ably  less  prominent. 
TliK  I'liiKriiBl  ill  lhi«  i'i'i<|ii>i*t  hctwocn  the  two  sexes  is  striking. 
"Til"  Hiliill  iiihIp,"  (o  i|iiiiI(i  ill"  lai)f(iingn  of  Walshe,  "seems  to  the 
i\\"  lit  Iwi'Hilt"  nilli  ill"  Klii|iiim>ti  Hiiil  the  lower  ribs,  from  about  the 
loitih  lit  ill"  M)\lhi  III"  tiilull  f"iiitilo,  with  tho  upper  third  of  the 
yAwi  tktitti","  tit  iilh"t'  <MinU,  ih"  hronlhing  peculiar  to  females  is 
iW  »t)^i*.<i'  isxiMf  'M**^'  >«li"i'"<i>>  i"  niiiU's  it  is  chiefly  the  abdomi- 
*i4),  l)>>it><i  aU.X  tVM»hl»">l,  i»iirt>  itr  Wno,  with  the  it^ffrior  eoOal  type. 
1V  i>W>i\i>  ihiii  dirtVivMiV  i»  ih"  two  wx*'*,  i(  is  only  necessary 
»tt*i  iV>  mii^m^w  W  dtV"»'list  l<*  ih"  swbjivi  when  in  the  presence 
»^i  \^>lu^f ,  Vm  \t  tn  iM>|>ivi(ill,\  tv\tt»pii>H»MW  «hpn  (he  hmthiog  is  con- 


TalsiTel;  aflecled  by  strong  menta]  emotions,  or  when  these  cmotionE 
»re  simulated  in  biHtrionic  pcrrormnnccs.  Hypothelically,  two  reasons 
suggest  themselves,  and  have  bwii  offered  to  aceoiint  for  these  dif- 
ferences in  the  two  eexea — diflcrencos  which  it  ia  of  importance 
shonld  be  borne  in  mind  willi  reference  to  the  study  of  divexses  of 
the  respiratory  apparatus.  One  of  lhe»e  reasons  is,  tlmt  nature  bxs 
in  this  way  provided  for  the  due  performance  of  respiration  during 
the  peciod  of  gestation,  when  the  diaphragmatic  movemeDls  mre 
mechanically  impeded.  Boerhaave  and  Ualler,  who  had  observed 
■  this  point  of  difference  (which  appears  to  have  been  lost  sight  of  by 
more  modern  writers  up  to  a  period  quite  recent),  considered  it  in 
that  light.  This,  however,  is  simply  adducing  a  final  cause.  An- 
ither  reason,  more  entitled  to  be  catted  an  explanatiou,  is,  that  the 
movements  of  the  diaphragm  and  lower  part  of  the  chest  become  per- 
manently impaired  in  females  by  modes  of  dressing  which  involve 
compression  of  the  inferior  ribs ;  and,  as  a  consequence,  the  superior 
thoracic  movements  are  unnaturally  developed.  The  validity  of  the 
latter  explanation,  it  is  evident,  hinges  on  the  question  whether  the 
differences  be  natural  or  acquired ;  and  this  question  is  to  be  decided 
by  examining  girls  and  adult  females  whose  waists  have  not  been  in- 
cused in  any  restraining  or  contracting  apparalus.  With  respect  to 
tliiK  j>oini,  Wabhe  states  that  he  has  examined  a  considerable  nuto- 
^ber  of  female  children,  aged  between  four  and  ten  years,  who  bad 
never  worn  stays,  or  any  substitute  therefor,  who  presented,  never- 
theless, the  predominant  action  at  the  summit  of  the  chest  ob- 
servable in  adult  females,  the  peculiarity,  however,  being  less  than 
in  later  year.s.  He  stales,  also,  thai  the  female  agricultural  laborer 
breathes  more  like  a  male  than  the  town  female;  and  that  during 
sleep  tliG  difference  between  the  .sexes  is  less  conspicuous.  Beaa 
and  Miiissiat  alTirni  that  they  have  observed  this  peculiarity  marked 
in  young  girls,  and  in  females  from  the  country  who  had  never  worn 
corsets.  But,  according  to  their  researches,  the  peculiarity  docs 
not  become  apparent  till  the  third  year  of  life.  Prior  to  the  age 
just  mentioned  the  type  of  breathing  in  female  as  in  male  children 
is  usually  ab'lomintil.  Ilutcbinsou,  in  bin  valunble  paper  already 
referred  to,  say^  he  "examined  24  girls  between  the  ages  of  11  and 
14  who  did  not  wear  any  tight  drens,  and  found  in  ihvm  the  aame 
peculiarity  in  ordinary  breathing.*'   Gibson'  attributvs  the  pccuharitj 


■  On  lliu  M'<vi'(ii<<iii*  of  Bnipimlion  in  UiHtaao.  and  on  tliu  U>*  uf  •  CbcaUmu*. 
■r«r.  3lt<l.-Clur.Tranf.ofR>>jn)Hcd.iindCbir.Sodatycf  London, voLszxl, IMS. 


28  ASATOUY    AND    PHTHIOLOOT. 

to  modifications  of  the  cheat  induced  by  tight  lacing.  He  states  tbat 
"the  form  of  the  chest  and  the  respiratory  movements  do  not  differ 
perceptibly  in  girls  and  boys  below  the  age  of  ten."  Stiil,  he  re- 
marks, *'  it  is  probable  that  in  females,  even  if  they  wore  no  stays, 
the  thoracic  respiration  would  be  relatively  greater,  and  the  diaphrag- 
matic less,  than  in  man."  Judging  from  the  foregoing  statements 
by  those  who,  within  the  past  few  years,  have  made  the  respiratory 
movements  the  subject  of  extensive  investigations,  it  would  seem 
that,  although  a  certain  amount  of  influence  may  be  attributable  to 
dress,  the  difference  which  has  been  pointed  out  is  not  wholly  derived 
from  that  source. 

The  respiratory  movements  are  modified  by  age.  This  is  owing, 
in  a  great  measure,  to  the  differences  as  regards  the  flexibility  and 
elasticity  of  the  costal  cartilages  which  belong  to  different  periods 
of  life.  In  boys,  the  costal  expansion  is  greater  than  adults,  for 
the  reason  just  stated;  and  in  old  men,  when  the  cartilages  become 
ossified,  forming  with  the  ribs  one  unyielding  piece,  the  diaphrag- 
matic movements  are  increased,  and  the  costal  movements  propor- 
tionably  diminished.  Between  the  two  extremes  of  life,  the  charac- 
ter of  the  respiration  wilt  be  likely  to  approximate  to  that  belong- 
ing to  the  one  or  the  other,  according  to  the  proximity  of  the  indi- 
vidual to  boyhood  or  old  age.  In  aged  persons,  whose  costal  carti- 
lages are  ossified,  the  action  of  the  muscles  elevating  the  ribs  tells 
exclusively  on  their  sternal  ends;  hence  the  motion  of  the  sternum 
is  marked,  and  owing  to  the  greater  length  and  obliquity  of  the 
inferior  true  ribs,  the  lower  portion  of  the  sternum  is  raised  and 
projected  more  than  the  upper  portion.  An  effect  somewhat  similar 
is  produced  in  cases  of  permanent  expansion  of  the  chest  from  dila- 
tation of  the  air-cells  in  cases  of  emphysema.  The  costal  cartilages, 
although  not  rendered  comparatively  non-elastic  by  ossification,  are 
kept  on  the  stretch  by  the  abnormally  increased  volume  of  the  lung, 
and  the  ribs  and  sternum  move  upward  in  the  act  of  inspiration  "  as 
if  in  one  piece." 

Infants  present  this  modification  :  the  abdominal  movements  are 
less,  and  the  thoracic  movements  proportion  ably  greater  than  in 
youth  after  the  period  of  infancy  is  passed. 

To  determine  with  exactitude  the  amount  of  the  alternate  expan- 
sion and  contraction  of  different  parts  of  the  chest  with  the  two  acts 
of  respiration,  some  method  of  accurate  measurement  must,  of  course, 
he  employed.   An  apparatus  for  this  end  has  been  devised  by  Sibson, 


THB   Tl 


29 


I 


vbicb  he  calls  tlie  ehett-mea^urer.  It  conHiitts  of  ««vera)  part*,  u 
follows:  1,  a  brostt  plate,  covered  irich  silk,  on  wbicli  the  patient 
lice;  2,  an  upright  rod,  diridod  into  inches  and  tenths,  to  indicate 
the  diameter  of  th«  chest;  3,  a  horizontal  rod,  moving  by  a  elide  oq 
the  upright  rwl,  which  can  be  lengthened  by  being  drawn  out  like  a 
ti.'U>»copu ;  4,  nt  the  exlremity  of  t)ie  latter  u  dial  and  rack.  The 
rack,  when  raised  by  the  moving  walls  of  the  chest,  moves,  by  meana 
of  a  pinion,  the  index  on  the  dial.  A.  revolution  of  the  index  indi- 
cates an  inch  of  motion  in  the  chc^t,  and  caeL  diTLaion  indicates  the 
100th  of  an  inch. 

By  mean*  of  an  instrument  of  this  description  the  extent  of  mo- 
tion uf  dilTurenl  purts  uf  Ihu  chest  may  be  ascertained  with  minute 
accuracy.  It  indicate!*,  also,  very  correctly  the  relative  duration  of 
each  of  the  two  respiratory  acts,  and  in  the  latter  point  of  view  is 
especially  n»eful. 

in  the  valuable  paper  already  referred  to,  Sibson  has  given  thfl 
resullo  of  a  large  number  of  observations  on  the  movements  of  res* 
fiiration  in  health  and  disease.  The  more  important  of  these  re- 
sult*, relating  to  healthy  movements,  arc  embraced  in  ihe  following 
Cumniary:  In  the  healthy,  robust  male,  the  movemeni  of  the  ster-  . 
nnm,  and  of  the  ribs  from  the  first  to  the  seventh,  is  from  .02  to  .07 
of  an  inch  during  an  ordinary  inspiration,  and  from  .5  or  .7  to  2  in. 
during  a  deep  inspiration.  The  ordinary  abdominal  movement 
(diaphragmatic),  is  from  .25  to  .3  in.  ;  the  extreme  from  .(i  to  J  in. 
As  regards  the  two  sides  uf  the  chest  compared,  the  expansion  of 
tbe  second  rib  is  alike  on  the  two  sides ;  hut  below,  the  inspiratory 
movements,  both  in  ordinary  and  forced  breathing,  are  somewhat 
IvM  on  the  left  thun  on  the  right  side,  especially  over  the  heart.  In 
females,  when  stays  arc  on,  the  thoracic  movement  at  the  second 
ribs,  is  from  .06  to  .2  tn. ;  the  abdominal,  from  .06  to  .11  in.  When 
the  stuys  arc  off,  the  thoracic  movement  is  from  .03  to  .1  in.,  and 
the  abdominal  from  .08  to  .2  in.  The  latter  observations,  as  Dr.  S. 
remarks,  render  it  certain  that  the  wearing  of  slays  materially  in- 
fluences the  respiratory  movements,  lessening  the  movement  of  the 
diaphragmatic  ribs,  and  exaggerating  that  of  the  thoracic.  They 
do  not,  however,  disprove  the  fact  that  a  natural  difference  exists  in 
the  two  sexes,  which  other  observations  appear  to  establish.  The 
reader,  desirous  of  farther  details,  will  lind  them  in  Ihe  paper  from 
vbich  the  above  summary  is  taken. 

The  eheat-meaturer  of  Sibson,  and  otlier  contrivances  to  det«r- 


30 


AVATOMT   A!ID    PHTSIOLOOT. 


mine  the  nmount  of  motion  with  the  same  exactness,  have  the  dis- 
■  sdvanlage  of  being  more  or  less  complicated  and  cumbersome.  A 
■imple  gradnated  tape  nil!  eniSce  to  determine,  with  tolerable 
nccuracv,  diflerences  of  siie,  both  lateral  and  antero-posterior,  be- 
tween a  full  inspiration  and  a  forced  expiration.  But  to  ascertain 
bj  this  mode  the  precise  degree  of  motion  in  ordinary  breathing  ia 
very  difficult,  the  results  varying  very  considerably  according  to  the 
degree  of  tcneion  with  which  the  tape  is  held.  This  diGBcnlty  will 
be  at  once  apparent  to  any  one  who  atiempts  to  employ  this  more 
simple  instrument  for  that  end.  The  results  are  only  remote  ap- 
prtixlniatloiis  to  accuracy.  Dr.  Qunio  has  endeavorcl  to  obviate  the 
difficulty  attending  the  use  of  the  simple  tape,  without  impairing 
much  its  simplicity,  in  the  instrument  contrived  by  him,  which  he 
calls  a  tttthometer.  It  consists  of  a  cord  connected  by  an  axle  with 
an  index  which  motes  over  a  graduated  dial.  The  cord  being  ex- 
tended from  a  fixed  point  on  the  chest  to  another,  the  extent  of  the 
rcJipiratory  movement  will  be  manifested  by  the  tension  made  on 
the  cord  being  communicated  to  the  index,  and  shown  in  6guree  on 
the  dial,  from  which  it  can  be  read  off  in  fractions  of  an  inch. 

Practically,  however,  it  is  not  of  much  importance  to  delcrtninc 
with  tnatbcmatical  accuracy  the  extent  of  the  thoracic  and  abdominal 
DioveiDeDta  with  reference  to  the  phenomena  of  disease.  The  eye 
will  answer  for  an  estimation  somewhat  rough,  but  sufficiently  exact 
for  clinical  purpoiies. 

lutra-thoracic  disease  may  he  evidenced  by  marlicd  diminution  of 
the  tftovement  of  a  portion  of  ihc  chest.  This  is  often  observed  in 
tuberculosis  of  the  lungs,  at  the  superior  part  of  the  chest  on  one 
side ;  oftcner  in  fcumlt'^  than  in  mates,  in  oouseifueaee  of  the  greater 
mobility  in  them  naturnlly  in  that  situation.  Local  emphysema  of 
the  lungs  msy  nUo  produce  a  similar  effect,  accompanied  by  an  ab- 
norniul  protrusion  or  bulging  of  a  portion  of  the  chc«l. 

The  respimtory  movement)!,  as  has  been  seen,  are  abnormally  !□• 
ereascil  ia  piegnancy,  and  id  various  affections  which  compromise 
the  function  of  bicmatosis.  When  this  increase  is  but  moderate,  it 
is  staled  by  Beuu  and  Maissiat  that  the  movements  in  one  individoal 
will  differ  from  those  in  another,  according  to  the  type  of  breathing 
natural  to  the  individual.  Thus,  if  the  type  be  purely  abdominal, 
the  abdominal  movements  alone  will  be  increased ;  bat  if  it  be  in- 
ferior costal,  OS  well  as  abdominal,  the  movements  of  the  lower  riba 
will  be  conspicuous;  and  if,  as  in  females,  it  be  superior  costal,  the 


UCIC    PABCBTBS. 


31 


I 


I 
I 


tisggcrntion  irill  be  fouiKi  to  nflfect  chieflj  the  superior  portion  of 
■he  cliMt.  In  cssce,  howt-vcr,  in  wbich  the  semte  of  the  wnnl  of 
rcKpi ration,  or  dyspna-a,  is  intfiise,  ftii<l  the  bretilhing  cxMedirigly 
Uborei],  till;  three  typ«3  niaj  he  ai  mill  tan  eoiisl/  repro»(;iit«d.  But, 
unilcr  th(-!>e  circuiuittunci.-^  the  thoracic  niuRcl«!t  more  e.spocislly  arc 
brought  into  aelivt  retiiiiHilion,  and  in  order  to  i-fTcfl  the  utmost 
.po8(tib)e  enlargement  of  the  ohest,  Tsrioiu)  auxiliary  muHolea  are 
employwi  which  are  capable  of  aiding  in  rei^piratiou.  An  vrect  or 
^tting  posture,  being  tumt  favorable  for  the  action  of  these  mus> 
files,  is  al«o  selected.  Theiie  changes  will  claim  attention  in  con> 
nection  witli  the  symptomatology  of  the  diseases  in  which  they  are 
exemplified. 

The  rhythmical  succession  of  the  two  act«  of  respiration,  in  other 
words  the  order  of  their  alternation,  relative  duration,  etc.,  and  the 
degree  of  power  belonging  to  eacit  act,  involve  certain  paints  of  in- 
terest, which  have  alao  important  relations  to  the  study  of  diseases. 

Of  the  two  acts,  mtpiralion,  in  ordinary  breathing,  is  accomplished 
ty  the  active  exertion  of  muscular  power.  An  ordinary  expiration 
follows  as  a  consequence  of  the  suspension  of  the  muscular  forc« 
which  has  occasioned  the  preceding  inspiration,  being  due  chiefly  to 
the  weight  of  llie  abdominal  organs,  which,  with  the  elasticity  of  the 
mbdoniinal  walls,  press  upward  the  diaphragm;  together  with  the 
elasticity  of  the  ribs,  costal  cartilages,  and  the  contained  pulmonary 
organs.  It  is  only  when  the  expiration  is  voluntarily  increased  or 
prolonged,  or  when  it  is  spasmodically  exerted,  as  in  coughing  or 
•neesing,  that  a  notable  degree  of  muscular  power  is  exerted  in  this 
Act.  But  the  co-operation  of  iho  muscles  with  the  several  cireum- 
ttaocefl  that  have  been  mentioned,  determined  either  by  volition  or 
spasmodic  action,  renders  (he  act  tuore  forcible  than  that  of  inspira- 
tion. Hutchinson,'  by  a  series  of  experiments,  showing  the  force 
of  the  two  acts,  respectively,  as  indicated  by  the  elevation  of  a 
column  of  mercury,  arrived  at  the  result,  that  the  expiratory,  with 
muscular  co-operation,  exceeds  the  inspiratory  by  one-third.  This 
excess  of  force  he  thinks  is  about  equal  to  the  elasticity  whiclt  ia 
brought  to  bear  on  the  former  act.  The  greater  power  of  expiration 
when  aided  by  the  will,  is  manifest  in  the  application  of  thiit  rcspiim- 
tory  act  to  rarious  uses,  such  as  singing,  ooaghing,  playing  on  wind 

trumcnta,  glasji-blowing,  etc. 


Op.  cit. 


4t2  AIATOXI    AVD    PHTSIOLOei. 

From  the  facts  whicb  hxTe  bees  stated  relative  to  ordinsry  breath* 
m^  it  follows  that  the  expiratory  moTemeot  oommenoes  at  the  ia- 
Maot  the  iuefHratory  ceaBes,  The  latter  is  merged  into  the  foroier, 
with  ecarcely  any  appreciable  ioterral  between  the  two.  So  far  as 
the  eipiratory  movement  is  readily  appreciable,  it  appears  to  be 
considerably  shorter  than  the  inspiratory,  and  an  interTal  of  some 
duration  seems  to  elapse,  after  the  completion  of  an  expiratory  act, 
before  the  next  inspiration  commences.  This  interval,  however,  is 
more  apparent  than  real.  After  the  expiratory  movement  ceases  to 
be  obrioos,  the  pulmonary  organs  probably  continue  to  contract,  in 
a  manner  not  readily  appreciable,  nearly  if  not  quite  to  the  recur- 
rence of  the  act  of  inspiration,  unless  restrained  by  a  voluntary 
effort.  The  latter  part  of  this  movement  is  due,  not  to  primary 
contraction  of  the  thoracic  parietes,  but  to  continued  collapse  of  the 
lung,  together  with  the  pressure  of  the  abdominal  viscera.  Walshe 
^timates  the  interval  between  the  end  of  one  expiration  and  the 
beginning  of  the  next  inspiration,  at  one-tenth  of  the  period  occu- 
pied by  both  acts.  But  if  we  were  to  be  goided  by  the  cessation  of 
the  obviotu  abdominal  afid  thoracic  movements,  the  interval  would 
be  considerably  greater. 

Judging  from  a  cursory  examination,  or  from  attention  to  one's 
own  respiration,  the  act  of  expiration  appears  shorter  in  doration 
than  that  of  inspiration.  The  two  acts,  however,  as  determined  by 
the  chcHt-measurer  of  Sihson,  in  ordinary  respiration,  are  generally 
equal  in  duration.  When  a  difference  exists,  the  expiration  is  oftener 
prolonged.  This  is  apt  to  be  the  case  in  the  tranquil  breathing  of 
women  and  children.  It  characterizes  also  the  respiration  in  old 
age.  In  hurried  breathing,  in  females  especially,  the  expiratory 
act  becotnes  relatively  lengthened. 

Neither  the  inspiratory  nor  the  expiratory  act  is  performed  with 
a  uniform  degree  of  rapidity.  The  inspiration  is  at  first  alow,  be- 
comes gradually  quicker,  and  again  is  retarded  toward  its  close. 
The  expiratory  act  is  performed  more  quickly  at  first,  and  during 
the  latter  part  more  slowly  than  the  inspiratory.  These  facts  will 
in  a  measure  account  for  certain  differences  which  distinguish  the 
expiratory  from  the  inspiratory  sound,  as  determined  by  ausculta- 
tion in  health  and  disease. 

Deviations  from  the  natural  rhythm  of  the  respiratory  movements 

.  will  be  found  to  furnish  characteristics  of  some  forms  of  disease.    In 

cases  of  obstruction  seated  in  the  larynx,  or  other  parts  of  the  an:- 


r 
r 


TBI    TDOKACtC    PAniBTES. 

ibe  expiration  U  morbidly  prolonged.  In  emphjscm& 
invoWing  an  mbnormal  diUt&tion  of  the  air-colls,  and  diminiithed 
elasticity  of  the  lungs,  the  expiration  becomes  obviously  mucb  longer 
tb*n  the  iitHpiration.  On  the  otber  band,  a  ehortvned  and  qnickcood, 
or  spasmodic  inspiration,  is  a  significant  symptom  of  some  afTcction 
of  the  nervous  system,  occurring  in  some  caees  of  hysteria,  and  kIm 
nodcr  circumstances  in  nhicb  it  is  of  a  much  more  serious  import, 
denoting  a  morbid  condition  of  great  gravity  affecting  that  portion 
of  the  ncr^-ous  centre  (medulla  oblongata)  which  presides  over  the 
involuntary  acts  of  respiration.  The  writer  has  called  attention  to 
the  importance  of  this  change  in  the  rhythm  of  rcspiralion  in  cacM 
of  continued  fever,  as  often  foreshadowing  the  occurrence  of  coma.^ 
Finally,  the  sixc  of  the  chest  is  a  point  remaining  to  be  noticed. 
This  may  be  estimated  by  circular  measurement  with  a  graduated 
tape.  Persons  differ  considerably  in  this  regard.  The  lioiitM  of 
variation  in  99i  cases,  in  which  the  ciroumrcrenoe  was  aseertainvd 
Ity  Ilotcbinsou,  were  from  30  to  40|  inche».  WaUhc  fixes  the  arer- 
•ge  sixe  at  about  33  inches ;  but  lhi>  normal  deTiations  being  so 
great,  iti«of  lilllcpracitcxl  utility  to  determine  a  standard  by  talcing 
the  mean  of  a  series  of  examinations.  This  point,  clinically,  ia  not 
of  much  importance,  especially,  as  the  researches  of  Ilutcliinson 
show  that  the  breathing  capacity  of  tbo  lungs,  as  dependent  on  the 
movements  of  tbo  chest,  bears  no  constant  proportion  to  its  siao. 
Formerly  it  was  supposed  that  contracted  dimensions  of  the  chest 
denoted  a  predisposition  to  diseases  of  the  respiratory  appsratos, 
more  e«pecially  tuberculosis  of  the  lungs;  but  it  is  now  pretty  well 
ascertained  that  tittle  or  no  tendency  to  that,  or  other  forms  of  dis- 
ease, is  derived  from  thi«  source.  In  determining  variations  in  the 
sise  of  the  chest,  either  by  measurement,  or  by  the  eye,  with  refer- 
ence to  the  evidences  which  may  be  thereby  afforded  of  the  existence 
of  disease,  we  do  not  take  the  dimensions  of  the  entire  chest  as 
the  standard,  but  institute  a  comparison  of  one  side  with  the  other. 
This  being  the  case,  the  capacity  of  the  thorax  proper  to  the  indi- 
ridual  is  a  matter  of  minor  importance. 


*  Clinical  Boport*  on  Ci>ntina«l  Fcwr,  •(&,  IftSS. 


AHATOMT    ASD    PBV&IOLOei. 


n.    PULHOSAIT  OeGAKS. 


Tltc  lungs  «ro  th«  light  fi^n|;y  bodies  contained  within  the  cbest, 
in  which  are  effected  the  blcxHl- change*  conetitating  the  fonction  of 
h^mutosLH.  These  orgnnx  are  double,  eonsifiting  of  the  right  snd 
U/t  lung,  enchoccnpTing  a  lateral  half  of  the  thomz.  The  long 
on  each  nidc  is  provided  with  a  distinct  membranoas  eiiTelope — the 
plenru — whicli,  after  furnishing  a  corering  for  llie  pnlioonarj  snrface, 
is  reflected  upon  the  thoracic  wall,  and  forms  a  shut  sac,  presenting 
the  Hiimc  arrangement  as  the  serons  ntembranes  in  other  sitaatioiu. 
The  two  pleural  sacs  are  in  contact  at  the  median  line,  forming,  bjr 
their  juxtaposition,  the  mediaMinal  partition,  or  septnin,  dividing 
the  two  sides  of  the  chest.  Joined  direct];^  beneath  the  Btemnni, 
they  diverge  to  form  the  anterior  mediastinom  whieh  incloses  die 
remnant  of  the  thymus  gland ;  approximating,  and  becoming  united, 
they  again  separate,  forming  the  middle  mediastinum  which  contains 
the  fibrous  sac,  or  pericardium,  inclosing  the  heart ;  and  by  a  third 
septtration  is  formed  the  posterior  mediastinum,  throngh  whieh  paas 
the  dcflcending  aorta,  thoracic  duct,  etc  The  portion  of  this  mem- 
brane investing  the  lungs  is  called  the  pidm<»tie  or  riteeral  plenra; 
and  that  lining  the  vails  of  the  chest,  the  e^itfaJ  or  partial  pleara. 
A  third  portion,  forming  a  covering  for  the  floor  of  the  thoracic  cav- 
ity— the  diaphragm — is  called  the  diaphraffmatic  plenrs.  Between 
the  free  surfaces  of  the  two  former  portions  in  each  lateral  half  of 
the  chest  is  what  is  termed  the  carity  of  the  pleura — erroQeooaly  so 
called,  inasmuch  as  the  free  surfaces  being  in  contact,  there  does 
not  exist,  strictly  speaking,  a  cavity.  Between  these  enrfaees, 
within  the  shut  sac  of  the  pleura,  liquid  effusion  takes  place  in  pies- 
ritis,  and  hydrothorax,  accumulating,  in  some  cases,  to  the  amount 
of  several  pounds,  compressing  the  lung  into  a  small  solid  mass, 
and  producing  changes  in  the  external  conformation  of  the  chest 
which  have  been  already  noticed,  viz.,  enlarging  its  siae,  pushing 
outward  the  intercostal  spaces,  elevating  the  ribs  from  their  oblique 
towards  a  horizontal  direction,  widening  the  distance  between  them, 
and  compromising  more  or  less  the  mobility  of  the  affected  side. 

The  parietal  or  costal  portion  of  the  pleura  is  thicker  than  the 
visceral  or  pulmonary  portion,  or  the  portion  covering  the  diaphragm. 
Tli«  areolar  tissue  uniting  the  membrane  to  the  parts  which  it 
invests,  called  the  subserous  areolar  tissue,  is  more  abnndant  and 


PULVOKAKT  OSOAirS. 


?5 


I 


I 


looser  ID  the  former  eitaalioD,  and,  coowqaontlj,  the  ecrons  tnem- 
riine  is  more  easily  dctachc-il  from  the  wnlU  '>f  ihv  chest  than  from 
be  sarfmcc  of  the  lungs.  This,  probably,  cxplnins  a  fact  puruin- 
:ng  to  inflnmmation  of  the  pleura,  vis,,  the  inflamiDnlory  action 
IN  more  inlcnfle^  and  the  products  of  iiiRaminatioD  itrc  more  abundant, 
on  the  costal,  than  on  the  pulmonary  stirfncc. 

The  lung  on  either  side  varies  in  sizeiicvording  to  the  quantity  of 
air  which  it  contains,  and  of  coarse,  its  volume  >s  alternately  in- 
crcascil  and  diminished  vitb  the  succe^Kiro  acts  of  inspiration  and 
of  vxpiraiion.  Its  form  is  conoidul,  the  Uise  being  downward.  The 
iportion  id  contact  with  the  walls  of  the  chest  enlcnds  lower  than  the 
evntral  portion,  in  consequence  of  the  arched  or  vaulted  form  of  the 
floor  of  the  chest, — the  diaphragm,  Between  the  sides  of  the  arcfa 
or  vault  formed  by  the  diaphragm  and  the  thoracic  walla  is  a  space, 
ileeper  behind  than  in  front,  which  receives  tbc  inferior  shelving 
border  of  the  lungs.  Thus  at  the  loner  part  of  tlte  chest,  on  each 
'cide,  a  margin  of  lung  intervenes  between  the  diapbrugm  and  the 
walls  of  the  chest,  more  especially  in  the  act  of  expiration,  when 
the  convexity  of  the  diaphragm  is  greatest. 

Owing  to  the  fact  already  stated  that  the  vertical  diameter  of  the 
right  side  of  the  cheat  is  less  than  that  of  the  left,  the  right  lung  ia 
shorter  than  it«  fellow.  Transversely,  however,  the  diameter  of  the 
right  lung  exceeds  that  of  the  left.  This  accords  with  a  fact  already 
stated,  vis.,  that  the  semi>circumfercnee  of  the  right  side  usually 
exceeds  that  of  the  left  by  about  half  an  inch.  The  situation  of  the 
heart  is  such  that  a  portion  of  this  organ  encroaches  souewlint  on 
ib«  left  thoracic  cavity,  at  the  expense  of  the  lung  on  that  side.  An 
irregular  quadrangular  space  between  the  fourth  costal  cartilage  nod 
the  sixth  rib,  is  occupied  by  the  heart  uncovered  by  the  lung  and  in 
contact  with  the  clieaU  Vertically,  this  space  averages,  in  the  adult, 
on  the  median  line,  about  two  inches;  and  horizontally,  from  the 
eenlre  of  ihe  sternitm,  it  extends  from  two  and  a  half  to  three 
inches  to  the  left.  <>verlappe<l  by  the  lung,  the  beart  encroaches 
still  farther  on  the  thoracic  8])ac«,  vi&.,  vertically,  from  the  third  to 
the  sixth  costal  cartilages;  and,  transversely,  nearly  to  the  nipple. 
In  Gons«quencc  of  its  lesser  transverse  diameter,  together  with  the 
enBToachmeDt  of  the  heart,  the  left  lung  is  smaller  in  volume,  not- 
witbstanding,  measured  in  a  perpendicular  direction,  it  is  longer 
than  the  right  lung.     The  right  lung  exceeds  the  left  in  weight  by 


•6 


AXATOMT    AXD    PHTSIOLOdT. 


•boat  tiro  onncca.     The  »vcrtge  weigbt  of  both  lungs  U  »bont  fortj- 
two  ouDces. 

Wh«D  free  from  disease,  or  the  eSecu  of  disease,  the  lang  is  d»- 
Toid  of  wty  direct  connection  with  the  sarronniling  parts,  excepting 
where  it  is  connected  with  the  bronchi,  together  vith  the  bloodres- 
sels,  l^'mphalics,  and  oerrea  which  enter  it  to  commonicate,  seTcr- 
My,  with  fiorresponding  etructores  forming  portions  of  the  polmo- 
nary  organs.  United  b^  areolar  tiBSne,  indinding  lymphatic  glands, 
and  inclosed  in  a  sheath  formed  by  a  reflection  of  the  pleura,  the 
parts  jost  cnnmeraied  compose  what  ta  termed  the  r«ol  of  the  long. 
Sj  the  root,  thus  constitnied,  the  lung  on  each  side  is  as  it  were 
suspended  or  fixed  within  the  chest,  the  surface  of  the  remainder  of 
the  organ  being  entirely  free  in  health ;  but  the  pleural  surface  ia 
often  adherent  over  a  greater  or  less  space  in  consequence  of  morbid 
attachments.  In  its  situation,  the  root  of  the  lung  is  about  equidis- 
tant between  the  base  and  apex. 

The  upper  extremity  or  apex  of  the  lung  forms  a  blunted  point, 
extending  in  some  persons  only  to  the  upper  margin  of  the  clariole, 
but  ill  other  persons  to  a  height  from  half  an  inch  to  two  and  a  half 
inchcii  above  the  clavicle.  It  riites  higher  generally  on  one  aide  thnn 
on  the  other,  and  it  is  much  oftencr  higher  on  the  right  than  on  the 
left  eidc.  It  is  more  npt  to  extend  aborc  the  clavicle  in  males 
than  in  females.  These  facts  were  ascertained  by  careful  meitsure* 
DtDts  in  one  hundred  bodies,  after  death,  by  the  late  Dr.  C.  E. 
laaaes. 

The  division  of  the  lungs  into  Iohe»i»  a  point  of  considerable  im> 
portance  in  the  study  of  certain  pnlmonary  ilJucases.  It  If  uiade  by 
deep  fisHuics  exteii<ling  in  an  oblique  direction  from  above  downward. 
The  left  lung  prosents  a  single  Utisurc ;  the  right  has  one  fissure 
extending,  like  that  of  the  left  lung,  around  the  whole  oircuinferencc 
of  the  organ,  and  a  second  running  from  the  anterior  border  ashort 
distance  only  upward  and  backward.  l*hus  divided,  the  left  lung  is 
said  to  consist  of  two  lobes,  culled  the  upper  itnd  lower ;  and  the 
right  lung  of  three,  called  the  upper,  lower,  and  middle  lobes.  The 
middle  lobe  of  the  right  lung,  however,  is  hardly  entitled  to  be 
ranked  as  a  separate  lobe,  but  is  *'  an  angular  piece  separated  from 
ihc  anterior  and  lower  part  of  the  upper  lobe."  It  is  of  importance 
with  reference  to  the  diseases  which  are  to  be  subsequently  consid- 
ered, to  note  the  situation  of  the  Bssures  dividing  the  lungs  into 
lobce,  M  indioaled  by  corresponding  imaginary  lines  on  the  exterior 


PfLMONAST  OnaAKS. 


37 


^surface  of  ibe  chest.  Poateriorlv,  they  commence  about  three 
inches  belov  the  apex  of  the  lung.  Indicated  on  the  chest,  the  line 
corresponding  to  their  direction  takes  ita  departure  at  a  point  not 
far  from  the  vertebral  extremity  of  the  Bpinous  ridge  of  the  scapula. 

K  On  the  loft  aide  the  boundary  line  between  the  two  lobes  passes 
from  the  point  just  named  obliquely  downward  to  the  intercostal 
space  between  the  fifth  and  siith  ribs,  the  anterior  point  of  division 

■  falling  a  little  to  the  right  of  a  vertical  line  passing  through  the 
nipple.  On  the  right  side,  the  line  marking  the  upper  border  of  the 
lower  lobe  passes  obliquely  downward  to  the  space  between  the  fifth 
and  sixth  coatal  cartilages.  The  line  dividing  the  middle  and  the 
upper  lobe  passes  from  the  fourth  cartilage  in  a  direction  upward  and 
outward  for  a  distance  varying  considerably  in  diflferent  individuals. 
It  follows  from  these  statements  that  a  small  strip  only  of  the  lower 
lobe  on  each  side  is  contained  in  the  anterior  portion  of  the  chest, 
the  greater  portion  being  situated  posteriorly.  The  physical  Bigna, 
therefore,  of  morbid  changes  in  the  condition  of  the  lower  lobe  are 
presented  mainly  in  the  middle  and  lower  portions  of  the  chest  be- 
hind. It  is  very  necessary  to  bear  this  in  mind  in  examinntione 
with  reference  to  inflnromation  of  the  lung  (piieiiuiuoitis),  which,  as 

^■irill  be  seen  ben-after,  in  a  largi^  proportion  of  cuscs  it  limited  to 
the  lower  lohe.  luatlention  to  this  point  may  It-aJ  the  medical 
practitioner  to  overlook  that  disease,  hia  examination  bi-ing  limited 

fta  the  anterior  portion  of  the  chest  in  cases  in  which  the  evidences 
of  its  exidtcnc<'  are  sufficiently  apparent  pot<icr!()rly. 
The  interlobar  fi Situ ri-  booomes  chnnged  in  iu  direction  by  emphy- 
sema seated  in  the  upper  lobe,  tending  under  these  circumstancee 
to  a  vortical  line.  This  i»  measnrahly  Iruc  of  lobar  pneumonitis  in 
the  second  stage.  The  situation  of  the  flNsure  is  not  the  siimc,  in 
health,  in  inspiration  and  expiration  ;  it  moves  downward  with  the 
former  and  upward  with  the  latter  act. 

The  foregoing  arc  the  more  important  of  the  circumEtances  per- 
taining to  the  situation  pf  ibo  InngM,  nnd  the  relations  of  their 
aeversl  parts,  which  claim  notice  from  their  pathological  bearings. 
But  an  analysis  of  the  anatomical  structure  of  these  organs  will 
develop  numerous  points  which  arc  to  be  taken  into  account  in 
^■studying  their  diseases, 

In  addition  to  bloodvessets,  nerves,  and  Iympbati<il,  which  ar« 
common  to  most  of  the  important  organs  of  the  body,  the  lungs 
■are  composed  of  the  divisions  and  subdivisions  of  the  bronchi  or 


8o  ANATOMY    AMD    PHT8IOL0OT. 

bronctiial  tubes,  and  the  air-cells  or  vesicles.  These,  combined,  give 
to  the  lungs  their  distinctive  structural  characters.  The  bronchi, 
after  penetratiDg  the  lung,  divide  and  subdivide  in  all  directions, 
the  divisions  generally  being  of  the  kind  called  dickotomous,  i.  e. 
consisting  of  two  branches,  the  mode  of  division  most  favorable  for 
the  speedy  transmission  of  air.  As  the  branches  increase  in  number, 
they  diminish  in  size,  until  at  length  they  become  extremely  minute, 
and,  finally,  the  ultimate  ramifications,  the  capillary  bronchial  tubes, 
terminate  in  the  vesicles  or  cells.  The  structure  of  the  bronchial 
tubes,  which  are  found  to  present  in  different  situations  important 
anatomical  differences  in  addition  to  their  gradations  in  size,  and  of 
the  air-cells,  the  relations  of  the  latter  to  the  former,  etc.,  must  be 
understood  before  the  student  is  prepared  to  enter  on  the  study  of 
diseases  affecting  the  respiratory  apparatus. 

But  prior  to  directing  attention  to  points  pertaining  to  the  struc- 
ture of  these  constituents  of  the  lung,  the  pulmonaiy  lobules  should 
be  described.  What  are  ordinarily  called  the  lobules  of  the  lungs, 
are  small  portions  of  pulmonary  substance,  irregular  in  shape,  united 
together,  and  at  the  same  time,  isolated  by  means  of  intervening 
areolar  tissue.  The  latter  forms  what  is  termed  the  interlobular 
gepta. 

If  the  surface  of  the  lung  be  closely  examined,  it  is  found  to 
present  a  great  number  of  polygonal  figures,  indicated  by  dark 
lines.  These  lines,  most  marked  in  the  adult,  owe  their  dark  color 
to  pigmentary  matter  deposited  in  the  interlobular  areolar  tissue. 
,  The  figures  are  very  irregular  both  in  form  and  size.  As  regards 
the  latter,  they  vary  from  a  quarter  of  an  inch,  to  an  inch  in  diam- 
eter (Kolliker).  These  polygonal  divisions  are  found  to  contain  sub- 
divisions, which  are  the  pulmonary  lobules.  Different  lobules,  al- 
though in  juxtaposition,  have  not,  as  already  stated,  any  direct  com- 
munication with  each  other.  This  is  demonstrated  by  the  following 
experiment.  If  a  blowpipe  be  introduced  beneath  the  pleural  cov- 
ering of  the  lung,  and  the  subserous  areolar  tissue  inflated,  the  air 
is  forced  into  the  interlobular  partitions,  the  areolar  tissue  in  the 
two  situations  being  continuous.  The  lobules  are  thus  surrounded 
by  air,  and  rendered  more  conspicuous,  but  none  gains  admission 
into  the  cells  or  vesicles  entering  into  the  composition  of  the  lobules. 
By  careful  dissection  of  lungs  taken  from  a  young  subject,  and 
especially  from  the  fcetus,  the  different  lobules  may  be  separated 
from  each  other.     They  are  then  found  to  be  quite  distinct,  being 


rTFLUOKABY   ORQAKS.. 


8» 


I 


1 
1 


connected  only  tij  the  minute  kroncliial  ttibeH,  ealleil  the  loiular  ftron- 
chial  luhr»t  together  with  blood feAseU,  ni^rveii,  «nd  lymjihftlic.H.  The 
diflvrrnt  lobuleti  of  a  lobe,  thus  separated,  but  attached  to  the 
bnwches  of  the  bronehtnl  tree,  are  likened  b^  Cruveilhier  to  grapes 
attached  to  their  fooititalka  and  hanging  from  a  common  stem.  Each 
lobidc  repr«6ents,  in  fact,  a  lung  in  miniature,  the  Hcvernl  lobes 
being  made  up  of  an  a^^jiregation  of  these  diminutive  lungs.  Con- 
sidered individually,  each  lobule  is  composed  of  the  minute  terminal 
branches  of  the  lobular  bronchial  lube — cullrd  the  hrvnchioiea,  or  the 
capillary  bronchial  tubes — the  air-cell^,  tin;  vcsmjIs,  and  nerrw, 
these  Mvcral  anatomical  consiitueuta  being  tuppurtcil  and  united  by 
arc<ilar  tissue. 

Collapse  of  lobules,  in  greater  or  less  nunibei-,  occurs  as  a  conse- 
(|nciiG4)  of  obntrnction  of  bronchial  tubes,  of  a  nature  permitting 
the  egress  of  air  from  the  cell"  with  expiration,  and  preventing  its 
ingress  with  initpirattvn.  This  takes  place  in  the  dittease  peculiar 
to  children  heretofore  incorrectly  called  hlndar  jmeumonttii.  Owing 
to  fceblencM,  or  other  cnuKc«,  in  newly  horn  childreD  certain  lobttU-a 
iDuy  not  undergo  expnnMon,  retitiniiig  thrtr  fcetal,  co1lapse<i  stntu. 
Tills  has  received  the  tiaine  of  ateUetatu,  or  imperfect  expansion 
of  the  luD^s.  The  embarrasHment  of  respiration  occurring  at  or 
soon  after  birth,  which  may  proceed  to  a  fatal  i«sue,  is  not  infre- 
qnentljT  due  to  this  condition. 

In  this  connection  it  may  be  remarked  thnt  the  pulmonary  lobules 
are  not  ettually  permeable  to  air.  Those  mo»t  pcrmenble  are  situ- 
ated at  the  apex  of  the  lung.  Thisdiflcrcnce  is  due  to  the  distriba- 
tion  of  the  larger  bronchial  tubes.  Aoconllng  to  Crnvcilhier,  "s 
moderate  inflation  of  iho  lungs,  made  as  much  as  possible  withit) 
the  limits  of  an  ordinnry  respiration,  docs  not  perhaps  dilate  one-third 
of  the  pulmonary  lobules."  Thus,  "there  arc  some  lobules  which 
are  kept  in  reserve,  as  it  were,  and  only  act  in  forced  inspiration.'* 
These  interesting  points  will  be  found  to  be  involved  !u  the  phc- 
Domcna  of  disease. 

The  areolar  tissue  forming  the  interlobular  septa  is  the  se«t  of 
the  rare  form  of  emphysema  of  the  lungs  called  interlobular  emphy- 
sema, in  wliich  air  obtains  access,  by  rupture,  between  the  lobules, 
widening  the  intervening  spaces,  and  causing  a  projection  of  the 
»cpta  abore  the  pulmonary  surface.  A  collection  of  air  is  also 
occasionaliy  found  after  death,  limited  to  a  circumscribed  space, 
within  the  urcohir  tissue  connecting  the  pulmonic  pleura  to 'the 


40 


AKATOMT   AHO    rBTSIOLOOT. 


Btirfat*  of  the  long,  Hcvattng  tbe  mftnlirwip  in  tbp  form  of  a  bleb. 
Tin*  form  of  croplij»«ma,  however,  which  vxi^tv  io  Ihc  vn»t  majority 
of  caws,  coRMAtR  in  ealar^roent  of  the  air>Mll)i,  or  Tc»icles,  either 
bj  ooalescenne  or  dilalaUon,  or  both. 

It  reiDkins  to  notice  cortaio  points  p«rtaining  to  the  rtmcttire, 
Arrangement,  and  mntufll  relations  of  (he  bronchial  tabes,  and  air- 
celln. 

Tlio  goncrni  coamc  and  diatribntion  of  the  bronchial  tobea  in  tbe 
several  lobes  have  been  already  des«ribe<I.  The  branches,  aacc«ft- 
sivt'ly,  end  in  double  diviitions,  and  with  multiplication  in  number 
tliere  i*  a  corresponding  diminution  in  tixe,  down  to  the  minute 
lobular  bronchial  tube*,  which,  after  penetrating  the  lobulca,  sab- 
diride  into  the  terminal  hraocheR,  the  bronchioles,  or  capillarj 
bronchial  tabes,  calle<l  by  Rainey  the  intercellular  passages.  In 
referring  to  differeni  wrts  of  the  bronchial  tuhea  as  the  seat  of  di»- 
eaiie,  or  of  physical  sigiH,  it  is  customary  to  conoidcr  them  aa 
embraced  in  three  clashes,  viz.,  the  larger,  the  smaller,  and  the 
capillary  tubes.  In  designating  the  site  of  morbid  appearances  after 
death  it  is  sometimes  convenient  to  indicate  the  divisions  m  tbooe 
of  the  first,  second,  third,  and  fourth  diameters:  that  is,  tlie  series 
of  double  brnochcs  are  tbns  enumerated  in  the  order  in  which  tbey 
■re  given  off.  These  arc  tlie  larger  bronchial  tubes,  the  smaller 
being  the  subsequent  series,  inclusive  of  those  passing  to  the  tobales. 

The  Ittrger  bronchial  tubes  arc  composed  of  a  fibrous  membrane, 
containing  irregularly  shaped  cartilaginous  plates,  the  latter  taking 
the  place  of  the  ineomplcte  rings  of  cartilngc  which  characterize 
the  air-tnbos  exterior  to  the  lung.  These  cartilaginous  plates  are 
situated  especially  at  the  bronchial  divisions.  They  embrace,  also, 
a  layer  of  circular  muacular  fibres,  of  the  kind  ealled  smooth  or 
unstriped.  belonging  to  the  muscular  system  of  organic,  as  distio- 
giiishod  from  animal  life.  This  anatomical  element  is  the  seat  of 
the  afTeelioD  known  as  asthma,  and  is  somelimrs  involved  in  certain 
symptoms  incidental  to  intlaminntion  and  irritation  of  th«  bronchial 
tubes. 

They  are  lined  by  mucous  membrane,  covered  with  a  layer  of 
ciliated,  cylindrienl,  or  columnar  epithelium,  the  object  of  the  latter 
being  to  propel,  and  thus  assist  in  the  removal,  by  expectoration,  of 
the  secretions  furnished  by  the  mucous  follicles  in  health  and  disease, 
as  well  as  various  morbid  products  formed  within  or  poured  into  the 


tt    ORGAHS. 


41 


I 


I 


tubes,  and  perhaps  to  aid  in  the  tidal  currents  of  sir.     This  mom- 
hrane  in  the  sent  of  inBaiDination  in  ordinnrj  bronchitis. 

The  emaller  bronchial  tohcn  present  marked  changes.  Tlie  fibrone 
membrane,  forming  iheir  basis,  becomes  thinner  a*  the  tabe«  diminish 
in  size:  the  cartilnginous  plates  are  less  numerous;  the  mucous 
membrane  is  more  and  more  attenuated,  and,  at  length,  when  the 
calibre  of  the  lubes  is  reduced  to  about  one-fiftieth  of  an  inch,  th« 
cartilaginous  plates  hare  disappeared,  and  the  mucons  and  fibrous 
lajers  appear  to  have  coalesced,  forming  a  single  thin  mcmbrajio. 
Tbo  inner  surface,  hovever,  still  presents  ciliated  epithelium. 

Finally,  within  the  lobules,  (he  ultimate  bronebiiil  tube*  term!- 
Italing  in  the  air-cells,  as  respects  siie,  are  truly  capillary,  having 
»  diameter  varying  from  ^i^lh  to  ^'jtli  of  an  inch.  These  capillary 
tabes  present  stiil  more  important  changes  in  struoture.  The  mem- 
brane constituting  their  walls  is  exceedingly  thin,  and  its  inner 
surface  does  not  present  epithelium,  cylindrical,  nnd  ciliated,  but  it 
is  that  variety  called  squamous,  tessellated,  or  pavement  epithelium. 
The  mucous  follicles  disappear.  These  tubes,  in  fact,  lose  the  char- 
acter! vrhtch  belong  to  the  bronchi  elsewhere,  and  bmuiuc  the  struc- 
ture of  the  air-cells,  with  which  they  sre  immediately  connected. 

The  anatomical  changes  which  thus  characterixe  different  divisions 
of  the  bronchial  tubes,  are  in  accordance  with  certain  striking  facts 
pertaining  to  diseases  of  the  respiratory  apparatus.  A  principle  of 
conservatism  is  often  evidenced  in'  the  history  of  diseases  by  their 
reluctance,  so  to  speak,  to  pass  from  one  part  to  another  part  con- 
tinnons,  or  contiguous,  but  presenting  differences  of  structure.  The 
latter  appear  to  constitute  the  restraining  barrier.  This  principle 
is  exemplified  in  the  fact  that  ordinary  bronchitis  is  limited  to  the 
larger  bronchial  tubes,  rarely  extending  to  the  smaller,  to  constilnte 
what  is  incorrectly  styled  eapillary  bronehilh.  The  latter  variety 
of  the  disease,  as  will  be  seen  hereafter,  is  vastly  more  severe  and 
dangerous. 

Conversely,  an  inflammation  seated  in  the  air-cells  and  capillary 
tubes  (pneumonitis),  is  usually  limited  to  these  parts,  not  extending 
to  the  branches  of  the  hronchi,  which,  although  in  direct  commoni- 
eation,  are  protected  by  differences  in  structure. 

The  air-cells,  or  vesicles,  are  the  minute  cavities  in  which  the 
bronchial  tut>cs  are  said  to  terminate.  Their  diameter  rarieM  from 
liilh  to  I'jth  of  an  inch.    After  birth  they  are  ncter  free  from  air, 


42 


AKATOHT    AKD    PHTStOLOOT. 


snd  tlieir  fiixo  will  Jcpcnd  on  their  degree  of  dieUnsion,  tbie  being, 
of  course,  comtiderably  greater  at  the  end  of  inspiration  than  of  ex- 
piration. Tkcjr  arc  attaclicd  to  tlie  extremities,  and  also  along  the 
■idea  of  lk«  terminal  branches  of  broDcbioles,  or  capillar^  bronchial 
tubes,  with  which  thej  commuDicatc  bj  free  opening.  Microacopi- 
cal  obserrcrs  have  differed  as  to  ibc  existence  of  direct  lateral  com- 
municatioiiH  between  the  cells.  According  to  the  beat  aalhoriliea, 
tbejf  do  not  communicate  with  each  other,  except  indirectly,  through 
the  hronchioleti,  or  capillar;  bronchial  tubes.  Their  eonnection, 
however,  with  the  latter  is  such  that,  although  not  direct,  the  coin- 
luunication  is  free. 

A  single  bronchiole  or  tenninul  branch  with  it4  attached  celts  may 
be  considered  to  form  a  common  space,  subdivided -into  numerous 
ee«tion8  or  alveoli.  The  air-cells  arc  larger  toward  the  surface  of 
the  lung,  and  also  toward  the  edges,  than  in  the  interior.  Their 
sise  increases  with  age,  and  they  are  smaller  in  females  than  in 
males.  Their  walls  possess  much  strength,  as  shown  b;  their  not 
being  easily  ruptured  by  artificial  inBation. 

The  air-cells  are  surrounded  by  yellow  elastic  fibres,  which  give 
to  the  lungs  a  considerable  degree  of  elasticity.  This  is  shown  by 
the  fact  that  they  collapse,  in  a  marked  degree,  when  the  cavity  of 
the  clicst  is  opened. 

It  is  within  the  cells  lliat  the  atmospheric  air  received  by  inspira- 
tion exerts  its  effects  on  the  blood.  The  pulmonary  artery  entering 
the  lobes  in  company  with  the  bronchi,  divides  and  sttbdivides,  with- 
out anaAiomosing,  its  brsncht-s  accompanying  the  air-tubes,  until  it 
finds  in  a  very  fine  capillary  network  ramifying  on  the  walla  of  the 
celts.  Here,  also,  commence  the  various  radicles  and  branches, 
which,  pursuing  a  retrograde  course,  like  that  of  the  arteries,  col- 
lect the  oxygenated  blood  and  convey  it  lo  the  left  auricle.  The 
blood  within  the  ciipillary  lucsbea  surrounding  the  cells  is  brought 
into  sufficient  proximity  to  tbe  air  contained  in  the  latter,  for  that 
interchange  of  gase«  to  take  place,  by  endosmosis  and  exoemosis, 
wbioh  is  concemeil  in  lixinatosiif. 

The  air-cells  and  cnpillary  tubes,  together  with  tbe  bloodvessels, 
nerves,  and  lymph aticM,  united  by  areolar  tiKsuc,  constitute  tbe  pul- 
monary parenchyma,  or  the  substance  of  the  lungs.  The  cells  and 
capillary  tubes  arc  the  parts  affected  by  inflammation  in  pneumoni- 
tis. Abnormal  distension  of  tbe  celU  and  capillary  tubes,  wiili  or 
without  atrophy  and  consequent  destruction  of  more  or  lets  of  the 


lOKABT   OBOAMS. 


48 


I 

I 

I 


cell-walls,  giving  rise  to  coaIe«cencc,  constitutes  tie  Ictioo  in  pul- 
monary or  vesicular  cmpby«cnia. 

It  will  be  wen  that  eome  of  the  most  important  of  the  physical 
mgat  of  diseases  vithin  the  chest  have  relation  to  anatomical  points 
which  the  foregoing  description  has  embraced. 

With  the  enlargement  of  the  chest  in  inspiration  the  lungs  are 
dilated  by  the  pressure  of  the  atmosphere  filling  (be  bronchial  tubes 
and  air-cells.  The  movements  of  the  diaphragm  and  walls  of  the 
chest  in  opposite  directions  in  inspimtion  and  expiration,  cause  a 
rnhbing  together  of  the  pulmonic  and  costal  pleural  surfaces.  This 
takes  place  especially  at  the  inferior  portion  of  the  chest.  As  a 
provbion  against  any  injurious  effects  of  the  friction  incident  to 
thoM  movements,  which  involve  a  considerable  degree  of  force,  the 
free  surfaces  of  the  pleura  arc  rcmnrkably  smooth,  polished,  and 
kept  moist  by  thv  presence  of  n  small  quantity  of  liquid.  Hence 
the  two  portions  of  the  mcuihranc  glide  over  each  other  with  the 
two  ncli*  of  inspimtion,  not  only  without  injury,  but  noiselessly. 
But  it  is  otherwise  in  somo  esses  in  whicli  thc«e  surfaces  are  rrn- 
dcrcd  rough  or  irregular  by  morbid  products.  The  rubbing  move- 
ments arc,  under  these  circumstances,  accompanied  by  friction 
sounds  which  become  the  signs  of  disease.  These  sounds,  as  might 
b«  expectetl,  are  moat  likely  lo  be  produced  where  the  movements  of 
th«  thorax  and  the  gliding  of  the  pleural  surfaces  are  greatest,  viz., 
at  the  lower  portion  of  the  chest-. 

The  movements  upon  each  other  of  the  pleural  ourfaceH  are  limited 
by  morbid  adhesions,  more  or  less  extensive,  of  these  surfaces,  which 
are  found  to  exiot  in  the  larger  proportion  of  bodies  examined  after 
death;  and  in  cerliiin  cases,  in  which  the  costal  and  pulmonic  por* 
tiooBof  the  pleura  are  universally  adherent  in  conBe<)uence  of  gene- 
ral pleuritiy,  they  must,  ofouui-ite,  be  entirely  arrested.  The  tatter 
eondiliou  it  might  be  presumed  would  interfere  with  the  expansion 
of  the  cheot.  Observations,  however,  show  that  this  is  not  the  fact. 
Mr.  Hutchinson  has  given  an  account  of  a  case  in  which  there  was 
not  a  square  inch  of  the  pleural  surfaces,  on  one  side  of  the  chest, 
thai  wa#  not  firmly  united;  nevertheless  in  lhi»  case  the  expunsioa 
of  the  chest  was  in  no  degree  diminished. 

The  r|uanli[T  of  air  contained  within  the  lungs  not  only  varies 
itly  in  different  persons,  but  in  the  same  person  it  is  constantly 
fluctuating  within  certain  limits.  It  is  difliculi  to  determine  tbe«e 
limits  with  exactitude,  hut  in  it.''  pathological  bearings  this  is  not  m 


44 


AVATOHT    IXD    PBYStOLOdT. 


of  importonee.  The  qa&nlitj  sFtcr  an  tDrpiration  is  of 
f  gmter  lltaa  tl»t  sficr  an  expiration,  jtut  in  proportioD  M 
tbe  aapEtvde  of  the  chest  U  increased  by  the  former.  »iid  diininisli«l  ■ 
bj  th«  Utter  or  tbew  acta.  Owing  to  the  control  which  the  will  caa 
eiert  0T«r  the  breathing  rooTements,  tnnch  will  depend  on  tb«  in* 
lacaee  of  Tolitioii.  Uuichinson,  in  a  paper  to  which  rererence  fau 
aintiy  bMn  made  more  than  once,  has  gireo  the  reantls  of  a  brge 
BiMber  of  experimenta  to  determine  the  quantity  of  air  expeUnl 
fran  tie  Itingi  bj  ft  forcible  act  of  expiration  succeeding  the  fullest^ 
poMible  in*piratioa.  This  be  considers  a  test  of  what  he  terms  tbe 
ntof  eapaeity  of  the  lungs.  Bt  mc^ns  of  an  inslrunient  called  the 
apir&matT,  the  qaantit  v  of  air  which  a  person  is  able  to  receire  ints 
Ukd  expel  from  the  longs  ia  ascertained.  The  resnlts  of  these  ex- 
periments it  is  evident  do  not  enable  ns  to  detertnine  the  qoantity 
of  air  received  ami  expelled  in  habitnal  respiration,  in  other  words, 
the  ordinary  brtalhing  capacity  of  the  longs.  Nor  do  they  assist  I 
na  in  det^nniiiing  the  absolute  quantity  of  air  which  the  lungs  are 
capable  of  containing,  since  a  r«Hidual  quantity,  varying  in  different 
tndividnaU,  remainii  after  the  most  forcible  act  of  expiration.  Never- 
theleas  the  results  obtained  by  Hutchinson  are  interesting.  The 
vital  capacity,  in  the  sense  in  which  this  exprcMion  is  used,  is  % 
eouKUnt  qiinnlity  in  each  individual;  that  i»,  each  person  poeseaaes 
the  ability  to  expel  n  certain  nnmbcr  of  cubic  inches  of  air  from  the 
lungs,  anil,  assuming  that  ho  remains  free  from  disease,  each  person, 
under  circumstances  equally  favorable,  will  be  found  to  lie  able  to 
expel  at  ditrerent  trials  about  the  same  quantity.  From  a  very 
large  number  of  observations  made  on  pcr«ons  of  different  occupa- 
tions, supposed  to  he  in  good  hcnltb,  Hutchinson  nscertninc^l  that 
the  quantity  of  expire*)  air  does  not  depend  on  the  sixe  of  the  chest, 
but  suNiainn  a  fixnl  n-laiion  to  the  height  of  the  individual.  The 
law  of  this  r»-li»liou,  deduced  from  an  immense  number  of  oiisc*,  is  the 
following:  "For  every  inch  of  height  (from  5  ft.  to  6  ft.)  eight  ad- 
ditional cubic  inches  of  air  al  60°  arc  given  out  by  a  forced  e.^pira- 
tion."  The  reason  for  this  relation  to  height  he  confesseji  hia  in- 
ability  to  give.  The  faet,  of  course,  involves  the  existence  of  some 
circuiQslances  pertaining  to  the  conformalion  or  movements  of  the 
chest,  which  enable  individuals  in  proportion  to  their  height  to  in- 
crease and  diminish,  with  the  alternate  rc«piralory  acts,  the  ampli- 
tude of  the  chest.  In  other  wor<U,  the  vital  capacity  is  another 
name  for  the  breathing  capacity,  dependent  on  the  extent  to  which 


PtrTMONART   OKOi 


46 


I 


I 


tlie  chest  may  1>e  expanded  with  the  act  of  inspiration,  and  con- 
traded  wiih  the  act  of  expiration.  Hodgkin  attributes  it  to  the 
"increased  length  of  the  dor&al  portion  of  the  spinal  column. "  Sib- 
aon  offers  as  an  additional  reason  the  greater  length  and  oblii]uitj' 
of  the  ribs  in  proportion  to  the  stature,  a  fact  which  gives  to  a  nar- 
row-cheated  tall  man  a  greater  range  of  motion,  and  cons.-quent 
breathing  capaoitj,  than  belong  to  a  short  man  with  a  chest  of 
greater  depth.  These  explanations  seem  probable.  A  relation  less 
constant  was  also  found  to  exist  between  the  vital  capacitj  and  the 
weight  of  individuals. 

Hutchinson  supposes  that  the  croployroent  of  the  spirometer  may 
be  made  serviceable  in  determining  the  existence  of  thoracic  disease. 
If  the  vital  capacitjr,  taken  in  connection  with  the  height  and  weight 
of  an  individual,  he  considerably  below  the  average,  some  morbid 
condition  compromising  the  pulmonary  organs  maj  be  suspected. 
But  the  evidence  is  only  presumptive,  for  the  vital  capacity  may  be 
reduced  by  various  causes  compromising  the  muscular  power  with 
which  the  respirations  are  carried  on,  irrespective  of  thoracic  dis- 
ease. This  must  be  the  case  if  even  slight  fatigue  of  the  respiratory 
muscles  will  aSect  the  result,  and  it  \»  elated  by  Mr.  II.  that  "if 
more  thnn  throe  observations  are  consecutively  made  at  one  time, 
the  number  of  cubic  Inches  of  air  will,  from  fatigue  generally  be 
fonnd  to  dccrcaM."  The  fact  is  nhown  by  some  observations  made 
with  reference  to  this  point,  niid  reported  by  the  late  Dr.  William 
Pepper  in  a  communicatioD  cunlained  in  the  American  Journal  of 
Medical  Sciences,  April,  1853. 

The  consiileration  just  stated,  together  with  the  fact,  that  the 
variations  in  dilfcrcnl  pcrsone  within  healthy'  limits  is  very  great, 
and  *l»o  the  fact,  that  even  when  presumptive  evidence  of  thoracic 
dwe«M  is  alTorded,  the  spirometer  gives  no  information  refipecting 
the  nature  or  K-at  of  the  afTcctiou,  will  prevent  this  from  becoming 
an  imporluHt  means  of  CJcnmiDation  with  reference  to  diseases  of  the 
respiratory  apparatus. 

>  T«  lUiulnle  the  wide  latorvtl  b«twMn  extremot  In  hmilthf  p«ri)on»,  la  a 
Mrie*  of  cwwa  reported  by  Dr.  Wm.  Popper  (Am.  Jour,  of  Mini.  Soimec*,  April. 
18(3),  tn  on«  yonon  6  It  In  hH^'lit,  Ibo  vlul  cnpncit;  wai  ISl  cubic  inchc*,  and 
in  another  p«non  6  (l.  lOJ  incbci.  it  nmuunlwl  tu  lU'.ti  cubic  loehw. 


46 


PHTBIOLOOT. 


III.  Thacbba,  Bbonoui,  *vt>  Labtxx. 

The  traclira,  bronchi,  niii]  Inrjnx,  are  separate  portions  of  the 
catikl,  or  ta1>c  lcii<)ing  from  the  phnrytix  to  the  luDgs,  trarerticil  kjr 
the  uir  in  its  piLSMogv  to  snd  from  ihc-  Intter  organs.  The  larynx 
in  addition  contains  the  organs  which  chiefly  compose  the  vocal 
appuratus.     The  three  divlaions  require  separate  oonaideralion. 


TraCHba.— This  portion  of  the  tube  extends  from  opposite  tlie 
fifth  cervical  to  the  fifth  or  sixth  dornnl  vertebra.  It  pun>ue«  n 
vorticnl  direction  from  the  larjnx  to  the  point  last  mentioned,  where 
it  ends  hj  dividing  to  form  the  two  primary  bronchi.  It  is  slightly 
deflected  to  the  right  nt  its  lower  cxtrcraity.  It  is  from  four  to  five 
inches  in  tcngih,  varying  witli  the  movements  of  the  head  and  neck ; 
■nd  its  dianieier  is  from  three-fourths  of  on  inch  to  an  inch  in  tho 
adult  male,  being  somewhat  smaller  in  the  female. 

The  ealibre  is  generally  enlarged  nt  its  lower  extremity,  where  it 
bifurcates.  It  is  composed  of  from  fifteen  to  twenty  cartiluginom) 
rings,  with  membranous  inlerspnces.  The  rings,  however,  are  not 
complete,  forming  only  about  four-fifths  of  a  circle.  The  deficiont 
portion  of  each  ring  is  situated  postcttorly,  and  the  connecting  sub- 
stance is  membranous.  The  posterior  one-fifth  or  membranous  part 
of  the  tube  is  flattened. 

The  anatomical  constituents  of  the  trachea  in  addition  to  the 
cartilages  are:  1st,  a  membrane  of  white  inelusltc  fibres,  containing 
also  longitudinal  yellow  elastic  (ibres,  most  abundant  posteriorly,  by 
means  of  which  the  tube  resumes  it;i  normal  dimensions  after  having 
been  stretched  or  conipre»sed;  2d,  fibres  constituting  the  trachealis 
muscle,  which  enter  into  the  composition  of  the  posterior  flattened 
portion,  extending  from  one  extremity  of  the  incomplete  cartilagi- 
nous rings  to  the  other,  and  attached,  also,  to  the  membranous  in* 
terspaces  between  the  rinj^s.  By  the  contraction  of  these  musoular ' 
fibres  the  walls  of  the  trachea  may  be  remlered  tense,  and  itaj 
ealibre  diminished;  3ii,  areolar  tissue,  forming  here,  ns  elsewhere," 
the  medium  of  the  union  of  the  different  structures;  -lib,  mucous 
membrane,  provided  with  colnmnar,  ciliated  epithelium  and  glnmlular 
follicles,  the  latter  being  most  numerous  on  the  posterior  surface,  a 
fact  which  perhaps  explains  the  greater  liability  of  the  membrane 
to  become  ulcerated  in  this  situatioo. 


TBAOHBA — BROirORr. 


47 


Sarrounding  llic  trnehna,  eapccially  the  itioracic  portion,  are 
lymphatic  vcs!c1h  iind  iiiiiiktquh  lymphatic  glaiidx.  The  latter  are 
liable  to  become  fn1nrj;H  by  diiirasc,  and  compress  the  air-tube  so 
as  to  mmlify  the  Hoiinds  produced  hy  the  current  of  air  to  and  fro 
vith  the  two  acts  of  rcKpirallon,  and,  in  some  ineilances,  give  rise 
to  obstruction  sufRcicni  to  occasion  results  more  or  less  serious. 

The  anatomical  construction  of  the  trachea  is  sncli  that  it  conforms 
rcndiiy  to  the  varied  movements  of  the  head  and  neck,  preserving 
ID  all  positions  a  free  channel  through  which  the  lungs  receive  the 
constant  supply  of  atmospheric  air  necessary  to  the  continaance  of 
life. 

The  iracliciL  in  rtirely  nttaclted  by  disease  independently  of  other 
parts  of  the  rRtpirntory  appartilus.  The  raucous  membrane  in  ibis 
situation  is  the  scat  of  ulcerations  in  a  certain  proportion  of  cases 
of  tuberculosis  of  the  lungs,  and  in  typhoid  fever;  it  is  involved  in 
inflammation  proceeding  frmn  the  larynx  downward  to  the  bronchial 
lubes;  and  in  that  peculiar  form  of  inflammation  characteriiing  the 
infantile  disease  called  diphtheritic  laryngitis  or  true  croup,  the  ex- 
udation of  lymph  often  extends  below  the  larynx,  sometimes  descend- 
ing to  more  or  less  of  the  bronchial  eubdiviflions. 


^ 


Bbokcui  Exterior  to  thb  Lckos. — Certain  nnatomtcul  points 
pertaining  to  the  xizc  and  disponition  of  the  bronchi  exterior  to  the 
tongs  poHHCHS  coTisidorabltt  iniportuncc  in  their  supposed  relations 
to  diSeretices  between  the  two  «tdos  of  the  chest,  ns  regards  the  res-, 
ptrstory  sounds  heard  iu  health  and  disease,  to  which  reference  will 
be  made  hereafter. 

The  lower  part  of  the  traehea  is  eontained  within  the  ohcst,  passing 
behind  the  upper  bone  of  the  sternum,  until  it  reaches  the  fifth  or 
sixth  dorRnl  vertebra,  when  it  bifurcates,  forming  the  right  and  left 
bronchus.  The  right  bronchus  diverges  froui  the  trachea  in  a  direc- 
tion nearly  horizontal,  forming  with  the  hitter  alinost  a  right  angle. 
lis  dinmctcr  is  about  half  an  inch.  It  is  about  an  inch  in  length. 
lis  form  and  anatomical  construction  is  like  that  of  the  trachea, 
being  composed  of  from  six  to  eight  incomplete  cartilaginous  rings, 
the  posterior  portion  being  membranous  and  flattened.  Before  pene- 
trating llic  lung,  which  it  does  at  a  point  equidistant  between  the 
apex  and  the  base  of  the  organ,  it  divides  into  two  branches.  The 
first  or  upper  division  is  tlic  smaller,  and  is  connected  with  the  upper 
lobe  of  the  lung.   The  second,  or  lower  branch,  after  passing  an  inch 


48 


AKATOJIY    ASD    PHT8IOL00V. 


downw&ri],  sabdividcs  into  tiro  iincquul  tmnohos,  ibe  $mM  one  going 
lo  the  middle,  and  the  larger  to  the  lower  lube. 

The  left  bronchus  ie  c(mt)i<lcnihly  eiDitllcr  tbui  th«  right,  the 
dinmcter  being  about  ihrcv-nighths  of  an  inch.  Its  length  U  Kbnut 
two  )Rchi<H,  being  twice  as  long  m  the  right  hronobu*.  Its  tlirection 
it  oblit|iielj  downwiird,  formiEig  with  the  trncliea  *n  obtUM  angle. 
It  ia  ronnod  precisely  like  tlic  right  bronchus,  embracing  from  nine 
to  twelve  incomplete  cartilaginous  rings.  It  subdivides  to  enter  th*] 
lung  on  a  lerel  vrilli  the  Gfth  dorsal  vertebra,  nbout  an  inch  lowe 
than  the  point  where  the  lubclivisions  of  the  right  bronchus  tolci 
place.  The  number  of  branches  is  two,  one  for  each  lobe,  Uie  lower, ' 
being  iiomewhat  longer  thitn  tho  upper.  In  site  or  calibre  the  two 
bronchi  united  exceed  the  traohes,  as  the  aggregate  of  tho  bronchial 
rami li cations  vriiliin  the  lungM  \»  greater,  in  this  rcttpect,  than  ihiit  of 
the  bronchi ;  "so  that  tho  volocitjr  of  the  expired  air  iucrcwoB  as  U 
approachoB  the  exterior.'" 

The  bronchial  dirisioiu,  like  the  tmehea,  are  surrounded  by  nnmer- 
oiu  lymphiitJc  glands,  called  the  bronchial  glands,  and  this  is  the  case 
also  with  the  bronchia]  ratniScutions  within  the  lungs  themselves. 
These  glands  enlarged  in  coacb  of  bronchitis,  typhoid  fever,  scrofula 
and  tuberculosis,  may  cause  contraction  of  the  bronchial  tubes,  so  Mj 
to  occasion  oert&in  acountio  phenomena  by  modifying  the  sooerou 
vibrations  incident  to  tlie  current  of  air  during  tlie  respiratory  act 
and  may  occasion  obstruction,  partial  or  complete,  to  the  transmis- ' 
sioii  of  air  to  the  bronchial  subdivisions  and  air-cells. 

The  bronchi  exterior  to  the  lungs  are  the  scat  of  inflammation  in 
ordinary  bronchitis,  the  inQam niHlifm   frequently  afTecting,  at  tbc 
same  time,  the  air.passages,  either  above  or  below.     Foreign  bodiefl 
introduced  through  the  larynx  frequently  become  lodged  in  thi* 
situation,  giving  rise  to  more  or  les.i  obstruction,  and,  if  not  expelled 
by  acts  of  coughing,  or  removed  by  surgical  moans,  not  infrequently^ 
causing  death  by  suSbcation,  or  from  tbc  eflccta  of  protracted  irri- 
tation.    The  statistical  rcaearclics  of  Prof.  Gross  show  that  forcigi 
bodies  become  lodged  much  oftencr  in  tho  right  than  in  the  left' 
bronchus.     This  may  be  attributable,  in  part,  to  its  larger  siie,  but, 
in  the  opinion  of  Prof,  tiross,  it  is  mostly  due,  as  was  first  suggcstc 
by  Goodall,  of  Dublin,  to  the  presence  of  a  spur,  or  ridge,  wltiob^ 
Frof.  G.  calls  the  bronchial  Beptum,  projecting  upward  within  the 


*  CrvTclUilsr. 


LABTNX. 


48 


tnchea  at  the  point  of  ita  bifurcation.  The  septum  is  situated, 
not  io  llio  niesinl  piftiie,  but  to  the  left  of  it,  and  therefore  serves  to 
direct  Boy  substuDcc,  espvciully  if  of  cousidorable  flUe,  into  tli«  right 
bronchiu.* 


^ 

^ 


Labtkx. — The  larynx  is  much  more  complex  in  its  anatomical 
construction  than  the  other  divisions  of  the  air-paessgex  irbich  hnre 
been  already  described.  This  is  owing  to  tbe  fact  that,  lu  adilition 
to  conducting  air  to  the  lungs  for  respiration,  it  contains  an  appnra- 
tosfor  the  production  of  tbe  voice.  To  describe  the  several  parts 
entering  into  ita  composition,  and  their  respective  offices,  would  in- 
Toive  details  needless  so  fur  ua  concerns  the  general  object  of  this 
introduction.  For  these  tbe  reader  is  referred  to  treatises  on  anat- 
omy and  physiology.  Certain  anatomical  and  physiological  points 
only  vrill  b«  noticed  which  are  of  Kpeeinl  importance  tu  their  bearings 
OD  the  study  of  the  diseases  of  the  re«piratory  apparatus,  and  these 
will  be  but  briefly  adverted  to. 

The  more  important  of  the  parts  which  compose  the  larynx  are 
the  thyroid  and  cricoid  cartilngcs,  the  epiglottic,  and  the  erj'tenoid 
cartilages,  the  latter  movable  and  provided  with  sovernl  muscles. 
Those  parts  arc  united  by  several  ligaments,  and  the  internal  cavity 
ia  lined  by  mucous  membrane  presenting  the  same  characters  as 
that  foand  in  the  trachea  and  branobi. 

Tbe  thyroid  and  cricoid  carlitiiges,  with  their  ligaments,  form  a 
solid,  nnyielding  box,  affimling  resistance  to  presnure  both  from 
without  and  within  its  cavity.  In  this  respect  the  larynx  diSers 
from  the  other  portions  of  the  nir-tiibe ;  the  iHtter  may  be  compressed 
or  dilated  by  a  moderate  amount  of  mechanical  force.  This  ana- 
tomical point  is  of  importance  with  reference  to  certain  diseases 
affecting  the  larynx.  Taken  in  connection  with  the  narrawncKS  of 
a  portion  of  the  laryngeal  canal,  tbe  resistance  to  pressure  from 
within  occasions  obstruction,  and  eren  occlusion,  as  results  of  the 
swelling  of  tbe  parts,  morbid  deposits,  or  abnormal  growths  in  the 
toterior  of  the  larynx.     It  is  owing  to  the  eircumstanoes  just  stated 

•  A  PtkIUuI  Tfontiso  on  Pornl|;n  Rodlni  in  thn  Air-Pft»»jigo*,  by  S,  D,  Orow, 
it.  v.,  «le.  elv.,  M*H.  Ttiia  w(>rk  cvntaiut  iltultictioiin  hannl  irii  the  KiulyiU  of  a 
eolUcliiMi  of  nowlj  flftj-  cbim,  Mnliracing  in  uddition  Io  Ihoio  cominjj  iindpr  the 
al«errBiion  of  ih*  Nuthor  and  bi»  proru«»ional  t>iend«,  »1l  thai  w«ru  tu  be  gaihenxl 
ft«n  medical  litGraluR. 


60 


AHATOMY    AKD    PBTSIOLOOT. 


tbftt  pome  diseases  of  tlie  larynx  inrolve  ecrions  cmbairamDCiit  of 
respiration,  tnd  frequenll;  end  fatally  by  inducing  apnoca.  Exam- 
ples arp,  fxudative  or  true  croup,  acute  laryngitis  with  submucoui 
infiltration,  and  ccdcma  glottidi^ 

Other  points  of  spMial  importance  in  their  pathological  rclatiou 
are  prosenlcd  when  the  larynx  ia  examined  internally.  Viewed 
from  aborc  downward,  the  larjmgeal  caoal  may  be  considered  a* 
dividfril  into  three  portions,  vii. ;  1,  the  superior  aperture;  2,  tia 
glottis  ;  S,  the  inferior  space.  Of  these  three  portiona,  the  first  two 
are  chiefly  important.  We  will  notice  the  points  pertaining  to  these 
-portions  respectively  under  dietinct  faeadii. 

1.  Supirrior  Aperture  of  the  Larynx. — This  embraces  the  triao- 
gulBrtpaea bounded  by  the  epiglottic  in  front,  thcvoca]  ehonU  below, 
■Di'latflrally  by  mucous  folds  extending  from  the  summit  of  the 
•ryteooid  cartilage  to  the  eptglntti»,  calKil  the  artfttno'tpij/htfidtan 
foldt.  Thiit  portion  of  the  larynx  poiisessc*  pathological  relations 
of  great  iinportHnce.  It  is  in  this  »ituatioQ  that  tliu  cubuiucous 
effusion  tAkea  place  in  the  affection  known  as  eedetna  gloUidi*.  Tlte 
areolar  tissue  uniting  the  mucous  membrane  to  the  subjacent  strvc- 
tarc  is  more  loose  and  extensible  here  tlian  in  other  portiona  of 
the  canal.  Henoe  the  liability  to  serons  and  poraloid  submucous 
effusions  in  this  situation,  forming  tumors  which,  acting  like  a 
balUvalve,  close  the  narrow  orifice  of  the  glottis  with  the  act  of 
inspiration,  producing  obstruction  to  respiration  manifested  in  tbe 
inspiratory  act,  and  unless  relieved  by  appropriate  means,  often 
lending  to  fatal  suflooation.  The  situation  of  tbei«e  tumors  ia  such 
thai  they  are  generally  within  reach  of  the  finger,  and  their  existence 
may  tlierefore  lie  determined  hy  the  touch,  rendering  tlie  dtagoosia 
of  adema  ghttidijf  positive.  This  accessibility  also  rcndcra  relief 
praeticablc  by  resorting  to  incit>ions,  or  scarifications  with  an  appro- 
priate surgical  instrument,  after  the  method  practised  with  racceas 
in  a  number  of  cases  by  Dr.  Qurdoo  Buck,*  of  New  York.  It  is 
an  interesting  fact  that  the  loose  attachmontof  the  mucoos  mem- 
brane at  the  superior  aperture  of  the  larynx,  which  exists  in  sdalt«, 
doea  not  obtain  in  children.     In  the  latter  the  membrane  is  closely 


■  InoArrtictlj  csllvd  »tana  gUittidU,  ibsHnuch  u  the  cedcma  to  utaat«d  abortt, 
not  at  th«  glottli. 
*  Sm  Trafiu«tliHi>  or  tbB  Aiucrictn  Mndical  Aoociatim,  Tok.  1  and  IV. 


.*•  ■•■  • 


LARTNX. 


51 


oonn«oted  vith  the  parts  Wneaili.     [Ivnce  oedema  f;Iottidi«  i*  not 
a  diMaae  aSccting  children,  hut  ocourii  only  after  adult  ngc. 

2.  Qloltiit. — The  portion  of  the  larynx  csllod  the  glottis,  !«  thut 
bounded  h;  the  chorda  voealtt,  or  vocid  chord*.  The  antttumical 
CODfonuation  of  this  part,  and  the  physiological  acts  which  here  lake 
place  in  connection  with  respiration,  ■»  WL-II  as  phonation,  involve 
i  certain  fact*,  not  only  interesting,  but  iraportitnt  in  their  relations  to 
ihe  study  of  disease.  The  vocal  chords  are  two  in  numher,  on  each 
,  side ;  the  upper  set,  formed  by  folds  of  the  mucous  mernhniiiQ,  ox- 
I  tending  front  the  bases  of  the  arytenoid  cttriiliigcs  to  the  anterior 
tinner  surface  of  the  thyroid  cartilugc  ;  the  lower,  oontaining  fibres 
of  clastic  tissue,  extend  in  the  same  manner  from  the  arytenoid 
cartilage  to  the  front  of  the  larynx.  The  upper,  or  superior  vocal 
chords,  are  also  distinguished  as  the/a/se,  and  the  inferior  as  the 
trve  vocal  chords.  Within  the  small  space  bctweeD  the  upper  and 
lower  Tocal  chords,  on  each  aide,  is  a  depression  or  cavity  called  tJie 
ventricle  of  the  larynx.  In  this  cavity  foreign  bodies,  accidentaJlj 
inhaled  into  the  larynx,  are  sometimes  lodged.  By  the  vocal 
chords  the  larynx  is  greatly  narrowed  at  the  glottis.  Viewed  in  the 
dead  subjcfl,  the  chords  diverge  from  the  point  of  their  junetion 
anteriorly,  to  their  attachment  at  the  arytenoid  cartilages,  leaving 
9  triangular  interspace,  culled  the  rinia  or  chink  of  the  gloitis.  This 
fissure  is  smaller  between  the  lower  than  the  superior  vocal  chords. 
In  an  adult  male  viihjcct,  the  antcro-posterior  diameter  of  the  glottis 
IS  ten  or  eleven  lines ;  and  the  greatest  transverse  diameter,  t.  e,  at 
the  base  of  the  tnniigle,  from  throe  to  four  lines,  the  measurements 
being  made  at  the  narrowest  part  of  the  glottis,  vix.,  on  a  level  with 
the  lower  vocal  chords.  In  females,  the  size  of  the  entire  larynx 
is  about  one-third  less  than  that  of  the  male.  At  the  glottis,  in  the 
female  subject,  the  antero-posterior  diameter  is  about  eight  linea, 
and  the  transverse  diameter  from  two  to  three  lines.  Prior  to  the 
age  of  puberty,  in  the  male  especially,  the  dimensions  of  the  glottis 
are  less  than  after  the  remurlcallc  development  in  the  size  of  the 
larynx  which  occurs  at  that  epoch.  The  small  sixe  of  the  aperture 
of  the  glottis,  cvpeciiilly  in  children,  accounts  in  part  for  the  great 
danger  attending  the  exudation  of  coagulable  lymph  in  tliis  situa- 
tion, which  occurs  in  croup. 

The  foregoing  deacription  relates  to  the  glottis  in  the  condition 
l.in  which  it  is  observed  after  death.  During  life,  the  condition,  as 
[respects  the  size  and  form  of  the  space  between  the  chords,  is  con- 


63 


AyATOXT   AXD    PSTSIOLOOr. 


staDtljr  rurying  in  conM^qucnce  of  morcmi-nt*  conni>cteil  irith  tbe 
vn  of  the  voice,  nod  aUo  with  the  icts  of  respiration.  In  »p«*kitig 
Bnd  singing,  the  dircTHitii-s  in  the  tonc«  of  the  voice  nn-  ii»inlT  t3u« 
to  the  different  degrees  of  approximaiion  and  tension  of  the  chords, 
produced  by  the  action  of  the  muscles  attached  to  the  arytenoid 
csrlilngo».  T\iC  movements  involved  in  vocalisation,  according  to 
tie  rcBrnrchc*  of  Claude  Bernard,'  are  governed  by  inHucnee* 
traD^niittcd  cxcluKivclj  through  the  spinal  acccseorj  nerve.  Pa- 
ralysiti  of  the  arytenoid  inui>elc«.  so  fur  as  they  are  concerned  m 
pfaonfttlon,  is  the  result  of  destroying  this  nerve,  tho  rc^pinitory 
movements  remaining  unaffected.  Thus,  if  the  nerve  bo  destroyed 
in  a  rabbit,  the  brrathing  continaes  undisturbed,  but  the  animal  is 
unable  to  utter  a  cry  when  hurt.  This  physiolopcal  discovery  is  in- 
tcreHting.  and  imporisDl  vrith  reference  to  the  seal  and  cliaract«r  of 
nervous  aphonic.  Local  affections  of  the  larynx,  involving  the  vocal 
chorda,  occasion  modifications  of  the  voice,  which  become  impo^ 
tant  diagnostic  symptoms.  Thus  in  siicplc  inBammation.  ax  veil  u 
in  croup,  the  voice  is  hoarse  and  may  be  temporarily  lost;  ulcer- 
ation of  the  chords  from  tuberculosis,  or  syphilis,  renders  it  busl^ 
and  stridulous,  and  even  the  abnormnl  dryness  inddent  to  epidemic 
cholera  occiiiiionH  a  mnrkcil  effect  amounting  sometimea  to  aphonia. 
Similar  modificftlions  of  the  xaiind  attendant  on  cough,  are  also 
produced  by  di«cnses  affecting  the  glotti»i,  which  ihuit  in  the  »aiat 
vay  become  diagnostic  of  a  muibid  coridiiiun  seuled  at  this  diviura 
of  the  air-passages. 

The  movenicnts  of  the  vocal  chords  play  nn  important  part  In 
respiration.  The  concnrrence  of  the  glottis  in  ccrluin  occasional 
respiratory  acts,  especially  coughing  and  itneeiing,  has  long  been 
Icnowii  to  physiologists:  but  recent  physiological  researches  have 
shown  that  with  ordinary  respiration  an  alteinate  separation  and 
approximation  of  the  vocal  chords  take  place,  aceompanying  (be 
two  acta,  in.ipiraiion  and  expiration.  These  movements  are  alto- 
gether aiitomalrc,  and  continue  to  go  on  even  after  a  large  opening 
has  been  made  into  the  trnchca  admitting  iin  iihunilniit  supply  of  air 
by  the  artificial  orifice.  Thesixcof  the  n'»iK  ffhttidis,  whvn  dilated 
with  the  act  of  inspiration,  may  beeome  iienrly  double  that  which 
it  has  when  the  vocal  chords  are  in  a  stiitc  of  rest;  but  in  this 
respect  there  is  considerable  variation  with  different  respu'ationa, 

'  Rcchorchr*  Mii»rtni(^atiil€«  hit  )«  fonctinn*  du  n<rf  tpinni,  on  acccMoiro  da 
'Willi*,  pur  M,  Clandn  Bernard.     Pari>.  1851. 


USO 


LARTKX. 


^ 


the  dilatation  being  more  marlied  when  the  breathing  is  hurried  or 
forced.  The  respiratory  movetocDts  of  the  gluttis  in  ordiaury  and 
forced  breathing  are  illustrated  by  vivisectioDit  in  inferior  aninials, 
and  they  may  be  satisfactorily  obiierved  in  man  by  meaoB  of  the 
Uryngoscope. 

The  rariations  4s  respccta  the  approximation  of  the  vocal  chords 
with  the  two  respiratory  act»,  and  with  different  respirations,  prob- 
ably eerrc  to  explain,  in  part,  the  diiferencea  bctwix-a  the  sounds 
of  iuspirntion  and  expiration  emunnting  from  within  the  trnehca  and 
bronchi,  and  the  variations  in  the  characters  of  sound  which  each 
net  may  pnetcnt  with  different  respirations,  to  which  reference  will 
be  hereafter  made  under  the  head  of  Auscultation. 

Abnormal  movements  of  the  glottis  may  become  important  morbid 
OTeots.  Spasm  of  the  mnscles  approximating  tho  chords  occttrs  as 
an  element  of  inflammation  of  the  larynx,  both  in  croup  and  simple 
laryngitis.  It  occurs  aUo  as  an  independent  iifTection  in  theso-callcd 
tarynffiatma  ttriduiu*  of  children,  and  occasionally  in  adults,  inter- 
fcring  with  reispiration,  occasioning  distress  in  proportion  to  the  de- 
gree of  obstruction  from  the  narrowing  of  Uie  orJGce  of  the  glottis, 
and,  possibly,  proving  fatal. 

The  respiratory  movements  of  the  glottis  are  under  the  control 
of  the  recurrent  or  inferior  laryngeal  nerves.  When  these  nerves 
are  divided  in  ririsections,  the  glottis  remains  immovable,  neither 
dilating  nor  contracting.  Under  these  circumstancea  the  column  of 
air  entering  the  larynx  with  inspiration  forces  the  chords  together 
and  obstructs  the  orifice,  causing  death,  which  takes  place  more 
quiekly  if  the  animal  be  young. 

8.  Inferior  Spacf. ~—Tbi»  embraces  the  short  space  below  the  vocal 
chords  included  within  the  larynx.  In  aiitc,  form,  etc.,  it  resembles 
the  trachea  into  wluch  it  merges,  and  therefore  docs  not  need  » 
separate  description. 


ABATOMT   A*»    PaT«I»L««T. 


SEcnos  n. 

TOPOOKApniCAI.  DIVI5It><CS  OP  TBE  CBEST. 

Fon  (ronrenimce  of  reference,  especially  «a  irgaHa  tti«  rcsahi  of 
ph;(iciil  explorslioD,  tbe  exurior  of  tbe  ebesi  b  dirided  into  sepante 
•pKOW,  nIM  rtgionM.  TbeftC  diTuiona,  altbongh  arbitntyand  eon- 
vcnltonal,  are  conrcniirnt,  and  ibe  ■tadi-nt,  before  cnlering  on  the 
Mlu'ly  of  dUi^aaos  affrchng  the  r(«piralnry  appsrattu,  should  make 
IiiniMlf  fnniiliar  with  their  boandariea,  and  with  their  anatomical 
relalionji  reflpectirely  to  th«  intra- thoracic  organfl.  To  these  prt- 
liiniiiary  pointa  this  flection  will  be  devoted. 

In  determining  the  topognphtca)  divisions,  the  so)e  end  beiitg 
ponvenienoe,  aimplicitj  ii«  to  be  conmilted  as  much  »a  ponsible.  Tlie 
nntnbcr  of  regions  ahoidd  not  be  nordlessly  multiplied.  The  boun- 
dary litica,  to  be  reeolli^cled  and  n-adily  aiicertained,  tthonld  be  not 
entirely  artificial,  but  baned,  as  far  as  practicable,  on  natural  ana- 
tooiical  divinions :  ntid  ihorc  it  nn  obvioux  iiiivnnliigv  in  dexifrnaling 
ihrni  by  terms  derived  from  namoi  already  aMigned  to  tht-  pares 
whicb  they  v  in  brace. 

The  fimt  division  i»  into  three  8urfscce,  vis.,  nn  anterior,  a  po«S^H 
rior,  iind  twu  lateral  aurfiicex.     The  untcnor  and  posterior  i^urfactfiPB 
In  fnet,  may  be  aaid  to  be  double,  each  lateral  balf  of  the  chest 
being  ooneidtred  xcparntrlr. 

For  the  tnost  pnrt  it  siifliocit  to  divide  tbo»o  surfaces  into  «  few 
fraotionnl  purtii.  Aeconling  to  this  plan,  the  anterior  nnd  posterior 
■urfacu  are  divided  into  three  partH,  and  designated  the  upper, 
middle,  and  tower  thirds,  of  the  nglit  or  left  cbe«t;  and  the  lateral 
HtrfaeM  into  two  equal  parts.  Thin  is  exceedingly  simple,  and  will 
often  answer  for  referencf  better  thau  more  tniiiute  divisions.  It  is 
iinportani,  therefore,  to  hear  in  mind  the  limits  of  these  fractional 
•eettons.     They  are  as  follows: 

AXTKHioa  Hl'RPACB. — The  upprr  third  extends  from  the  soperior 
exlremily  of  the  chest  to  tlie  lower  mar^D  of  tlie  second  rib.  The 
mi-Mlr  Ihini  en)brae«<s  the  epace  between  the  Utter  boundary  and 
the  intors|HieM  between  the  fourth  aud  fifth  rib*.  The  loiefr  third 
is  the  portion  of  the  chest  bidow  ihe  line  just  mentioned. 

PoCTKHIOlt  Svhpacs.— The  N/>/vr  Mini  eompnM*   the   portioti 


J 


TOrOliRAPHICAL    IXVISIOKS    OF    THB    CHKST. 


above  the  spinous  ridge  of  the  scapnU  and  at  line  in  the  same  direc- 
tion continued  to  the  spinal  columo.  The  midlife  third  i&  the  apa«e 
between  the  lower  boundary  of  the  upper  third  and  a  transveiee  line 
JDiersecting  the  inferior  angle  of  the  scspuhi.  The  lower  third  is 
the  remainder  of  the  chest  below  the  middle  third. 

Lateral  Surfacs. — This  is  divided  into  two  equal  portions, 
called  the  upper  and  the  lower  lateral  half  of  the  right,  or  the  l«ft 
Bide  of  the  chest. 

Not  infrequently  it  is  desirable  to  refer  to  spaces  more  circum- 

ibed  than  the  foregoing  divisions.  Hence  it  becomes  necessary 
Id  subdivide  more  minutely  into  reijiunn  than  the  fractional  sections 
already  mentioned.  The  regional  subdivisions  which  are  generally 
I  adopted  arc  the  following: 

AxTERloH  ReiitONS. — a.  Pott  ctai-iimlar,  or  mtpra-elaiHmlar.  The 
space  above  the  clavicle,  situated  over  the  apex  of  the  lung.  b. 
Clavicular.  The  space  occupied  by  the  clavicle,  e.  I^fra-elaiifuiar. 
Situated  bclwcen  the  clavicle  and  the  lower  margin  of  the  third 
rib.  d.  Mammary.  Bounded  above  hy  the  third,  and  below  by  the 
sixth  rib.  e.  Infra-mammari/.  The  portion  of  chest  btlow  the 
inferior  boundary  of  the  mammary  region. 

These  regions  arc,  of  course,  double,  t.  e.,  existing  on  both  sides 
of  the  chest.     In  addition  to  the«c,  the  portion  of  the  chest  ante* 

■  riorly  occupied  by  the  sternum  is  divided  into  a,  the  upper,  and  b, 
the  linear,  sternal  region.  The  two  regions  just  natacd  arc  separated 
by  a  line  connecting  the  lower  margins  gf  the  third  ribs.  The  space 
at>oro  the  sternal  notch,  the  trachea  lying  beneath,  is  called  the 
ntpra-iternal  region. 

Poi;tkkiok  RKfiiOMS. — a.  Scapular.   The  space  occupied  by  the 

■  scapula.  This  space  is  subdivided  into  the  upper  and  hieer  scapular 
regions.     The  former  emhraces  the  portion  above,  and  the  latter 

•  that  below  the  spinous  ridge  of  the  scapula,  h.  Infra-tcapular. 
The  space  between  a  line  intersecting  the  lower  angle  of  the  scapula, 
and  the  inferior  extremity  of  the  chest,  c.  Interscapular.  The 
space  between  the  posterior  margin  of  the  scapula  and  the  spinal 
column. 

These  regions  are,  of  course,  double. 

Latkral  Rehions. — a.  Axillary.  Extending  from  the  highest 
point  in  the  axilla  to  a  transverse  line  coottnuons  with  the  lower 
boundary  of  the  mammary  region,  fc.  Jnfra-axillar//.  Extending 
from  the  axillary  region  to  the  lower  limit  of  the  chest. 


regions,  seTffriilljr,  to  tlie  organs  i 
within  the  chest,  ar«  important  l«  be  prrmised.  Sappocing  the 
dimioQs  to  be  not  conBaed  to  the  »Drfac«,  bat  extendc)  to  the 
centre  of  tbe  che»l,  «bal  snatomicu)  parts  wonld  cacli  itt'ctioo  coo- 
tain?  In  answering  this  question,  *o  far  a»  is  practically  importani, 
we  will  notice  the  different  rcginng.  tmatim,  in  the  foUuwing  order: 
l»t,  thoKe  8ituate<i  anieriorljr ;  1A,  those  «tiut«d  poateriurly ;  and 
3d,  tho«c  eituuted  luU-rally. 


I.   AXTBKtOl  Br«IO.VS. 


i.^ .  V 


1.  SrPBA- OR  Po8T-CL*nci!LAR.—B<!neath  this  region  lies  bsta 
sma]l  portion  of  tang,  vis.,  that  part  of  the  npcx  which  often  pro- 
jects abore  the  che«t,  rising  in  most  persona  a  little  higher  on  the 
right  than  on  the  left  side.  The  space,  however,  is  of  conaiderable 
importanoe  in  the  diagnosis  of  certain  diseatic*.  The  physical  signs 
of  tubercle  are  sometimes  early  mniiirested  in  this  situation,  tbe 
tuberculotu  deposit  gencralh-  (nittng  place  firHt  &t  the  apex  of  the 
long.  Monnallj',  the  vurfucv  in  this  region  is  more  or  less  depreSMJ, 
forming  a  concaritj.  An  abnormal  increaM  of  this  depre:iisioQ  will 
be  found  to  constitute  one  of  the  signs  of  adTaoccd  tuberculosis; 
and  on  the  other  band,  the  xpaco  is  sotnetimes  abnormally  raised, 
and  perhaps  becomes  bulging,  in  another  affection,  riz.,  einpliysoma. 

2.  Clavicular. — The  clavicle  extends  over  the  apex  of  the  lung, 
and  the  remark  just  mude  rc«pocting  the  importance  of  the  poBi< 
clavicular  region  as  a  site  for  the  evidences  aflorded,  espccislly  by 
pcrcuanion,  of  incipient  tuberculous  disease  is  here  equally  applicable. 

3.  iNrKA-CLATicuLAR. — TLis  is  also  an  Important  region  with 
reference  to  the  physical  signs  of  tubercle.  The  signs  of  all  the 
Stagoa  of  that  disease  are  usually  to  ho  sought  for  in  this  region.  A 
Motion  carried  to  tbe  centre  of  the  chest,  embracing  ibc  limits  of  the 
region,  would  contain  an  important  portion  of  the  upper  lobe  of  the 
lung.  The  primary  bronchi,  after  the  bifnrcation  of  the  trachea, 
situated  cxtenor  to  the  pulmonary  §ubstancc,  are  also  contained  in 

,this  section.  Tbe  bifurcation  takes  place  on  a  level  with  tbe  second 
rib.  From  this  point  the  bronchi  on  the  two  sides  diverge,  pursuing 
directions  somewhat  different,  as  already  described,  tbe  right  being 
situated  beneutb,  and  the  left  a  little  below,  the  costal  cartilage  of 
the  second  rib.  The  presence  of  the  bronchi  gives  rise  to  certain 
modifications  of  the  sound  produced  by  respiration,  in  health,  as 
well  as  disease,  in  this  region;  and  owing  to  anatomical  diffcre&i 


iA&i 


I 


I 


ANTEniOB   BBOIOKB. 


S7 


I 


in  tbc  tvo  primitrj  bronchi,  vrliicli  hure  been  noticed  in  ScotioD 
I,  it  will  be  eci'n  bcrciiflcr  tbai  n  niitarni  ilispurity  bctwt-cii  tbo 
two  sides  cxinu  as  ru^^pccls  tbcse  modiScatioua  of  rf>[iirnloryHouniI. 
Normally  the  iofru-cUvicular  region  is  in  most  persona  slightly 
convex,  different  persons  diflt-riiig  coneidorftMy  in  itiis  purticiilar. 
This  convesity  ttbnormtilty  incrvu^cd  becomes  it  sign  of  emphyfteins, 
and  an  nbnormnl  dcprosvion  or  flattening  in  this  situation  Trcqucntly 
attends  tul>vrcuIo8is  of  tbo  lungs. 

4.  Maumarv. — Some  important  points  pcrlaiuingto  tbeanntomj 
of  tbc  intni-tboravic  organs,  buve  relation  to  the  «pacc  occupied  bjr 
thi8  region.  As  respects  tbc  organs  lying  beneath,  the  two  sides 
differ.  A  considerable  portion  of  the  heart  is  situated  in  the  loft 
side  within  its  limits,  viz.,  the  left  ventricle,  and  auricle,  and  a  por- 
tion of  the  right  Tentricle.  The  site  of  the  heart  is  often  diatin- 
fuisbcd  as  a  separate  ri^gioD,  called  the  cardiac,  or  the  prsecordia. 
Otet  a  quadrangular  space  extending  from  ihe  sternuni  into  the  left 
matDmnry  region,  the  heart  is  in  contact  with  the  walls  of  the  chest. 
Thi«  space  lies  between  the  fourth  and  sixth  ribs.  The  limits  of 
tbo  heart  beyond  this  space  are  to  be  taken  into  account  in  physical 
exploration.  They  extend  vertically  from  the  upper  to  the  lower 
bonndary  of  the  left  mammary  region,  i.  e..  from  the  third  to  the 
sixth  rib»,  and  transversely  in  the  line  of  the  fourth  rib  nearly  to 
H  the  nipple.  The  presence  of  the  heart,  as  will  be  seen  hereafter, 
Boonsions  important  modifications  of  the  phenomena  determined  by 
^liflrcussion  and  auscultation,  and  disturbs  that  equality  between  the 
right  and  left  mammary  region,  as  respecu  the  physical  signs  inci. 
dent  to  health,  which  generally  characterizes  corresponding  locali* 
ties  on  the  two  sides.  The  disparity  just  referred  to  is  of  practical 
itnportsnce  in  its  bearing  on  physical  diagnosis.  Appreciating  its 
degree  and  extent  prevents  attributing  to  changes  produced  by 
disease,  phenomena  which  are  entirely  normal ;  and  on  the  other 
band,  a  morbid  condition  may  occasion  a  notable  diminution  in  the 
norma]  disparity.  The  latter  obtains  in  cases  of  emphysema,  in 
which  the  over-distended  lung  covers  the  heart  entirely,  and  some- 
limes  crowding  it  from  its  natural  situation  occupies  its  place  in  the 
pnecordia.  The  impulse  produced  by  the  striking  of  the  heart's 
apex  against  the  walls  of  the  chest  falls  within  the  left  mammary 
^  region  from  a  half  indi  to  an  inch  and  a  half  within  a  vertical  line 
H passing  through  the  nipple;  IWm  line  is  called  the  iin^a  mammaiit. 
Kormally  the  impulse  is  seen  and  felt  between  the  fifth  and  sixth 


88 


ASATOMT   15D    rDrsiOLOGT. 


ribs.  Tl>e  ntsaUoD  ef  Uus  paiBt  of  Apex-tinpalse  is  importut  m 
eoDDcction  nith  disMAes  tBeetiag  tbt  rMpintorj  apparatus  as  *d 
aa  (he  hcurt.  In  wruiit  pdinoiurT  affections  the  bean  is  diaphnd. 
It  is  carried  in  some  ciMs  of  ebroDic  plenritis  to  the  right  of  tk 
Bternum,  and  the  tmpalse  may  be  felt  in  the  right  mainmarj,  ir 
infra-cUricular  region.  This  traasfereiioe  of  the  heart's  impube  M 
other  siiuatioas  thus  becomes  an  iraportant  diagnoatic  tiga  of  pid- 
nioiiarj  disease.  Absence  of  the  impolae  in  the  normal  pocitioiii 
■ithout  its  being  appreciable  elsewhere,  maj  also  b«  a  valaable  «ga 
of  ]iulinoiiarTiiiiica.«c. 

The  linM  cur m ponding  to  the  fianrea  ditiding  anleriorl;  the 
lobes  of  tho  lungs  fall  within  the  mammary  regioits.  The  relatieu 
of  these  linr«  to  the  exterior  of  the  chest  are  important  to  be  bone 
in  Hiind.  On  the  l^fl  side  the  interlobar  fissure  commences  al  s 
jraint  n  little  below  the  nipple,  between  the  fourth  and  fifth  ribs,  aad 
from  this  point  it  runs  oblit^oclv  upward  and  ontvard  to  the  axillsir 
region.  On  tlio  right  side  the  fis-urc  dindiog  the  npper  and  middle 
lobes  eommeDocs  at  the  fourth  costal  cartilsge,  and  pursae«  a  eonne 
ob1i(|nely  upward  and  oolvard  for  a  distance,  rarjing  in  diffiereat 
persons.  The  (issare  between  the  middle  and  lower  lobes  oomracseca 
a  short  diataDcc  belnw,  and  extends  in  a  similar  direction.  Tfao  pM- 
lionoflhcloworlobesituated  anteriorly  below  themiddlelol>c,i*quite 
•nail,  as  hsa  been  alrendr  j^ccii.  and  Mmetimea  the  whnlc  of  tbb  lobe 
b  aontained  in  (he  Inti'mt  mid  po«icrior  regions  of  the  chest. 

A  smHll  (Mrt  of  the  heart  is  contained  beneath  the  right  mam- 
ninry  rogixn,  vi».,  portinns  of  the  right  auriele  andrentriclc. 

On  tho  right  niile,  the  cwnvcxily  of  the  diaphragm  riics  into  the 
munininry  rrgign  lut  hij:h  as  (he  fourth  rib.  On  the  left  aide,  the 
point  to  which  i(  exteudH  i«  a  little  lower.  This  fact  may  aocoant 
for  ccTtiiin  modilicationa  of  phenomena  derdoped  by  phyaeal  ex- 
ploration. 

Tho  preaoneo  of  tho  mammary  gland  in  the  female,  and  in  nne 
iMUtnces  a  Isrge  darolopment  of  the  pectoral  muscle  in  the  male, 
•ro  found  to  interfere,  to  some  extent,  with  physical  esplorniion  in 
this  region. 

fi.  iHrHA-MAUMAKY. — This  region,  like  the  preceding,  has  rela- 
tions, on  tho  two  sides,  to  different  organs.  On  the  right  sid^ 
extending  upward,  nearly  or  i]uiie  to  (he  superior  boundary,  t.  e,, 
to  the  sixth  rib,  is  the  liter,  covered  with  the  diaphragm.  The 
phenomena  lietennined  by  phy«oal  exploration  in  health,  are  quite 


PDETBRtOn    RRQtOKt). 


r 


different  from  those  in  otber  regions  inctirding  pulmonary  sabstanoe. 
Theee  phenomena  are  someiimes  attributed  to  disease  by  those  who 
overlook  the  fact  that,  oning  to  the  presence  of  the  liver,  they  are 
normal  in  this  situatioD.  On  the  left  side,  this  region  embraces  the 
anterior  portion  of  the  lower  lobe  of  the  lung  together  with  portions 
of  the  stomach,  spleen,  and  left  lobe  of  the  liver,  but  the  relative 
proportion  of  the  latter  parts  lying  within  the  limits  of  the  region 
varies  considerably  in  different  individuals,  and  still  more  at  diSercnt 
times  in  the  same  person.  This  is  owing  to  the  fact  that  the  size  of 
the  three  organs  mentioned  is  far  from  uniform  in  hcuUh,  and  this 
is  true  more  especially  of  the  stomach.  Greater  or  Icm  distension 
of  the  stomach  with  gas.  occasions  marked  diversities  in  the  phe- 
nomena determined  by  physical  exploration  of  the  left  infra-mam- 
mary region.  Enlargement  and  atrophy  of  the  liver  and  spleen, 
also  ocGSBion  modifications  of  these  phenomena. 

In  this  region,  the  intercostal  depri's«ion»,  if  visible  anjwhcri>,  are 
(uaally  more  or  less  marked.  The  «igns  of  dittnase  which  pertain 
to  the*c  depressions  are,  therefore,  to  be  sought  for  in  this  portion 
of  the  chest.  The  evidences  of  the  prescnctt  of  liquid  effusion  within 
the  pleural  sac,  are  presented  especially  in  the  infra-mammary  region, 

6.  SnPBA-STBKNAL. — No  portion  of  the  substance  of  the  lungs 
lies  beneath  the  smatl  space  occupied  by  this  region,  but  the  whole 
of  the  space  is  filled  by  the  trachea.  In  this  space,  examination  ia 
made  in  studying  the  phenomena  of  the  tracheal  respiration, 

7.  Uppkr  Stebnal. — Beneath  the  upper  portion  of  the  sternum, 
ftt  the  centre  of  a  line  connecting  the  second  ribs,  the  bifurcation 
of  the  trachea  takes  place.  Below  this  point,  the  lungs  on  the  two 
sides  are  nearly  in  contact  at  the  mesial  line,  covering  the  primary 
bronchi. 

8.  LowBR  Sternal, — This  part  of  the  sternum  covers  a  portion 
of  the  heart,  viz.,  a  large  share  of  the  right,  and  a  little  of  the  left 
ventricle.  The  liver  encroaches  somewhat  on  this  region,  and  also 
the  stomach  when  distended.  Situated  above  the  heart,  a  emal) 
portion  of  the  left  lung  is  contained  within  its  hmits,  and  to  the 
>tght  of  the  meaial  line  a  larger  portion  of  the  lung  on  that  side. 

n.   POSTRRIOB  RcUIOKft. 
1.  Scapular. — The  scapula  i»  situated  over  the  posterior  portion 
of  the  upper  pulmonary  loho,  covering  also  a  portion  of  the  upper 
put  of  the  lower  lobe,  no  other  important  parts  lying  beneath  it. 


60 


ANATOMY  AND    rHTSIOLOOT. 


This  region  h  snlxlividcd  iau>  Llio  u[i|M)r  and  lover  teapnUr;  the 
former  Bittwtctl  abov«,  and  tlic  ]«tt«r  Inflow  tlic  tpinous  ridge. 

At  the  upper  pnrt  of  tbe  lower  fcapiiUr  region,  teminatca  Uie 
fituaro  separating  tlie  upper  and  lower  lobes  of  tbe  lungg.  From 
tlu»  point  of  tcrminKtion,  the  interlobar  fiHsnro  porsun  an  obli<)De 
direction  doirnmird,  pauing  through  tho  lower  axillary  and  mam- 
marjr  regions  to  the  fifth  interspace  on  the  right  Mdc,  and  to  the 
space  between  the  fourth  and  fifth  rilu  on  tho  left  side.  A  diagonal 
line  drawn  between  the  two  puintH  just  nicn(ione<t.  will  mark  tfac 
siloatign  of  the  division  between  tho  lob«!i,  a  matter  of  interest  and 
importance  in  the  diagnosis  of  lobar  pneumonitis,  or  inflammntion 
of  tile  subalanco  of  tbe  lungs  extending  over  a  lobe. 

2,  IvPnA-SCAPDt-Aft. — Pulmoaary  substance  occupies  tbe  space 
within  the  chcttt  corrcitponding  to  thin  region,  on  the  right  side  above 
a  transverse  lino  drawn  from  the  eleronth  rib,  The  liver  rises  to 
this  line.  On  the  left  side  tbe  lower  part  of  the  region  contaios  a 
portion  of  the  spleen. 

The  lower  lobe  on  the  left,  and  the  lower  and  middle  lobes  on  the 
right  side,  Gil  the  whale  of  this  region  above  the  diaphragm,  and 
also  a  portion  of  tho  itcapular  region.  In  cases  of  inflammatioa 
affecting  (as  is  usual)  the  lower  lobe  in  the  adult  (lobar  pneumo- 
nititi),  the  physical  evidences  of  disease  are  here  presented,  and  are 
to  bo  Booghl  for  posteriorly,  not  in  fron^  a  small  portion  only  of 
the  lower  lobe,  as  already  stated,  extending  to  llie  anterior  part  of 
the  chest. 

8.  Ihtbr-scapular  Reiiiok. — In  addition  bo  the  substance  of  the 
tangs  on  both  sides,  the  trachea  descends  into  this  region,  and  bifur- 
cates. The  point  of  bifurcation,  as  already  stated,  is  at  the  fourth 
dorsal  vertebra.  From  this  point  the  two  primary  bronchi  diverge, 
running  acrosR  the  region  oblifiucly  downward  and  outward,  tbe 
direetion  on  the  two  sides  being  somewhat  diflereut,  as  described  in 
Section  I.  It  is  in  tlita  region  behind,  and  in  tbe  infra-clavicnlar 
region  near  the  sternum,  in  front,  that  examinations  are  made  for 
the  respiratory  sounds  developed  within  the  primary  bronchi,  a 
matter  of  interest  and  importauce,  as  will  be  seen  hereafter. 


III.  Latebal  Rboion'9. 

1.  .\xiLURT. — A  section  corresponding  to  tho  boundaries  of  this 
region  would  contain  a  portion  of  the  upper  lobe  of  tbe  lungs,  with 
Urge  broncliial  lubes. 


LATERAL    BBGIONS.  61 

2.  Infra- AXILLARY. — A  section  here  would  embrace,  in  addition 
to  lung  eubetance  on  both  sides,  a  portion  of  the  spleen  and  stomach 
on  the  left  side,  and  on  the  right  side  the  upper  part  of  the  liver. 
The  liver  rises  on  a  vertical  line  in  the  middle  of  the  axillary  space, 
or  the  linea  axillarit,  as  high  as  the  eighth  rib. 

The  topographical  divisions  of  the  chest  have  been  described  in 
thia  section,  and  the  relations  of  the  several  regions  to  the  organs 
lying  beneath,  stated  briefly,  but  comprehensively  enough  to  prepare 
the  student  to  enter  on  the  study  of  physical  exploration.  The 
details  that  have  been  presented  are  in  themselves  dry  and  uninter- 
esting; nevertheless,  they  should  not  only  be  read  and  compre- 
hended, but  dwelt  upon  until  they  become  perfectly  familiar,  as  a 
preparatory  step  to  the  subjects  which  are  to  follow.  In  order  to 
obtain  a  clearer  knowledge  of  the  regions,  and  that  the  mind  may 
become  so  familiarized  with  them  as  to  refer  to  them,  and  their 
important  anatomical  relations,  with  readiness,  it  will  be  found  to 
be  a  useful  exercise  to  practise  mapping  them  out  either  on  the 
patient  or  on  the  cadaver.  By  marking  with  ink  or  black  paint 
the  boundary  lines  of  the  different  divisions,  their  situations,  etc., 
will  very  soon  become  firmly  impressed  on  the  memory,  and  much 
more  satisfactorily  and  usefully  illustrated,  than  by  means  of  pic- 
tures or  diagrams. 


PART  L 

PHYSICAL  EXPLORATION  OF  THE  CHEST. 


PART    1. 

PH7SICAL  EXPLORATION  OP  TUB  CHEST. 


I 


I 


CHAPTER   I. 

DEFINITIONS-DIKFEBENT      METRODS     OF       EXPLORATION— 
80CBCES  OF   TUE    DISTINCTIVE    CUARACTKR3   OP   DIP- 
rKKENT  SOUNDS-GENERAL  REMARKS. 

Pbtsical  exploration  of  the  chest  i»  the  oxatDination  of  this  por- 
tion of  the  body  bv  means  of  certnin  methods  invulvJDg  principles  of 
physical  science,  with  a  view  to  determine  tho  cxi«tcncc  or  non- 
existence, the  nature,  aitualion  and  progreas  of  intra-thoracic  diftwiBO. 
Ijimiling  ntlentioii  to  the  respiratory  organs,  various  abnormal  phy- 
Bical  conditions  are  incident  to  the  different  affections  to  which  they 
are  liable.  Among  these  abnormal  physical  conditions  are  solidifi- 
cation, greater  or  less  in  degree  and  extent,  of  the  pulmonary  organs, 
dtsplaceoient  and  condensation  of  these  organs  from  the  accumulation 
of  liquid  or  air  in  the  pleural  cavity,  the  existence  of  pulmonary 
fptTJtif^.  'he  presence  of  mucus,  serum,  pus  or  blood  in  the  air-paa- 
Mgdt^*  dilatation  of  the  air-cells  and  bronchial  tubes,  etc.  Owing  to 
the  oonformation  of  the  chest,  the  elasticity  of  its  walls,  the  move- 
menta  which  they  undergo,  and  the  structure  of  the  eoniaini^d  organs, 
air  being  constantly  present,  and  in  motion  to  and  fro  with  the  acts 
of  respiration,  these  abnormal  physical  conditions  ar«  represented  by 
certain  phenomena  appreciable  by  the  senses,  and  these  phenomena 
are  distingai.«lioda»  the  pAy^fWiItu/iu  of  disease.  The  diacrimination 
of  diseases,  so  far  as  these  signs  are  concerned,  constitutes  phgneal 
diagnoti*. 

The  following  are  the  different  methods  of  phyi^icnl  exp1orati<m : 
1.  Striking  the  chest  with  the  finger,  or  an  artificial  instrument, 
in  order  to  determine  deviations  from,  tlie  sounds  elicited  by  this 
process  in  health.     This  method  is  called  p«Tvu»rion. 

6 


PART    1. 

POTSICAL  EXPLOUATION  OP  THE  CHEST. 


I 


CHAPTER   I. 

DEFINITIOSS— DIFFERENT      METHODS     OF       EXPLORATION— 
ftODBCES  OF  TUE    DISTISCTIVB    CUARACTERS  OF  DIF- 
FERENT SOt'MOS— GENEKAL  REMARKS. 

PareiCAL  «xploration  of  ihe  chest  Is  the  examiDation  of  this  por- 
tion of  the  hoij^  by  means  of  certain  metbods  involving  principles  of 
physical  scienci>,  nith  a  view  to  determine  the  existence  or  noa- 
vxistcnoe,  the  nature,  nitiiftlion  anr}  progress  ofinlrs-thoracic  disease. 
Limiting  attention  to  lln;  renpiratory  organs,  various  abnormal  phy- 
MCnl  conditions  ar^  incident  to  the  different  affectionit  to  which  they 
aro  liable.  Amonj;  these  abnormal  physical  conditions  arc  solidifi- 
cation, greater  or  less  in  degree  and  extent,  of  the  piilmonnry  organs, 
displace mrnt  and  condensation  of  these  organs  from  the  accumulation 
of  liquid  or  air  in  the  pleural  cavity,  the  existence  of  pulmonary 
cavities,  the  presence  of  mucus,  serum,  pus  or  blood  in  the  tvir-pas- 
Mges,  dilatation  of  the  air-cells  and  bronchial  tubes,  etc.  Owing  to 
the  oooformation  of  the  chest,  the  elasticity  of  its  vMs,  the  murc- 
tncnto  which  they  undergo,  and  the  structure  of  the  contained  organs, 
ftir  being  constantly  present,  and  in  motion  to  and  fro  with  tlic  acts 
of  respiration,  ihvsc  abnormal  phvsical  conditions  arc  represented  by 
certain  phenomena  appreciable  by  ihe  senses,  and  these  phenomena 
arc  distinguished  as  the  pli>/»ieal tiffns  of  disease.  The  discrimination 
of  diMaws,  HO  far  as  these  signs  arc  eonccincd,  constitutes  phtftUal 
diagnon*. 

The  following  are  the  different  methods  of  physical  exploration : 
1.  Striking  the  chest  wilh  the  linger,  or  an  artificial  in.ttrument, 
ID  order  to  determine  deviations  from  the  sounds  elicited  by  this 
process  in  health.     This  method  is  called />^(^um'on. 

6 


66  rsraiCAL  BXPL0Ri.TiQ5  or  thi  chbbt. 

2.  LUtening,  with  che  ear  spplleii  -iirectlT  to  the  chest,  or  through 
a  conducting  inatranaen:.  co  illaouver  morbid  Motula  prodaced  bjthe 
movements  of  the  »ir  ia  respincion.  or  br  the  ftcts  of  speakiag  ud 
coughing.     This  meth<>l  L-  cali^l  ■nw.'ultiitim. 

3.  Examining  the  chest  «ith  the  ere,  to  see  if  there  be  deTutiou 
in  form  or  aymmeirr,  ikD'i  if  the  visible  motions  be  annatoraL  This 
method  is  calleii  intpaction. 

4.  Applying  the  hand  to  the  chest,  to  ascertain  whether  abnormal 
sensations  are  appreciable  bv  coach,  doe  to  the  morements  of  respira- 
tion, and  more  capeciallr  the  act  of  speaking.  Thia  method  is  caUed 
palpation. 

5.  Measuring  the  chest,  or  parts  of  the  chest,  bj  means  of  a  tape, 
or  graduated  measure,  and  other  insimments,  to  obtain  accurate 
information  of  alterations  in  siie  and  mobiliij.  This  method  it 
called  menturaiiim. 

6.  Shaking  the  bodrto  develope  sounds  produced  when  Uqnid  and 
air  are  contained  in  a  caritj.  which  occurs,  ocoasionallj,  as  the  result 
of  disease.     This  method  is  called  ntiTctuwm. 

The  phenomena  resulting  from  the  six  methods  of  examination  jmt 
enumerated,  are  called  phi/tic^t  npi*.  in  distinction  from  the  ordL 
nary  symptoms  of  disease,  and  the  latter  are  sometimes  called 
rational  or  rital  symptoms.  The  worls  «j/iu  and  tymptoint,  are 
often  used  without  any  adjective,  the  drst  to  denote  the  phgncal  and 
the  secoud  the  vital  phenomena  of  disease.  It  is  convenient  thus  to 
employ  these  terms,  and  there  can  be  no  objection  to  attaching  to 
each  the  distinctive  sense  just  mentioned,  in  conformity  with  conren- 
tional  usage. 

The  branch  of  physical  science  especially  involved  in  the  practice 
of  physical  exploration,  is  that  which  treats  of  the  phenomena  and 
laws  of  sound,  viz.,  aeouttiet.  An  adequate  knowledge  of  physical 
signs,  however,  requires  only  sn  acquaintance  with  acoustic  principles 
anfficiently  obvious,  and  with  which  almost  every  one  ia  famiUar. 
Although  it  may  he  true  that  a  thorough  acquaintance  with  the 
science  of  acoustics  will  qualify  one  to  understand  more  folly  and  to 
investigate  with  greater  success  the  signs  based  on  the  facts  of  that 
science,  this  is  nut  necessary  in  order  to  comprehend  and  apply, 
sufficiently  for  all  practical  purposes,  the  rules  of  physical.diagnosis. 
It  is  important,  however,  before  entering  on  the  study  of  the  signs 
which  are  obtained  by  the  two  first  named  methods  of  exploration, 
viz.,  percussion  and  auscultation,  to  have  a  clear  apprehension  of 


DBPiniTioirs. 


67 


I 


tli«  obvioae  eoarces  wlionce  •»  derived  the  distinctive  c)i»raclers  of 
different  munda ;  in  atUer  words,  to  understand  clearl}'  hovr  difTereut 
Bounds  are  distingutsUed  from  each  other.  Sounds  differ  as  regards 
intensity,  pitch  and  quality.  The  discrimination  ordilferentitoands 
inrokes  mainly  distinctive  characters  derived  from  these  three  noarcet 
of  difference,  and,  more  especially,  characters  derived  from  differenoM 
relating  to  pitch  and  quality. 

Intensity  denotes  quantity  of  sound.  A  sound  differt  from  another 
sound  in  simply  being  louder.  UiRereuces  iu  pitch  nrc  expressed 
commonly  by  the  terms,  high  and  low,  or  acute  and  grave.  Varia- 
tions in  the  pitch  of  different  musical  notes  arc  rea«Iily  apprrciated ; 
but  obvious  differences,  in  this  respect,  obtain  ainotig  sounds  which 
are  not  musical  notes.  It  will  be  seen  hereafter  thai  the  most  dis- 
tinctive of  the  differential  characters  of  many  of  the  sigii.i  obtained 
by  j>ercu3sion  and  auscultation,  arc  derived  from  diffcrcncw  in  pilch. 
Attention  to  variations  in  pitch  as  a  means  uf  discrtininatiug  the 
ugna  which  are  soundit,  lnut  hcretuforc  been  too  little  considered. 

The  term  quality  or  timfirr.,  applied  to  a  sound,  dcnotetc  a  peculiar 
character  which  is  independent  of  either  inlen»ity  or  pitch.  The 
90uud  of  any  famtltur  musical  instrument  is  at  once  nicoguised, 
tJthoagh  the  inHtrumcDt  be  not  seen.  Every  one  would  recognise 
Ute  sound  of  a  violin,  for  example,  were  the  performer  in  another 
room.  The  recognition,  it  is  plain,  does  not  depend  on  the  loudness 
of  the  notett.  nor  on  the  pitch,  for  it  make«  no  difference  vhethcr  the 
notes  be  high  or  low;  the  sound  is  recognixed  because  its  quality  is 
peculiar,  arising  from  the  particular  construction  of  that  instniment. 
The  peculiar  quality  of  any  sound  can  only  be  known  by  becoming 
practically  familiar  with  it;  no  verbal  description  would  euflice  to  give 
s  correct  idea  of  the  peculiar  sound  from  a  musical  insiruineol,  to 
one  who  had  never  heard  it.  The  only  way  in  which  an  approach 
can  be  made  to  a  correct  idea  of  the  quality  of  a  particular  sound, 
without  hearing  the  sound,  is  by  means  of  a  comparison  with  some 
otber  sound  to  wbicb  it  bears  a  resemblance.  Difference!),  as  regards 
quality,  among  sounds,  are  numberless.  Tbi»  fact  may  be  illus- 
trated by  reference  to  the  human  voice  in  speaking.  Almost  every 
one  has  a  peculiar  quality  of  voice,  so  that  a  familiar  friend,  whose 
voioe  is  well  known,  is  at  onee  reoognized  when  the  voice  is  heard. 
The  voices  of  difi'erent  persons  show  almost  as  many  shades  uf  varia- 
tion as  the  expression  of  the  face. 

It  conduces  to  simplicity  to  resolve  the  characters  derived  from 


68 


PBT8ICAL   BXPLORATION   OP   TflS   CBB«T. 


quality  of  sound  into  an  few  an  will  oufiice  for  the  discrimination  of 
Bigna.  The  following  are  names  denoting  the  differeoceji,  in  this 
point  of  view,  of  the  sohikIh  obtained  hy  porcuHsion  aiid  aunculuiion : 
resicalnr,  tympanitic,  Te«i«ulo-tyinpiu)itic,  blowing  or  hollow,  ttibn- 
litr,  Tp«ieiili>> tubular,  erackling,  bubbling,  muiiical  or  amphoric,  Tab- 
bing, grating,  etc. 

Other  sources  of  difference*  among  sounds  relate  to  dryness  or 
moisture,  nearneAa  or  diHinnci.',  tlurntion,  etc.  Pistinctivc  cbaractere, 
however,  derived  from  intcnsily,  pitch,  and  ijuality,  arc  especially 
involved  in  the  ilijtcriminntioH  of  the  most  important  of  the  physics) 
signs  perceived  by  the  sense  of  ht-nrin;;. 

Tbc  physical  higiis  of  dist-asc  represent  abnormal  physical  condi- 
tions within  the  chest.  Thus,  certain  signs  represent  a  greater  or 
lei^s  degree  of  eolidifiuiition.  other  signs  represent  pulmonary  cavities, 
others  liquid  in  the  pleural  cavity  or  in  th«  air-paasages,  etc.  It  is 
not  true,  however,  as  is  sometimes  supposed  hy  those  who  have  not 
.  given  attention  to  phyf^ical  exploration,  that  the  different  signs 
respectively  represent  different  diseases;  in  other  words,  that  each 
disea&e  has  its  own  special  signs.  The  signs  offer  definite  infonnatioii 
of  the  existence  of  certain  abnormal  physical  cooditions;  hut  many 
of  these  conditions  are  common  to  a  greater  or  less  number  of  dis- 
ease*. The  term  rational,  as  applied  to  symptoms  in  distinction 
from  signs,  would  seem  to  imply  that  (lie  perceptive  fneuUie«  only 
are  involved  in  the  application  of  the  latter  to  diagnosis.  The  in- 
ference is,  that  to  determine  the  value  of  signs,  processes  of  reasoning 
arc  not  required:  that  the  signs  express  in  themselves  their  full  im- 
port, and  that  the  ability  to  diseriminate  different  diseases  thereby 
depends  mainly  on  manual  tact  and  the  cultivation  of  the  senses. 
The  student  should,  as  soon  as  possible,  dispossess  the  mind  of  this 
error.  Few  signs,  individually,  are  pathognomonic.  Their  diag- 
nostic signification  depends  on  their  cotabination  with  other  signs, 
and  on  their  connection  with  symptoms.  Hence,  something  more 
than  delicacy  of  bearing  and  skilful  manipulation  is  requisite. 
Thought  and  the  exercise  of  judgment  are  needed,  not  less  than  in 
determining  the  nature  and  scat  of  diseases  by  their  vital  phe- 
Domcna.  In  sliort,  physical  exploration  develops  a  series  of  facta 
which  are  to  he  made  the  subjects  of  ratiocination  in  their  applien- 
tion  to  diuguosis,  as  much  as  facts  obtnined  by  other  methods. 

To  be  convinced  of  the  great  benefit  which  pructicn!  medicine  has 
derived  from  the  introduction  of  physical  methods  of  exploration,  it 


J 


flBXIEKAL    BKMARKS. 


^ 


is  only  n«cc«sarT  to  contrast  the  facility  of  dtecrimin^ling  the  most 
common  palmonarj  affections  at  the  present  time,  with  the  diflicitlty 
vhicb  confcsHcdly  exieted  prior  to  the  employment  of  these  methods. 
If  the  reader  will  turn  to  the  works  of  Cullen,  or  the  more  recent 
vritingii  of  Good,  he  will  find  that  these  authors  Kcknowleilffe  the  in- 
ability of  the  practitioner  often  to  distinguish,  by  means  of  nynip- 
tome,  pneumonitiii,  pteurilis,  and  bronchitis  from  each  other,  so  that 
for  practical  purposes  it  was  deemed  sufficient  to  consider  these  three 
affections  us  one  dt»<<»se.  At  the  present  timt-,  with  lh«  aid  of  signs, 
it  is  very  rarely  the  cii^c  thiit  tin-  di»urimiM.-itioii  cannot  bt-  made 
easily.  And  that  this  improvement  is  mainly  duv  to  phyaicftl 
exploration,  is  thown  by  the  fact,  that  to  dintinguiiih  thi-se  affccliona 
by  means  of  pymptoinn  atom',  i.i  ntill  nearly  an  difhcuU  as  heretofore. 
But  to  realize  the  importance  of  the  aubject  it  is  not  necessary  to 
institute  a  comparison  of  the  prt^Ncnt  wiih  the  past.  It  is  stiSicient 
to  refer  to  (he  mistakes  in  dliignosis  daily  made  by  practitioners 
who  rely  cxclugircly  on  «ymptom.*,  which  might  be  easily  avoided  by 
resorting  to  phyi^ical  ifigns.  ExnnipU-«  of  confounding  tlic  three 
aflcctions  jui>t  named  nrc  sufficiently  common.  Of  thcxc  affections, 
pnenmonitis  and  pleuritis  are  not  unfrequently  latent,  as  far  as  dis- 
tinctive vilal  plii-iiiinieiia  are  coni^erned,  and  consequently  are  oTer- 
looked.  Chronic  pleuritis  is  habitually  mislakcu  for  other  affections 
by  those  who  do  not  employ  physical  exploration.  Ofu  considerable 
number  of  c-ases,  the  bii>tortcs  of  which  I  have  collected,  in  a  lirge 
proportion  the  nature  and  seat  of  the  di^aso  had  n»t  been  asct^^- 
luined.'  Yet  nothing  is  marc  simple  tliun  to  determine  ilie  exist- 
fence  of  this  affection  by  an  exploration  of  the  chest.  Acute  pleu- 
ritis and  pneumonitis  arc  sometimes  completely  masked  by  the 
symptoms  of  other  associated  affections,  and  thus  escape  detection. 
Tbis  is  observed  in  fevers,  and  when  head  symptoms  become  de- 
veloped, especially  in  children.  Under  thc«c  circumstances,  the 
practitioner  who  availshimself  of  physical  signs  is  alone  able  lo  arrive 
*t  a  positive  conclusion  as  to  their  existence.  Emphysema  is  an  af- 
feclion  which  cannot  be  recogoiKed  by  tymptoma  alone,  and  hence, 
thry  who  neglect  a!gns  have  no  practical  knowledge  of  it.  Acute 
tnWrcnlosifi  I  have  known  repeatedly  to  he  called  typhoid  fever;  on 
the  other  hand.  I  could  adduce  numerous  examplea  of  different  affee- 
tioas  erroneously  eoni^idervd  lo  be  phthiiti*,  and  a  still  greater  num- 


■  dib  C'lioiuil  Bpport  on  Chroalc  PUurltj,  by  lb*  author. 


pffraiCAt  ispLORATroH  ov  tvm  «bmt. 


ber  of  ioBtanccs  in  wIiicL  patieote  iriili  tLiit  affection  were  incorrvell; 
snppoBed  to  be  affected  witli  tome  olfacr  diMasc  tban  tuberculosis. 
Wore  «c  to  dwell  ui>on  tlic^c,  nnil  otiier  mistakes  wbich  might  be 
added,  it  would  be  easy  to  abow  that  th«7  are  onfortnnate,  not 
merely  in  a  scientific  point  of  i-iew,  but  witfi  reference  to  practical 
consc()Denc«e  involriog  the  welfare,  and  U  may  be  the  livcB  of 
patienUi. 

The  physical  exploration  of  the  cbest  has  certain  (Striking  advan* 
tagc»  which  may  bo  brieBy  noticed.  The  phenomena  tbuB  developed 
are  entirely  oty'*rfiW.  They  have  no  connection  with  the  mind  of 
the  patient.  They  are  therefore  free  from  the  difficulties  and  1inbili> 
ties  to  error  arising  from  ignorance,  deception,  self-delusion,  dispo- 
wtioD  to  exaggeration,  or  desire  of  concealmenl,  which  belong  to 
$vfijfeticf  symptoms.  They  are  available  in  children  too  young  to 
give  information  respecting  their  diseaaes;  in  cases  of  mental  de- 
rangement, and  in  the  condition  of  coma.  The  evidence  which 
tbey  afford  of  morbid  conditions  is  more  positive  than  that  furnished 
by  symptoms.  Frequently  in  stiempting  to  arrive  at  a  diagnosis 
by  means  of  the  latter,  we  can  only  reach  an  approximation  to  cer- 
tainty. In  forming  conclosioDS  ne  are  obliged  t«  balance  proba- 
bilities. Tl)i!>  uncertainly,  of  courM\  inflii'^ncci'  the  miinngi-ment  of 
diseatte.  Jlut  the  informution  oblnined  by  the  aiil  of  si^jus  is  often 
so  complete  and  prccixe,  as  to  leave  nothing  moro  to  be  desired. 
The  proof  of  the  existt-nec  of  certain  affrction*  i*  cxncl  and  d©- 
monairativc,  leaving  no  room  for  hesitation.  Physical  signs  are 
more  readily  and  quickly  available  than  symptoms,  diagnosis  U 
thus  more  prompt,  as  well  as  more  positive.  Hence,  diseases  are 
recogutiol  at  an  earlier  period, — a  point  often  of  very  great  eonse- 
qucnec  as  regards  successful  treatment.  Their  value  is  frequently 
aa  conspicuous  negatively  as  positively;  that  is,  deductions  from 
tJieir  absence  arc  as  important  and  decisive  as  from  their  presence. 
Finally,  in  view  of  the  considerations  jiist  presented,  this  branch  of 
practical  medicine  BlTords  to  the  practitioner  a  sense  of  gratifica- 
tion greater  than  that  whith  be  derived  from  clinical  inTestigalion* 
by  means  of  symptoms. 

By  thus  directing  attention  to  some  of  the  points  of  contrast  be- 
tween symptoms  and  signs,  it  is  not  to  be  concluded  that  these  two 
classes  of  phenomena  hold  conflicting  relations  in  the  practice  of 
medicine.  Neither  is  to  be  employed  in  diagnosis  to  the  exclui>iofl 
of  the  other.     Tbey  are  not  to  be  disconnected  save  for  abstract  con* 


OIRBIIAL    BBMAnRB. 


71 


■ 
■ 

I 


aidoralion.  The;^  mro  alwmys  to  be  brought  to  bM>r  conjointly  ia 
clinical  invo»tig«tioiiit ;  coRibincd,  tbev  lead  to  conclusions  which 
neither  may  be  competent  lo  cstaMiwh  alone.  They  mHlunllj  serve 
to  correct  or  confirrn  (!cducit»ii»  drawn  front  either  separately.  It 
is  never  to  be  lust  t>igbt  of  in  the  study  or  practice  of  physical  ex- 
plor»tion,  that  to  devote  too  exclusive  attention  to  signs  is  as  much 
ft  fault  KS  to  ignore  their  vsliic,  and  rely  entirely  ou  syniploma. 

14otvith:>tan<Iing  the-»c  ndvanlages,  and  llie  importance  of  physical 
exploratiou  in  the  dia^^noitis  of  diseaaeA  alTecting  the  respiratory  ap- 
parstns,  it  is  Ktill  employed  by  only  a  small  proportion  of  medical 
practilivnerv.  ^^omc  even  now  profess  to  attach  bat  little  value  to 
signs;  a  much  larger  number  practically  repudiate  them.  This  fact, 
however,  may  be  stated,  viz.,  no  one  who  ban  devoted  But!ic>ent  attcn- 
tjon  to  the  subject  to  apply  succeiwfulty  the  wt'll.«8tahti.-lifd  rules  of 
physical  diagnosis  at  the  bedside,  has  ever  denied  having  received 
great  assistance  therefrom,  or  advocated  a  neglect  of  them.  They 
■who  depreciate  and  forego  the  benefita  of  physical  methods  of  exami- 
nation have  had  little  or  no  experience  of  their  practical  application. 
If  the  foregoing  assertion  be  true,  the  explanation  of  the  fnct  that 
this  branch  of  practical  medicine  is  properly  efltimaled  and  cultivated 
by  BO  few,  iii  to  be  sought  for  in  causes  discouraging  the  pursuit,  or 
in  difficullieti  attending  it  which  are  not  easily  BunuountL-d.  Such 
cauaes  and  apparent  difhculties  vxixt.  It  i»  a  cotanion  improsaion 
that  it  is  uselesii  to  attempt  to  areompli^h  anytbiijg  salii>fMCtory  in 
physical  exploration  unless  the  sense  of  hearing  be  aingularly  apt  lo 
distinguish  nice  abadett  of  dilfcrence  in  sounds  ;  and,  in  addition  to 
this,  extraordinary  application  and  opportunities  arc  tiiippo^cd  to  bo 
indispensable.  These  ideai<  do  great  iujlltkticl^  to  the  subject.  So 
far  as  the  more  iuiporlant  diagnostic  principles  arc  concerned,  both 
in  their  apprehension  and  application,  they  are  exceedingly  simple. 
The  points  which  are  abstruse  or  intricate,  aa  n  general  remark,  are 
those  which  are  of  the  least  practical  consequence.  Oral  instruc- 
tion  by  an  expert,  with  explanations  and  illustrations  at  the  bedeide, 
are  undoubtc^lly  of  very  great  use,  as  well  us  the  selection  of  cases 
which  a  large  hospital  utTords.  But  these  advantages,  although 
highly  desirable,  arc  not  absolutely  essential;  and  it  ia  possible 
for  an  intelligent  student  or  practitioner,  solely  with  the  aid  of 
books,  and  opportunitic«  for  observation  which  may  be  enjoyed  every- 
where, to  acquire  a  practical  knowledge  of  physical  signs  sufhcicnt 


V2 


PHYSICAL    EXPLORATION    OP    THE    CHEST. 


for  ordinary  purposes  of  diagnosU.'  A  lithe  of  the  time  so  oft«n 
occapii-d  bv  medicitl  students  in  becoming  Tery  indifFercnt  perfonnora 
on  some  musical  instrument  would  more  than  answer  to  make  (hem 
adepts  in  the  practice  of  physical  ezplomtion.  Acutenera  of  Uw 
sense  of  heariog,  and  an  ear  for  music,  are  doubtless  uacful  qoalifi- 
GS110D9 ;  but  the  sounds  to  be  recognixed  snddistinguiBbed  from  each 
other  arc  generally  easily  discriminated,  aod  I  have  known  tolerably 
good  auscultators  who  were  not  only  unable  to  appreciate  musical 
notes,  but  who  labored  under  some  degree  of  deafness. 

In  treating  of  physical  signs,  they  are  to  be  considered  nnder 
three  aspects.  The  first  aspect  relates  lo  the  distinctive  cbaractera 
of  the  physical  signs,  respectively,  as  the  means  by  which  they  are 
to  be  recognized  and  discriminated.  The  sources  of  the  distinctive 
characters  of  iho  signs  obtained  by  percussion  and  auscultation,  u 
baa  been  seen,  are  mainly  diSerences  with  respect  to  tntenaily,  pitch, 
and  quality  of  soimd.  The  Grstelep  in  the  study  of  physical  cxpl^ 
ration  is  to  learn  to  distinguish  practically  the  different  signs  by 
means  of  their  distinctive  characters.  It  is  not  sufficient  to  have  a 
general  indefinite  knowledge  of  the  signs;  they  must  be  thoroughly 
known,  and  this  knowledge  c^n  only  be  acquired  by  nnulysing  those 
signs  which  arc  sounds,  with  reference  especially  to  intensity,  pitch, 
and  quality.  The  characters  of  the  signs  must  be  verified,  and  the 
signs  made  familiar  by  practical  11  lust  rations,  or,  in  Other  words,  by 
direct  observation;  and  vrith  reference  to  a  practical  knowledge  of 
the  signs,  examinations  of  the  healthy  chest  are  to  be  premised.  The 
results  of  examinations  of  the  healthy  chest  constitute,  of  coano, 
tbc  point  of  (U-pnriurc  for  iletenniiiing  the  characters  of  the  f'tj^nt 
of  disease;  ami  by  tbeiie  examinations  are  dctermine<!  the  variations 
which  exist  irrcHpcctivc  of  disease,  i,  «.,  within  the  limits  of  health. 

The  second  sspcct  relates  to  the  stgnificuncc  and  value  of  the 
signs  separately  and  in  combinultun.  What  are  the  abnormal  con- 
ditions which  they  represent  ?  In  a  practical  treatise,  the  facts 
embraced  in  tins  view  of  the  subject  are  of  paramount  iioportance. 
Hew  arc  these  facts  ascertained  ?  in  other  words,  in  what  manner  is 

>  1  would  Dot  bo  understood,  by  Ihcte  rpmorki.  to  undcrviilaa  Ib«  imporlaiicn 
of  n  iiis«t«rV  Siiatruc'lioii  ;  but  fur  ihu  «riourHp<mi.-iiI,  of  Ili<>4u  wlio  miiy  not  be 
able  to  BViil  ilirrotclvea  of  thU  advanugc,  in  conncoUrin  with  hoipUnl  op^Minu. 
niti»,  I  4**\rf  10  tijireu  tbe  conviction  thitl,  wllhoul  th<-iii,  ■  f>ronctPt>i:y  suO- 
cioni  for  ducrl  mi  nation.  In  a  largo  proportion  of  tbe  cMot  occurring  in  mrdiol 
prx-'tice.  in  Hiultinlile. 


GKITKBAt    SBHXBKS. 


78 


I 
I 


oar  knowledge  of  signs,  as  the  reprcsentativps  of  morbid  pitysicsl 
comiiiions,  (itlitinH  ?  l*liy«ical  jihenoraetia  beporae  signs  of  the  mor- 
bid c)iaiigc«  incident  to  di^cttae  vrlieiiover  it  U  e»lablishcd  thai  there 
eicisUi  a  conatAncy  of  M«ociation  of  thotic  phenomena  with  the  pby- 
cical  change*  which  <liHen«e  induce*.  Being  uniformly  found  together, 
a  eonnectioa  between  the  two  is  logically  provetl,  and  Ihe  former 
may  bo  ri'garded  as  representing  the  latter.  This  is  the  basis  of  the 
•cieDce  of  physiail  exploration.  And  this  constancy  of  association 
is  dctemiinml  by  clinical  observation  together  with  the  information 
derived  from  post-iDortcm  examinations.  Certain  physical  phe* 
nomcnn  observed  during  life  arc  found  uniformly  present  in  eases  in 
which  ili»:<«ction  reveals  certain  morbid  changes.  Hence,  whenever 
particular  phenomena  are  recognized,  we  arc  authorised  to  infer  the 
existence  of  corresponding  morbid  conditions;  the  phenomena  in 
this  way  become  signs,  and.  contcrscly,  whenever  certain  morbid 
conditions  exist  prior  to  death,  we  may  expect  the  phywcal  phc- 
nonena,  or  signa,  which  previona  observation  has  shown  to  coexist 
with  them.  In  short,  ihe  evidence  of  the  value  and  si^ificance  of 
signs  rests  nn  experience.  This  is  a  fact  not  to  be  lost  bight  of  in 
the  study  of  physical  diagnosis,  and  especially  in  the  endeavor  to 
eontribule  additions  to  our  knowledge  of  the  subject.  Much  as  has 
been  already  accomplished,  there  is  ample  scope  for  further  re- 
searches in  this  direction.  Many  questions  of  practical  interest  and 
importance  are  open  for  investigation  by  means  of  the  aiialyitia  of 
recorded  observations  in  the  living  and  dead  subject.  The  applica- 
tion of  the  numerical  method  to  the  study  of  physical  signs  is  far 
from  having  been  completed. 

A  third  aspect  under  which  physical  signs  are  to  he  conridered  ia 
Ihe  mcehaniAm  of  their  produuti'>[i.  This  is  the  tlieoreticil)  pftit  of 
the  subject,  and  is  to  be  pursued  with  great  circumspection.  The 
endeavor  to  account  for  the  results  of  physicnl  explorntion  open*  a 
wide  range  for  speculntion.  A  jmori  conclusions  ns  to  the  phe- 
nomena which  ought  to  ftcciimpany  certain  physical  chnngeif  are  not 
•dniinfible  except  as  tempornry  hypotheses  to  be  tested  by  the  results 
of  clinical  and  post-mortem  observations.  Experiments  made  <m 
the  dead  sabject,  and  artificial  contrivances,  in  order  to  imitate  the 
sounds  which  characterize  certain  signs,  or  to  prove  the  correctness 
of  hypothetical  explanations,  are  to  be  received  with  a  certain 
amount  of  ilistrust,  for  it  is  almost  impoBsible  to  ascertain  and  ro- 
prodnee  all  the  physical  elements  which  are  combined  in  the  living 


74 


PHT8ICAL    IXPLOnATIOX    OF    TBB    CHEST. 


body.  There  ia  reason  to  believe  that  thU  attempt  has  giren  rise  to 
false  riews,  to  which  reference  will  be  made  hereafter.  Desirable  u 
it  undoubtedly  b>  to  understand  as  fully  as  |kasaible  the  rationale  of 
physical  signs,  thoir  importance  and  availability  in  diagnosis  by  >o 
means  depend  on  tbe  attnininent  of  this  end.  Several  of  the  signs 
will  afford  illustrations  of  the  truth  of  this  remark ;  its  correctness 
indeed,  is  implied  in  the  fact  already  stated,  vis.,  that  our  positive 
knowledge  of  tbe  aignlficance  and  value  of  signs  is  based  on  ex- 
perience. 

In  entering  on  the  study  of  physical  cxplorntioD  the  first  objeoi 
should  be  to  keeome  acquainted  nilb  the  ascertained  facts  pertaining 
to  tho  subject.  It  is  sometimes  advised  that  tbe  student  should  at 
onco  CDtnioence  clinical  observation  without  previous  acqoaintaDce 
with  the  knowledge  which  has  been  acquired.  This  is  to  place  bin 
in  the  position  of  the  original  explorers,  without,  it  may  be  pre- 
sntned  in  most  instances,  their  genius  and  industry.  Progress  in  thil 
way  must  bu  slow,  and  unsalisfaclory,  compared  with  ttnt  whick 
may  be  made  by  availing  oneself  at  the  outset  of  the  labors  of  othen. 
Tbe  facts  which  have  been  ascertained  are  to  be  understood  by  re- 
sorting to  oral  innlruction  or  books,  and  as  fast  as  practicable  tbej 
are  to  be  rerilird  by  actual  obHerralion.  The  signs  developed  by  tho 
different  methods  of  exploration  are  to  be  studied  singly  and  coo- 
biDed.  Isolated  from  tbe  others,  the  knowledge  perlainiog  to  each 
has  relation  to  its  distinctive  cliaracters,  its  significance  and  diag- 
nostic value,  and  the  probable  e.ipUnation  of  tbe  mode  of  its  pro- 
daction.  It  is,  however,  as  alrea<ly  intimated,  very  rarely  the  case 
that  the  diagnosis  resU  on  a  single  sign.  Various  signs  are  generally 
associated,  and  it  is  by  their  combination  thai  we  are  enabled  to  ar- 
rive at  positive  conclusions  as  to  the  nature,  seat,  or  stage  of  dis- 
eases. Were  it  necessary  to  rely  exclusively  on  the  Bpecial  signifi- 
cance of  individual  signs,  ibe  application  of  physical  exploration  to 
diagnosis  would  lie  much  more  limited  than  it  is.  Its  scope  is  greatly 
enlarged  by  uniting  the  information  derived  from  the  different 
meihodd  of  examination.  Moreover,  in  determining  the  existenoe 
of  individual  »igiis,  our  uIkot  vat  ions  are  rendered  positive,  or  other- 
wive,  by  reference  to  their  combinations.  The  mutual  relations,  there- 
fore,  of  the  different  signs  constitute  a  highly  important  branc])  of 
the  suhjcrt.  f^epuratety,  the  signs  may  be  compared  to  the  wonls 
whid)  compose  a  Innguage;  the  law»  of  their  combinations  are  an- 
alogous to  syntax.  A  knowledge  of  both  is  necessary  in  order  to 
interpret  oorrcaily  ihn  physical  expreasiou  of  disease. 


6EXBRAL    RBMARKS. 


75 


For  the  succeMfiJ  practice  of  physiciil  exploration  tbc  factit  per- 
tainiiig  thereto  toast  not  only  be  undcretood,  bat  lh«-j  inui>l  ht  nt 
command,  &o  as  to  be  readilj  availablG.  The  prnctitioniT  iiiii«t  b« 
qaalified  to  appreciate  characteristic  sounds,  and  detennine  the  value 
or  their  combinations,  without  waiting  to  refer  to  anthorities,  or  even 
for  deliberate  meditation.  The  signs  must  be  made  as  fftmilinr  M 
houMhold  words.  This  id  to  be  attained  by  practice,  and  preserved  by 
DODBtani  exercise.  Evcrp  one  ac«iistoined  to  pmciise  physical  ex* 
ploration,  miiHt  have  nolic«d  that  after  an  intermission  in  its  employ- 
mcnt  for  some  time,  the  u»ual  facility  and  cjuickness  in  arriving  at 
satisfactory  r«au)ls  are  U-mporarily  somewhat  impaired.  For  thu 
reason,  were  there  none  other,  the  habit  of  daily  examining  the 
chest,  to  a  greater  or  Wx  extent,  in  all  ca»e.s,  is  to  be  recommended. 

In  treating  of  the  prineiplet*  and  practice  of  physical  exploration 
in  the  following  pngoe,  the  aim  will  be  to  pr<-sent  facts  and  conud- 
erations  which  have  direct  prnclical  bcoriDgs  on  diagnosis.  Infiulries 
parely  theoretical  or  relating  remotely  to  tbediscriminaiion  of  dts- 
ca8«8,  and  discusttioiis  of  mooted  points,  will  receive  but  little  atten* 
tioD.  Snch  inquiries  and  diHcus«ion«,  for  the  most  purt,  have  refer- 
ence  to  the  Diechanism  by  which  the  phenomena  detected  by  the 
different  methods  of  exploration  are  produced.  To  this  department 
of  the  subject  I  shall  devote,  relatively,  but  a  small  space,  in  part 
from  a  conviction  that  the  advRniage  of  iho  render  will  thereby  b« 
consulted,  and,  it  is  hut  candor  to  add,  in  part,  because  my  own 
stodieM  have  been  chiefly  confined  to  clinical  observations. 


IH AFTER  II. 


PBRCnSSION. 

ExpMRATian  hy  percussion  consbiui  in  striking  th«  cliMt  so  as  to 
indaoe  nonorouii  vibr»tions.  In  consequence  of  the  olasliciij  of  the 
thoracic  walls,  and  the  presence  of  air  in  the  pulmonary  oelU,  ■  cer- 
tain degree  and  kind  of  Bonorousticss  are  produced  when  strokes  un 
innde  in  a  manner  to  elicit  &ound;  and  various  changes  as  regards  the 
phjrsica)  conditions  incident  to  disease,  occasion  corresponding  den- 
■  lions  from  the  tjpe  of  sonorousness  pertaining  to  a  heallliy  state. 
Pt-rcnsvion  may  be  practised  in  different  modes.  As  first  introdaecd 
by  .\uenl rugger,  in  1761.  the  blows  were  applic<l  directly  to  the 
clie9l,  without  any  intervening  medium.  Thi«  is  ciillcd  immrJutU 
percussion.  Shortly  after  the  more  recent  discoveries  by  LaennM, 
vhich  served  at  once  vastly  to  enhance  the  importance  of  the  method 
of  exploration  under  present  consideration,  mediate  percnssion,  as  it 
is  termed,  was  employed  by  Piorry,  of  Paris,  and  has  since  been 
generally  adopted.  In  medittte  percussion  the  blows  are  made  on 
an  intervening  solid  medium,  applied  to  the  chest,  and  styled  uplex- 
imritT.  The  plcximoler  used  by  Piorry  is  a  thin  oval  disk  of  polished 
ivory,  about  two  inches  in  length,  and  an  :neb  in  its  greatest  width, 
vith  an  upright  border  at  both  extremities  projecting  about  half  an 
inch.  These  projections  serve  as  handles  by  which  the  inatroment 
is  adjusted,  and  held  in  contact  with  the  thoracic  walls.  On  one 
side  a  Hcnic  for  mcniinromcnt  is  sometimes  marked  in  black  lines, 
irbich  is  useful  in  determining  occiinitcly  spaces  and  distances  on 
the  chest.  The  plcximcter  which  I  have  used  for  several  years  has 
the  form  of  Piorry 's  instrument,  but  is  made  of  tinrd  india-rub- 
ber. The  auricles  should  be  roughened  on  the  outer  surface,  and 
sufficiently  large  for  the  instrument  to  be  conveniently  held.  As 
it  is  desirable  to  avoid  as  much  as  possible  noise  from  the  plex- 
imeter  in  practising  percussion,  an  improvement  is  to  cover  the  vppw 
surface  with  a  thin  layer  of  soft  india-rubber  or  wasb-leather.     A 


psBci;eaioH. 


77 


iKinare  blocit  of  india'robber  ansirera  tolerably  w«)1  as  a  p1eximet«r; 
but  tbe  rc&oiiance  elioUed  by  percu&sion  ujvon  it  U  much  leaa  thin 
when  a  pleximet«r  of  ivorj  or  hard  rubber  is  used.  Many,  however, 
Bif  not  most  practiiioners  who  practise  physical  exploration,  use,  for 
the  most  pan,  simply  the  fir^l  or  flt-coml  fiii};t'r  of  tho  left  hand,  tbe 
palmar  surface  being  applied,  in  n  traiisverNc  dirMtion  to  iho  uhesU 
The  finger,  as  a  plexinieter,  is  superior,  in  many  respects,  to  any 
artificial  instrument.  In  size  and  form  it  ia  well  adapted  to  be  ap- 
plied over  the  nb-s  and  in  the  intercostal  npncea.  Tliv  force  with 
which  it  is  applied  can  be  easily  gradii«ted.  It  renders  the  oper* 
ation  of  percussion  loss  formidable  to  the  pnlicnl,  and  in  cnws  of 
children  espvcially,  this  it  not  a  small  odvanta;;c.  It  affords  infor- 
mation as  ret^pceto  the  imte  of  re»i»t<inee,  which  it  will  bo  seen  pres- 
ently is  a  point  of  considerable  imporlniicc.  Finally,  among  minor 
recommendations,  it  costs  noihing,  and  in  the  inoHt  literal  sense  is 
always  at  hand.  Th«  only  disadvantagu  attending  it  is  the  liability 
to  sniFer  tnjnry  if  in  constant  use.  This  I  have  found,  nt  times,  a 
aerioDs  impediment.  The  dorsal  surface  is  opt  to  become  tender, 
•wollen.  an]  in  fact,  periostitis  may  be  induced  by  the  repeated 
blows,  contiant-d  daily,  especially  when  forcible  percussion  is  prac- 
tised with  a  view  to  clinical  illustrations.  Other  plexiroetera  than 
the  finger  obviate  the  dinieuUy  just  mentioned,  but  anide  from  this 
advantage  it  may  be  doubted  if,  for  ordinary  purposes,  there  arc  any 
reasons  why  they  may  not  lie  dispensed  with,  nt  lenst  in  private 

t  practice.  In  hospital  or  dispensary  prauliee,  owing  to  the  number 
of  patients  to  bo  examined,  an  artificial  instrument  may  be  requisite. 
Percussion  may  be  made  by  one  or  more  of  the  fingers  of  the 
right  band,  or  with  some  kind  of  hammer  constructed  for  that  pur- 
pose. The  latter  is  termed  a  perctmor.  A  variety  of  instruments 
for  making  percussion  have  been  contrived.     The  percussor  which  I 

»faav«  used  for  several  years,  consists  of  a  hammer  composed  of  india- 
rubber  in  the  form  of  a  double  cuue.  This  is  6rmly  fixed,  at  the 
oontrci  in  a  metallic  ring,  which  is  attached  to  n  handle  of  courenieot 
eiee  and  length.  This  instrument  produces  as  little  noise  us  possible, 
exclusive  of  the  resonance  coming  from  within  the  chest,  and  it 
seems  to  me  to  leave  nothing  to  bo  desired  as  regards  weight,  form, 
and  durability.  Most  proctilioners,  however,  are  satisfied  with  one 
or  more  of  the  fingers  of  the  right  hand,  bent  in  a  half  vircle;  and 
percussion  thus  made  answers  all  practical  purposes. 

The  mode  of  performing  percussion  is  a  point  of  practical  impor- 


78 


rBTIICilt.  BXPLOKATlOir  «P  TBI  CRSST. 


It  M  DoC  »t  ODM  so  easT  mftttcT  to  strike  so  u  to  pndttM 
n  lh«  aoat  aattsfactory  nunner  soooroas  TibnttoD&     CertAto  nilts 

uv  to  be  obecTTcd.  mad  tset  is  to  be  »eqmred  by  prutice.  Tb« 
fingers  are  to  be  fleied  m  tbat  their  ettda  ^11  bll  perpeodiaiUrl; 
on  the  plcxitoewr,  sn<)  the  strokes  xre  not  to  be  nnde  with  the  ptilpjr 
portion  of  their  extremities.  The  Mows  sboold  be  girea  with  i 
eeruin  <)mckness,  the  fingers  brooght  into  contact  with  the  p]cx- 
imeter  and  withdrawn  as  it  were  tnstaniaDeoa&ly,  hj  a  moTemnt 
finited  almost  entire);  to  the  wrt^i-joint.  When  a  light  percaasiiM 
it  deiired,  the  index  or  middle  finger  alone  maj  be  employed,  bit 
when  greater  force  is  requisite,  two  or  three  fingera  shoald  be  naed 
oonjmntly.  In  the  latter  case,  it  i«  better  to  percssa  with  the 
fingers  on  a  tine,  wilhont  bringing  forward  the  thomb  into  appo- 
■ition.  With  the  thumb  free,  the  raovements  at  the  wrist  are  un- 
restrained, and  the  fingers  do  not  nev<]  any  additional  support. 
The  type  of  perfect  percmuion  is  witnessed  in  ms«icnl  performances 
on  a  series  of  bells  representing  the  different  notes  of  the  gamut 
It  ■■  also  seen  in  the  manner  in  which  the  little  hammers  atrike 
•nd  reboand  from  the  strtogs  of  a  piano-forte  when  the  keja  are 
touched.  The  object  tn  these  examples  is  precisely  the  same  aa  in 
peroossing  the  cheitt,  viz.,  to  elicit  sounds  as  distinct  and  pare  as 
possible,  sad  they  may  therefore  be  taken  as  models  for  imitation. 
It  is  generally  easy  to  know  at  a  glance,  by  the  mode  in  wbich 
percoMion  is  made,  whether  it  he  reoorted  to  in  order  to  develop 
phyaical  signs  witli  the  import  of  which  the  practitioner  is  practi- 
cally familiar,  or  whether  it  be  employed  merely  for  form's  sake,  or 
to  affect  nn  itcquuintancu  with  the  subject.  Kulcs  of  manipulation 
pertaining  to  the  prtivticc  of  percuij«iou,  in  addition  to  the  fore- 
going, will  be  given  presently. 

A  mode  of  prnetising  percussion,  inrotving,  for  certain  pQn>*)^^ri 
an  important  improvement,  was  proposed  some  time  since,  by  ^^4 
O.  I'.  Cammann,'  and  Prof.  A.  Clark,  of  New  York.  The  pecu- 
liarity of  this  mode  consists  in  combining  with  percussion  another 
of  the  methods  of  exploration,  vis.,  nusciiUatiou.  Percosftion  is 
made  while  the  ear  is  applied  to  s  cylinder  of  woml,  or  slethoaoopc, 
placed  in  contact  with  the  chest.  This  is  distingnitihed  as  aittctU- 
talttri/  p^reuMiaH.  Its  advantugcs  consist  in  the  better  transmis^ on 
of  sounds  than  when  they  are  communicated  through  the  atuoaphere^ 


>  Now  Tork  Journiil  of  Medicine,  July,  IBM 


PBRCUBBIOir    ITt    BRALTH. 


19 


«nd  in  the  pester  distinctness  with  which  differences  in  pitch  and 
qnality  are  appreciated.  It  is  particularly  useful  in  determining 
the  boundaries  of  the  solid  organs,  other  than  the  lungs,  which 
encroach  on  the  thoracic  space,  viz.,  the  hesrt,  liver,  and  spleen. 
Auscultatorj  percussion,  however,  is  rarely  resorted  to,  because, 
for  ordinary  purposes,  the  other  and  simpler  mode  suffices.  In 
some  instances,  for  example,  when  it  is  desirable  to  ascertain  with 
exactitude  the  space  occupied  by  the  heart,  it  may  be  employvd 
with  adrantage. 

I  In  treating  of  the  resulla  of  percusaion  we  arc  to  consider,  fir$t, 
the  phenomena  pertaining  to  health;  and,  neecnJ,  the  phyaicol  signs 

'  «f  disease. 


PKBCDSgiOM  IX  Health. 


I 

■  Percuesion  made  on  the  chest  of  a  person  in  health,  develops  a 
Hresonanoo  which  is  peculiar.  The  quality  of  sound  is  highly  char- 
•clcristic,  and  cannot  he  dc:<crihcd  nor  illustrated  by  comparison. 
This  quality,  or  timbre,  is  due  to  the  fact  that  the  nir  within  the 
chest  is  contained  in  an  immense  number  of  minute  spaces — the  air- 
resicles.  The  sonorousness  denotes  the  presence  of  air,  and  the 
contrast,  in  this  respect,  is  readily  shown  by  percussing  6rst  the 
cbflSt,  and  next  a  portion  of  the  body  composed  of  a  solid  mass  of 
bono  and  muscle,  for  example  the  thigh.  The  peculiar  quality  of 
Bound  is  appreciated  by  percussing  successively  the  chest  and  ah. 
domeo,  provided  the  stomach  or  intestines  be  somewhat  flatulent. 
In  the  latter  situation  the  sonorousness  arises  from  the  presence  of 
gas  in  a  free  space  of  considerable  sise,  and  in  distinction  from  that 
due  to  the  presence  of  air  in  the  lungs,  it  is  called  tympanitic  rtao- 
fume*.  This  kind  of  resonance  becomes,  as  will  be  seen  hereafter, 
under  certain  circumstances,  a  physical  sign  of  disease.  Its  type, 
as  the  name  impli<'s,  is  the  sound  produced  by  percussing  the  ah- 
domen  when  tympanitic.  On  the  other  hand,  the  sound  peculiar  to 
the  cheat  is  distinguished  as  the  pulmonrtn/  or  vfticttlar  rftonanee. 
The  term  vetiailar  is  preferable,  and  I  shall  tliL-rcfore  employ  it. 
HpD  naing  the  tvnu,  however,  it  is  not  to  he  understood  that  the  ehsr- 
■eter  of  sound  would  suggest  A  priori  the  existence  of  air-vesicIes, 
bm  its  appropriateness  is  based  ou  the  fact  that  the  distinctive 
qoaljty  of  the  resonance  is  attributable  to  the  presence  of  air  in  the 
Mr-reaieles.     In  addition  to  ics  peculiar  quality,  the  vesicular  re»»- 


80 


7HTSI0AL    RXPLOKATIOIt    OV    THB    CflEST. 


nanG«  has  a  certain  pitch,  and  m  this  respect,  compared  vnth  «11  the 
abnormal  sounds,  it  is  lov.or  grave.  The  sound  also  baa  a  oertMD 
degree  of  intensity. 

As  regards  the  normal  resonance  in  the  three  aspects  jost  meo- 
lioiiod,  vis.,  Tcaicular  <[uslitj,  pitch,  and  intensity,  it  b  not  identi- 
cal when  percussion  is  practised  in  the  same  manner  on  the  chests 
of  difierent  persons  in  health.  Tiiin  may  be  demonstrated  by 
placing  a,  number  of  pi.-ri«ons  in  a  row,  and  percussing  them,  seTer- 
ally,  in  succession,  in  i!ic  Mime  situations.  The  sound  in  no  two  of 
tlte  persons,  perhaps,  will  be  exactly  alike.  It  will  present  marked 
diflVrences  in  the  dcp-cc  of  vesicular  ijuslity,  in  pilch,  and  in  is- 
ten!>ity.  This  is  owing  to  differences  in  the  eliuiticily  of  the  thora* 
cic  walls,  in  the  volunir  of  the  pulmonary  organs,  in  the  amount  of 
muscular  mid  iidipOMV  ti^^iien  covering  the  chest,  and  other  circun- 
stances  not  so  ensily  apprecisted. 

Nor  is  the  percussion-vound  idenlicsl  over  every  portion  of  tht 
chest  in  the  same  person.  In  corresponding  sitaations,  on  the  tw» 
sides  of  the  chest,  howerer,  with  certain  exceptions,  the  tonnds 
developed  by  percussion  arc  coniiidored  to  be  identical,  or  nearly 
so.  This  is  a  very  important  fact  in  tts  bearing  on  physical  explo- 
ration. It  is,  indeed,  of  fundamental  importance  in  estimating  the 
physical  signs  of  disease,  inasmuch  as  the  latter  are  determined  not 
by  reference  to  an  ideal  standard  of  health,  bat  by  cotnparisMi  of 
one  side  of  the  chest  with  the  other  side.  As  respects  normal  res- 
onance, e<iuality  of  the  two  halves  of  the  chesi,  with  some  excep- 
tions, is  assumed.  Were  we  not  warranted  in  doing  eo  to  an  extent 
•ofGoient  for  most  practical  purposes,  it  would  often  be  difficult  to 
decide  whether  or  not  the  sound  developed  by  percussion  denote 
discai^e;  and  the  same  is  not  less  true  of  other  methods  oF  explo- 
ration thiin  of  percussion.  But  it  is  obviously  important  to  as- 
certain as  completely  as  possible  the  deviations  from  this  ruW  of 
equality,  which  may  exist  within  the  limits  of  health;  otherwise 
there  is  a  liability  that  such  deviations  may  be  mistaken  for  the 
physical  evidences  of  disease.  In  order  to  determine  to  what  ex- 
tent and  in  wlmt  piirtioutnrs  dispivrily  between  corresponding  por- 
tions on  the  two  sides  may  he  eouipiUible  with  beullh,  examinaiiou 
are  to  he  made  of  the  cheats  of  persons,  selected  for  tliat  purpoae, 
who  are  presumed  to  be  entirely  free  from  pulmonary  disestsc;  the 
phenomena  must  be  carefully  recorded,  and  a  eollvction  of  &cU 


PSHCVS8I0X    IK   HEALTH. 


81 


thus  obtained  sabjected  to  analysis.  I  eb&ll  give  the  results  of 
such  an  investigation  as  regards  percussion,  and  the  other  methods 
of  exploration.  1  will  now  prooei'd  to  a  nomparisou  of  the  scTcral 
regioDH  of  llic  ch<«t  on  llic  two  sidos  respectively.' 

1.  ro8T.CLAVlcui.AR  Bboion.'— Pcrcu,*.*ion  in  tills  silaation  gen- 
erally' elicits  a  pretty  clear  n-Moiiiiucc,  the  vehicular  quality  being 
Imoitt  marked  in  the  central  portion.  Toward  the  sternal  entrcinitjr, 
owing  to  tlic  proximity  of  tlic  trachea,  the  quality  of  sound  in  some- 
vbat  tyinpitnitic,  and  this  quality  predomioatctt  in  proportion  as  the 
dircctJoa  of  th«  pcrcusion-strokes  \a  toward  the  trackcu.  The  res- 
onance in  this  region  is  greater  in  females  than  in  males.  It  is  very 
difficult  to  upply  above  the  clavicles  tho  Gnger  used  as  a  picximeter 
equally  on  the  two  sides;  and  if  an  artificiul  instrument  be  eta- 
ployed,  an  inclinution  totvard  the  trachea,  slightly  greater  on  one 
side  than  on  the  other,  modifies  tho  sound  sufficiently  to  produce  & 
disparity  between  tho  two  regions  in  the  pitch  and  quality  of  the 
resonance.  In  making  comparatin-  observations  in  healthy  subjects, 
I  have  found  it  almost  impossible  to  produce  uniform  results  with 
repeated  percussions.     This  should  enforce  caution  in  regarding  an 

(apparent  difference,  if  it  be  slight,  as  a  morbid  sign.  To  denote 
dlMSM.',  the  difTiirence  must  be  well  marked  and  constant.  With 
proper  care,  and  making  due  allowaiit^e  for  disparity  arising  from 
iuetjuality  in  the  performance  of  perctisalon  on  the  two  sides,  impor- 
tant evidence  of  the  exi:^lc'nuc  of  disease  is  sometimes  obtained  by 
.percussing  in  this  situation,  in  ciLsea  of  tuberculosis  of  the  lungs. 

■  2.  ClavICULak   UsaiON.— Over  the  clavicles  the  resonance  u 

■  somewhat  tympanitic  near  the  internum,  from  the  proximity  of  the 
V  trachea;  on  the  central  portion  the  vesicular  quality  is  apparent, 

and  at  the  acromial  extremity  the  intensity  of  the  sound  Is  dimia- 
istied.  Equal  percussion  can  bo  made  on  tho  two  sides  in  this  region 
without  difficulty.     A  slight  disparity,  however,  is  not  infrequently 


I 


•  Tba  ciamiiiBlioni  of  corrnponcling  rrgiom  of  tho  two  aide*,  tho  miilu  of 
wbkb  STB  givvn.  wi.T«  astit  In  iit-rt'iit  not  only  fren  frnm  all  tippVHTDOCM  of 
dlH«a»,  bnt  alio  from  tn^  apparcnl  dpvJAtion  from  the  ijriiiniiitrio&l  conformft- 
tian  «C  tho  cbMl.  Der<?niiltiu*  ot  (lie  vhMt,  ^Ithor  oon^MilMl  or  rptulUng  fToiD 
dlwsM,  will,  of  coano.  occuion  (lii|inrUjr  between  tbu  two  tidui  in  tlic  fbenani- 
cn*  derelopfd  bjr  jihyticiil  cxplurRtion.  Tbo  rnsiilla  in  tbi>  rditlnn  are  givea 
ai  condMly  u  pcmiblo,  omitting  lanay  detsila  which  w«r«  tialed  in  the  Bnt 
edition. 

■  For  lb*  boundatio*  cf  th«  regioiu,  lea  iDtroduutlvn,  Section  II,  pa^e  M,  rt 


8S 


PHYSICAL    BXPLORATIOK    OF    THE    COSST. 


appreciable  it)  health,  vrben  the  chest  appears  to  be  symmetric*!, 
owing,  probably,  to  some  difference  in  the  8i:te  and  curves  of  the 
bone.  A  slight  difference  in  these  respects  in  well-formed  chests  is 
sometimes  apparent  on  examination  vith  the  eye  and  by  ibe  toucb. 
To  be  considered  an  evidence  of  disease,  a  disparity  in  tbe  resonance 
should  be  veil  marked,  constant,  and  a^sonated  with  a  eorrespoDd- 
ing  variation  in  the  percuss  ion -sound  of  the  two  sides,  eitber  in  the 
post-clavicular  or  infra- clavicular  regions,  or  in  both. 

&.  IxFUA-CLAVicuLAK  R£fl[0!i. — I'ercu&sion  here  elicits,  gener- 
ally, a  resonance  more  marlced  than  elsewhere,  save  in  (he  axillary 
re^on,  and,  in  gome  pvnton*,  bcluw  tho  scapula,  behind,  in  thii 
•ituation  examination  \i  to  be  made  carefully  for  the  physical  signs 
of  the  eurly  stage  of  lubcrealous  disease;  and  a  slight  abnormil 
diMpiirity  in  the  perciit>sion>euund,  takvn  in  connection  with  other 
signs,  and  with  sj'ioptoms,  convtitulcs  strong  evidence  of  a  deposit 
of  tubercle.  With  reference  to  thd  diagnosis  of  incipient  phthisis^ 
the  following  deviations  from  the  ruW  of  eqtiahty  at  the  summit  of 
the  chest,  incident  to  health,  is  highly  important  to  be  taken  into 
account :  In  the  majority  of  persons  the  resonance  on  the  left  side 
is  somewhat  more  intense,  the  vesicular  quality  is  more  marked,  ami 
the  pitch  lower  than  on  the  right  side ;  />it  ronlra,  the  resonance 
and  the  vesicular  quality  are  less,  and  the  pitch  higher,  on  ibc  right 
■ido.  These  points  of  disparity  arc  mort'  apparent  in  some  persons 
thait  Tn  others.  The  practical  bearing  of  the  fact  that  ther«  doea 
not  exist  in  mast  [ii-rnoim  absolute  ci]uii]ity  of  resonance  on  the  two 
aides  in  the  infra-clavicular  region,  will  appear  hereafter;  the  fact 
rests  on  observation,  and  is  independent  of  any  explanation  that 
may  be  offered.  Tht-orelically,  in  viow  of  the  greater  capacity  of 
tbfi  right  side  of  the  chest,  it  would  tteein  perhaps  more  reasonable 
that  the  difference  between  the  two  sides  should  be  the  reverse  of 
that  which  is  found  to  exist.  The  larger  development  of  the  right 
pectoral  muscle,  in  eoiiKcquencu  of  the  greater  use  of  tlie  right  upp«r 
extremity,  may  account  for  the  fact  in  some  instances,  but  the  di>- 
parity  exists  in  cases  In  which  there  is  do  apparent  difference  in  the 
muscular  covering,  in  this  situation.  Possibly  the  different  physical 
conditions  at  the  base  of  the  thorax  may  afford  an  explanation.  Oo 
the  right  side  the  lungs  repose,  with  the  diaphragm  inlervening,  on 
the  liver,  which  occupies  the  whole  of  the  base  on  that  aide.  The 
prcscnou  of  this  solid  viscus  may  slightly  diminish  the  aound.  On 
(be  left  wdo  below  the  iung  is  situated  the  stomach,  frequently  more 


PBBCDSSIOH    tX    HRAI.Tn. 

or  less  difttcndei]  with  gas,  nnd  the  i-fTcct  of  this,  it  maj  bo  sap- 
poeod,  is  to  incrciisp  titc  soiiurouvoi'ss  on  that  »i<lc,  even  at  the 
sninmit,  indc  prudently  of  th<i  t  ran  Emission  of  the  tympanitic  gastric 
BOtind  which  is  Mtnctimes  obscrvt-d. 

4.  Scapular  Rroiok. — I  ciiuincrato  this  region  next  to  tbe  pre- 
c«ding  bccaase,  being  at  the  suinmit  of  the  cheat,  ite  rcUtiooe  is 
disgDOMa  are  similar.  Like  the  infra-clavicular,  it  is  an  important 
region  Vfitb  rofercnce  to  the  phy^ica)  signs  of  pbtliisis.  The  normal 
dvgret;  of  resonance  over  the  scapula  is  much  lens  than  at  the  sum- 
mit ii|  front,  for  suflicicnti}'  obvious  rensons.  The  vesicular  quality 
of  resonance  is  U-h#  apparent.  A  distinct  sonorousness,  however, 
exists  here,  notwithDtnnding  the  percussion  bus  to  be  made  on  a 
layer  of  bone,  and  a  imuM  of  musck<  placed  upon  it.  These  circum- 
stxDccs  do  not  deaden  the  found  ^uliicicntly  to  render  the  region 
nearly  or  even  (piiie  unimportant  in  physical  exploration,  as  stated 
in  a  work  on  diseases  of  the  eliei^l.'  On  the  contrary,  percussion  in 
this  situation  is  often  of  great  utility  in  the  disgiiusis  of  tubercle. 
The  region  is  subdivided  into  the  auyra  and  ii^'ra  spinous  portions. 
The  sonoTOUHness  is  greater  over  the  latter. 

Disparity  between  the  two  sides  is  less  frequent  at  the  summit 
'-behind  than  in  front.  When  present,  however,  the  general  rule  is 
the  same,  rijc.,  less  sonorousness,  and  a  higher  pitch  on  the  right 
aide. 

■  5.  I»TKH?CAPULAii  Rboion. — Id  this  region  a  certain  amount  of 
B  8onoroaene&s  exists,  notwithstanding  the  mass  of  muscular  substance. 

■  Tbe  veeicalar  quality  of  souo<I  is  feeble.     The  degree  of  sonorous- 

■  nesa  is  )es!s  and  tbe  pilch  higher  on  the  right  side  in  some  persons. 

'  6.  Maumarv  Rkuiox. — The  mammary  region  offers  marked  dif- 
ferences on  the  two  sides,  owing  to  the  upper  cotivex  extremity  of 
the  liver,  in  the  right,  and  the  situation  of  the  heart  in  the  left  side 

V  of  tlic  chest.     From  the  fourth  rib,  on  the  right  side,  diminished 

I  resonance  is  appreciable,  which  increases  as  percussion  is  made 

downward  to  the  point  where  the  pulmonary  sonnd  ceaaea.     This 

point  marks  what  maybe  called  ihc  h'ne  of  fiepatie  Jiatne»»,  {.  e.,  the 

,     lower  border  of  the  lung.     This  point,  which  is  somewhat  variable 

Bio  different  persons,  usually  falls  a  little  below  the  lower  boundary 

of  the  mammary  region,  or  the  sixth  rib.    Next  to  the  aternuin,  on  this 

aide,  between  the  third  and  fifth  ribs,  the  presence  of  a  portion  of 


■  Swett  OB  IMmmm  oT  tbe  OhMl. 


84 


parStCAL    EXPLOBATtOK    OF    TSB    CBBSt. 


the  right  auricle  ami  ventricle  occasions  d!rniDishe<I  sonorouEnees 
over  a  space  extcmling  about  a  finger's  breadth  frota  the  tight  margia 
of  the  sternum. 

On  the  left  side,  dimintfihed  resonance  eiUts  in  the  prtecordnl 
apace,  and  over  a  portion  of  this  space,  id  which  the  heart  is  in  con- 
tact with  the  thoracic  walls,  there  is  notable  diminution  of  sonoroos- 
oeaa.  Percussing  in  a  vertical  direction  from  abore  downward,  mid- 
way  between  an  imaginary  line  passing  through  the  nipple,  and 
another  line  coincident  with  the  left  margin  of  the  sternum,  dimin- 
ished resonance  exists  at  the  upper  bonier  of  the  mammary  region, 
vii.,  the  third  rib.  At  the  fourth  rib.  on  a  horitontal  lino  passing 
Uiroiigh  the  nipple,  the  resonance  \»  much  dimtniiihcd,  in  couticqnniM 
of  a  portion  of  the  heart  in  this  situation  being  unoovercd  by  lung. 
From  the  fourth  to  the  sixth  rib  Ibc  nbM'nc«  uf  rosonancc  continued, 
and  extends  more  and  more  to  the  left  of  the  aternum,  the  iattcr 
border  of  the  left  lung  receding,  so  as  to  Wve  the  heart  in  contact 
with  the  wall  of  the  chest  over  a  Sjmcc,  the  wtdMl  part  of  which  is 
indicated  by  a  horizontal  line  touching  the  fifth  rib  at  a  point  a  littU 
within  the  nipple.  Percussing  hdrixontally  from  the  sternum  out- 
ward, on  a  line  passing  through  the  nipple,  rcaonanoc  is  notably 
diminished  to  within  about  a  finger's  breadth  of  the  nipple.  Dimin- 
ished resonance,  however,  is  appreciable  nearly  or  quite  to  the 
nipple,  owing  to  the  fact  that  the  heart  cxtcndH  thus  far  covered  by 
lung.  The  preM;ncc  of  the  heart  in  the  left  side  thus  givea  rise  to 
alterations  in  the  pcrcu^ion-Kouuil^  wliicli  ar«  twofold.  Firat,  nota- 
ble diminution  of  vesicular  resonance.  This  is  the  ease  over  the 
space  in  which  the  left  lung  fails  to  cover  the  organ.  Sfe<m4t 
slightly  or  moderately  diminished  resonance  over  an  area  extending 
a  certain  distance  beyond  the  bonndaries  of  that  space.  The  preebe 
limits  of  these  two  areas  are  important  in  connection  with  the  stndy 
of  diseases  of  the  heart.  Variations  in  the  degree  of  resonance  in 
the  pnccordia  are  also  involved  in  the  diagnosis  of  pulmonary  affec- 
tions. In  health,  the  degree  of  resonance  is  different  with  the  two 
acta  of  respiration,  and  may  he  aETectcd  voluntarily  by  increasing 
the  extent  of  inspiration  and  expiration.  Ity  iuspiration  a  larger 
portion  of  the  heart  is  covered  hy  lung  than  in  expiration ;  on  the 
one  hand,  the  space  covcrd  by  means  of  the  former,  and,  on  the 
other  band,  that  uncovered  by  means  of  the  latter  act,  other  thing* 
being  equal,  are  proportioned  to  the  forced  expansion  of  (ho  lung 
in  inspiration,  and  the  contraction  in  expiration.     A  morbid  coo* 


PBRCtrSSIOX    IK    HBALTH. 


85 


ditioo  or  the  lung,  consisting  in  pcrniancuC  di^Uniiion  of  the  air-cells 
(wliicb  oblMinii  ill  ciiipliysi^iiia),  will,  of  (rourse,  diniiuish  the  epace 
ovvr  wliidi,  in  licnlth,  rcHonance  is  notably  dirainislieil.  Abnormal 
resonance  in  thv  privcordia,  hcoec,  becomu«  n  phyitieal  nigii  of  that 
•RV-ction.  On  the  other  hand,  atrophjr  of  the  lang  ha^  a  contrary 
cficct.  There  are  conKidfrablo  dilTercnccs  ns  n.>9pcot  the  degree  of 
diminution  of  resonance,  and  also  the  limits  of  the  two  areas  in  dif- 
ferent persons  in  whom  the  lungs  are  perfectly  healthy.  In  other 
words,  the  lung  overlies  the  heart  more  in  some  iodiTtdnals  than  in 
others,  of  which  fact  percussion  furnishes  pliy§ical  evidence. 
B  The  mode  of  performing  percussion  in  order  to  develop,  Jirtt-,  the 
notable  du!n^»  due  to  the  contact  of  the  heart  with  the  thoracic 
wall,  and  tfcond,  tlie  lesser  degree  of  duhuaa  occasioned  by  the  pres- 
ence of  thiit  portion  of  the  organ  which  is  covered  by  the  lung,  is 
somewhat  diSerent;  and  this  di{fer»?nce,  which  involros  a  rule  appli- 
cable to  the  practice  of  percu8(>ion  in  other  ititualionti,  both  in  health 
knd  diHea^e,  may  he  here  stated.  In  dcienDiiiing  the  epace  which 
the  heart  occupies,  uneovereil  by  lung,  pcrcus^ipn  should  be  lightly 
made ;  but  to  fix  the  boundaries  to  which  the  organ  extends  corerutl 
by  lung,  beyond  this  space,  greater  force  of  percussion  is  requisite. 

(The  difference  in  the  practical  results  of  these  two  methods  of  pei^ 
eossing  wati  fir«t  pointW  out  by  Piorry.  In  general,  a  li^ht  per* 
eassion  reveals  phy»ical  eonditions  pertainiug  to  parts  situated 
directly  beneath  the  thonicic  wall* ;  while  a  more  forcible  pcrcuanion, 
the  blows  being  made  to  bear  on  parts  more  deeply  seated,  is  necea* 
sary  to  obtain  information  of  the  physical  condition  of  parl.i  situated 
more  or  less  beneath  the  nurface  of  ihc  lung.  To  the  Brat  mode, 
Piorry  gives  the  name  tupurficial  percumon  ;  and  the  second  mode 
he  calls  Jeep  perciunon.  Forcible  or  deep  percut^ion  is  necessary 
B  to  determine  tlie  existence  and  the  size  of  indurations  of  long  from 
pneumonitis,  pulmonary  apoplexy,  or  tuberculous  deposit,  which 
are  removed,  to  a  greater  or  less  distance,  from  the  surface  of  the 

I  lung. 
The  mamraary  region  affords  a  de;^ec  of  resonance  considerably 
less  than  the  region  situated  above  it,  vi«.,  the  infra-clavicular,  for  rca- 
wms  other  than  those  already  mentioned.  The  pectoral  muscle  dimin- 
ishes the  sonorousness :  and  the  difference  in  the  bulk  of  this  mu«cle, 
in  diflt-renl  persons,  i^  a  cause  of  the  differences  in  the  degree  of 
'  resonance  oWrved  in  this  region  within  the  limits  of  health.    In  the 
I  female,  the  nummary  gland  lends  still  more  to  deaden  the  sound. 


86 


PHTBICAL    BXPLOBATIOIT    OF    THE    CHBST. 


and  in  the  size  of  thiti  gland,  it  inwoll  known  different  femaloa  present 
a  very  wide  rnngit  of  difference.  It  is  »n  error,  Lowcvcr,  to  s«j  th«t, 
on  tiiifl  account,  the  mutumiiry  region  in  ftmtilrs  "  is  of  no  value  in 
pereus.tion."'  Even  when  the  mamrou  is  umtsunllj  large,  sn  abnormal 
degree  or  kind  of  resoimncc  maj  be  determined  in  this  sitaatioa 
»ufGcientlj  for  the  pructicnl  ohjecto  of  diagnosis.  In  making  percot- 
sion  orer  the  mammary  gland,  the  ivory  or  hard  india-rubber  plei- 
imeler  may  be  uoed  with  advantage.  With  its  broad,  smooth  siir> 
face,  the  soft  parts  may  be  compreiwed  more  firmly,  and  the  strokes 
brought  to  bear  more  efficiently  on  the  thoracic  walls. 

The  left  mammary  region  frequently  yields  a  tympanitic  sound  01 
percussion,  due  to  the  presence  of  gas  within  the  stomach. 

7.  IxFBA-MAMMAKr  RtGioff. — In  tWs  region,  as  well  as  in  the  prt- 
ceding,  the  two  sides  present  a  marked  disparity.  Over  nearly,  and 
in  some  persons  ijuite,  the  entire  region  on  the  right  side,  there  is 
absence  of  resonance,  owing  to  the  situation  of  the  lirer.  This  fact 
is  not  infrequently  overlooked  by  persons  but  little  accustomed  is 
physical  exploration,  and  the  want  of  resonance  atlribnted  to  intra- 
thoracic disease.  Instances  of  this  error  have  often  fallen  under  my 
observaUon.  The  line  marking  the  lower  anterior  extremity  of  the 
right  lung,  in  other  words  the  line  of  hepatie  fl"ttir»t,  varies  consid- 
erably within  healthy  limit.i.  Deterniint-d  by  pcrcuawng  downward 
on  a  vertical  line  passing  throii)|h  the  nipple  (the  persons  standing 
or  sitting),  the  point  »t  which  rcfoiinnce  ceases,  in  the  majority  of 
instances,  will  he  found  over  the  iicvi'nlh  rib.  Xot  un frequently, 
however,  it  is  over  the  sixth,  and  occasionally,  as  low  as  the  eigbtli 
rib.  The  line  of  hepatic  flatnnjus  now  referred  to,  ts  that  existing 
with  ordinary  respiration.  Even  with  ordinary  respiration,  tbe  line 
is  not  fixed,  owing  to  the  play  of  the  diaphragm  with  the  two  respi- 
ratory acts.  This  may  bo  thus  shown :  tbe  finger  employed  as  a 
pleximeter  may  he  placed  at  a  certain  point,  where,  continuing  for 
some  time  repeated  percussions,  with  some  of  the  strokes  a  resonance 
will  be  observed,  and  with  others  none  whatever.  But  forced  acta 
of  iDspiration  and  expiration,  in  consequence  of  lh«  convexity  of  the 
diaphragm  with  the  latter,  and  its  depression  with  the  former  act, 
affect  considerably  the  point  at  which  resonance  ceases.  If  the  line 
of  flatness  in  ordinary  respiration  bo  over  the  sixth  rib,  the  effect  of 


■  Swott  on  DifcaicB  of  tho  Cbast. 


PBROUSSIOir    IR    HBALTO. 


[a  deep  inspiration  is  to  lover  it  to  the  seretith  rib ;  and  if,  in  ordinary 

^iration,  the  line  is  on  the  seventh,  it  is  depressed  to  the  eighth 

In  iin  instance  in  which  the  lini;  with  ordinarir  rcttplrnlion  lay 

Icn  the  eighth  rib,  it  was  deprc»sed  to  the  nintli.     The  distance  to 

which  it  maj  thus  be  voluntiinljf  carried  dowimurd,  is  pretty  iini- 

•  formly  about  1^  inches.  On  the  other  hand,  hy  forced  expirotioa 
the  line  of  flatness  is  cIcTatcd  to  an  extent  less  unifonn  in  diflicrcot 
penon*.      It  is  carried  upward  to  the  sixth,  fifth,  and  fourth  ribs, 

IUio  distance  raryin;;  from  iji  to  £^  inches.  The  distance  from  the 
line  of  hepatic  (latneKs  after  ft  deep  inspiration  to  that  aAcr  a  forced 
expiration,  in  dilTi-rent  perwjns,  varies  from  4  to  7  inches.  This 
distance  is  u  pretty  good  criterion  of  tlic  breathing  capacity  of  the 
in  dividual. 
Above  the  line  of  flntneas,  on  making  forcible  percussion,  ditoinished 
Tesicular  resonance  extends  upwnrd  for  one  or  two  inches.  This  is 
caused  by  the  convex  upper  surface  of  the  liver,  covered  by  the  thin 
■  extremity  of  the  right  lung. 

H  A  tympanitic  resonanoe  is  sometimes  produced  by  percussing 
BoTer  the  lirer,  due  to  the  presence  of  gas  in  the  transverse  colon. 
H  In  the  left  infra-inamuiary  region  the  percussion-sound  not  only 
varies  in  diflerent  persons  but  in  the  same  person  at  different  times ; 
and  also  in  different  portions  of  the  region  at  the  same  time.  These 
variations  depend  on  the  difierent  organs  below  tho  diaphragm  which 
encr<t3ch  on  the  lower  division  of  the  thorax.     Into  the  right  portion 

I  of  the  region,  the  left  lobe  of  the  liver  enters  to  an  extent  somewhat 
variable,  genornlly  about  two  inches  to  the  left  of  the  median  line. 
Light  percussion  over  this  portion  elicits  a  flat  sound,  or  absence  of 
resonance.  The  left  boundary  of  the  liver  may  generally  he  d«- 
fined  by  the  pcr«nssion-«ound.  Beneath  the  left  portion  of  the  re* 
gion  lies  the  spleen,  an  or^jan,  the  rolumo  of  which,  as  is  well  knovo, 
varies  considerably  within  the  limits  of  health,  nod  iu  eorlnin  disenses 
(typhoid  and  intermittent  fever),  becomes  enlarged  to  a  greater  or 
B.I0SS  extent.  Its  average  dimensions,  according  to  the  observations 
of  Piorry,  arc  about  four  inchw  in  length,  and  three  inches  in  width. 
Tho  stomach  is  situated  between  the  two  solid  organs  just  named, 
and  this  organ  is  consliintly  fluctuating  as  regards  degree  of  disteo- 
iion,  and  the  nature  of  its  enntcnts.  Enlarged  by  the  presence  nf 
gas,  it  occasions  a  tympanitic  resonance  frequently  pervading  the 
whole  infra-mammary  region,  and  sometimes  extending  to  the  mam. 
nary.     The  sound  is  ehurncterisiic,  and  may  be  distinguished  as  the 


88  ?aTBIOAL    EXPLOBATIOn   OF  TBI  CBB8T. 

goBtrie  tympanitie  retcnanee.  It  is  high  in  pitch,  nnti  ofton  has  % 
nnging  metallic  lone.  These  charnctera  arc  rendered  oltrious  bj 
comparing  it  vith  ih«  tympanitic  resonance  elicited  by  perciissioii 
orcr  the  int«ittines.  The  pcrcuKsion-Hound  over  the  lower  part  of 
the  left  ride  of  the  chest  is  frri]uently  more  or  less  modifie<l  hj  the 
presence  of  giuttric  tympanitic  rc»onniicic.  On  th&  other  hand,  when 
the  stomach  is  filled  with  solid  or  liquid  alimentary  substances,  the 
percanion -sound  is  flat. 

8.  Sternal  Keoiokr. — These  regions  arcsinglc;  that  is,  thej  do 
not,  like  the  regions  already  referred  to,  consist  of  corrcj^ponding 
divisions  of  the  thorax  situated  on  cither  side  of  the  mesial  linr.  On 
this  account,  and  in  eonseqocucc  of  the  sternum  forming  a  oontin- 
nons  bony  covering,  devoid  of  the  elasticity  belonging  to  the  ribs, 
and.  moreorcr,  over  the  greater  part  of  its  extent  other  organs  than 
the  lungs  lying  beneath,  it  is  rarely  the  case  that  much  important 
information  respecting  pulmonary  disease  is  here  obtained  by  meaoB 
of  percussion.  Over  the  greater  portion  of  the  upper  sternal  regioot, 
Tis.,  above  the  lower  margin  of  the  second  rib,  there  is  more  or  It«s 
sonorousness,  which  is  non-vesicular  in  character,  being  due  to  the 
sir  contained  in  the  trachea  above  the  point  of  bifurcation.  Frota 
the  character  of  the  sound  it  is  sometimes  distinguished  as  tvbvhr 
$o»oroutnf.»»,  but  for  nil  practical  purposes  it  suSiocs  to  consider  it 
a.<*  tympanitic.  Below  the  point  of  bifurcation,*.  «.  from  the  second 
to  the  lower  margin  of  the  third  rib,  the  inner  border  of  the  lung) 
on  the  two  sides  approximate,  and  the  resonance  has  more  or  leas  of 
the  vesicular  quality.  The  remnant  of  the  thymus  gland,  and  the 
deposit  of  a<lipo:<e  siibxtimce.  however,  sometimes  render  the  percus- 
eion-Gound  d«ll  in  this  situation.  The  presence  of  the  Urge  Teseek 
leading  from  tho  heart  conduces  to  the  same  result. 

Over  the  lower  sternal  region,  i.  «.  from  tho  lower  margin  of  the 
third  rib.  the  combination  of  several  different  organs  occAsions  vari- 
ous modifications  of  resonance.  Beneath  the  region  are,  1.  a  portion 
of  the  right  lung,  lying  to  the  right  of  the  mesial  line;  2,  the  greater 
part  of  the  right  ventricle  of  the  heart,  and  a  portion  of  the  left; 
8,  at  the  lower  part  n  portion  of  the  liver;  and  4,  occasionally, 
where  distended,  a  portion  of  the  stomach.  It  is  obvious  that  the 
percuss!  on -sound  must  vary  in  different  pari*  of  the  region,  and 
present  often  a  mixed  character.  By  care  and  (act  in  perctwaion, 
however,  it  is  practicable  fre<)iicntly,  if  not  generally,  to  define  ibe 
boundaries  of  the  several  organs  which  are  embraced  in  a  aeouon  of 


ttJLCrSBStOV  IN   UBALTB. 

this  region,  by  tniMins  of  Uic  dialinctivc  sonnds  {>crtaininf;  to  ibfin 
rCTtpcctircIy.  Tin*,  which.  «ccoriling  fo  Wiilslio,  "is  one  of  the 
most  ilifficult  priictifiil  problemit  in  tht;  iirl  of  percussion,"  inro1v«a 
m  question  of  notnc  inU'rosl  aniJ  iinportHncc  in  iU  benring  on  physical 
cxplorntioi),  to  wliicli  referent!*  I1118  nut  vet  been  made,  and  which 
may  tc  briefly  notluci)  in  ibe  presriit  conntclion.     The  question  is, 

\  X)o  the  diflfcTont  solid  orgnnit  of  the  body,  the  lirer,  heart,  spleen, 
kidney,  etc.,  yiebJ.  on  percuwion,  »ound8  distiiiclive  in  characier? 
Piorry.  asenming  the  atSnnativo  of  this  qucftton  to  be  true,  haa 
deecrib«d  %  series  of  sounds,  each  of  which  he  regarded  as  charac- 
t«riatic  of  the  organ  lying  beneath  the  point  percussed.  Thus,  ac- 
cording to  him,  there  is  a  liver-sound,  11  vpleeii-snund,  etc.,  and  each 
of  these  diEcinctiTe  sounds  is  supposed  to  depend  on  the  molecular 
arrangement  belonging  to  the  structure  of  the  piirlioidar  organ. 
The  correctness  of  the  opinion  just  stated  is  denied  by  Skoda.' 
According  to  this  author,  "there  is  no  differcnc*'  in  the  percussion* 
found  by  which  we  cam  distinguish  between  organs  not  containing 
»ir,  snob  as  the  liver,  the  spleen,  the  kidneys,  bepatized  lung,  or  hing 
completely  deprived  of  air  by  coiDproKsinn,  and  fluids ;  a  bard  liver 

I  yields  the  samu  sound  »t  a  soft  liver,  a  hard  spleen  as  a  soft  spleen, 
and  blood  the  »ame  sound  iis  pus.  water,  etc.  We  may  readily  eon- 
ritice  ourselves  of  the  fact,  by  placing  lhe.«c  different  organs  on  a 

|non>re»onaHt  support,  and  percus.iing  them  one  after  the  other,  cither 
with  or  without  m  plexinieter  ;  fluids,  similarly  supported  and  in  suf- 
ficient quantity,  may  also  be  percuwed  by  aid  of  o  plexiiucter,  care- 
fully applied  to  their  surfaec."*      Walshc  makes  a  similar  statement.-' 

L  Others  have  arrived  at  nn  opposite  conclusion  by  menus  of  the  very 
experiments  cited  by  Skoiln,  and  eoniend  that  of  the  different  solid 
organs,  and  different  Huids,  each  has  its  peculiar  sound,  as  the  wood 
of  various  species  of  trees  may  be  distinguished  from  each  other  by 

I  pcrcuMion,  or  as  bone  and  enrtilngc  differ  in  this  respect,  according 

I'to  Skoia*  himself.  This  point  of  physics  is  of  less  consequence 
than  may  at  first  appear,  inasmuch  as  the  question  whether  the 
several  organs  namod  have  not  peculiarities  of  sound  lit  tUu  hy  no 
BMaoa  hinges  upon  it.     Hkoda  and  Walsbo  do  not  deny  dtstioctioD 


'  A  Treatit*  on  AuKulttitlon  anil  PcrFiiwion,  b;  Dr.  Joippli  Skoda. 

*  Traaiilalko,  bj  W.  C.  M«rl;hom,  U.O.,  London  nJition,  page  i. 
'  Op.  cit. 

*  8«*  nuic  to  French  IransUtion  pf  Dr.  Skoda'*  trealliH,  Vj  tbe  Iranilator,  Dr. 
[7.  A.  Aran.pogad. 


90 


PHYSICAL    KXPLOBATtON    OP   THB    CBRST. 


of  percussion- son nd  pertaining  to  xhf»c  orgnn*  la  Oicy  are  AJtiialed 
in  tlic  boi\y,  but  they  account  for  the  difference  from  ttic  rr1.ttiow 
of  the  organs  to  neighboring  pnrtx  whicli  contain  uir,  \iz.,  the  lungs, 
Btomach,  and  intestines.  The  question,  therefore,  maj  be  settled  b; 
the  result  of  examinations  practised  on  living  and  dcud  isulijccti. 
Facts  thus  obtained  undoubtedly  eMtnblisIi  lh<!  exislencc  of  o  dilfer' 
eoce  in  sound  by  which  the  sites  of  the  different  organs  m»y  be 
determined  and  tbetr  boondnry  lines  often  mapped  out.  For  exas- 
ple,  the  sound  produced  by  percussing  OTcr  the  liver  differs  obviously 
from  Ibflt  elicited  over  the  heart,  and  the  boundary  line  is  generally 
deUTininiiblc.  It  is  Iiigbly  probable  that  tbi»  difference  is  due  to  the 
disparity  in  sise  of  the  two  organs,  and  the  parts  in  juxtaposition, 
rather  than  to  intrinsic  peculiarities  of  the  organa  alone.  The  fact 
of  the  difference,  however,  exists  irrespective  of  the  explanation. 
The  peculiarities  of  sound  emanating  from  solid  organs  are  more 
ebarply  defined,  and  appreciated  with  greater  facility,  by  employing 
'*  auacuttatcrypercugiion,"'  than  by  percussing  in  the  ordinary  mode. 
The  practice  of  ordinary  percussion,  which  is  more  simple,  and 
therefore  more  readily  available,  viih  a  view  to  determine  and  mark 
out  the  boundaries  of  the  different  solid  organs  encroaching  on  the 
chest,  is  an  exercise  to  be  highly  recommended,  not  only  as  a  means 
of  becoming  familinr  with  the  cliaructerii>tic  sounds  of  each,  but  as 
tending  to  impress  on  the  mind  the  relative  situations  of  them 
orgiDis,  and,  at  the  same  lime,  conducing  to  practical  skill  in  the  use 
of  the  mt'lhod  of  physical  exploration  under  present  conitidrration. 

9.  iNFRA-scAPirLAR  Rkoioks. — -IVrcussion  posteriorly,  b«low  the 
scapula,  generally  yields  a  marked  degree  of  vesicular  resonanee- 
The  larger  portion  of  the  infi-rior  lobe  being  embraced  in  this  n^itm, 
and  a  very  small  portion  only  of  this  lobe  extending  into  thcaatt* 
rior  part  of  tliir  cli<-sc,  it  is  here  especially  that  exploration  is  made 
for  the  physical  signs  of  In  flam  in.t  lion  of  (he  lungs  or  pncumonilil, 
the  lower  lobe  being  the  one  affriMed  in  the  great  majority  of  cases 
of  tbnt  disi'ttM-  The  point  to  which  the  lower  extremity  of  the 
pulmonary  subtitnucc  oxtemls  \»  over  the  eleventh  rib.  On  th«  right 
side  the  line  of  hepatic  flatness  commences  at  or  near  this  point, 
varying  somewhni,  ns  in  front,  in  different  persons.  This  line,  aain 
front,  is  depressed  from  one  to  two  inches  by  iv  deep  inspiration,  and 
elevated  to  a  greater  or  less  extent  by  a  forced  expiration.     Here, 


>  Sev  £«sy  bjr  Dr.  Csnimann  ■nd  CInrk,  pn-Tiouilj-  ifferriNl  to. 


PESCUBRIOir    IH    HSALTB. 


91 


I 


I 


I 


too, as  inl)i<>  right  infra-maminarj' region,  above  the  lineoffialneeain 
ordinary  reopiration,  a  marked  degree  of  dulnesa  on  percnsnion  is 
appreciable  for  a  distance  of  from  one  and  a  half  to  two  inches. 
On  the  left  side  the  reoonance  ma;  be  more  or  lees  tympanitic,  from 
the  presence  of  gas  in  the  sioinach.  Below  the  eleventh  rib  there 
tDai^  be  tympanitic  resonance  from  intestinal  gas;  and  near  the 
ppine  the  limits  of  the  left  kidney,  which  is  here  situated,  taaj  1m 
indicated  by  the  percussion-sound;  at  the  outer  side  of  the  lower 
part  of  the  region,  tho  »pace  occupied  by  the  spleen  is  in  some  ia- 
•tanees  determinable. 

10.  Latsbal  Kkgioks. — The  axillary  region  on  both  sides  is 
liighly  sonorous  on  fx^rcuit^ion,  tho  vehicular  (jiialily  usually  being 
strongly  marked.  The  infra-nxillary  region  genernlly  presenla  more 
or  less  disparity  on  comparison  of  the  two  *\t\e».  On  the  right  side, 
near  the  eighth  rib,  the  absence  of  rcfonnncc  denote»  tho  line  of 
hepatic  fiatties.->,  the  situation  of  the  line  bi-ing  »uliji-ct  to  the  same 
depression  and  elevation,  with  inspiration  am)  expiration  voluntarily 
increase"!,  as  in  front  and  behind.  l>ulnestt  for  s  short  distance 
above  this  line  in  nleo  here  marked.  On  the  left  vi>h  the  percus- 
tioD-sound  may  be  rendered  more  or  \tt*  dull  by  the  presence  of  tbo 
spleen;  but  it  i*  much  oftcner  rendered  tympanitic  by  the  presence 
of  gas  within  the  stomach.  Crossing  the  infraaxillary  region  diago* 
nally  is  tbe  interlobar  fissure,  which,  alihougli  not  deterniinnblc  in 
health,  may  be  traced  by  means  of  percussion  in  disease  (pneumo- 
nitis), a  fact  of  importance  in  diagnosis. 

K«viewing  the  regions  which  have  just  been  considered  in  connec- 
tion with  the  phenomena  developed  by  percusMon  in  a  »tatc  of 
bealih,  it  will  be  seen  that  the  following,  ns  regards  the  intra-tho- 
racic  organs  embraced  within  their  limits  respectively,  nrc  iiearly 
similar  or  symmetrical  on  the  two  sides  of  tbe  chest :  anteriorly,  ibe 
supra -clavicular,  clavicular,  and  infraclavicular  regions;  posTeriorly, 
the  scapular  nnd  intcr-scapular  regions ;  lattralii/,  the  axillary  region. 
The  remainder,  viz.,  the  mammary  and  the  infra-roammary,  the 
infra-axillary  and  the  infra-scapular,  present  anatomical  points  of 
db«imilsrity  attended  by  a  want  of  correspondence  in  the  physical 
phenomena  produced  by  tbe  method  of  exploration  under  consid- 
eration, as  well  as  the  other  methods  remaining  to  be  considered. 
The  regions,  however,  which  in  an  anatomical  point  of  view  are 
similar,  or  nearly  so,  do  not  invariably,  as  has   bc«a  seen,  yield 


9S- 


PHTSICAL  BXPLORATtOT  OF  THS  CEBST. 


idenlicnl  percuss! oo-BOunds,  bot  to  »  certain  extent  deviationa  occar 
entirely  compatible  with  he«1th. 

lu  instituting  camparisons  of  the  cotresponding  regions  of  the 
two  sides,  hitherto,  it  has  been  assamed  that  the  cheat  is  free  from 
dteparity  resalting  from  deformity  or  previous  disenae;  in  other 
words,  that  the  two  aides  are  symmetrical  in  confonnstioD.  But  in- 
stances presenting  deviations  from  sttatomical  symmetry,  as  has 
been  seen  (Introduction,  Sect.  I),  are  of  frequent  oecnrrence,  la 
the  practice  of  percussion,  and  other  methods  of  exploration,  it  ti 
necessary  to  take  cognizance  of  the  points  of  dissimilarity  which  are 
determined  by  the  method  of  tntpfeliOH.  This  is  a  rule  of  funda- 
mental importance  in  physical  diagnosis.  The  roost  prominent 
canacs  of  visible  alterations  in  the  symmetry  of  the  iwo  aides  of 
the  chest,  as  already  stated,  are  spinal  corrature,  rachitis,  fractnrec^ 
prolonged  pressnre  on  the  thorax  in  infancy,  tight  lacing,  and  con- 
traction after  chronic  pleurisy.  The  exiatence  or  nonexistence  of 
alterations  from  the  operation  of  these  or  other  causes  ia  always  to 
be  ascertained,  and  taken  into  acconnt  in  drawing  inferences  from 
points  of  contrast  which  ihe  physical  phenomena,  pertaining  to  the 
two  sides,  may  oifer. 

Allusion  hiiK  been  mnde  to  various  circamstances  occasioning  h 
different  ht-aUhy  persons  wide  differences  in  the  intensity  and  other 
characters  of  the  resonance  on  percussion,  vis,,  the  greater  volutae 
of  the  lungs  in  some  inilividuuls  than  in  others,  greater  elasticity 
of  the  thoracic  walls,  varying  amount  of  muscular  derelopment  aa 
well  as  adipose  deposit,  etc.  Age  has  a  certain  influence.  Other 
things  being  equal,  in  consequence  of  the  greater  elasticity  of  the 
costal  cartilages  in  early  life,  the  degree  of  resonance  is  greater 
than  at  a  later  period,  when  the  cartilages  become  stiffened,  or  rigid 
from  ossification.  As  a  rule,  tlie  pitch  is  lower  and  the  sense  of 
resistance  is  less  in  early  life.  In  old  age,  the  vesicular  quality  of 
the  resonance  is  impaired  by  the  atrophied  condition  of  the  lung  inct* 
dent  to  advanced  years,  and  the  sound  assumes  somewhat  a  tympam- 
lic  character. 

The  percuss  ion -sound  may  also  be  found  to  vary  at  different  peiiods 
of  an  act  of  respiration  in  the  same  individual.  The  quantity  of 
air  contained  within  the  air-ceits.  and  consequently  the  relotive  pro. 
portion  of  air  and  solids,  are  not  the  same  after  a  fall  inspiration 
and  after  a  forced  expiration.  This  difference  in  lung-expansion 
may  occasion  an  appreciable  disparity  in  resonance,  according  as  the 


PBBCIT««I0H   IH   URALTff. 


98 


I 


I 
» 


percussion  is  mad?  at  the  concluflion  of  u  fall  inspirftttoii  or  a  forced 
expiration.  The  dispBrity  is  not  apprcrinble  unifornily  iii  diflV-n-iit 
persons.  When  it  is  oppnrcnt,  it  iwuallj  tonsiiitts,  toiitrarj  irt  wlial 
ni^fat  perbnps  have  been  nnlieiputcd,  and  tiie  rvver»c  of  what  is 
usaally  Slated  in  works  on  pliysifil  cjtplontlion,  in  diminished  n-so- 
nancc  and  elevation  of  pitch  at  the  vuiicliisioii  of  iuApiratiuii.  Tins 
i«  probably  to  be  explained  by  the  greater  degree  of  t«n.iion  of  the 
longs  and  tbomcio  wall.71  prodiivi-d  by  ibspiration  Toluntarily  pro- 
longed niid  tnaintainc-d — a  condition  presenting  physical  obstacles  to 
sonorous  vibrations  more  than  fniflicient  to  counterbalance  the  in- 
crcssetl  proportion  of  nir  witliin  the  celU.  It  in  a  curious  fact, 
worthy  of  notice,  that  the  two  sides  of  the  chc«t  kre  not  always 
found  to  he  affected  ei^uutly  ns  regurda  tliv  perciwsion-sound,  at  the 
conclusion  of  a  foil  inspiration,  contrasted  nith  that  after  a  forced 
expiration.  I  hare  obst-rved  tlie  contrast  to  be  more  striking  on  the 
right  than  on  the  left  side;  and  in  one  instance  on  tlie  left  side,  the 
resonance  was  less  intense  and  somewhat  tympanitic  at  the  end  of  a 
full  inspiration,  while  on  the  right  side,  the  opposite  effect  was  pro- 
daced,  and  the  sound  became  quite  dull  ut  the  end  of  a  forced  expi- 
ration. In  view  of  these  variations  in  a  certain  proportion  of  in- 
•tSDcea,  incident  to  different  periods  of  a  single  respiration,  in  some 
CMes  of  disease  in  which  it  is  desirable  to  observe  great  delicacy 
in  comparing  the  two  sides,  pains  should  be  taken  to  percuss  oor* 
responding  points  at  a  similar  stage  of  respiration,  and  the  cloxe 
of  a  fall  inspiration  is,  perhaps,  the  period  to  be  preferred.  Ordi- 
narily, the  liability  to  error  from  this  source  is  obviated,  either 
by  repealing  a  series  of  strokes,  first  on  one  side  and  next  on  the 
other,  or  by  percussing  both  sides  repeatedly  in  quick  succession,  in 
order  mentally  to  obtain  the  average  intensity  and  other  characters 
of  the  sound  during  the  succefesive  stages  of  a  respiration.  The  in- 
stances of  disease,  bowerer,  are  exceedingly  rare  in  which  such 
nicety  of  comparison  is  important. 

Certain  rules  pertaining  to  the  practice  of  percussion,  have  al- 
ready been  stated.  Others  important  to  be  borne  in  mind  remain 
to  he  □H>ntioned.  These  practical  rules  are  equally  applicable  to 
examinations  of  the  cheat  in  health  and  disease;  and  it  will  not, 
tkcrefore,  be  neccHsury  to  recur  to  this  subject  in  connection  with 
tlio  morbid  signs  developed  by  percussion. 

Jn  percussing  different  portions  of  the  cheat  it  is  not  a  matter  of 
indifference  in  what  position  the  person  examined  is  placed.     To 


94 


PUYSICAL    KXPLOBATtOX    OP    TUB    CHEST. 


explore  tlic  anterior  t^urfnvc  of  tlic  cheitt  the  position  most  fnrornblo 
it)  Htaii'iini!;,  the  shouHcra  thrown  modcrntoly  Inckirard,  and  tlie 
back  ri'»ti»g  againAt  a  door  or  «  thin  partition  wall;  next  to  this  is 
n  miting  posture,  the  back  resting  against  a  Brm  support.  A  re- 
cumbent position,  allltougfa  lens  Favorable,  is  frequently  the  only  on« 
aTnUnblc  in  cooes  of  disease,  owing  to  the  weakness  of  the  patient. 
Id  each  of  tbeso  three  positions  tlio  upper  extremitic*  should  be 
equnlly  disposed  hy  the  side  of  tho  bodj,  tho  shoulders  maintained 
on  the  same  level,  as  nearly  as  possible,  and  the  two  sides  of  the 
ohcsi  on  the  sntnc  plane.  Particularly  in  the  recumbent  poctnre, 
etrc  tihould  be  taken  thai  the  bod  and  pillows  be  so  arrangod  u  to 
•void  any  inutiuality  nflocting  one  side  more  than  tho  otlior.  For 
an  examination  of  the  posterior  surface  in  the  most  satisfactory 
manner,  the  patient  must  assume  n  .tilting  posture,  the  body  inclin^ 
a  little  forward,  the  arnis  brought  forward  and  folded  so  as  to 
render  tense  the  muscles  attached  to  the  scapula.  An  imperfect 
exploration,  but  frequently  sufficient  for  the  objects  of  diagnosis  in 
cases  of  disease  precluding  the  sitting  posture,  may  be  toado  of  the 
two  sides  in  succession,  the  patient  lying  first  on  one  side  and  thco 
on  the  other;  or  it  may  be  practicable  sometimes  for  the  patient  to 
rest  on  the  abdomen.  In  percussing  the  lateral  surfaces,  the  pos- 
ture may  be  sunding,  sitting,  or  recumbent,  the  hands,  with  the 
fingers  interlocked,  resting  on  the  top  of  the  head. 

The  position  of  the  explorer  ia  also  a  matter  of  consequence.  If 
the  person  examined  stand,  it  is  of  coarse  necessary  to  take  the 
same  position.  If,  however,  the  patient  be  seated,  or  recumbent, 
the  examination  will  bo  most  conveniently  made  in  the  sitting  po 
ture.  It  IB  well  to  be  placed  as  nearly  as  possible  in  front  of  th4 
mesial  tine,  in  order  to  receive  the  percussion.sounds  from  each  side 
of  the  eheal.  at  an  equal  distance.  If,  however,  a  lateral  situatioi 
be  preferred,  or  necessary,  with  reference  to  the  same  end,  pain 
should  be  taken,  wherever  a  delicate  comparison  ia  made,  to 
from  one  side  to  the  other,  so  aa  to  percuss  on  corresponding  point 
whilst  in  a  similar  relative  position  to  the  patient.  Identical  sound 
reaching  the  ear  from  unequal  <liatanoeB  may  appear  to  differ  in  in- 
tensity, if  not  in  otlicr  reapecls. 

The  manner  in  which  the  strokes  are  to  be  made  in  peroassina 
has  been  already  described.  If  the  finger  or  fingers  of  ifae  lot 
hand  be  the  pleximeter  employed,  they  may  be  placed  horisont«llj 
on  the  dtest,  first  on  the  ribs,  and  next  in  the  interooUal  epacea;  or'' 


PBRCV8BI0K  IN   R8ALTB. 


rcTticalty,  at  right  niiglcH  with  the  t\\i».     Whcncrer  careful  pvrcos- 
lioii  IK  Tvi^uiri'il,  both  position!*  should  be  rcritOTlci)  to.      In  pvrca^s- 
ItQg  the  acromiiil  portion  of   the    infrn-clttvicular  ri-gion  tbc  most 
onvciiiral  disposition  is  to  pincc  the  ling«r«  in  m  diugonnt  direction. 
It  if  better  to  pUce  the  pnliniir  nurface  of  the  fingers  in  apposition 
tto  the  chem,  und  strike  on  the  dorsal  snrfncc,  although  the  reverse 
US  prnctiMd  bjr  houc  who  are  dielinguishud  in  the  art  of  physical 
exploration. 

Perenwiion  i«  to  bo  made  on  corresponding  points  of  each  side  of 
n     the  chest  alternately,  c»re  being  taken  to  strike  on  the  ribs,  or  the 
Kintercoital  spaces  successively,  nod  to  compare  the  sound  elicited 
^from  the  two  sides.     As   already  slated,  deviations  from  healthy 
sounds  are  determined  by  means  of  this  comparison,  and  not  by 
^vreference  to  any  fixed  standard.     Hence,  the  differences  natural  to 
^^tho  chest  of  different  persons  do  not  affect  the  value  of  percussion 
in  developing  signs  of  disease.      It  is  therefore  important,  that  the 
H-pcrcussion  bo  made  in  every  respect  as  equally  as  possible  on  the 
two  sides.     The  same  degree  of  force  is  to  be  given  to  the  strokes; 
they  are  to  be  made  in  the  same  direction,  and,  in  short,  so  far  as 
Bpractic«b1e,  in  precisely  a  similar  manner.    By  the  non-observance 
~  of  due  precaution  on  this  point,  it  is  easy  to  produce  a  disparity  in 
the  percusaion-sonnds,  in  cases  in  which  there  is  in  reality  no  differ- 
ence as  respects  the  physical  conditions  on  which  the  sonoronsness 
depends.     For  example,  suppose  percussion  to  be  made  in  the  infra> 
scapular  region ;  and  let  the  strokes  on  one  side  be  made  with  the 
ends  of  the  fingers,  in  a  direction  opposite  to  the  spinal  column, 
and  the  movement   favorable   for  tbo  production  of   the  highest 
^ftmount  of  resonance;  then,  directly  afterward,  on  the  other  side, 
Blet  the  strokes  be  made  with  the  pulpy  portion  of  the  fingers,  in  a 
direction  toward  the  spinal  column,  and  tbc  movement  intentionally 
modified  so  that  the  fullest  amount  of  resonance  shall  not  be  pro- 

Idoced,  the  disparity  between  the  two  siSes  will  be  marked,  and  yet, 
;if  sttch  an  experiment  be  not  watched  by  a  critical  observer,  the 
difference  in  the  mode  of  percussing  will  not  be  detected.  A  dilTer- 
•nce  in  cimply  the  force  of  percussion  on  one  side,  iu  any  situation, 
while  the  niu.'icular  offorl  appears  to  be  similar,  and  in  all  other 
tcdpectB  the  blows  are  identical,  will  suffice  to  occasion  an  obvious 
disparity  in  sound.  Hence,  before  deciding  on  the  actual  existence 
H  of  I  slight  diitparity,  percussion  should  not  only  be  made  with  great 
earc,  but  repeated  often  enough  to  obviate  the  liability  to  deception 


.--.-..  ■  .—  -  _        _.  ■:—    -     ■  i~a_"i-:i-    i    ~-iTir-i,  :-i 

.....  .     -.  '^     3_.     --J"  I,  -      7;  i     I    iTjTlir.— ri   'T 

■' -      ■         ■    ■-■  ■  --:  J       rr:.-.!     :     1^    d—^    uri-zict. 

-    .  ■  ■  .;    ".-    ■^...  •^-.•^.i.   ■  _  ...    :    •^^.~  1   -^^-:; —  it-r-*!ar7. 

,-...-■.    -„.        ..■■■:    -    -  .— '-;-i.  -.zr^.;.mn.>-a  3L17 

■  T  ■-     "  ;:.    .:    :..r   _;— .■=^:;~    :     - —  '-  -  1117  jturzaa.  :i 

.     '.J-    -■   -   ..    -'-  — -—- ^^=-.-n.  moitT-iui:  i- 

'  ■  ■  :  ■     ■     ■,:.  ■  :  ■■-"     ::  —  .     ■    :.-  =..z.  v.-r.     -  ■  "i*nt-i  1 "  tirwioi 

.-    .-  ■.  .-  -»■  ,^      '    -.^ir  ,;;.  -.  ■    :.r   ~  y^  TTi-T   TCTti. 

,  .      ,■■;■■■      :     w     :„■-    I  ..„-.       ■      "..7-      _■-— -    ..-■    .r'Z"'ri.     't    ZJKiT  ■iiaa- 

■■  ■■       .•    ■,':.-.     - -i:. ..::,-.   t:  ..h     ..c-   -:.  i-;^   117^   •m~jf,-L:x£  m 

•  .■       ,..-•  •■[:.■   n    i.    1;:;.:,..      ^1  ■".-;-    -■■;.:::*  r:'.t^~\    "Jis  ji  T'ai-liriK'l 

■  ,■.■'■■■■      ■■.'    ;—• vL-^^ij    n    '.:.^    -^ir    n^^-llaJII^a^  T^^:c. 

•  .  ■  •     -  -,•!.  .!■    Li   :-•  —   • :  .-v.    la'L   :•  'T~"i--~Ti j  iik  r;s!Kjj.>:i*  wiia 
-  ■     '■        ;    -."-■■i-    ;i    ■  -  :.r-  ir  -.,.:  :-i;.:r  ■:!.—  li"  ■art  :iieK  :c  li< 

'■'    '      ■      '     '-*'        '-•'      ■''.  •      ■.  ^  '"     ','    '■"".'    1      "^'     "_i<*     .t^.^    i:'L*t     ;"*     "J.-t     — 'ilJw         A 

■,■«','      ■.      .     I    ■       ;•■--     -i-'  r  -r'i     '-,■""— ii;i.C>LJU    "I'-'r;!"^  —  'Til'Ii  IB 

■<  .  <  ;  '■  .■.  '.  '.t  ;-t  ._•  •:..--.  ■.•r-/.~~t  1  -.i--ii:ul  TLrt  ::"  iii^ase. 
/  ■  *  ;  ■  -.■■  ' ,  ■.  1-  -.^  .— .  -.  -J:!  -  -.■:  rr':>:-i:^-L  ■'■J.,  *■:  ijt'i.^iiia  :ie 
;.  "  '>  ".'  .  '.-.  '.'  ■■.%  '■.■>■•-.  ;-.t"  :■;.-■:_■-  ::  :!:>;  iz.:ri---or»cii: 
'.'/.-'  "".'  ".'.".■,'•  ,".-'.. .V(  •.■.■:■:.  i  '-i  1-1":  'izz  '.z  i'S'iirnun*  a 
'■    '■■''    ■'   i-'yf  :-■■-  '.;.   -.'.''.■.-^■i'..^-'.   i.'.^:L:.:z,t,  :';r:.':'.^  c-er^-'u^iioii 

•  ■'■;■■'.  (;.  '.'.•,•.'•.*■..-.  *.•.•,  -,-..•  r-.'.r.  -.-.  U  :■:  ':-e  ^Tai-i-i  cLit  or- 
'Ii-  .f  .  / ..'.  't.':  (,-*'.-, -.•!  ',f  p^.'Ti.'-'-.r.,  iTl.:*;-:  i-.r^i^.  »a:L'a.  Jo  not 
V'.'.-'.f.  (.".'1,  '.'.f  f.f-.'.'fi'.Aii  af.p*«.*ar.^^  .>:'  r  L'^jr'mesj.  answer  every 

(if  r.'  N'.rtl    y<H\r'f''-. 

'\hi.  U'-U  nri'l  fniiii  ulii'rli  hav^  thas  b*«n  given  nn-ler  ifae  head 
((t  ('''f'-'iiKinii  ifi  Il'-iilrli  nri!  r;'>»iiri':rt'le'i  11  iLe  attentive  consiiier- 
liM"ii  uf  III"  Mitf'l'rtt  l;r-fV,rc  ctit'rriri;:  on  the  Biuiiy  of  Percussion  in 
\i\m-nkit,  Al'i'i  lii'i'iiriiiij^  r>ir(iiliiir  with  all  that  has  already  been 
|ili'a«lili'il  mtiilivK  I'l  |iin!ii4hi<>ri,  and  [imctically  c.'ipert  by  resorting 
Id  noimtiiMtliiii*  (if  lii-jiltliy  rhi-jtlH,  the  knowledge  of  the  morbid 
lilUltii  ihivi>lii|ii'i|  ],y  DiJH  iiicilniit,  niid  iiH  iipplicutioQ  in  the  diugnosiB 


PBaCUSStON    IK    DISEASE. 


07 


of  thoracic  affection^  arc  caifily  attained.     In  fact,  to  so  f^pat  an 
cxi«nt  may  the  physical  plivnomt-nu  of  dUc^asc  be  xtudicd  in  health, 
'  that,  after  sact  a  prcparntion,  the  aabjoct  offers  few  difficulties. 


rsUCUSeiOK   IN   DlfiBASK. 


i     dent 


The  rariona  physical  ohanges  incident  ti>  diHeasea  afTeeting  the  in- 
trm-lhoracic  orgnna,  nocasion  eorreitpondi ng  raodificatioiifl  of  the 
•eutd  elicited  by  perci»Hion,  and  hence,  the  latter  become  the  «^ita 
of  the  former.  The  more  importutit  of  the  physical  changes  inci* 
dent  to  different  forms  of  diseaiie,  arc  the  following :  over-diitiensioa 
if  the  pulmonary  vcHiclea,  involving  abnormal  expansion  of  ibe 
It,  and  a  greater  degree  of  tension  than  l>eloiig»  to  health; 
Ine  reduction  in  the  quantity  of  air,  associated  with  more  or  less 
increased  deni^ity  of  lung,  from  the  deposit  of  effused  blood,  serum, 
and  the  inflamnialory,  tuberculous,  or  other  morbid  products;  the 
presence  of  air  or  li<|uid,  or  both,  in  escarations  or  cavities  formed 
at  the  expense  of  the  pulmonary  substance;  liquid  of  different  kinds 
in  the  pleural  sac,  compressinj;  the  lung,  and  sometimes  supplanting 
it  entirely;  and  air  or  gas  contained  between  the  surfaces  of  the 
pleura,  generally  with,  at  the  same  time,  a  greater  or  less  propor- 
tion of  liquid.  Certain  physical  phenomena,  ascertained  by  per- 
cussion, as  well  as  the  other  methods  of  exploration,  are  found  by 
clinieal  observation  to  accompany  the  foregoing  morbid  conditions, 
Uid  on  the  constancy  of  the  connection  between  these  phenomena  and 
the  morbid  c«nditions,  establishing  the  relation  of  cause  and  effect, 
depend  the  signiEcance  and  value  of  the  former  as  representing  the 
latter.  Resonance  of  the  healthy  chest  has  been  seen  to  involve 
the  following  elements,  via.,  a  certain  amount  of  intensity,  or  loud- 
ness; relatively  lowness  of  pitch,  and  a  peculiar  quality  or  limbrc 
characterited  as  vesicular.  Morbid  deviations  from  heallhy  reso- 
nance are  to  be  analysed,  and  studied  under  the  same  general  aspects. 
It  is  by  attention  to  the  characters  derived  mainly  from  intennity, 
pitch,  and  quality  of  sound,  that  the  signs  developed  by  percussioD 
are  recognized,  and  discriminsted  from  each  other.  Abnormal 
aounds,  then,  I  repeat,  are  distinguished  from  healthy  resonance, 
and  from  each  other,  by  variations  in  intensity,  in  pitch,, nod  in 
quality. 
Proceeding  to  a  description  of  the  physical  signs  of  disease  devcl- 

7 


PHTilCAL   ■XPLORATIOS    OF   TBB   CBBST. 

oped  hj  perouBion,  the  queation  at  ono«  arises,  what  arrangeniMl 
ftitd  wh*t  unna  shall  be  adopted  ?  Authors  difTer  upon  tbia  poinu 
Th«  following  classification  appears  to  ine  safficientlv  oomprehennre 
and  minute  for  practical  purpou^cs. 

1.  At»fne€o/r«totiancc,conimon\y\LnovaaaJlatntmt,  Thetypeof 
this  sign  is  produced  wfaeti  ihc  thigh  is  percussed.  Flatness  is  not 
s  •onnd,  but  the  absence  of  sound ;  whnt  is  hcAnl  is  a  nuiiie  produced 
by  (he  ioHlninienta  used  in  percussion.  It  lias,  therefore,  neither 
pitch  nor  qoalitjr,  since  these  belong  only  to  resonance.  2.  J>immaitd 
re$oiiatiM.  I>imination  of  re«ODanoo,  the  vesicular  quality  being 
more  or  less  prcwrved,  is  called  tlulae$».  Tlic  characters  of  tbti 
sign  are  lettifGneil  intensity  and  elevation  of  pitch ;  diminution  of 
reaonanco  invariably  inrolves  a  higher  pitch  than  thut  of  the  Dormal 
Tcsicnlar  resonance  of  the  person  examined.  8.  T^mpanitie  rtt^- 
nance.  Under  thi*  uarnc,  I  embrace  all  kinds  of  sonorousness  in 
which  the  vesicular  quality  is  absent.  It  includes  the  rarieties 
called  by  some,  metallic,  tubular,  amphoric,  and  tlie  cracked  metal 
Bound.  The  essential,  distinctive  character  of  this  sign  relates  to 
quality  of  sound:  the  tympanitic  takes  the  place  of  the  vesicular 
quality.  Intensity  does  not  enter  into  ils  characters;  it  may  be 
more  or  less  intense  than  the  normal  vesicular  resonance  in  the  per- 
son examined.  The  pitch  of  tympanitic  resonance  is  always  higher 
than  that  of  the  normal  vesicular  resonance,  but  the  pitch  is  by  no 
means  uniform.  4.  Eiaggtrattd,  vr  ve»iealo-tympanitic  rt*onane€. 
The  characters  of  this  »igii  are  increased  intensity  of  sound,  the 
pitch  alwayit  greater  than  that  of  the  normal  vesicular  resonance; 
and  the  quality  is  a  combination  of  the  vesicular  and  tympanitic 

■It  svems  to  me  that  all  the  phenomena  developed  by  percussion 
in  disease,  may  bo  arranged  in  the  foregoing  divisions;  in  other 
words,  that  the  signs  of  disease  which  this  method  of  exploration 
funishcft,  are  resolvable  into  the  four  just  named. 

It  remains  to  consider  the  phenomena  falling  under  the  foregoing 
eUeaes  severally,  and  their  relations  to  tlie  different  morbid  ooodi- 
tiona  of  which  llicy  are  the  signtt. 

1.  Absbkcb  or  Kbsohanck,  on  Flatness.— Complete  Abolition 
of  eouad,  or  flatne»s,  is  oblaincti  cspecinlly  v  hen  the  pleural  sac  is 
filled  with  liquid  effusion,  cilher  serum,  sero-lyniph,  or  pus.  The  flat' 
DMs  tlien  eztend»  over  Uk'  whole  of  the  affected  side.  If  the  chest 
be  partially  Bllcd,  flatnCKS  may  cxii«t  below  the  level  of  the  liquid; 
i^  ItovcTcr,  the  •inount  of  liquid  be  quite  noal),  there  is  a  greater 


PBBCC88I0X    IN    DIBRA^R. 


99 


I 


or  Ires  degree  of  dulness  below  its  level,  not  oomp1et«  absence  of 
rcsoiinncc.  An  efTosioii  of  liquid  into  the  mr-vc«ic1vit  of  n  conud- 
erablf  portion  of  long,  uonHtituting  pulmonary  udemu,  may  give 
ritto  to  flatncDH.  FlalncK«  mny  be  due  to  complete  solidiGcation  of 
lung  from  inflammation  or  tuberculous  deposit,  but  it  is  rarely  the 
case  that  the  solidi&catioQ  is  bo  complete  as  to  abolish  all  sound. 
Hence,  instead  of  flatness,  there  is  dulness,  which  may  approximate 
closely  to  flatness.  Moreover,  the  presence  of  air  in  the  trachea 
and  in  the  bronchial  tubes,  exterior  to  and  within  the  lungs,  and  the 
proximity  of  the  solidified  portion  (if  the  vhole  lung  be  not  aolidi* 
fied)  to  another  portion  in  which  the  vesicles  contain  air,  occasion  a 
Blight  degree  of  resonance,  although,  perhaps,  so  slight  ati  not  to  bo 
appreciable  without  comparison  with  tbo  effect  of  percussion  on  a 
pat-t  which  yields  absolute  flatness.  Finally,  a  tumor  within  the 
chest  may  give  rise  to  flatness. 

If  flatness  exiiit  over  the  whole  of  one  side  of  the  chetit,  and  th< 
affection  be  not  acute,  the  ehitnceti  at-e  nine  to  ton  that  the  pleural 
sac  is  filled  with  liquid.  For  if  tJie  flatness  be  not  dni;  to  this  con- 
dition, excluding  a  tumor  filling  one  side  of  the  chest,  the  entiro 
luDg  ia  completely  solidified  by  either  inflammatory  or  tuberculous 
deposit.  Now,  if  the  dcpoitit  he  inflammatory,  ami  the  disease  be 
not  acute,  chronic  pneumonitis  exists,  n  di^eose  of  very  great  Infre- 
qnency ;  and  a  deposit  of  tubercle  is  almost  never  so  groat  and 
extensive  as  to  abolish  all  resonance  over  an  entire  lung.  The 
preeenoo  of  liquid  filling  the  chest,  however,  is  established  by  other 
rign«  coexisting  with  fiatnees. 

In  cases  in  which  flatness  exists  over  a  portion  of  the  chest,  the 
discrimination  lies  between  liquid  effusion,  solidification  of  lung,  and 
»  tumor  or  morbid  growth. 

I>i8p)aceinent  of  the  lung  by  the  aecumolation  of  llijnld,  or  a 
solid  tumor,  may  occasion  absence  of  all  resonance,  while  over  lung, 
be  it  ever  so  much  solidified,  there  is  usually  only  an  extreme 
of  dulness.  Rut  in  making  this  discrimination,  important  informa- 
tion is  derived  from  the  situation  of  the  flatness,  and,  in  curtain 
eases,  the  effect  of  variations  in  the  position  of  the  patient.  If  the 
flatness  be  situated  at  the  superior  portion  of  the  chest,  the  proh- 
abiliiiea  are  vastly  opposed  to  its  being  due  to  the  presence  of 
liquid,  for,  excepting  in  some  very  rare  inManccs  in  which  liquid 
effusion  b  confined  to  the  iippor  part  by  adhesion  of  the  pleural 
surfaces  below,  it  will  fall  to  the  bottom  of  the  sac,  and  the  flatness 


rSTSICAl.    BXPLOBATIOS    Of   TBI    CBBST. 


Oped  hj  pCTeunon,  the  qgotioii  al  eoee  utMs,  wlwt : 
and  vliat  teraM  dull  be  wiopttd  !     Antbon  dilcr  npoa  Ou»  ] 
Tbe  following  clawificstion  appcw  to  nc  wifieieetl;  eonpt^iensiTe 
and  minale  for  [iractical  parposcfl. 

1.  Abaf»ceofrf*<>nanee,comiBcnly\aowam»/tahu»M.  TbetjpeoT 
this  n^  a  prodoccd  wbeo  the  thigh  is  pereosecd.  Flatness  is  not 
a  sonnd,  bat  the  absence  of  soani ;  what  is  beard  is  a  mnte  produced 
bjr  the  ioairaraeots  used  in  percassion.  It  ha»,  therefore,  neither 
pitch  nor  qnalitv,  since  these  belong «nlir  to  resoQance.  2.  Dimim^ttd 
Tttonanee.  DiraiantJoa  of  resonance,  the  resicular  quality  bdtig 
nore  or  lees  praaerved,  is  called  duiiut.  The  characters  of  tbtt 
sign  are  Ueaeaed  intensit;  and  elevation  of  pitch ;  diminotion  of 
rcaonanee  invariably  inrolves  a  higher  pitch  than  that  of  the  Qonoal 
vesiciilar  resoaaitce  of  the  person  examined.  3.  Tj/npamUie  na^ 
noNM.  Under  thin  name,  I  embrace  all  kinds  of  sonoroosoefls  id 
which  the  veBicolar  qoalit/  is  absent.  It  includes  the  Tarietiei 
called  bj  some,  metallic,  tubular,  amphoric,  and  the  cracked  metal 
•oand.  The  essential,  distinctive  character  of  this  sign  relates  to 
quality  of  sound :  the  tym|»anitic  takes  the  place  of  the  Tesicnlar 
quality.  Intensity  does  not  enter  into  its  characters;  it  maybe 
nore  or  less  intense  than  the  noma!  resicular  resonance  in  the  per- 
son examined.  The  pitch  of  tympanitic  resonance  is  always  higher 
than  that  of  the  normal  vesicular  resonance-,  but  the  pitch  ta  by  no 
means  uniform.  4.  Ezaggeratedy  vr  vejicuh-tj/mpanilie  rei&nancs. 
The  characters  of  this  sign  are  increased  intensity  of  sound,  the 
pilch  always  greater  than  that  of  the  normal  vesicular  rcsonanoe; 
and  the  quality  is  a  combination  of  the  vesicular  and  tyui|kanitic. 

■It  seems  to  mc  that  all  the  phenomena  developed  by  percuauon 
in  disease,  may  be  arranged  in  the  foregoing  divisions ;  in  other 
words,  that  the  signs  of  disease  which  this  method  of  exploration 
furnishes,  arc  resolvable  into  the  four  just  named. 

It  remains  to  consider  the  phenomena  falling  under  the  foregoing 
classes  severally,  and  their  relations  to  the  different  morbid  condi- 
tions of  which  they  are  the  signs. 

1.  A]i3B!iCB  OF  Bbsokancs,  OR  FLATNESS. — Complete  abolition 
of  sound,  or  flatness,  is  obtained  especiully  when  the  pleural  sac  is 
filled  with  liquid  effusion,  either  serum,  scro-lympli,  or  pu».  The  flat- 
ness thon  extends  over  the  whole  of  the  affected  side.  If  the  chest 
be  parlially  GItcd,  flatness  may  exist  below  the  level  of  the  liquid; 
il^  however,  the  amount  of  liquid  be  quilo  small,  there  is  a  greater 


PBBCD8SI0H    IN    D1&SASE. 


99 


or  lr«s  degree  of  dultKtss  below  its  level,  not  complete  nbscncc  of 
resonanco.  An  effusion  of  liquid  into  the  nir-vi-tticles  of  k  consid- 
erable portion  of  lung,  constitutiog  pulmonnry  ccdema,  mnj  give 
rise  10  flatness.  Flatn»?ss  may  I>e  due  to  complete  solidification  of 
lung  from  inflammation  or  tuberculous  deposit,  but  it  is  rarel;  the 
Cftse  that  the  solidification  is  so  complete  aa  to  abolish  all  sound. 
Hence,  instead  of  tlntncss,  there  is  dulness,  which  may  approxiinate 
closely  to  flktness.  Moreover,  the  presence  of  air  in  the  trachea 
and  in  the  bronchial  tubcfl,  exterior  to  and  withio  the  lungs,  and  the 
proximity  of  the  soliditivil  portion  (if  the  iihote  lung  be  not  solidi- 
fied) to  another  portion  in  which  tlie  vesicles  contain  air,  occasion  a 
slight  ilegrev  of  resoniviice,  althougti,  perhaps,  so  slight  as  not  to  be 
appreciable  without  comparison  with  the  effect  of  peronsaion  on  n 
paM  which  yiel<U  absolute  flatness.  Finftlly,  a  tnmor  within  the 
cbc»t  may  give  rise  to  flslness. 

If  Batness  exist  over  the  whole  of  one  side  of  the  chest,  nnd  the 
aficcLion  be  not  aculo,  the  cbanccs  aro  nine  to  ten  that  the  pleural 
B3G  is  filled  with  liquid.  For  if  the  flatness  he  not  due  to  this  con- 
dtltoD,  excluding  a  tumor  filling  one  side  of  the  chest,  the  entire 
lung  is  eomplctvly  solidified  by  either  ioflammatory  or  tuberculous 
deposit.  Now,  if  the  deposit  be  inflammatory,  and  the  disease  be 
not  acat«,  chronic  pneumonitis  exists,  a  disease  of  very  great  infro- 
qiieDcy;  and  &  deposit  of  tubercle  is  almost  never  so  great  and 
extensive  as  to  abolish  all  resonance  over  an  entire  lung.  The 
prenence  of  liquid  filling  the  chest,  however,  is  established  by  other 
signs  coexisting  with  flatness. 

in  cases  in  which  flatness  exists  over  a  portion  of  the  chest,  the 
discrimination  Ilea  between  liquid  efl'usion,  solidification  of  lung,  and 
a  tumor  or  morbid  growth. 

Diitplacemenl  of  the  lung  by  the  accumulation  of  liijuiil,  or  i 
•olid  tumor,  may  occasion  absence  of  all  resonance,  while  over  lung, 
be  it  ever  so  much  solidified,  there  is  usually  only  an  extreme 
of  dn1nc«s.  But  in  making  this  discrimination,  important  informa- 
tiou  is  derived  from  the  situation  of  the  fiutncss,  and,  in  certain 
eases,  the  eflect  of  variations  in  the  position  of  the  patient.  If  the 
flatness  be  situated  At  the  superior  portion  of  the  chc«t,  the  prob- 
abilities are  vnntly  opposed  to  its  being  due  to  the  presence  of 
liquid,  for,  excepting  in  some  very  rare  instances  in  which  liquid 
effusion  is  uonfincd  to  the  upper  ptirt  by  adhesion  of  the  pleural 
surfaces  below,  it  will  fall  to  the  bottom  of  the  sac,  and  the  flatnosa 


100 


PHYSICAL    EXPLORATION    OP    TUB    CHEST. 


irill  extend  upwAi-tl  fnr  a  dijitnnce  proportionate  to  the  nmoant  of 
the  efTuHion.  PlatncH!!,  iliic  to  solidification  of  the  lover  or  npptr 
lob«  in  piieiimonitiB,  may  be  a.-«c<'rtained  by  delineating  on  the  cheit 
its  boutidarj,  and  finding  that  the  line  pursues  the  direction  of  the 
interlobar  fisiture.  This  iii  a  point  pertaining  to  the  phj^fiiesl  diag- 
nosis of  pnenmonltia,  to  which  writere  on  the  Babject  bare  not  soS- 
oiently  adrerted.  Moreover,  the  limit  of  the  flatness  incident  to 
that  diHeane  remains  iiiinltcred  in  every  position  of  the  patient. 
The  flame  remark  wilt  apply  to  tumors,  unless,  M  may  happen,  uA 
an  instance  is  given  by  Walshe,  they  are  not  attached  except  by  a 
small  pedicle.  Bat  in  a  certain  proporlion  of  cases  in  which  liquid 
is  contained  within  the  plenral  sac,  the  level  of  the  surface  of  tlie 
liijuid  varies  with  different  positions  of  the  bwly,  and  may  be  ascciN 
tained  without  difliculty  by  pereiission.  If  the  level  be  ascertaioed 
by  determining  the  line  of  flatness,  and  marked  on  the  chest  when 
the  body  of  the  patient  is  in  an  upright  position,  it  will  be  foimd  to 
encircle  the  chest  nearly  in  a  horizontal  direction,  the  liquid  obey- 
ing the  Hnine  law  of  gravity  within  the  chcjrt,  as  if  it  were  contained 
in  a  veaiwl  out  of  the  body.  If  now  the  patient  take  a  reoumbeitt 
posture,  the  level  of  the  liijnlil  in  front  will  be  found  to  have  dis 
Bcendcd,  and  a  line  denoting  tite  upper  boundary  of  the  flatncsi, 
purauea  from  thia  point  a  dingonnl  direction  intersecting  obliquely 
the  horieonlal  line  previously  made.  Or,  without  taking  puins  to 
demonstrate  the  variation  of  level  so  elaborately,  which  in  not  al> 
ways  convenient  in  practice,  let  the  upper  limit  of  the  flatnen  in 
front  be  iiHcertaincd  by  percussion,  while  the  trunk  is  in  n  vertical 
{»o«ition;  then  cause  the  piitient  to  lie  down,  and  ascertain  if  tfat 
resonance  do  not  extend  an  inch  or  more  below  the  point  at  which, 
in  the  previous  position,  the  upper  limit  of  flatness  mu  found  to 
exiirt.  A  few  ouncca  of  fluid  in  the  pleural  cavity  may,  in  some  in- 
ttancea,  be  detected  iu  the  manner  just  described.  The  physical 
cuplnnation  of  these  changes  is  siifTieicntly  obvious.  This  mode  of 
dctermiuing,  by  percuesion,  the  presence  of  liquid  is  not  applicsblo 
to  all  cases,  but  only  to  those  in  which  the  quantity  is  not  so  great 
as  to  fill  the  pleural  sac,  compresHing  the  lung  into  a  small  spacn, 
and  tu  those  in  which  the  movement  of  the  liquid  is  not  prevented 
by  ailhcaions  of  the  pleural  surfaces.  Both  these  conditions  may 
be  wanting  in  p1curi;(y,  and  hence  the  test  is  not  so  constantly 
avulahle  in  that  affection  as  in  hydrolhorax.  The  discrimination, 
however,  of  flatness  occai^ioned  by  liquid  eCTuaion,  from  that  which 


PBRCT79SION    IH    DISBABB. 


101 


» 


Hen 


may  Im?  iae  to  so1idi6catioa  of  laog,  does  not  depend  exolusivrly  on 
the  evidence  obtained  by  percuBsion.  The  physitial  aigna  derived 
from  other  methods  of  exploration,  combined  with  Uiose  afforded  by 
percoseion,  generally  warrant  a  positive  diagnoniii.  Tlie  employ- 
ment of  percussion  after  the  mk-a  just  given  enables  the  practi- 
tioner to  determine  from  day  ta  day,  or  from  week  to  week,  the 
changes  nhich  take  place  in  the  <{uantily  of  liquid  efTunioii.  Ilis 
progre^  of  the  diceiwe  and  the  effects  of  remedies  may  thus  be  ao- 
onralcly  observed.  Thif<  is  a  practical  conitideration  of  no  small 
importance.  With  a  view  to  note  the  increase  or  diminution  of  the 
fluid,  the  line  of  Batnetf^,  denoting  the  level  of  the  liquid,  while  the 
body  ia  in  a  vertical  position,  may  be  penoanently  marked  on  the 
cbcst  by  means  of  a  slick  of  the  nitrate  of  silver.  The  series  of 
linr-s  thus  made  daring  the  course  of  pleurisy  or  hydrothorax,  form 
a  kind  of  diagram  illustrating  its  past  history. 

The  physical  conditions  producing  absence  of  resonance,  or  flat- 
ness, occasion  at  the  same  time,  and  usually  in  a  notable  degree,  a 
sense  of  increased  reaistancc;  in  other  words,  the  ribs  are  less  yield- 
ing to  pressure  from  without.  This  sign,  eaieru  paribut,  will  be 
marked  in  proportion  to  the  elasticity  of  tlie  costal  cartil»gC8,  and 
hence  be  more  obvious  in  early  life  than  after  the  thoracic  wolU 
become  unyielding  from  the  stiffening  and  oesiGcation  incident  to 
advanced  years. 

2.  DiutKisBBD  RseoHANCB  Oil  DuLNBse. — Tbis  sign  exists  when- 
ever the  intensity  of  the  resonance  is  less  than  in  health,  provided 
the  vesicular  quality  be  not  lo»L  The  diminution  of  resonance 
may  bare  every  degree  of  griulation,  from  the  least  appreciable  duU 
OCM  to  «  degree  falling  ju»t  vh»rt  of  absence  of  resonance;  the 
sound  ia  dull  unlci's  there  be  itatneH.*.  It  sufEcea  to  express  dilTer* 
ent  degrees  of  dulness  by  adjeclircs  of  quantity,  such  as  slight, 
loderate,  considerable,  great,  etc.  This  sign  occurs  in  a  large 
proportion  of  thoracic  dtseases.  The  physical  conditions  which  it 
reprcMRts  are,  in  general  terms,  those  in  which  the  relative  propor- 
tion of  solids  or  liquid  to  air  in  the  pulmonary  vesicles  is  morbidly 
increased.  Generally  the  disproportion  Is  due  to  an  increase  of 
golidfl  or  liquid;  but  sometimes  it  arises  from  the  air  being  decreased 
without  any  actual  increase  of  solids  or  liquid.  An  exception  to 
tlie  general  fact  just  stated  with  respect  to  the  relative  diminution 
of  air  in  Uie  air  cells  to  solids  or  liquid  within  the  chest  when 
dulne&}  exUta,  is  afforded  by  some  cases  of  emphysema.     In  tlus 


[OS 


PBTSICAL    BZPLOBATIOK    OF   THB    CHB8T. 


ftflVetton  the  air  is  incrM$«d  without  iiicrcase  of  wlidj  or  liqoid. 
Oeoerallj  the  rexanance  ix  exaggerated  in  this  afTMlion,  but  excep- 
tionsUy  it  cauoeii  diilne*^,  owinj;  prohnhly  to  extreme  len-tion  of 
the  pulmonary  organa  and  the  walls  of  the  eheat.  Dulneaa  always 
niR«ii  the  pitch  of  soiind.  Benring  in  uiind  this  fact  will  prevent 
the  error  of  eoiinidering  the  norninl  rosioiiance  on  our  side  of  the 
oheiit  as  dull  when  the  rei'Oiiniice  on  the  other  side  is  morbidly  ex- 
aggerated. Morever,  attention  to  tbe  pitch  of  the  sound  is  of  aid 
in  appreciating  a  :tlight  degree  of  dulnes*.  The  senve  of  resisttinoe 
on  pi'rcHN»ion  is  sl»o  increased,  as  a  rule,  in  proportion  to  tha 
degrve  of  dulucss.  The  more  important  of  the  abnormal  conditions 
giving  riw  to  a  greater  or  lew  degree  of  dulDctut  irreepcctivo  of 
certain  cm««  of  cmpbyttoma,  which  have  been  referred  to,  are  as 
follows : 

a.  In  some  rare  instances  a  disproportion  between  tbe  solid  stra^B 
tnres  and  the  air  takes  place  as  the  result  of  the  reduction  in  flV 
quantity  of  tbe  latter,  the  former  not  being  increased.  An  obstruc- 
tion may  exist  from  the  presence  of  a  morbid  product  or  a  foreign 
body  within  the  bronchial  tubes,  which  resists  the  ingress  of  air  (o 
the  cells  with  inspiration,  but  permits  its  ogress  with  expira^oa. 
Collapse  of  more  or  lew  of  the  pulmonary  lobules,  under  these  cir* 
Qomstances,  may  follow.  The  efTet^t  on  the  pcrcussion-aouiid  is  to 
diminish  the  normal  resonnnce,  which  depends,  etrteru  paribut,  on 
tbe  quantity  of  air  contnincl  in  the  pulmonnry  vesicles. 

h.  A  Ktratum  of  liquid  between  the  pleural  surface*,  either  sonini 
]d  hydrotborux  or  s<^'ro-lyniph  id  pleuntis,  may  occasion  more  or  leas 
dulness  on  pcrciisvion.  Liquid  eSusion  is  an  infreqnent  cauae,  the 
quantity  gynernlly  being  sutEcicnt  to  occasion  total  loss  of  reso- 
nance, or  flatnesK,  over  a  greater  or  lees  distance  from  the  base  of 
the  chest  upward.  Instances,  however,  occur,  in  which,  from  ad- 
hesioDs  of  the  pleural  surfaces,  a  small  quantity  of  these  prodacU 
tnay  bo  confined  wilhio  circumscribed  limits,  removing  tbe  lungs 
from  the  walls  of  the  chest  sufficiently  to  diminish  but  not  abolish 
resicular  resonance. 

In  cases  in  which  a  targe  quantity  of  liquid  is  contained  within 
tbe  pleural  sac,  the  lung,  of  necessity,  undergoes  coinprcsKion  and 
condensation.  Over  the  portion  of  the  chest  beneath  which  the 
condensed  lung  lies,  the  resonance  is  diminished,  the  reduction  of 
the  lung  in  volume  increasing  the  |)ruportiou  of  solids  to  the  quantity 
of  air  within    tbe   cells.     At  the  summit  of  the  chest,    therefore, 


PBE0V88I0!r   IV  DISBASB. 


108 


I 
I 


the  percuss! on- sound  is  dull.  With  a  lesa  amount  or  liquid,  an  in- 
creasi'd  sftiiorouttne^K  frotiiiently  cxiiit:*,  moilifiisl  iu  igiiHlity,  vrliicli 
will  be  noiiwrl  under  tbe  head  of  Exaggerated  or  Vcsiculo-tjra- 
panilio  Kesoniinoe. 

c,  A  viiTv  large  iiccunuiliition  of  morbid  product*  witliin  the  bron* 
chial  tubes  may  be  attended  by  ((light  dulnuxs.  This  nlso  in  ex- 
tremely rare.  UuIcsh  tbc  quantity  bo  »o  greitt  us  not  only  lo  liU  the 
tabes,  but  distend  tbeui,  and  thus  encroitoh  upon  the  air-ocliii,  the 
resonance  on  percussion  is  not  uppreciubly  lessened;  hcnco,  as  will 
be  seen  hcrenftcr,  in  cases  of  bronchitis  attended  with  very  ubun- 
dant  expectoration,  the  normal  resonance  is  not  sensibly  impaired. 
Skodn  denies  that  appreciable  dulncss  ever  exists  in  cases  of  bronch- 
itis. This  assertion  is  too  positive,  and  docs  not  accord  witli  llie 
observations  of  others. 

d.  Congestion  of  the  pulmonary  veeMla  may  exist  to  ench  nn  ex- 
tent that  the  blood,  occupying  spac«  at  the  expense  of  the  nortoal 
capacity  of  the  air-cells,  the  resonance  i«  diminished.  Moderate 
or  eren  considerable  congestion  does  not  produce  this  effect;  the 
engorgement  must  be  great.  A  sufficient  degree  obtains  in  some 
cases  at  least  of  pneumonitis,  during  the  first  stage,  or  stage  of  en- 
gorgeraent,*  and  in  the  hypostatic  congestion  of  the  dependent  por- 
tion of  tbe  lunge  taking  place  towards  the  close  of  life  in  various 
diseaeea. 

«,  Inflammatory  exudation  within  the  air-cells  which  charaoteriitea 
the  second  stage  of  pneumonitis,  or  the  stage  of  solidification,  occa- 
stona  notable  dulness.  Here  the  cells  themselves  arc  to  a  greater 
or  leas  extent  Hlled  with  solid  matter,  supplanting,  in  proportion  to 
its  abundance,  the  air.  The  dulness  will,  ctrterii  prtribui,  be  pro- 
portionate to  the  quantity  of  exudation,  occasionally  merging  into 
fl«tnes8.  When  an  entire  lobe  is  partially,  not  completely,  aotidi* 
fi«d  in  pneumonitis,  the  dulness  will  be  bounded  by  an  oblique  line 

■  Thte  appeal*  to  ho  denied  by  Skodn ;  and  vinco  dc«th  raroljr  occur*  from 
pomrtuonlU*  durini;  thi>  tlnf^it  i>f  on);»rK;''in<'rjt,  opportuiiitira  tu  d«Duu>lrnte  tho 
comctnoHof  ilic  •inlcmt'tit  which  Imi  buiin  mndc  arc  not  often  obuincd.  Id 
•  cam  iiiid«r  my  otMnrvaiiixi,  In  wlikh  »  ('Hllpnt  AM  with  urturniuu*  diliitiiiiun 
«f  tha  lM«rI  ihortly  attvr  kn  ■ttock  of  pucumoDitJi,  tho  Ijinitivf  ibo  lownr  lob« 
of  til*  right  lUDK  bad  bcnn  lunrkod  on  Ihti  chrM  bj  a  ilnii  or«bv1oil*du1b«u  ua 
percuasiuii ;  and  tliii  lube  anpr  dcalb  (nu  found  in  the  flrft  tUge  of  inflamma- 
tipn,  no  Hilid  ciudutiun  huving  tnken  place.  Tbc  denial  hj  Skoda  li  not  la  ac- 
inca  wlib  thuob»urvfi[iun«  uf  otbun. 


PHTfllOAL    KXPLOHATIOH   OF  THB  CHEST. 


puniuing  the  direction  of  the  itil«r1obftr  Baaure,  a«  \n  the  esse  of 
fliitucwi  wlicD  a  lobe  ts  cotnpletcl}'  HoliJiReJ. 

/.  EffusioD  of  serum  within  the  air-vesicles  of  lie  loa^,  is  an- 
other morbid  condition  attended  b;  dulness,  provided  the  effuBion  be 
not  sufficient  to  occasion  flatness. 

ff.  Depoait  of  tuberculous  matter  vritliin  the  cellR  is  the  most  fre- 
qucnt  in  its  occurrence  of  tlie  morbid  oondittons  giving  rise  to 
dulnesa. 

h.  CaroinomstOHS  infiltration  of  the  pulmonary  parenchyma,  ha[ 
pily  extremely  rare,  occasions  dulne«8,  in  the  sitmo  mnnoer  as  tuber 
culous  matter. 

I,  Extravasation  of  blood,  oonstitntinp  pulroonarjr  apoplexy,  is 
another  rare  form  of  disoa.tc,  producing  the  same  effect  in  tho  sau9 
way. 

k.  Tumors,  morbid  growth*,  nneurinns,  and  enlarged  bronchial 
glands,  are  occasional  forms  of  diHCnse,  which,  according  to  ths 
extent  of  enoroaclimcnt  on  the  tlioracic  apitoc,  lead  citlier  to  diminu- 
tion or  absence  of  rcaonanue. 

In  these  various  affections,  percussion  alone  develops  nothing  be- 
yond tliL'simpIc  fact  of  the  existence  of  nome  physical  alteration  girinj 
rise  to  dulnefis.  It  affords  no  information  in  particular  cawM  u 
which  oMf  of  thtt  different  morbid  conditions  cxist«.  To  dcterniiuftl 
this  point  the  co-operation  of  other  methods  of  exploration  is  rcquisito, 
uken  in  connection  with  symptomfi,  and  the  known  laws  of  discasfUii 
In  cei-uin  cases,  however,  the  »ituntion  of  the  dulnees,  irrespeotiv 
of  other  signs,  or  of  symptoms,  is  a  sufficient  ground  for  a  stron| 
presumption  as  to  the  nature  of  the  dioeiuc.  If  the  dulness  extend 
over  the  space  occupied  by  tho  lower  lobe,  especially  of  the  right 
lung,  it  probably  arisen  from  pneumonitis,  this  affection  hcing  scatod, 
in  the  great  majority  of  caHctt,  in  tho  lower  lobe,  oftcner  of  the  right 
than  the  left  side.  If,  on  the  other  hand,  the  dulness  exi^t  at  the 
summit  of  the  chest  on  one  side,  the  chances  are  greatly  in  favor  of 
its  prooiH'ding  from  a  tuherculoua  deposit,  in  view  of  tho  fre^ucuc/ 
of  that  disease,  taken  in  connection  with  the  fact  that  tbe  deposit 
lirsl  tftkvH  place,  almost  invariikbly,  at  or  near  the  apex  of  tho  lung 
on  one  side.  Jiut  it  is  rarely,  if  ever,  necessary  to  rely  vn  tbe  evi- 
dence afforded  by  one  only  of  the  methods  of  exploration,  or  to 
depend  on  signs  to  the  exclusion  of  symptons.  And  it  is  one  of  the 
great  advantages  pertaining  to  physical  diagnosis  that  plienomens 
developed  by  different  modea  of  examination  may  bo  brought  to- 


PERCtlSSIOH    IK    DISEASE. 


105 


I 


gether,  mutunllj  scrring  to  )upplj  deficiencies,  obviate  liabilities  lo 
error,  and  comkiniDg  to  render  positive  the  conclusions  tberefrom 
dedaced. 

Diminished  TcncnUr  raitonaiice,  in  different  forms  of  disease,  is 
ssn-naincil  by  contracting  the  two  sides  of  tbe  chest;  for,  happily, 
the  laws  governing  the  polmonary  alTections  do  not  conflict  with 
making  one  side  a  standard  of  comparison  bj  shich  to  cslimatA  the 
deriations  from  health  on  the  other  side.  With  very  few  excepliona, 
in  cases  of  pulmonary  diseases  attended  by  deviations  from  the  nor- 
mal resonance  on  percussion,  either  (he  afTection  is  confined  to  one 
aide^  or  it  is  more  advanced  on  one  aide  than  on  the  other.  Tbis 
wonld  almost  seem  to  be  an  express  provision  for  fnciiily  of  diagnosis. 
In  l>j  far  the  greater  proportion  of  cases  in  which  the  resonance  on 
one  side  is  diminished  from  a  morbid  cause,  Uie  fact  is  determined 
without  difficulty:  the  disparity  between  corresponding  points  on  the 
two  sides  is  sufficiently  obvious  to  be  easily  recognixed.  Occasion- 
ally, a  delicate  comparison  is  necessary.  This  ia  sometimes  the  case 
in  the  early  stage  of  tuberculosis,  when  the  morbid  deposit  is  in  the 
form  of  small  disseminated  tubercles.  To  appreciate  a  alight  dul- 
ness  which  may  be  signiiicnnt  of  the  aioall  physical  change  that  baa 
aa  yet  taken  place,  observing  all  tlic  precautions  that  have  been 
pointed  out,  and  repeating  on  corrc«ponding  points  at  tlio  summit  of 
the  ohest  a  sucovMion  of  stnikcs  n»  etgual  in  every  respect  as  possi- 
ble, the  sound  elicited  on  iho  two  sides  is  to  be  compared  as  rrrpeels 
ioteusity,  vci'icnlar  quality,  nnd  pitch.  My  obncrvations  have  led 
me  to  regiird  attention  to  pitch  as  particularly  useful  in  ca^es  in 
which  delicacy  of  discrimination  is  required.'  A  variation  in  pileh 
ta  more  easily  recogiiiwd  than  a  ulight  disparity  in  the  amount  of 
resonance :  and  in  some  instances  the  former  may  be  distinguishable 
vitbout  dilliuiilty,  when  the  latter  is  inappreciable.  The  importanco 
of  attention  to  the  pitch  of  pen- uiw  ion -sounds  with  a  view  to  greater 
nicety  and  accuracy  of  discrimiiiatiuo,  seems  to  me  not  to  bave  been 
Bofficiently  appreciate<l  by  moat  writers  on  the  subject  of  physical 
cjcpbiration.  A  )n<c  writer,  indeed,  whose  views  have  attracted 
much  attention,  declares  that  variations  in  tliis  respect  arc  of  little 
value  in  practice.'  It  is  worthy  of  remark,  that  in  the  classiGcatioa 
of  percussion-sounds  by  Anenbmgger,  variations  in  this  respect 
occupied  the  firitt  rank,  although  with  reference  to  this  point,  be  was 


'  See  Pris«  Exaj  tij^  author. 


'  Skods. 


108 


•  PHTfilCAt    SXPLOBATIOX    OF    THB    CHEST. 


tniiiapprch ended  bj  his  transUlor  and  GotnmeDtAtor,  CorrisBrt,'  % 
fact  whk'li  ma;,  perhaps  Krre  to  aceoont  for  lU  hanng  be«n  laWt 
qucntif  ovcrlookcii  by  olhcrti. 

In  e«tiiiiBtinf;  th«  dikfrriMtic  raine  of  a  alighl  disparitr  in  tbc 
•ooods  elicited  hj  p«reuuion  on  the  summit  of  ihe  chesi,  the  fset 
that  in  but  a  snail  proponion  of  instances  is  there  perfect  corre- 
spondcncc  in  pcnionii  presumed  to  be  in  perfect  health,  and  whose 
clie«l»  do  not  exhibit  anr  appure nt  deviation  from  STmmetrr,  is  to 
be  borne  in  mind.  The  rule  found  bj  observation  to  govern  the 
difference*  compalihle  with  health  and  good  confornialioa,  Also  has 
a  vcrj:  itopoTtatit  practical  bearing  in  diagnosis,  ris.,  in  the  great 
majority  of  instances  in  which  such  differences  exist,  slight  relative 
dulneca  is  found  on  the  right  side.  Prom  this  fact  it  follows  that 
•light  diilncsN,  siiiialeii  on  the  right  side,  is  rery  likely  to  be  d«e 
to  a  natural  disparity  between  tlie  two  sides;  hut  situated  on  the 
]«tt  side,  it  proceeds  from  a  morbid  condition. 

In  iii«titnting  a  oloae  comparison,  as  already  remarked,  care 
tboiild  be  taken  to  make  percusiiion  o»  each  side  when  the  chcM  it 
eqnallr  expanded.  This  \»  tg  be  done  by  requesting  the  patient  to 
hold  his  breath  after  a  full  or  moderate  inspiratioo,  until  the  con- 
parison  is  made.  It  is  stated*  that  in  some  cases  of  flight  solidifi- 
cation from  disseminated  lubercles,  the  two  sides  may  present  a 
marked  difference  in  the  contrast  between  the  sound  elicited  on  the 
same  xide  by  percussing  first  after  a  full  inspiration,  and  next  after 
a  forced  expiration.  The  pathological  significance  of  a  disparity  in 
this  respect  is  impaired  by  the  fact  that  it  is  sometimes  observed  in 
examinations  of  the  healthy  chest. 

In  every  instance  in  which  a  slight  disparity  between  the  two 
sides  of  the  chest  is  discovered,  before  concluding  it  to  be  a  sign  of 
present  disease,  it  is  to  be  ascertained  whether  it  he  not  due  to  a 
want  of  symmetry  in  confonnalion,  which  may  be  so  slight  as  to 
escape  observation  unless  attention  be  directed  to  the  point.  Im- 
portant errors  will  he  likely  to  be  committed  without  the  observance 
of  this  prccnution.  A  slight  deviation  of  symmetry  arising  from 
the  position  of  the  patient,  will  occasion  a  disparity  of  the  reso- 
nance on  the  two  sides  of  the  chest. 

3.  Tympanitic  Rksonancb. — Agreeably  to  tbede6nttioD  already 


■  Kotrt  to  Frcni^b  edition  of  Skndn  bj  the  traniUtor,  Dr.  Aran 
•  Dr.  WaUht  sud  Di.  J.  UugIim  ItuDovci. 


J 


PSRCGS6I0H    IX    DISKASR. 


107 


I 


I 
I 


£)v«n,  under  the  name  tjDipanitic  resonance  are  embrace  all  Iflnda 
of  srnioronsnesa  vhich  lack  the  special  quality  due  to  air  in  tlio  air- 
Te»clr«;  in  other  worda,  the  resonance  is  tympanitic  whenever  it  is 
devoid  of  the  vesicular  quality.  It  is  proper  to  state  that  the  term 
tjmpanitic  resonance  is  not  always  used  in  so  com prehen sire  a 
seiiH«.  By  some  writers  the  term  is  applied  to  an  exaggerated  reft- 
onanc«  without  regard  la  its  quality.  It  simplifit's  the  subject  and 
obviates  oonfuaion,  to  call  all  percussion-sounds  tympanitic,  which, 
however  they  may  differ  among  themselves,  agree  in  this,  via.,  they 
ftre  non- vehicular.  The  most  distinctive  feature,  thus,  of  tympanitic 
resonance,  pertains  to  ita  quality.  It  may  have  any  degree  of  in* 
tensity  so  long  as  it  has  the  negative  feature  just  named.  It  may 
be  more  or  less  intense  than  the  normal  vesicular  resonance.  The 
pitch  of  tympanitic  resonance  is  always  higher  than  that  of  the 
normal  v«Hicular  resonance  in  the  person  under  examination.  The 
ramtion  uf  pitch  in  dilTcrent  cumcm  is  considerubW;  but  to  the 
Statement  just  made  there  are  no  exceptions. 

Tympanitic  re»onancc  occurs  in  dtfforcot  forms  of  disease,  itnd 
presents  certain  modifications,  which,  to  some  extent,  arc  significant 
of  particular  morbid  conditions.  These  modifications,  which  may 
be  considered  aa  forming  varieties  of  this  sign,  will  be  noticed  in 
connection  with  the  difrereiit  affeclions  giving  rise  to  the  quality  of 
resonance  under  GonHideruiion. 

Existing  in  a  marked  dfgrve  of  intensity,  exceeding  that  of  nor- 
mal resonance,  it  becomes,  combined  with  other  cireumstance!i,  a 
sign  quite  distinctive  of  the  presence  of  air  or  gas  within  the  pleu- 
ral sac.  This  physical  condition  chnractcrijvs  the  disease  called 
jmnuTHothoraz,  or  as  nir  and  liquid  are  iixially  conihinod  in  variable 
proportions,  piuumo-hifilrolhorar.  In  ihii*  aflcction  percussion  over 
tlie  cpaee  occupied  by  air,  elicits  a  eonorousnesa  totally  devoid  of 
vesicular  quality,  and  which  gives  to  the  nnnd  an  impr<-K<ion  of  a 
hollow  space  of  consiiJeraMe  size  tilled  with  iiir.  So  far  a.t  an  idea 
of  siie  is  conveyed,  it  is  what  SIcoda  calls  ti/ull,  in  distinction  from 
an  empty  sound.  W>ien  (he  cheat  is  greatly  distended  by  n  largo 
accumulation  of  liquid  nnd  air,  the  degree  of  sonorousness  is  less 
than  when  the  distruflon  is  but  moderate ;  the  sound  may  become 
quite  dull.  This  fact  is  probably  due  to  the  extreme  tension  of  the 
thoracic  walls.  A  similar  phenomenon,  as  remarked  by  Walsbe,  ia 
observed  in  a  drum.     "If  a  drum  be  tightened   to   the  extreme 


w 


FBT5IC1L   SXPtOBATIOS    OF   TBB   CBSST. 


poiot  poosible,  sod  all  MCipe  of  sir  £roia  its  c*vttT  prevented,  its 
Mtin^.  when  atmck,  becomes  muffled.  ionel«sF.  almost  null." 

Tlie  tvmpanitic  re»onance  in  pneumo-hrdrotborax  amnetiates  kit 
•  ringing  metallic  tone,  resembling  ibe  Bound  produced  by  tAppug 
Ugbtly  the  baek  of  the  hand  when  the  palm  is  applied  Gnnlj  orer 
the  Mr.  This  character  of  resooance  is  more  apparent  if  percnsaion 
be  made  while  the  e*r  is  applied  to  the  chesU 

The  prcMncc  of  liquid  effusion  in  cases  of  pneomo-hydrothoni 
maj  girc  riMe  to  flatnns  on  percassion  below  the  inferior  bouDdaiT 
of  tympanitic  rcmnuncc,  and  the  rclatire  portions  of  the  surfaeeaf 
the  chcM  OTcr  which  resonance  or  flatness  are  found  will  seireto 
determine  the  rclnlivc  quantity  of  liquid  and  of  air.  If  the  pleunl 
Mirfaec*  be  free  from  adhesions,  the  tympanitic  resonance  will^  of 
eoarwi,  exist  at  tlic  superior  portion  of  the  chest,  the  body  being  in 
a  verticul  position.  But  inasmuch  as  pni-iitni>.hydrothorax  oecnn 
oDviKT  as  an  accidental  complication  of  phthisis  than  otherwise, 
and  since  in  the  latter  affection  adhesions  generally  lake  place  to  ■ 
greater  or  less  extent,  the  air  may  be  proTcntcd  from  distending 
the  upper  part  of  the  pleural  sac.  Under  thc«o  circumstsiicea, 
tlwrc  may  be  a  liability  of  attribating  the  tympanitic  sonorousncet 
due  to  sir  between  the  pleura)  surfaces,  to  presence  of  gas  within 
the  alomacb.  Tlie  situation  of  the  space  occupied  by  air  will  he 
found  to  vary  with  the  position  of  the  patient.  Thus,  if  when  tbe 
trunk  is  inclined  far  backward  tbe  space  on  the  surface  of  the  chest, 
within  which  the  resonance  is  tympanitic,  be  marked  on  the  chett 
in  front,  it  may  be  considerably  lessened  by  repeating  the  examinv 
tion  when  the  iraiik  is  inclined  far  forward.  The  same  is  true,  ot 
course,  of  the  posterior  iturfaee.  The  level  of  tlie  surface  of  the 
liquid  may  be  ascertained  us  in  ordinary  pleurisy,  or  in  hydrotho- 
rax,  and  this  will  be  found  to  vary  with  different  positions  of  the 
body,  as  in  the  diseases  just  named. 

The  diagnosis  of  piicumo-hydrolhomx  does  not  rest  exclusively 
on  perciiNiian,  althouf;h  llie  eirideuce  afforded  by  this  method  i* 
generally  in  itself  quite  conclusive.  With  an  imperfect  knowledge 
of  tbe  subject,  however,  there  are  liabilities  to  deception.  Bmphy- 
sema  gives  rise  to  exaggerated  sonorousness,  and  a  quality  of  reso- 
nance approximating  to  tbe  tympanitic.  It  does  not,  however,  lose 
entirely  the  vesicular  quality.  It  is  unaccompanied  by  tbe  pliya- 
col  signs  of  liquid  effusion,  and  is  dislingniahed  by  signs  obtained 
by  other  methods.    The  whole  of  the  left  side  is  somelimcft  rendered 


PBRCCSBtOX    IX    DTSBASB. 


109 


I 


I 


highlj  tympanitic  by  diRtension  of  the  stomach  with  gas.  In  Budi 
iDatanc«<i,  aaide  from  llie  distinctire  circumstances  which  are  not 
leas  applicable  than  in  emphysema,  the  intensity  of  the  tympanitic 
resonance  in  greateflt  at  th«  lower  part  of  the  ohcst;  and  diminishes 
in  proportion  as  pi-miiiisinii  \s  niadi-  toward  the  summit,  ihiH  revers- 
ing thv!  rule  which  (ihliiiiis  in  inoitt  ciiHCM  of  pneiiiiio>hydro thorax. 

Exaggerated  and  tympanitic  resonance  exists  sometimes  over  the 
1o*rer  lijbMi  when  solidified  in  pneumoniti.-t.  On  the  left  side  this  is 
Dot  nncommon,  and  the  explanation  which  ftl  once  suggests  itself, 
rofers  the  resonance  to  the  transmitted  ga«tric  sound  so  frequently 
found  in  health  at  the  inferior  portion  nf  the  left  side.  On  the 
right  side  it  may  be  duo  to  the  presence  of  gns  in  the  transverse 
colon. 

Tympanitic  rrsonnncc,  more  or  less  intense,  Komctimcs  exists  over 
consolidation  of  an  upper  lohc  of  the  lung  from  pneumonitis  or 
tabercuioais.  Under  thcHo  cJrcunHtnnces  the  Tcsonancv  mu:«t  come 
from  the  air  in  the  trachea  and  the  bronchial  tobca  without  and 
perhaps  witliin  the  tioliilified  lobe. 

The  sources  of  tympanilio  resonauce  which  have  been  named  are, 
■ir  or  gaa  in  the  pleural  cavity,  nir  in  the  bronchial  tubes,  the  upper 
lobe  of  the  lung  being  completely  solidified,  and  gas  in  the  stomach, 
or  when  furnishing  a  resonance  i«hich  may  be  conducted  upward  to 
ft  greater  or  less  extent,  especially  when  the  lower  lohe  of  the  lung 
is  solidified.  Another  source  is  air  in  pulmonary  cavities.  In  the 
latter  case,  tympanitic  resonance  may  be  more  or  less  marked 
vitbin  a  circumscribed  space  or  spaces  corresponding  to  the  situa- 
tion of  a  cavity  or  cavities.  This  will  be  referred  to  hereafter  »» 
one  of  the  cavernous  signi*  in  pulmonary  tuberculosis. 

Thus  far  tympanitic  resonance  has  been  considered  as  a  non- 
vesicular sound  differing  in  different  instances  only  in  iotensily. 
It  is  occasionally  presented  with  modifications  of  quality,  which  are 
significant  of  a  special  pathological  condition.  These  modifications 
are  amphoric  rctonance,  and  the  craeked-metat  sound. 

Amphoric  resonance  denotes  a  musical  intonation,  such  as  is 
sometimes  elicited  by  percussing  over  the  stomach,  and  which  may 
[  be  imitated  by  filliping  the  cbeek  when  the  jaws  are  moderately 
separated  and  the  integument  rendered  somewhat  tense,  as  Is  done 
in  the  trick  of  imitating  the  pouring  of  liquid  from  a  bottle.  The 
percosRion-soaiid  occasionally  assumes  this  intonation  in  pneunio- 
hydrothorax;  and  sometimes  over  the  upper  lobe  in  cases  of  sulidi- 


to  kBBieeU- 

vcre  placed  betacn 

ycaapM,  MMBy 

i>  eftildrcn  attW 

excanitaoa,  nd 

Of  thb  £Kt  repeated  cs- 

1W  fradnctka  aT  tlui 

foreibl;  ei- 

pdlfd  &aa  a  csritr  fiMiMJeiriig  «ilfc  the  kmcfai  bv  fm  open- 
ia^  praoMlT'  ac  Aa  Uav  aa  Ae  bM  opdi  tk  air  betvmi  the 
pilM  la  tke  tritk  bf  atiah  tfca  aaad  Bay  W  imitalcd.  To  riiei; 
tW  Maa4  a  fwdMt  ftnmtmm  m  wetmmuy,  nai  a  ngle  bloa  ii 
better  tiaa  ae««al  strofcta  refMtriJ  ■•  qnck  taeeaaBCio.  The 
pMitat't  aoatb  ibaaU  W  ifea.  IT  tW  ■a*lh  aad  BOMrib  art 
tomfititij  daati  tW  ^a  '»  a«l  haaid.  Thii  bet  sn>"*'*  *°  ^*- 
ttc  tb«  prodadMa  of  ^  waad  ia  At  ■aaser  j»t  «tst«<i 
I  n  oeean  ia  cUdna  wiili— t  Ae  tjuatmm  «f  a  eavitj-,  it  m 
dmB  to  the  air  bdag  cxpcilal  fnm  tW  Iw^prWrndual  tob««uit 
is  frooi  fta  excaratioa.  Pem«noe  »t  tb«  raM»il  of  tbe  cbtst  ui 
diildmi  nsT  b«  bro^bt  to  b«ar  oa  ibe  broacknl  tabes  wilb 
effect  than  ia  sdiltt.  oan^  to  dw  ptattr  tiaatkitj  «f  tbe 
eaitilages  b  carl;  life.  TW  oga,  bavcrer,  baa  bcaa  obaerrwl  in 
adolta  IB  ea»a»  <^  oeaMfiJatioa  «f  tbe  appet  Mw  of  tbe  hutg.  I 
bare  repeatedlj  obeerred  tt  ia  casee  of  paeaneaitii  ia  wbi^  tltt 
apper  lobe  wu  soUdificiL  Occarrisg  at  tbe  •mnmit  of  tbe  dicsl  in 
a  ctrcnmscribed  qwce,  aipiriailj  if  not  near  tbe  Mental  cxtresitf 
of  tbe  tDfra-elaviealar  regioa,  aad  if  associated  witb  arnptoas  d^ 
Doting  advanced  luberenlona  diaeaae,  the  encied-meta]  reacmaiiM 
is  almost  conclBsire  eridenee  of  tbe  exbtenee  of  a  caritj,  but  tbe 
erideDce  may  frei^nenily  be  rendered  complete  b;  ita  association 
with  other  eigtis. 


PERCUSSION     I»     DISEASE. 


Ill 


It  woulil  be  nn  error  to  suppose  that  either  of  the  preceding 
iTftrielieH  of  trmpanitic  ivson^vnce  is  found,  save  in  a  certain  propor- 
[tion  of  the  cases  in  which  excavations  in  the  lungs  hare  taken 
Ifeee.     For  the  peculiar  sounds  to  be  produced,  the  cavity  must  be 
considerable  sise;  the  walls  must  bo  sufficiently   rigid  not  to 
Icollapac  vhen  free  of  liquid  contents;  it  must  be  situated  near  the 
[soperficiee  of  the  lung,  or  the  pulmonary  substance  between  the 
jcavity  and  (he  walls  of  the  chest  must  be  solidified;  and  other  con- 
ditions  may  be  essential,  the  importance  of  which  is  not  so  appre- 
ftble.   Cavities  resulting  from  circumscribed  gangrene,  or  abscesses 
fin  connection  with  pneumonitis,  do  not  embrace  the  necessary  phys- 
lical  conditions,  and  the  signs  are  therefore  chiefly  Bigni6cant  of 
itaberculous  excavations.   They  may  occur  in  connection  with  pouch- 
like enlargement  of  the  bronchi.     Both  varieties  of  tympanitic  reso- 
^Hftnce  may  frequently  be  ascertained  by  means  of  Cammann'a  titctb* 
.  Dsoope  (percussion   being   made  when  the   pectoral  extremity  of 
the  stethoscope  is  brought  near  the  open  month  of  the  patient)  in 
^  cases  in  which  it  is  not  otherwise  appreciable.     By  this  application 
B  of  auscultatory  percus^on,  a  light  percussion  stroke  may  be  suffi- 
cient  to  elicit   a  well-mArk<-d   crncked-metal   or  amplioric   sound. 
Bringing  the  naked  ear  npar  to  the  open  irioutli   of  the  patient 

Ias«LstH  in  the  recognition  of  this  sound,  when  the  stethoscope  is  not 
tiacd. 
It  has  been  already  stated  that  a  cavity  may  give  rise  to  a  well- 
narked  tympanitic  resonuncc  on  percussion,  the  eouod  being  neither 
amphoric  nor  of  the  crackcd-mctal  character.  Under  these  dr. 
cimutaaces,  how  is  a  cavernous  resonance  to  be  distinguiitbcd  from 
the  resonance  which  in  some  cases  of  tuberculous  disease  Is  found 
at  the  sninmit  of  the  cbost  prior  to  softening  and  excavation? 
Guided  by  the  evidence  which  percussion  alone  affords,  it  would 
certainly  be  difficult,  if  not  impossible,  to  make  the  discrimination. 
If  ft  distinct  tympanitic  resonance  bo  found  within  a  circumscribed 
space  at  the  summit  of  the  chest  on  one  side,  the  sound  elicited 
around  the  border  of  this  space  being  dull,  the  evidence  of  the  ex. 
iatenco  and  situation  of  a  cavity  is  very  strong ;  and  the  evidence 
become*  quite  conclusive  if,  the  disease  having  been  of  considerable 
duration,  and  attended  by  pretty  copious  expectoration,  it  should 
be  found,  by  percussing  at  dilTcrent  periods  of  the  day,  that  the 
tympanitic  resonance    is    sometimes   present  and  at  other  times 


lis 


PnYSICAL    EXPLORATION    OF    TIIK    CDEST. 


ab^pnt;  (he  former  being  oWrvcil  to  occur  ttfter  Troo  fsprotomtic 
and  the  latter  whro  tberv  is  r^iison  to  tiippose  th»t  the  cavitj 
filled  witli  tlio  morbid  products  which  nre  expectorated.  Occftwoa* 
ally  a  tympanitic  rcsonmico  tit  the  summit  of  th«  chest,  on  one  side, 
i§  found  to  be  suddenly  developed  in  a  circuDiMribcd  8fMic«  in 
which  preriooH  dulne«s  had  been  nsccrtnined  to  cxiat,  nnd  this 
occurs  afVcr  a  more  or  ict»  copious  oxpectoratioo.  Under  the 
circumetances  the  evidence  of  »  cavity  is  <)utte  conclusive. 

The  physical  dingnoitis  of  exmrations,  however,  does  not  rMt  ex- 
closivety  on  the  eridcnee  atforded  by  percussion.  Imporlnnt  signs 
arc  obtained  by  other  mcthodB  of  vxploration,  especially  auseulta- 
tton. 

4.  EXAOOSRATBD  OR  VSSICDl:.0-TTMrAN[TtC  RKBONAKCB.— TllC 
terms  exaggerated  and  veeiculo-tympniiitic  resonance  nre  applied  to 
a  digii  having  tlio  following  distinctive  c)iarncters:  Tlie  iiileniiity 
greater  than  that  of  the  normal  resonance  in  the  person  examined, 
the  quality  a  eompound  of  the  vesicular  and  tympanitic,  and  the 
pitch  more  or  less  raised.  Tho  term  Te«icuIo-tyn){Minitic  is  dwwrip- 
tire  of  the  quality  jast  stated.  Increase  of  intensity,  as  oompared 
with  the  normal  vesrciilar  resonance,  is  nn  essonlifll  chanictor  of 
the  sign.  Were  the  intensity  less  than  that  of  the  normal  vctieular 
resonance,  tlio  sign  could  not  be  distinguished  from  dulnea.  Rec- 
ognizing  increase  of  intensity  as  essential,  the  sign  cannot,  of 
course,  be  confounded  with  duliiess;  but  in  cases  in  which  the  res- 
ouaticc  is  exaggerated  on  one  side  of  the  cbe«t,  or  in  which  Hw 
exaggeration  is  greatest  on  on«  side,  there  is  a  liability  to  the  erra 
of  eonsiilering  the  resonance  as  dull  on  the  side  in  which  it  is  not^ 
ox*ggorated,  or  in  which  the  exaggeration  is  less  tlmn  ou  the  oppo- 
site side.  This  error  may  always  be  avoided  by  a  comparimn  of 
the  resonance  on  the  two  sides  with  rc«prct  to  pitch  and  ([unlity. 
Assuming  the  resonanoe  to  be  more  intense  on  one  side  of  the  chest 
than  on  the  other  side,  the  di.'tparity  must  be  doe  either  to  exaggc 
rated  resonance  on  one  side  or  to  dulncss  on  tlio  other  side.  NoVfj 
if  it  bo  due  to  exaggeration  of  resonance  on  one  side,  the  resonanci 
on  tho  other  side  being  unafTt-cted,  or  to  the  exaggeration  beioj 
greatest  on  one  side,  the  pitch  of  the  sound  will  be  higher  on  tt 
tide  on  which  the  resonance  is  grent«r,  and  the  quality  of  the  rosfl 
nance  on  that  side  will  be  fesiculo- tympanitic  as  compare)]  with  tb( 
opposite  side.  On  the  other  band,  if  ifae  disparity  be  due  to  dul* 
ncss  on  the  side  on  which  the  iatensily  of  resonance  ia  leas,  the 


pERCus8io:r  in  disease. 


lis 


I 


pitch  of  th«  sound  iriU  be  higher  on  that  »ii]c,  and  the  r^ualily  mire 
Tesicular  or  in  a  Iom  degree  Tcweolo-tyinpnniltc,  Whenever  the 
resonance  is  morbidly  cxnggeriLted,  provid<^d  the  eonnd  he  not  pnrelj 
tjmpnDitic,  the  quality  is  vesiciilo-tympanitic  and  the  pitch  is  »lwaj8 

ised. 

Eiaggerstcd  or  vesiealo-tjrapanitioreaonanceia  an  important  stgn 
&8  representing  the  condition  existing  in  vesicular  eraphyeema,  viz., 
abnonnal  dilatation  of  the  air-cellR.  In  most  eases  of  emphysema, 
the  resonance  i»  exaggerated;  but.  exceptionally,  aa  already  stated, 
owing,  probably,  Ut  extreme  tension  of  the  pulmonary  organs  and 
the  walls  of  the  chest,  the  resonance  is  diminished,  that  ia,  there  U 
dulnc««.  Emphysema,  excepting  when  it  ia  circumscribed  or  coit- 
fined  to  a  few  lobule.^  nfTects,  as  n  rule,  both  lunga,  the  upper  lobes 
being  especially  nffcctcd;  but  in  the  great  majority  of  cases  the 
emphysema  is  greater  on  one  sidt!.  This  ia  an  important  law  with 
respect  to  the  diagnoinis.  Were  the  emphysema  equal  en  the  two 
sides*  it  would  be  difficult  to  dcterniinc  that  the  resonance  was  ex* 
aiggerated,  owing  to  tho  want  of  a  disparity  in  resonance  between 
the  two  sides.  The  greater  exaggeration  of  the  reaenanoe  on  the 
side  mo»t  alTeclcd,  is  easily  determined;  hut  it  ia  to  he  borne  in 
mind  tliat  rdstive  iltilnc»s  sometimes  exists  on  this  side. 

It  is  probable  that  when  the  lung  on  one  side  acquires  an  in- 
created  expansion  in  consequence  of  the  lung  on  the  other  side 
being  rendered  useless  by  (ltsca«e,  as  in  case*  of  chronic  pleuritis 
with  large  eifuaion,  the  resonance  on  the  healthy  side  is  exagge- 

t«d.  But  this  cannot  be  positively  determined  without  knowledge 
of  the  degree  of  resonance  existing  prior  to  the  disease;  in  other 
vordR,  the  standard  of  health,  as  regards  resonance,  is  wanting  in 
these  cases.  The  fact  of  an  exaggeration  of  resonance,  under  these 
<ir«umslancr-S,  is  of  no  importance  in  diagnosis. 

Exaggerated  reifonancc  is  often  found  in  coses  of  pleuritic  effu' 
•ion  OR  the  affected  udc  above  the  level  of  the  liquid,  provided  tho 
quantity  of  liquid  he  not  too  great.  If  the  liquid  be  not  quito 
small,  or,  on  the  other  hand,  not  rising  much  above  midway  from 
the  base  to  the  summit  of  the  cheat,  the  resonance  above  the  liquid, 
as  a  rule,  is  more  intense  than  in  health,  and  the  vesiculo-iympan- 
itic  character  is  more  or  leas  marked.  If  the  quantity  of  liquid  be 
sufficient  to  rise  much  above  the  middle  of  the  cheat,  the  eondenaa- 
tion,  by  pressure,  of  the  lung  above  the  liquid,  gives  rise  to  dulnees. 
The  rule  just  stated  with  respect  to  exaggerated  resonance  above 

8 


114 


PBT8ICAL    KXPLORATIOH    OP    THB    CBEST. 


the  liquid,  ie  not  invariable.  It  is  less  likely  to  exist  when  the 
plenral  cavity  has  been  filled  and  tbe  liquid  has  decreas«d,  than 
vhen  the  liquid  haa  not  been  sufficient  to  extend  more  than  half 
way  to  the  summit.  Dulness  in  the  former  case,  and  in  excepiioiial 
cases  It  hen  the  pleural  cavity  hsj)  not  been  filled,  may  be  due  to 
lymph  coaling  ilie  upper  portion  of  the  lung.  The  increased  soikk 
rousuess  above  the  liquid  may  lead  to  ihc  error  of  buppoi^iug  that 
dulucss  exista  on  the  healthy  side;  and,  if  the  examination  b« 
limited  to  the  summit,  the  disease  may  be  supposed  to  be  pulmonary 
tuber (^ulosis.  1  have  known  this  error  to  be  committed.  It  may 
always  be  avoided  by  attention  to  the  pitch  and  quality  of  sound  a« 
ulrciidy  stat«d;  the  pitch  is  higher  on  the  aide  which  yields  the 
most  resonance,  and  the  quality  is  vesicolo-tympanitic,  whereas,  if 
the  dinpnrity  were  due  to  duluess  on  the  opposite  side  the  pilch 
would  be  higher  on  tfaal  side  and  the  ve»iouUr  quality  less  marked. 
In  gome  ease.'*  uf  pleuritic  elTuHion,  the  intensity  of  resonance  above 
the  liquid  niid  thv  predomi nance  of  the  tympanitic  qaalicy  might 
lend  to  the  «ui<pieion  of  pneumothorax.  Tbiti  error  may  «lwfty»be 
avoided  by  having  recourse  to  other  signs. 

In  ca»es  of  pneumonitis  affecting  one  lobe,  the  resonance  over  the 
other  lobe  of  the  same  lung,  as  a  rule,  ia  exaggerated.  The  sign  ii 
more  marked  over  the  upper  lobe  when  the  lower  lobe  is  solidified; 
but  it  esisu  over  the  lower  lobe  when  the  upper  lobe  is  in  the 
second  stage  of  pneumanitis.  I  have  repeatedly  met  with  cases  in 
which  the  upper  and  the  lower  lobe  of  the  right  lung  were  solidifiied, 
the  middle  lobe  remaiDtng  unaflcctcd;  in  these  cases  the  resonance 
over  the  middle  lobe  is  usually  intense  and  notsbly  vcsicnlo- tympan- 
itic. It  follows  from  the  rule  just  stntcd  that,  ihc  existence  of  pneu- 
monitis affecting  a  lower  lobe  of  one  lung  being  known,  the  sitnalion 
of  the  pneumonitis,  that  is,  the  side  affected,  may  be  ascertained  by 
percussing  over  the  upper  lobe.  Extensive  solidification  of  the  lower 
lobe  from  tuberculous  deposit  also  renders  the  resonance  over  the 
upper  lobe  vesiculo- tympanitic. 

The  rationale  of  the  production  of  this  sign  over  the  healthy  tobt 
when  a  lobe  of  the  same  lung  is  solidified,  and  over  lung  situated 
above  the  level  of  liquid,  has  given  rise  to  mnch  discussion. 

A  probable  explanation  is  as  follows:  The  presoDG«  of  liquid 
and  the  expanded  volume  of  the  solidified  lobe  keep  the  affected 
side  of  the  chest  more  or  less  expanded,  and  the  consequence  is,  the 
proportion  of  air  to  solids,  above  the  liquid,  in  pleurisy  and  in.  &» 


TABCLAB    VIKW. 


116 


nnafTeclol  lobe  in  pni^unionitiii,  is  greater  th»n  in  health.  The  con- 
lition,  in  fact,  approxiinatiL-$i  to  that  in  einpb^senta. 
Kxnggoritted  ri'^onanoo  iit  not  uncommon  orer  an  upper  lobe  con- 
Itaiiiiiig  ft  lobcrculouft  ilcpoEiit.  Under  tliese  circumstances  the  sign 
[u  ntiribiitalile  to  ciiiphy»ematous  lobults  in  the  neighborhood  of  the 
[tuberculous  deposit.  The  coexistence  of  these  tvo  cobdiuone  is  Dot 
finfrequentlj  found  in  autoptical  examinations. 

TABUt.AB   VIKVr   OS  TUK   DISTINCTIVE  CIJAItArTKK«  Of,  AM>  Tlllt  PllYR- 
ICAL    ConniTIOXS    RKrRKBE^TCD    BV,   IBK   S10H8   OVTAinUi   IIT   FKH- 
I       CUSSIOJt    IN    HKAI.Tn    ANR   IlISKAtii:. 


tniM. 


Oiwnwuntt  cauuACH. 


1.  Nonnil  Terien- 


pitch     low     and    qu&Jit; 


3.  FlalrHiiii  or  ab. 

•DC*  of  nail  Din  w. 


S.  DalnaM.  or  dt- 
alabkid  taunaaea. 


4.  TjmpaiiiUe  t**- 


7*ri«llM  of  tjm- 
paalii«  rHnonnrr  - 
feini'brrrffl  und  cnck- 
«4  iD<(>i  ruoDuna. 


Ko  IDUDd. 


Inlcndtr  lau  thu  In 

b*ii1lb,  th#  liiftfln^d  iti' 
t«DfUj  vnr^lit^  bptir^tn 
rvrjitfcht  nnil  T<ff  pli|Eh( 

Tba  piUb  biibfT  tban  id 

bHlUl. 


Pimui  CoxmiKa. 


HMltb;  lang- 


Llqnid  iti  ptpDKl  lac  or  id  tb*  idr- 
T«ftvt« ;  d(taip1vte  fplidiAcfttton  of 
Inu); .  ilii|i!iCTinaDt  i-l  Inojf  bj  tu- 
mot  01  mutbid  gtawth. 


Enltn  tbwDco  at  ttao 
mlfluliLT  qajiUij.  Bnd  tho 
jiitoh  mofft  or  Imc  raiitvd. 
lb*  InMutl;  Tulablo. 


h.  Bi*sg*r>Ud  or 
TMiodlo-  lj«p*o't''> 
nMOue*. 


MaBi4?a>  intoDAlton  in 
Iha  uophonD,  aoil  ■ 
ohinli^rie  -nuEid  an  thfl 
oriukod  meUI  imrielj. 


Tho    Intsntit;   gniUr 

Iban  in  ht^iilih  ,  ib^iuil' 
it;  k  OdiupuuDd  of  [hi 
TMloulnr  and  tho  I;id- 
puiUin.     «od     Ui>    iiiub 

moro  or  Uu  [Kued. 


Pulial  tolidiflftllon  of  Inoft  fron 
inllnnimatuTj',  inbttfculoui.  of  olbor 
d«po)^t ;  gri-fi  vEiAeuTftr  on^r^^ 
inadt :  onndnnrijitioii  rlu*  lo  macrblDl* 
oal  pr»»furt  or  colUj4u  :  lomll  plaD- 
ritio  fifruKidn  hid  pnrti'l  B^Mnf*  of 
•It'Cclln  oltb  liquid  :  ficcomululioa 
of  marun  ia  brnnobiil  Uihrt  e>ud^ 
lluDof  Ijntpb  un  Ibe  iiEaurHio  turfnos^ 
and.  •iHptinnnllj,  dllalatioD  of  (b« 
■if^otlJa  in  ouipbjia  Din- 


Air  In  tbtpkural  a**llr  (pniumo- 
Iborai)  ;  inWouluDii  iimiiiH  con- 
taining air  ;  aulldilieallun  of  lbs  up- 
ptr  lobe,  tbo  rMonanc*  dori^ed  from 
air  in  tho  Irafiban  and  bronitbiaJ 
lub«,  or  ib<  naonanca  oandoewd 
ttom  tba  ilDiDaiib  ud  onion. 


Qanarail J  tub^reuloua  oatltiat  i 
toiaeiimFi  obtained  over  tho  Upper 
li>be  Ti}iiElin*r),  null  punivtitoM  In 
health  orvf  Iba  upper  loba. 


SllataUon  ot  tha  ■Ir.eall*  la  au- 
fibj'^mn :  ohiftEiiwi  frpqoantij  ovar 
iuiijc  abaia  liquid  in  (be  plonml 
ooiii]r,*nd  ovn  ■  beallby  Inha.  tbe 
uthar  toba,  or  labai^  cf  tha  aami 
inng  baiDg  lolidiAad- 


i 


StTria,  m  1732. 

•r* 

itttrfemiL*  Thewtkr 
died  a  1809.  Tfc*  mkjtn  axtrtatii  ataxtAj  aay  attention,  aoA M 
lallea  ttto  afcGnoB,  «W*  tkinj  jckn  afi«rwiL  the  oiMlwd  n* 

^pGed  to  tke  dbgMMii  «f  aleebeas  of  th»  heart,  br  ibe  difltn^iuM 
Frendi  plirwisa,  C«rnsul,  «h«  tnarided  Afh  agger's  irc&BH 
into  tlw  Freaeh  lutgaag*  Id  ISOS.  IV  hner  vu  tnoslsted  mu 
Ettgluk  !>/  I»r.  Forht^  m  lS3t. 

Tbe  nlu  of  jii  ii«iiiiiiii  wu  JMCMwrmMy  cshBoeed  bj  the  )£»• 
mnry  of  sueBluiioa.  Of  tko*evbohs««ai1t!rst«d  tbrart  of  per 
nmioa.  nnee  thft  line  «r  C«rrisut,  Viortj,  of  Pmis,  is  tlie  moll 
fRvnitteot.  MHutc  peroaMoa  «as  ntndoeel  by  bin.  He  U  ik 
antbor  of  •eveal  woriu  m  tbe  nbjed.'  In  practice,  bowerer,  ht 
plaeea  too  exclaHTe  refiaaee  oa  tbia  netboi,  rejecting  anseoluiita; 
and  be  profeawg  to  aehtnr  tmtlu  with  tb«  pleximeier,  to  whidi 
oUiera  witb  »iual  abtUtj,  aad  not  !«■•  eooMieatiotuiiessi,  bare  failed 
to  attain. 

'rb«  idea  of  cotubining  awcnltstion  «ritb  pereasdoe  naT  be  Mid  to 
bare  originate*!  with  Ijuimvc.  lie  resoned  to  it,  bowerer,  to  a 
Tor;  limited  extent.  Tbc  plan  of  practi^ug  the  two  methods,  siiatit 
taneoniil/,  with  a  ricw  c^peciallj-  of  deienninin^  accurately  the 
■ituation  and  dimenaionii  of  ttie  solid  rtMwra  encroaching  on  tbt 
thoraoie  »pac«,  which,  although  it  has  not  come  into  general  nse,  and 
perhapn  never  will,  in  consc(uence  of  the  ordinarT  simpler  modes 
being  adequate  to  most  of  the  objects  to  be  obtained  by  percanion, 
originated  with  Drs.  Cammann  and  Clark,  of  New  York. 

I  Ova  cuinol  nTitj  nu  muitlon  nf  M>rmw  at  Ih*  thaa|rhl  lliat  Aomtm^x")*' *)■' 
40Tol«d  Mim  jt»n  to  nwBichu,  u  be  mti,  inter  Uiba  et  I^Avrtt,  <ould  not  bar* 
•q^j«d  durinc  hi*  libliina  th*  lallifMdoii  of  wtwwintiftiMpocfafof  pftKOirfoB 
la  MMn*  ffiHwar«  apprfclaUvL    In  tbU  retpcct  ih«  dbaovcrar  of  aiwmltaUga  w«  ^ 
Btr  marr  btuml.  | 

•  Traiii  do  U  VaremOm  inMU*,  Pari*,  1838,  and  Du  ProoMI  oplratir  d*  la  ' 
PmtcuuImi,  Paris,  IMI.     Th«  riewi  of  M,  Piorry  arc  alio  embodied  in  a  mora 
raMDl  voik,\rf  o»n  at  \At  pupilt,  M.Mfiilli>L.Tnitv<l«laPeT<7UMioa  isMiii|«,<te. 
Tho  1«ll«T  hai  b*«n  iraa>l«lcd  inu>  EogUih,  but  not  republiihcd  in  tliii  i 


I 


iMiii|«,<te.  m 

2 


CHAPTER    III. 


AUSCCLTATION. 


Tkb  tirni  auscultation  is  applied  ta  tlie  act  of  listening  to  ibt 
[BOUDfltt  proi]uccil  within  tlic  cliettt,  in  connection  with  respiration, 
Ispi-aktng,  nnd  coughing.     The  use  of  the  t«rni   io  this  resirictcd 
Iccnsc  ii  conrcntioaal.     Properly  speaking,  the  phcnomi^na  developed 
bj'pcrcmsion,  involving,  us  thejdo,in  their  application  equally  an  act 
'of  liat«Ding,  should  come  within  the  domain  of  auscultaiion.     There 
is,  however,  this  distinction,  vix.,  in  pcrcusKigo  the  sounds  are  pro> 
l^uced  by  the  listener,  whereas  in  auscultation  they  result  fiom  ihe 
■ction»,  either  instinctive  or  voluntary,  of  the  patient.     The  ex- 
plorer, in  the  one  case  is  an  active  agent  in  originating  the  impres- 
sions received  through  the  sens©  of  hearing ;  in  the  other  case  he 
is  little  more  than  a  passive  recipient.     Another  point  of  differeoce 
is,  that  percussion  may  he  practised  on  the  dead  as  well  as  on  the 
living  body,  while  auscultaiion  19  available  only  so  long  as  life 
continnes. 

The  act  of  listening  to  soundii  emanating  from  the  thornx,  may  be 
performed  in  two  ways,  via,,  with  the  ear  applied  direelly  to  the 
cheat,  or  by  means  of  a  conducting  medium.  Tht-se  two  inodctt  arc 
distinguished  by  the  name  termi)  employed  fur  an  analogous  purpose 
IB  percussion,  vis.,  mirdiatt  and  immt^Jiali:'  In  immndiaU  awiealta- 
tion,  the  sound*  are  received  by  thu  ear  placed  in  immediate  contact 
with  the  chest.  Mediate  au*<^ltaCion  requires  an  instrument  whiob 
is  interposed  between  the  chest  and  the  ear  of  the  listener,  through 

f-whicli  the  sounds  arc  transmitted.  This  instrument  is  caile^l  tlie 
tMi4)«eope,  a  term  signifying  cliest-explorer. 
The  question  at  once  arisoi^,  of  the  two  modes  of  practising  aus> 
Oall«tion,  which  is  to  be  preferred!  £aeh  mode  ha^  its  peculiar 
advantages,  and  neitlier  should  he  adopted  to  the  exoUision  of  the 
other.  Imitiediute  suscultittiun  is  the  simpler  mode;  it  is  in  most 
cases  practised  more  readily,  and  the  exploration  of  the  whole  cheat 
is  more  expeditiously  madr.  In  a  large  majority  of  cases,  to  one 
practically  familiar  with  auisciiltatory  pbcoomcDaj  it  sutGcea  for  all 


*  Thaw  bwKB  w«i«  flnt  cniplojod  hj  Lacnnco,  aad  •ubwq'oentljr  Iwrrowed  and 
■ppUai  i«  ptHnadoB  ij  Piorrj. 


118 


rmrnvAh  »rb«BATXov  or  thk  chsst. 


tliit  is  deaircd  vttli  rcvpect  to  the  £igM*ift.  With  children,  who 
&re  apt  to  be  frtghteoe4  at  the  appoTvae*  of  «n  instmtDent,  thin 
Bode  ia  otua  more  aruUUc.  Bat  n  crrtaia  parts  of  the  tfaoncic 
Mu-faee  the  ear  cannot  be  applied,  for  iiMtaoce.  the  axilla  and  the 
poeUiUvicoitr  regwD.  If  the  patient  be  m  feeble  as  not  to  be  able 
to  be  ruUed  from  the  reeambeat  pcvtare.  and  the  bed  be  low,  the 
position,  on  the  part  of  the  explorer,  BcecsMry  to  practise  immedial* 
aoeculution,  renders  it  ineoarettieat  tad  difficult.  The  uncleanly 
coiiditioii  of  thr  piUicnt  is  oft«a  not  s  triflhig  objection ;  and  with  ft- 
males,'  delicacy,  or,  at  all  cTents.  fa«tid>oaaiess,  mav  oppoae  a  resort 
to  tliiit  nio>Ir  over  the  anterior  corface  of  the  diest. 

Mediate  auicultatioR  beoones  almost  meessary  in  some  instance«, 
in  which  it  i»  important  to  isolate  the  phenomena  prodiiccfl  at  a  par- 
ticular point  from  those  of  the  sorrounding  part:>.  Whrn  the  bead 
is  placed  in  apposition  to  the  thoracic  walK  sounds  emsDattng  from 
a  coiitiidcrabic  distanoc  arc  brought  within  the  focus  of  hearing, 
boin);  conducted  by  the  parts  sarrounding  the  cnr  which  is  in  cod- 
tact  with  tlic  chest.  With  the  Methoscope,  the  area  whence  the 
sounds  arc  transmitted  is  more  circumscribed,  and  tfais  is  an  impor- 
tant iidvnntage  under  some  circnms(anco»,  ns  in  seeking  for  the 
auBcultotor;  signs  of  nn  excavation,  or  of  tuberculous  consolidaiim 
contained  within  a  small  space.  In  some  cases  in  which  the  surface  of 
the  chest  has  been  rendered  very  irregular  by  injuries,  or  deformi- 
ties, nnscultstioQ  is  available  onlj  by  means  of  the  stethoscope. 
Neither  mediate  nor  immediate  auscultation,  then,  is  to  be  cultivated 
or  practised  to  the  entire  neglect  or  exclusion  of  the  other,  hut  eacb 
is  to  be  resorted  to  as  it  ma;  be  specially  indicated,  and  freijuently 
both  employed  in  the  snmc  examination. 

The  pari  performed  by  the  stethoscope  in  auscultation  was  much 
eiaggented  by  the  illuslrious  discoverer  of  this  method  of  explora- 
tion, and  is  still  misunderstood  by  many.  The  instrument  is  simply 
a  conducting  medium ;  and  the  glory  which  will  ever  attach  to  the 
name  of  Laennec,  as  has  been  justly  remarked,  is  in  no  measure  dfr- 
rived  from  iho  invenUon  of  the  stethoscope,  but  solely  from  the  di^ 
eorery  of  auscultation.  A  great  variety  of  stethoscopes  have  bcea 
in  use.  Almost  every  one  who  has  bestowed  e8pe<'ial  attention  on 
Uiis  branch  of  practical  medicine,  seems  to  have  felt  it  incumbent  to 
originate  an  instrnment  po&seesiDg  some  one  or  more  peculiarities, 
which  frequently  are  of  no  practical  importance.  The  material  of 
which  it  is  made,  its  siie,  length,  form,  eto.,  offer  vide  scope  for 


(]ir<^niity  of  cooBtruction,     But  the  truth  is,  that  if  tbc  sounda  are 
ooti(lu«tei!  to  the  ear.  the  constraction  of  the  iDstrumcnt  is  in  n  ^re»t 
measure  a  matter  o(  tasie  or  convenience.  The  first  stethoscope  con- 
strncted  by  Laennec  was  composed  of  throe  quires  of  writing  paper 
rolled  compactly  in  the  form  of  a  cylinder  and  securc-d  by  p»»tc. 
Afterward  a  cylinder  of  wood  was  substituted,  and  of  this  material 
the  iDatrumenifl  emplored  since  tho  tune  of  Laennec  have  generally 
been  made.     Wood  is  not  the  best  mcditim  for  the  transmission  of 
Bound,  but  owing  to  its  lifrhtness,  and  some  other  recommondatioDS^ 
it  is  to  be  preferred  to  metal  or  glass,  which  arc  better  conductors, 
lostrumenla  have  lately  been  conatructed  of  gutla  perchs;   with 
these  I  have  had  no  practical  acquaintance.     They  are  recommended 
as  fulfilling  all  the  conditions  of  a  convenient  stethoscope  by  com- 
Vpetent  authority.'     It  would  be  ()uite  unnecessary,  to  say  the  least, 
to  enter  into  a  diecnaaioD  of  the  numerous  delaib  pertaining  to  the 
length,  size,  form,  etc.,  of  the  cylinder.     It  will  suffice  to  notice, 
briefly,  the  general  principles  to  be  observed  in  its  construction. 
Some  (Hughes,  M''atson.  and  Blakiston)  prefer  solid  wooden  cylin- 
ders.    Most  of  the  inHtruments,  however,  in  common  use  are  per- 
forated through  the  centre,  and  the  general  impresflion  is,  that  the 
sound  is  conveyed  partly  along  the  woody  fibres,  and  in  part  by  the 
^  eolumn  of  air  inclosed  within  the  canal  passing  through  the  cylinder. 
H^    Of  ibe  different  kinds  of  wood,  either  cedar  or  ebony  is  usually 
^Kriwted  from  their  lightness  and  ittraightness  of  fibre.     The  instru- 
^^mnt  should  be  of  Hutficient  length  for  the  bead  to  be  removed  to  a 
comfortable  distance  from  the  body  of  the  patient;  but  if  it  be  too 
long,  there  will  be  difliculty  in  keeping  it  accurately  adjusted  to  the 
chest.     Six  to  ten  inches  are  the  limits  of  a  convenient  length.     The 
aural  extremity   should  be  broad  anil  moderately  concave,  so  as 
to  receive  ihc  extenial  ear,  and  admit  of  pressure  upon  the  whole 
surface  with  the  head,  without  closure  of  the  meatus.     Many  iitellio- 
•copes  are  faulty  in  lIioj«e  pointa;  the  aural  extremity  \»  ton  small, 
and  the  concavity  cither  too  great  or  insufficient.     But  the  same 
instrumcut  will  not  equally  fit  the  curs  of  all  persons,  and,  as  Dr. 
Walshc  remarks,  "  it  is  as  necessary  to  try  on  a  new  stethoscope 
as  a  new  hat."     It  is  better  that  the  ear-piece  be  vf  the  same  mate- 
rial as  the  body  of  the  instrument.     It  is  frequently  made  of  ivory, 
which  may  be  more  pleasing  to  the  eye.  but  diminishes  somewhat 
the  conducting  power.     The  pectoral  extremity  should  be  trumpet 

1  Dr.  J.  Uugbw  BccD«tl. 


ISO 


PBTSICAL   IXPtVaAtlttV  «r  til   OBBST. 


•r  fnmcl-alisped,  ami  aot  tea  imgt.  A  ^MMttr  of  •&  ineb  or  u 
tncb  sod  a  bmlf  n  mCobbI.  IW  •%*  Aad4  W  raonded,  to  t^ 
die  reiitwite  HMvat  «f  pr— '■  Aril  mvC  kart  the  ikiD.  For  lb 
sake  of  iigbbMM,  IW  Mf  «r  ataa  if  A*  Mtnanit  m»j  W  ndnecJ 
in  Bse  to  »  CTtioder  cf  tW  £aaeter  «f  half  aa  inch,  tf  Uw  maUm] 
bo  ebon  J.  or  aa  iacb  «r  mk,  if  it  W  cedar.  Tfca  txterior  afrd  tbe 
bore  of  the  hutnaeaC  Aa«M  he  isMlh  aad  poMwd.  With  the*e 
data  the  stadent  «r  practilMer  a^iht  nasa  oae  to  be  coostructtd, 
or,  imiuting  the  eiafle  «f  I^ana^  MMli^et  one  with  his  on 
hatuk,  without  akj  aoJcL  SltAweapM,  havcrcr,  ar«  so  cooiiimb, 
that  it  b  odIt  neeeasarr  to  wleei  fnm  %  varietjr  of  Bprcimcns  tW 
one  which  appears  b<si  lo  caaabiae  the eaalili— jast  stated.  Ilabil 
will  be  found  to  hare  maeh  to  do  with  the  ease  and  facilJtj  with 
which  a  partienlar  iiiaUaiaeat  ia  eBfloyed;  and  it  ■•  aBdeabtadlf 
true  (bat  a  stethoiMpe  dcfcetm  in  certua  potua  of  eonBCrttim 
will  be  preferred  bj  one  aecvBloaed  to  its  aae,  orer  another  whidi 
is  in  reality  superior,  but  to  whidi  be  n  sM  hahiiaated. 

Flexible  sielhA>acop»  hare  beeo  oaed  to  aoaae  ezteot,  and  by  aoot 
preferred  to  the  wooden  ojlinder.  A  Sexible  inaimtnent  sereml 
years  ago  was  devised  br  Dr.  Pennock,  coostmcted  of  coiled  me- 
tallic wire,  covered  with  a  silk  or  worsted  web;  the  pectoral  ez- 
treniit;  consists  of  a  mcullie  cone,  and  to  the  aaral  cstr#aiity  a  tabe 
is  attached,  aita  of  metal,  which  is  introduced  within  the  externa] 
ear.  The  chief  recommendation  of  a  flexible  stethoscope  is  that  it 
admits  of  application  to  different  parts  of  the  chest,  without  the 
necessitj  of  mach  change  of  position  on  the  part  either  of  the  patient 
or  explorer.  In  some  instances  this  is  an  important  desidcrstotiL 
The  instrument  is  a  enBGoicntlj  good  conductor  of  the  thoracic 
sounds.  A  disadvantage  of  it  is,  the  pectoral  extremity  requires  to 
be  held  in  apposition  to  the  chest  with  one  hand,  and  the  aural  ex- 
tremity  kept  within  the  ear  by  the  other  hand.  Sonnds  produced 
by  the  contraction  of  the  muscles  of  the  bauds,  and  by  friction  on 
the  instrument  are  apt  lo  be  commingled  with  those  received  froa 
the  chest.  A  little  practice,  however,  enables  the  listener  to  dis- 
connect the  latter  and  observe  them  separately.  In  this  variety  of 
stethoscope,  if  not  indeed,  in  the  ordinary  wooden  cylinder,  the 
column  of  air  appears  to  be  the  important  conducting  medium ;  and, 
in  fact,  a  common  ear-trampet,  with  a  caontchouc  tube,  answers  the 
purposes  of  a  stethoscope.     M.  Landouzy,  of  Paris,  has  saggeated 


i 


AtrsctrtTATrou. 


121 


I 


stctlioMope  with  a  Dumber  of  gufn>c1a»tic  tul>e6,  b;  means  of 
which  ecvcral  persons  may  ausculUtD  Hinmltaneouslj. 

A  Dcxililc  Fteiboscope  on  a  luiv.-l  i>lnn  was  inrcoted  sbouE  twelve 
>gu  bv  the  late  Dr.  Caniiniinn,  of  New  York.  It  oonusts  of 
a  bc1l-»biipcd  pectoral  extremity,  mule  of  ebony,  about  two  inches 
in  diitoiolt-r,  to  which  are  attached  two  lubes  of  metallic  wire  covered 
with  gum-elastic,  aod  with  the  latter  arc  connected  two  tubes  of 
German  silver,  geniiy  curved,  ami  eiidiii;:  tn  ivoT*"  knob;*,  which  are 
intended  to  be  introduced  within,  and  to  fill  accurately,  the  external 
ear  on  both  sides.  The  sounds  are  ihuii  received  ihroagh  both 
organs  of  hearing,  and  other  souniU  than  ihoso  traDsmittod  by  the 
ioGtrument  are.  in  a  great  nteaHurc,  cjclude^l.  In  the  construction 
of  this  instrument  the  agency  of  the  colnmn  of  air  in  conducting  the 
thoracic  sounds  was  established  experiineatally ;  for  it  is  stati'd  that 
the  solid  media  were  changed  many  liuie^  without  the  conducted 
sound  lo»ing  it«  intensity,  nnd  the  found  was  lo«t  by  ninking  the 
pectoral  extremity  mlid.  Thoracic  sounds  arc  hvanl  by  means  of 
Ibis  ioiitninieiit  with  great  intensity,  and  they  are  rendered  dJAtinct 
when  eearcely  iijiprcciiiblr  by  the  irnki^l  ear,  or  with  the  ordinary 
cylinder.  lu  the  Utter  respect'  it  enlarges  the  application  of  au8- 
eoltation  by  furnishing  informntion  in  cssn>  in  which,  by  fomter 
nodes  of  ensmination.  the  signii  arc  not  nruilable.  It  also  render* 
auscultation  practicable  for  thove  whose  sense  of  hearing  is  iropaire<l. 

In  the  fonncr  olitJon  of  th!«  work  I  stated  that,  in  the  conduction 
of  thoracic  i^ouuds  by  Cnmmnnn'sbinnnriil  stethoscope,  iheir  quality 
and  pitch  were  altcreil,  nnd  that  it  was  more  difhcult  to  make  com- 
parisons of  different  sounds,  in  these  respects,  than  with  the  wooden 
cylinder  or  by  immediate  auscultation.  At  that  time  the  instrument 
bad  been  quite  recently  invented,  and  I  liad  Died  it  for  only  a  brief 
period.  After  having  nuw  H»ed  it  a)mr<st  daily  for  more  than  ten 
years,  I  atn  mach  better  prepared  to  ipcak  of  its  merits.  The  oh- 
jection  on  the  score  of  the  alteration  of  the  pitch  and  quality  of 
■ounds  I  have  long  Kince  found  to  be  without  foundation,  and  I  am 
rare  tliat  this  instrument  will  supplant  all  wooden  stethoscopes  as 
soon  as  it  is  fully  appu'ciated.  The  power  of  conduction  is  greatly 
mcrcaicd  by  the  reecptioD  of  the  sounds  simultaneously  into  both 
can.  Its  superiority  over  in«trnmeut*  which  conduct  the  sounds 
into  one  car,  is  analogous  to  that  of  the  binocular  over  the  tnoD* 
ocular  microscope.     The  ease  and  comfort  with  which  it  is  applied 


1S2 


riTSIOAL  BXPiOBATIOV  OF  TBI  CBBST. 


oomatttotc  not  «  «miill  rccommendntion.  Th«  excln^mi  of  otker 
KHimIs  ittan  thiffc  con'luctoi)  bj  the  inHtntment  is  *a  important  tA- 
T«Dtsgc.  In  short,  to  bceomo  to  mach  attach^  to  it  w  to  dtapcaae 
entirclj  «ith  oihpr  ^tclhoxcopm,  one  needs  only  to  become  >c«b»- 
tomed  to  it«  hm-.  Some  practice  is  requisite  to  realixe  its  Tilne; 
hence,  msn;  rrjfK^  it  sl^r  an  insufficient  trial,  when,  had  tbej  eoo- 
tinaed  to  use  it,  ther  voald  have  been,  after  a  time,  trnwilUng  u 
girp  it  np.  Since  the  first  edition  of  this  work  waa  written,  I  hart 
had  seTerat  hundred  private  pnpiU  in  anscullation,  and  I  bar»  Tocnd 
that  many,  at  first,  are  confused  in  ming  it ;  bnt,  invariably,  aft« 
•ome  practice,  it  is  preferred,  not  only  to  other  stethoscopes,  bat  t* 
the  use  of  the  car  applied  directly  to  the  chest,  so  that  immediate 
aoBcoltation  is  apt  to  b«  neglected  in  conseqaeDcc. 

In  the  practice  of  anaculiation  it  is  important  not  to  neglect  the 
exercise  of  the  ear  without  Cammann'a  stetboscope.  It  has  beea 
aaggcated  that  the  Dse  of  the  latter  ia  likely  to  impair  the  aenae  of 
bearing  when  immediate  aa^cullation  ia  praeiised.  There  b  so 
ground  for  apprehension  on  this  score,  proTide<l  exercise  of  the  ear 
without  the  stethoscope  be  not  neglected.  In  beginning  to  nee  the 
insiniment  ihe  fact  is  to  be  home  in  mind  that  it  conducts  all  soondt 
as  well  as  those  which  are  from  within  the  chest.  Sounds  produced 
by  friction  of  substances  upon  it  are  to  be  aroided.  The  peetoial 
extremity  must  be  applied  to  the  naked  ^kin  to  aroid  extrinsic 
soands.  The  pectoral  extremity  is  to  be  held  with  the  finger*  ia 
order  to  keep  it  firmly  and  e<inally  applied  to  the  chest.  The  elastic 
band  connecting  the  metallic  tubes  should  be  sufficient  to  hold  the 
knobs  in  the  ear  with  the  proper  amount  of  force  without  the  fingers 
being  used  for  this  purpose.  The  proper  construction  of  the  inslm- 
mcnt  is  eaecntial.  The  curves  of  the  aural  extremities,  the  siie  of 
the  irory  knobs,  ihe  flexibility  of  the  wire  tubes  which  connect  the 
metallic  portion  with  the  pectoral  extremity ;  the  perTionsnesa  of  both 
tubes,  and  the  smoothness  of  the  interior,  are  points  which  aro  to 
be  properly  nttonded  to  in  the  construction.  Some  of  the  instru- 
ments sold  are  worthless  from  defects  in  these  or  other  points.'  This 
kind  of  stethoscope  is  well  suited  for  auscultatory  percussion,  as  pro* 
posed  hy  Dr.  Cammann,  in  connection  with  Prof   Clark, 

I>r.  Alison,  of  London,  has  proposed,  as  a  modification  of  Cam- 


<  The  in»mim(int«  w«dc  by  TJMoann  A  Co.,  No.  67  Chathiai  Strccl.  NcwT'n'lt, 
nuT  be  relied  upuo. 


AOSCULTJlTIOSf. 


138 


I 


tmann'fl  st«lhoscopfi,  tvto  pwtomi  extremities,  bo  that  eonnds  frfim 
two  different  eituatioDg  may  be  simaltaneously  perceived.  The  object 
is  to  compare  the  sounds  from  the  two  situations.  lie  calls  the  in- 
stniment  tJie  differtntial  ttethoscope.  The  conduction  of  the  sound 
into  each  ear  is  much  weaker  than  when  a  sound  is  received  into  both 
ears ;  the  advantage  of  the  binaural  character  of  Cammann's  in- 
strament  is  lost  in  the  differential  stethoscope.  Moreover,  a  com- 
parison of  sounds  is  not  so  easily  made  when  they  are  heard  together 
as  when  they  are  heard  separately.  Of  this  fact  one  may  at  <inc« 
convince  himwlf,  by  raising  the  inquiry  whether  notes  from  two 
different  musical  instruments  are  beat  compared  when  produced 
simuliaReonsly  or  successively.  After  some  trial  of  the  differentia) 
stethoscope  it  has  not  seemed  to  me  to  be  an  improvement  ae  regards 
the  application  of  auscultation  to  pulmonary  signs. 

Or,  Alison  has  also  proposed,  as  an  appendage  to  the  BtethDBCope, 
the  <0e  of  an  india-rubber  bag,  611ed  with  water,  the  bag  being,  when 
filled,  of  about  the  sise  of  a  large  watch.  This  is  to  be  applied  to 
the  chest,  and  the  pectoral  extremity  of  a  flexible  stethoscope 
placed  upon  it,  the  sounds  being  thus  transmitted  through  the  water. 
Dr.  A.  calls  the  water  bag  the  hydrophone,  and  claimti  that  respira- 
tory aoands,  healthy  and  morbid,  are  made  by  it  more  audible  than 
when  m  simple  flexible  stethoscope,  or  Oammann'a  instrtimcDl,  i« 
used  without  this  appendage.  Other  advantages  ar«  the  facility  with 
which  it  is  applied  to  the  chest,  adapting  itself  to  the  intercostal  de- 
pressions and  other  irregularities  of  the  surface,  and  giving  less  pain 
if  the  cheat  be  tender.     It  is  not  suited  to  the  ordinary  modern 

latethoscopes ;  hot  it  may  be  used  satisfactorily  with  the  ear  applied 

'directly  npon  it.' 

I  have  lately  compared  with  Cammann's  instrument  a  binaural 
iastrument,  simitar  in  all  respects  except  that  in  the  pectorul  ex- 
tremity are  placed  two  thin  diaphragms  of  india-rubber,  from  two 
to  three  inches  apart,  the  space  between  the  diaphragms  fdleil  with 
vfttcr.  The  lower  diaphragm  being  at  the  extremity  of  the  instru- 
nent,  the  advantages  of  Dr.  Alison's  hydrophone,  as  regards  the 
facility  with  which  it  is  adapted  to  the  walls  of  tbo  cfa«8t,  are  W^- 
eared.  I  am  satisfied,  however,  that  the  power  of  eondaotion  is 
impaired  by  this  arrangement.     With  the  diaphragms  alone,  that  is. 


'  Ffab  Phftical  KiaminBtiuD  of  th«  Clioit  in   Pulmonuj  Coiuiunptioo,  etc. 
\ij  Saaivrrlllc  Sn>tt  Aliion,  M.D.,  etc.     London  :  IMl. 


1^ 


PHYSICAL    EXPI.OBATIOX    OP   TUB    CHEST. 


vithout  the  irntcr,  tbc  conductioD  is  1cs«  than  irith  tbc  ordioarjr  In- 
aaral  stethoscope.' 

In  (be  perTonDancc  of  sn»ciilintioii  ceiisin  rules  arc  to  be  obaerrd, 
the  iDore  important  of  wbicb  may  be  bcre  stntwl.  Wbcncrer  pT*fr 
ticable.  the  person  to  b«  exsmtDciI  should  be  a«sted  io  a  chair  inA 
a  bigb  back,  fumubing  a  firm  support  for  the  shonldcrs,  which  are 
to  be  thrown  moderately  backward  vbeo  the  che&t  is  explored  in 
front.  In  examining  the  back  a  stool  is  preferable,  or,  if  the  panm 
be  of  the  male  sex,  his  position  may  be  revenged,  the  face  ttimed  to 
the  back  of  tbc  chair ;  the  body  should  be  inclined  forward,  and  the 
arms  folded  as  in  prnetisinj;  pcrcititi«ion  on  the  posterior  surface  ttf 
the  che«t.  In  exploring  the  laterul  surfaces,  the  hands  should  be 
dasped  Qpon  the  head,  as  when  percussion  is  made  in  this  situation. 
If  the  patient  be  confined  to  tbc  bed,  the  chest  in  front  majr  be  ei* 
amined  to  the  recumbent  position,  and  afterward,  if  the  diseaae  be 
not  accompanied  by  extreme  debility,  he  may  be  raised,  and  sup- 
ported in  u  sitting  pofitioii  while  (he  examination  is  made  behind  and 
laterally.  It  is  sometiincs  the  case  that  patients  are  too  feeble  to 
endure  a  titling  posture  eren  for  a  short  time.  Inclining  the  body 
first  on  one  Hide  and  thru  on  (he  other,  a  partial  exploration  oiaylw 
made  tinder  these  circumstances  by  mcnns  of  Cnmmano's  etetbo- 
scope.  It  is  more  satisfactory  to  divest  the  chest  of  all  clothing,  in 
order  to  judge  better  of  corresponding  points  on  the  two  sides  to  be 
explored  in  alternaiion.  So  far,  however,  as  concerns  the  transmis- 
sion of  sohnds  in  immediate  auscultation,  this  is  not  necessary.  A 
single  ihin  covering  of  cotton  or  linen  offers  little  or  no  obstruction, 
but  several  thicknesses,  or  a  thick  woollen  article  of  dress,  interferes 
with  the  appreciation  of  ausculiatory  phenoraena.  If  a  oorerii^ 
remain,  it  should  be  soft  and  flexible,  so  as  not  to  occasion  a  mstling 
noi!<e  from  the  movements  of  the  chest,  or  by  friction  against  du 
car.  In  immediate  ausculmtion,  a  soft  napkin  or  handkerchief  in- 
terposed between  the  skin  and  the  ear,  obviates  the  disagreeable 
circuntKlancoH  often  attendant  on  applying  the  head  to  the  naked 
surface.  A  regard  for  delicacy  may  prevent  complete  exposure  of 
the  chest  of  the  female.     The  portions,  however,  most  inportant  in 

■  Dr.  OiartM  L.  Hugeboom,  of  th'u  city  (Kcw  York),  ban  tnggvMl  m  aa  im- 
provcment  of  CBinmiinn't  inalnimcnt,  ex  tendinis  Hcrou  tbo  pnctaral  opvaiaga 
pitwu  of  jMirRhnient.  Tlie  iiarcliiiifiit  tlinuM  bu  b^iixd.eo  us  tu  bu  in  ontaet  wilb 
tbc  ikin  ftod  roaUt  a  curtAin  amount  of  (ir«iuro.  Ailar  ioiac>  uml  of  an  lavlni. 
niuut  lliu>  prepared,  tlii>  puwvr  of  voiiiluctiuii  t^mt  to  ma  to  bu  unuewhat  in* 
er«a«ed  withuul  otticr  GbBn)[<^,  and  tbc  (ourcc  of  the  (ound*  appcan  to  b*  clrcaao 
•eribed  b;  the  addition  nf  lh»  paivhainnt. 


AQSOITLTATION. 


125 


Ceuies  in  wliich  k  minute  cxaminntion  i»  most  likely  to  be  reqaired, 

Itiz.,  tho  »iiinmit  in  Trout  nnil  behind,  maj,  witbont  impropriety,  be 

I  divc«tpd  of  the  dress.    The  tempunituro  of  the  room  shouM  he  prop- 

Lfirly  regal&ted,  especially  if  the  ehcst  he  exposed.      This  ts  impor- 

I  tent,  not  only  to  obviate  the  liability  of  the  patient  suffering  injury 

[from  the  impression  of  cold  on  the  surface,  but  to  prevent  a  difficulty 

ffliich  may  interfere  with  the  examination.     The  action  of  cold  on 

the  muscles  of  the  che«t  sometimes  occasioDS  trembling  morementa, 

accompanied  by  a  rumbling  noise  which  obscures  tie  intra-thoraoic 

MDods,  and  without  knowledge  of  this  sonrce  of  an  exterior  mur- 

iDur,  it  might  be  supposed  to  emanate  from  within  the  chest.     The 

poBition  of  the  explorer  should  be  one  favorable  for  listening  with 

attention,  and  which  may  be  maintained  for  some  time  without 

fatigue  or  discomfort.     If  he  assume  a  constrained  posture  his  mind 

will  he  diverted  from  the  object  oF  the  examination  to  his  own  scn- 

Mtions,  and  he  will  be  nnabic  to  reserve  his  perceptions  exclusively 

■for  the  thoracic  sounds.     A  stooping  posture  is,  as  much  as  poesible, 

Bto  be  avoided,  not  only  for  the  reason  just  mentioned,  but  because 

^Pt}ie  graritation  of  blood  to  the  head  induces  a  temporary  congestion, 

I  which  dulls  the  sense  of  hearing.     It  is  not  uncommon  to  see  prac- 

titionrm  inclining  their  beadft  tto  low  in  performing  aiucultation  that 

tthe  face  become*  deeply  injected,  nnil  the  veins  largely  dilated.  I 
find  it  most  convenient  and  comfortable  to  rest  npon  one  knee.  la 
tbis  position,  if  the  pntienl  he  silling,  the  head  may  be  placed  in 
contact  with  the  clici^t,  and  kept  upright,  or  nearly  so.  Of  course 
these  precautions  bavc  reference  to  the  practice  cither  of  immediate 
anacultalion,  or  the  use  of  the  wooden  cylinder.  Wiih  Cammann's 
stethoscope  the  explorer  may  remain  sitting  by  the  side  of  the  pa- 
tieitt,  the  latter  lying,  or  sealed,  as  the  case  may  be.  This  is  one 
of  tlic  rccommcndntioDK  of  this  instrument. 

The  ear  le  to  be  pressed  Bgainut  the  cheat,  in  immediate  anscnlla* 
tioR,  with  a  certain  amount  of  force.  If  the  pressure  be  made  too 
lightly  the  sounds  are  not  tranitmitted,  or  an  unnatural  character 
may  be  communicati'd  to  them  which  may  be  mistaken  for  morbid 
pfa«nomcna.  Tliii!<  the  resonunco  of  the  voice  by  the  non-obscrrance 
Hof  this  rule,  aoraelimea  assumes  a  modification  analogous  to  the 
f)hyifical  sign  called  wgophony.  On  the  other  hand,  if  too  great 
force  h«  applied,  pain  may  be  occasioned  sufficient  to  disturb  the 
respiratory  movements,  or  the  expansion  of  the  chest  may  even  be 
impe4led.  Attention  to  this  point,  with  practice,  will  enable  the 
si^liator  to  hit  the  medium  between  the  two  extremes.     If  the 


126 


PHTSICAt    KXPLORATIon   OF    THB   CBBST. 


cjlieder  be  employed,  the  pectoral  end  sbonld  he  evenly  applied  « 
the  cheat,  and  held  in  place  with  the  fingers  of  the  right  baud  natfl 
the  eAi  is  nicely  adjaated  to  the  aural  extremity.  The  hand  is  tlua 
to  be  reraored  from  the  inMtrumcnt,  which  is  to  be  kept  in  pUoe  bj 
meiaDa  of  pressure  with  the  ear  alone. 

Id  practising  inDmediate  auscaliatlon  it  is  well  to  accoatom  oocttlf 
to  the  use  of  either  ear  indifTerentlr,  if  the  sense  of  hearing  W 
equally  acute  in  both.  Ad  exploration  of  both  surfaces  of  the 
cheat  can  then  he  made  without  the  necessity  for  change  of  poutiMi 
OD  the  part  of  the  explorer.  Perfect  sileDce  in  the  apartmeDt  is  M 
first  necesaary.  The  habit  of  meota)  abslraotioD,  and  the  power  to 
concentrate  the  atteniioD  exclusively  on  tbe  thoracic  sounds,  ate 
not  generally  acquired  without  more  or  less  pains  and  p«rseTeraaee> 
After  a  time,  however,  extrinsic  noises  are  le&s  troublesome,  and  aa 
exploration  may  bo  made  tinder  unfavorable  circumstances.  Die 
ability  of  acquiring  the  power  to  withdraw  the  senses  and  thoa^ua 
from  surrounding  objects  ia  DOt  equally  possessed  by  all  individual^ 
and  it  is  owing  in  part  to  differences  in  tUb  respect  that  some  |Mr> 
BODS  become  much  better  ansoultators  than  others.  Erery  one  so- 
cu»toini.'d  to  physical  exploration  must  have  observed  that  the  facihlj 
and  sutiafacCiou  with  which  examinations  are  made,  differ  coa3ide^ 
ably  at  different  times,  owing  to  diSerertoea  in  the  state  of  menial 
activity,  preoccupation,  eto.  After  auscultating  for  a  time,  the 
quietness  and  correctness  with  which  thoracic  sounds  are  perceived 
are  liable  to  be  impaired  by  fatigue.  It  is  a  useful  caution,  there- 
fore,  not  to  continue  this  kind  of  investigation  too  long.  From  one 
to  two  hours  of  continuous  exploration  is  sufficiently  long  without 
an  inttrval  of  rest. 

The  phf-noiiiCTia  revealed  by  auscultation  relate  lo  the  respiralioa, 
tlie  voice,  anil  the  act  of  coughing,  the  latter  being  comparatively 
of  little  cvusequeiicc.  In  li.ttcnlng  to  the  n-spiratory  rounds,  the 
manner  in  which  the  patient  breathes  ia  a  matter  of  importance. 
Mental  excitement  or  apprehension  often  gives  riae  to  more  or  leas 
divtiirbaiieo  of  the  respiration.  The  hroathing  becomes  hurried  and 
irregiilur,  and,  on  this  account,  the  examination  may  bo  untuiti*- 
faecnry,  or  even  prove  nhoTtivc.  In  persons  of  great  nervous  im- 
pre««ibilily  it  i«  frequently  iicccKi'itry  to  wait  until  calmness  ia  re- 
Btorcd  before  proceeding  with,  or  completing  an  exploration.  At 
justly  remarked  by  Fournct,  the  umniier  and  bearing  of  the  physi- 
cian have  much  to  do  with  this  point.  If  h(^  wear  a  solemn  mien, 
and  favor  by  his  looks  or  actions  the  idea  that  the  examination  ia 


AU8C1JLTATIUX. 


127 


I 


k 


>e  of  formidable  import,  he  will  be  less  succcBsfuI  than  if  be  maDsge 
direst  it  of  repulsive  features.  It  ia  generally  denirable  to  came 
e  patient  to  breathe  with  somewhat  wore  than  onlinai-y  force  in 
the  progress  of  the  exaraiiialion,  and  it  is  sonietiraes  oxtremelj 
difficult  to  effect  tilts  object  Hati»fi>ctorilj'.  He  accelerates  the  re«- 
pintioD,  or  takers  a  ilcep  iiiHpirntion  and  holds  liis  brcolli,  or  in 
different  ways  alters  the  rhythm  of  the  reitpiratorjr  acts.  The  cod 
desired  is  simply  to  render  the  breathing  somewhat  more  intense 
ithout  change  in  other  respects ;  and  the  best  mode  of  securing  the 
[md  is  to  br«athe  ourselves  Just  as  we  wish  the  patient  to  do, 
rcqnesting  him  to  observe  and  imitate  us.  as  elosfly  as  possible. 
Another  method  is  to  request  the  patient  to  cough  while  the  ear  is 
applied  to  the  chest,  the  respiration  succeeding  au  act  of  coughing 
being  deeper  or  fuller  than  ordinary.  In  some  inslnnces  the  res- 
piratory phenomena  are  not  appreciable  except  the  force  of  the 
breathing  be  voluntarily  or  involuntarily  increased.  It  is  ncc<^ssary 
lo  caution  the  unpractised  auscultator  to  avoid  miMaking  (he  noise 
frequently  produced  by  the  current  of  air  at  the  mouth  of  the  per- 
tOD  examined,  for  sounds  emanating  from  the  thorax.  The  patient 
should  be  instructed  to  avoid  making  labial  sounds,  which  tend  to 
distract  the  attention,  if  tliey  do  not  lead  lo  the  error  just  incn- 
tiODvd.  In  auscultating  the  voice,  the  best  plan  is  to  cause  the 
patient  to  oount  from  one  to  three,  repeating  these  numbers  as  often 
as  may  be  mjuixitc,  witli  care  to  utter  each  numeral  wiili  the  same 
tone  and  strength. 

Id  auecultaliuu,  as  in  percussion,  the  phenomena  of  disease  arc 
not,  as  »  general  remark,  dctcnniTii-il  by  reference  to  any  fixed 
standard  of  health  applicable  alike  to  all  individuals.  It  will  be 
seen  presently  that  auscultatory,  not  less  than  percussion  sounds, 
differ  widely  within  healthy  limits.  Here,  as  in  the  practice  of  per- 
enssion,  s  comparison  is  instituted  between  the  two  sides  of  the 
cheat.  The  laws  of  disease,  in  it  large  proportion  of  cases,  permit- 
ting one  side  of  the  chest  to  retain  the  phenomena  of  health,  we  are 
enabled  to  judge  of  morbid  phenomena  by  meuus  of  a  want  of  cor- 
respondence between  the  two  sides.  This  remark  does  not  apply  to 
auscultation  to  the  same  extent  as  to  percussion,  for  several  of  the 
phenomena  revealed  by  the  former  are  in  themwetves,  irrespective  of 
'«uch  a  comparison,  well-marked  physical  signs  of  disease.  But  in 
certain  instances,  as  will  be  seen  hereafter,  a  close  comparison  of 
corresponding  points  of  the  two  sides  is  very  necessary  in  dcler- 


128 


PHYSICAL    BXPLORATIOK   OF   TBB    CBBST. 


mioing  the  fixiatciioe  of  morbid  pheDomena.  Wbeo  this  is  the  cste, 
obHerraiiM  of  unirormitj  in  every  particular  in  au»euli«iiog  atk 
Hide  in  fuccession  in  not  lews  occeiMitrT  llian  in  prartiaing  percasaMD. 
Tbc  onnncialifltt  of  thia  general  rule  wilt  suffice,  without  stopping  la 
dwell  upon  details.  CompartHoii  of  [>oinla  in  exact  correspoodenoei, 
taking  care  to  make  an  ecjual  amount  of  pro&aare  vith  the  ear, 
CMistDg  the  respiratory  movcmontA  or  the  voice  to  b«  as  Qearlv  idea- 
tioal  a*  possible,  etc.,  are  points  nut  to  be  overlooked  when  nicetj 
of  discnminalion  is  involved  in  tlie  diagnosis. 

Kinallv,  to  cmploj  nnMTuliaiton  s»uci'«#fully,  the  explorer  RiDSt  be 
qualihod  by  knowledge  and  prnctlce  to  apprecintc  the  M>unds  imi- 
dent  to  respiration  and  the  Toicv,  in  (he  diiferent  aspects  in  nhitk 
morbid  deviations  from  benlih  are  liable  to  be  presented :  he  taiHt 
be  pn-pared,  in  other  irord^,  to  recognise  the  morbid  signs  vbitk 
may  exist,  and  to  du  this  he  m<ist  nnike  himself  conversant  vitk 
llieir  dislinclive  charnctom,  fir^l  mentally,  and  afterwards  practi- 
cally, OiJierwisc  he  is  root  by  all  the  dilKridiie.i  which  the  pio- 
Dcer^  in  the  cullivalion  of  this  field  of  rcAcitrch  were  obliged  to  «»■ 
counter;  difficiillios,  thanks  to  the  genius  of  the  illnstrions  foander 
of  auscultation,  and  the  liibors  of  his  successors,  no  long<T  existiig 
to  retard  and  limit  the  progress  of  one  who  at  this  day  aimA  to  b^ 
come  a  profictent  in  phyMcal  exploration. 

In  the  study  of  auscultation,  as  of  pcrcn*»ion,  the  point  of  de- 
parture for  invesligntini;  the  fiigii«  of  disease  is  an  aninaintanet 
with  the  phenomena  pi.-rtiiining  to  the  healthy  chcM.  The  rcmaiDder 
of  this  chapter,  therffore,  will  be  divided  into,  1.  Auscultation  in 
Health,  and,  2.  Ausculution  in  Disease. 


I.   ACSCOLTATIO^f   IN   IlEAtTH. 


J 


Tt  is  essential  to  the  application  of  auMultation  to  the  dia 
of  disease,  to  become  prnctioully  faiuilinr  with  the  sounil*  prodi 
by  respiration  and  the  voico  in  bcAlth,  for  without  this  knowledge  it 
would  be  impoitsible  to  drtermine  whether  sounds  heard  in  cases  af 
Buspecied  disease  are  natural  or  morbid.  In  treating  of  AuseultSr 
tioD  in  Ilealth  we  are  to-eoniiider  the  phenomena  incident  to  respira- 
.lion,  to  the  voice,  anil  to  the  net  of  coughing.  We  will  consider 
these  phenomena  nmler  separate  heads. 


AtrSCULTATIOX    IN    KRALTH. 


12ft 


I.     PHBNOMBNA    INCIDBKT  TO    RMPIKATIOS. 


Tliwff  plicitomcna  arc  hy  no  means  the  same  in  al!  parts  of  ihe 

fT«»pira(ory«ppnratiis.     The  respiraterj  sountls  am  wiJtlj  tiiffercnt, 

jMconling  to  the  sources  whence  they  emanate.     As  dislingtii^hcd 

[Ity  their  origin,  they  may  b«  arranged  into  two  claaae»,  vis. :  I. 

Those  produced  in  the  trachea  and  larynx;  2.  Those  prAdiiec<l  in 

Iihe  nir-vcsicles.  The  phenomena  thus  incident  to  tracheal  or  laryn- 
geal and  vesicular  respiration  are  to  be  iuveetigated  Beparat«ly,  and 
contrasted  with  each  other. 
\  1.  Tbachbal  or  Lartkobal  Kb^piratiov. — To  ansooliate  thv 
trachea  ihc  stethoscope  is  necessary,  which  is  to  he  place<l  in  front 
jiul  above  the  sternal  notch.  Applied  in  this  situation  a  sound  is 
almnst  invuriably  found  to  accompany  each  respiratory  act.  Tho 
sound  with  both  inspiration  and  expiration  has  a  certain  timbre  or 
quality,  conveying  to  the  mind  the  idea  of  »  current  of  air  forcibly 
impelled  through  a  tube  of  considerable  siie;  hence  it  may  be  dis- 
tinguished as  a  tufiular  sound.  The  respiratory  and  the  expiratory 
tracheal  AOu II d  pri>s<tnt  .ionic  dilTcrences,  and  merit  separate  notice. 
The  sound  with  inspiration,  if  observed  for  some  time,  will  be  found 
to  vary  considerably  wiUi  dilforcnt  respirations  as  regards  intensity. 
Oenerally,  it  ia  intcufie  with  ordiniiry  breathing,  but  it  always  b»- 
O0m««  much  more  so  when  the  force  of  the  breathing  is  voluntarily 
increased.  The  intensity  with  forced,  bnt  still  more  with  ordinary 
breathing,  differs  considerably  in  different  persons.  Occasionally  it 
is  excoeiliiigly  ft-cbic,  almost  inaudible,  except  when  the  force  of  the 
breathing  is  increased.  Compared  with  the  expiratory  sound  as  re- 
gards inlenxily,  i(  is  freiiuently,  but  not  generally,  more  intense  in 
onlinary  re^ipiralion,  but  almost  invariably  in  these  cases  becomes 
less  intense  than  the  expiratory  sound  in  forced  breathing.  In  du- 
ration the  inspiratory  sonnd  falls  a  little  short  of  the  period  occu- 
pied by  the  inspiratory  sot.  It  attains  its  maximum  of  intensity 
quickly  after  the  first  development  of  sound,  and  maintains  the  some 
tntensily  to  the  close  of  the  act,  when  the  sound  abruptly  ends,  as 
if  suddenly  cut  off.  An  regards  pitch,  it  may  be  remarked,  that  it 
■a  higher,  i.  «.,  niore  acute,  or  sharper,  than  the  sound  emanating 
from  the  air-vct>icles. 

The  expiratory,  like  the  inspiratory  sound,  varies  in  intensity  con- 

9 


» 


180 


PDTSICAL    BXPLOBATIOK    0?    THS    CHB«T. 


uderably  with  diSereot  respiratiooB,  and  ts  babiuully  feeble  m  : 
indJriduals,  while  it  18  strongi;  marked  in  others.  This  stateiaeil 
applies  to  ordinary  respiration.  When  the  respiration  is  forced,  iW 
sound  almoat  invariably  becomes  intense.  In  trani)ui)  breathing,  in 
intensity  is  in  »ome  instances  greater,  and  in  some  leas,  than  tkattf 
the  inspiratory  sound ;  but  in  forced  breathing,  it  is  almost  iDTariaify 
more  intenso.  As  regards  pitch,  it  is  more  acute  than  th«  in^in- 
tory  sound.  Its  duration,  in  the  great  proportion  of  insteocee,  a 
somewhat  longer  than  tho  inapirfttory  sound;  and  tliis  is  non 
marked  in  forced  tlian  in  ordinary  respiration.  Occasionally  tW 
sounds  with  the  two  nets  arc  about  equal  in  length.  The  expiratory, 
like  the  inspiratory  sound,  quickly  attains  its  maximum  of  intsa- 
sity,  but  iDStead  of  preserving  the  i^amc  intensity,  it  gradually  W- 
comes  weaker,  and  <»id»,  not  abruptly,  bat  is,  as  it  were,  lost  imper 
cepiibly. 

The  inspiratory  and  expiratory  sounds  are  not  continnoBs,  bsl 
separated  by  a  brief  interval. 

The  foregoing  description  Is  bnscd  on  obscrrations  in  forty-foar 
healthy  persons,  the  fuels  being  noted  at  the  instant  of  obserTstioo 
and  afterward  analyicd. 

The  characters,  then,  distinctive  of  the  tracheal  respiration,  taking, 
as  a  type,  a  respiratory  act  somewhat  more  forcible  than  in  ordinaij 
breathing,  arc  as  follows: 

A  sound  of  inspiration  and  of  expiration ;  both  having  s  tuhular 
quality ;  both  higher  in  pitch  than  the  vesicular  respiration ;'  a  short 
interval  separating  the  two  sounds;  the  expiratory  sound  more 
inlcnae,  longer,  and  higher  in  pitch,  than  the  inspiratory. 

The  student  should  practically  verify  these  characters,  and  iropresi 
them  on  the  memory.  They  wilt  be  iiecn  hereafter  to  have  an  im- 
portant practical  bearing  on  the  Rtudy  of  disease.  The  tracheal 
respiration,  observed  elsewhere  than  over  the  trachea,  is  a  significant 
physical  sign,  of  frequent  occurrence. 

The  laryngeal  respiration  is  said  by  some  writers  on  auscultation, 
to  differ  in  a  marked  degree  From  the  tracheal.*    I  have  recorded 


'  In  order  ta>pprnclat<i  tlili  polnliif  illtllnotion  In  nnticijistlnnor  th«ooBfhl* 
aradoa  of  thaTf^iuular  retjiiratioii,  tbv  ittKlciit  niny  coinpur*  tlie  iwo  by  1i(t«ti- 
Ing  to  tba  r«apirntion  with  thu  ear  applied  \q  the  cUcsi  after  kutculuting  Uia 
tTMchea. 

■  £V,  ST,  Barlh  trnd  Boger,  "Sur  1e  laryiix  mtme  lo  mtinaore  varle  *fiMir«;  II 
rewembto  a  I'oiptce  do  iMuQle  ijua  d&tcrmliicnLli  I'ontrao  d«  I'alt  dAiu  iui«  cavitj 


1S1 

[eomparatire  obserratJons  mode  with  care  in  riglitccn  pereuns,  nnd 
'ill  none  of  time  inatanci?fl  were  there  niiT  nolublv  points  »r  ilimparitj 
I  save  in  inwusity.  Frc(|ucinly  tbc  rcspirotory  sonnil^  ln-iinl  by 
Kplnoing  the  stethoscope  on  the  side  of  tho  Urynx  vcit  1c8k  inteoM 
Bthan  over  the  trachea.  In  other  characters  tliey  were  eMeniially 
wjdcnlical. 

H  It  IB  foreign  to  my  purpose  to  enter  into  much  discassion  con- 
cerning the  laws  of  physics  by  which  auvcultiilory  pheDxtncna  are 
to  1>«  explained.  It  is  easy  to  understand  why  a  column  of  air 
tnoTing  to  and  fro,  with  considerable  velocity  and  force,  through 
tlie  trachea  and  larynx  should  give  rise  to  a  tubular  sound.     The 

•  Bound  may  be  iinitati;(l  by  Mowing  through  a  tulie  of  uniform  she, 
or  through  the  larynx  and  trachea  removed  from  the  body.  Tho 
different  characters  pertaining  to  the  inspiratory  and  expiratory 
•oundA,  way  probably  be  readily  liccoiinted  for,  by  reference  to  tho 
different  circumstances  belonging  to  the  two  acts  respectively.  Tho 
force  of  the  inspiratory  movement  is  suelained  eijually  to  its  close; 
hence  the  intensity  of  the  inspiratory  sound  is  maintained,  and  ends 
1 1»  abruptly  as  the  act  itself.  On  the  other  hand,  the  force  of  the 
expiratory  movement  is  greatest  at  its  beginning,  and  gradually 
lies;  hence,  n  corresponding  diminution  in  the  iotcnsity  of 
tHUld.  The  fact  that  the  expiratory  aol  involves  more  power, 
especially  in  forced  brothing,  explains  the  greater  relative  intensity 
of  the  expiratory  «vund;  and  its  greater  length,  the  corrcMponding 
longer  duration  of  the  sound.  The  highvr  pitch  of  the  expiratory 
sound  i»  due  to  the  greater  contraolion  of  the  glottis  by  the  approxi- 
mation of  tbi^  vocal  eliords  in  expinition,  the  spnec  between  the 
Prhords  iliUling  regularly  with  inspiration.  Tliii*  appruxiniution  is 
ler  in  proportion  as  the  respiration  is  forced,  a  faet  which  cor- 
onds  with  the  more  marked  elevation  of  pitch  under  these  cir- 
Htanccs.  (Introduction,  pages  5'2  and  32.) 
he  pitch  and  intensity  of  llu-  tracltca!  respiration  may  be  readily 
imitated  by  modulating  breath-soiindii  with  the  mouth.  Skoda  has 
proposed  to  represent  tho  respiratory  sounds  peculiar  to  different 
eilDAtions  by  means  of  whispered  letters.  A  similar  mode  of  cstab- 
lifihing  types  of  cardiac  bellows  murmurs,  was  proposed  by  Bouillaud 
H  And  llope.     Following  Skoda,  the  letters  ch,  sofl,  will  repreaeot  » 


pliu  lnr)[(i;   Dutrr  *a  rudcwc,  II  prend  un  (^>riM:tiro  ca>«rnpiix  besucuup  plua 
JBaniuf  et  O0B«tilu«  1«  bruit  impiratoira  tarrngfa."    Op,  oil.  p.  36. 


182 


PIIVfilCAI.    EXPLORATION    OP    THE    C1IE6T. 


trncliv*!  MOuni].     TKe  pilch  ami  loiidncKf  maj  he  TnrieJ  by  grailn- 
fttin^  Ihu  force  with  which  tho  itJr  i»  oxpi-llcd  when  thcAc  letters  nr« 
whiKpLTci],  itnd  allcring  «omewliat  the  disjMnition  of  the  lipe.     In 
this  wsy  mny  he  reproduciMl  thi*  tubular  in«pTration.  nnd  the  mor 
inti'nsp,  vharpur  sonml  i>f  expiration,  which  chnrnctenic  the  reepi-' 
rntory  eouniU  coniiiij;  from  iho  triicbi-a  and  larynx. 

The  trnchcnl  rcHpirntion  uisy  be  hi-iird  with  distinetnfRa,  and 
somettmcD  with  considcnibli!  int«-iiHity,  when  the  stethoscope  is 
placed  on  the  neck  b<.'bind,  over  the  cerricul  vertebra). 


2.  Vk3IC1;i,ar  Rbspiiiatios. — The  respiratory  sound  heard  ovei^ 
the  eht^jit  is  ciiDcd  the  pulmonary  or  veHteular  reHpimtion  or  inurniur. 
Both  tertns  imply  lluit  the  sound  is  produced  within  the  sir-cells  or 
rmcloa  ef  the  Imifi^.  Thii>  i»  not  strictly  true.  The  vesicalar; 
respiration  is  a  mixed  dound,  being  pnrtly  due  to  the  air  enteriog 
tlie  ccll«,  in  part  to  the  current  traversing  the  bronchial  tabes,  and 
to  some  extent,  probably,  in  certain  purtn  of  tho  chest,  to  trn&»- 
milted  troeheal  respiration.  It  it,  however,  true,  that  the  predom- 
inant and  distinguishing  character  of  the  vesicular  respiratioo 
origitiales  within  the  air-cells  and  bronchioles.  Botb  terms  are 
tfaerefare  eulfioiently  appropriate,  and  the  term  resicular  b  selected 
aa  the  moat  distinctive,  and  the  one  generally  adopted. 

In  treating  of  the  vesiculur  rcHpJration,  the  facts  of  intereiit  and 
importance  in  a  practicn!  point  of  view,  will  be  found  to  relate 
mainly  to  1.  The  characters  wliich  distinguish  this  variety  of  r«8pi> 
ration  from  the  Iraclieal  or  laryngeal;  2.  The  variations  within  thi 
limits  of  health  obflorvetl  in  diHcront  persons,  and  on  eA^aminations 
of  corresponding  situatiomt  on  the  two  sides  of  the  cWnt  in  tli« 
same  person;  S.  The  diflerent  modifioations  proMiited  in  different 
regions  on  the  same  nide. 

The  point  first  claiming  attention  is  the  first  of  the  foregoia| 
three  divinions,  vis.,  "Tho  characters  which  ilistingnish  this  variety 
of  respiration  from  the  tracheal  or  laryngeal."  In  considering  this 
point,  inasmuch  as  the  vehicular  respiration  in  every  part  of  the 
chest  is  not  in  all  rcspecla  identical,  some  region  is  to  be  selected 
as  furniahing  a  type  of  this  flp«ciefl  of  respiration.  A  region  con- 
venient f^r  this  purpose  is  the  summit  of  tho  left  lung  a  little  below 
the  clavicle,  midway  between  tlic  acromial  and  sternal  extremities. 
On  auscultating  the  tuniiiiit  of  the  left  side,  at  the  point  mentioned, 
either  immediately,  or  with   th<t  stethoacopo,  a  sound  more  or  loss  , 


AOSCCLTATIOX    IK    HRALTB. 


U8 


iDt«n«c  is  generally  founi)  to  accvmpniiY  the  inNpirntorj  net.  Com- 
'  paring  tliis  sound  with  tlint  hcsird  over  tho  trucbea  or  larviix,  it  is 
found  to  present  a  Btrikin;;  diETcrcnce  in  quality.  Instead  of  being 
tubular^  it  bas  a  quality  difficult  to  describe,  but  which  the  atudcnt 
will  readily  appreciate  on  making  the  coDipari&on  practically.  The 
irords  aoft.  breezy,  eryanslce,  are  applied  to  it.  It  is  compared  to 
the  slightly  audible  breathing  beard  at  a  little  distance  froio  t, 
person  in  deep,  (jniet  sleep;  to  the  sound  produced  by  a  gentle 
breexe  among  the  branches  and  leaves  of  trees;  to  that  of  a  pair 
of  bellows  the  valve  of  which  acts  noiselessly;  to  softly  sipping  the 
air  with  the  lips,  etc.  These  comparisons  are  but  rudely  approxi- 
mate, and  are  of  little  value,  since  it  is  so  easy  to  become  familiar 
»«ith  the  Bound  itself  by  prnctirtiiig  ati.icullalion  for  a  fcv  moments 
OD  the  ohesl  and  trachea,  alternately,  of  a  bralthy  pcrMU  in  whom 
the  vesicular  respiration  is  tolerably  developed.  This  special  ((ualily 
it  is  convenient  to  designate  the  v«»ieular  qualitg.  an  esprescton 
which  will  be  frequently  used  in  the  following  pages.  The  vesicular 
quality  of  respiration,  a«  of  percussion,  is  thai  peculiar  kind  of 
sound,  not  suggesting  d  priori  the  existence  of  cells,  but  due  in  a 
great  measure,  at  least,  to  the  cellular  arrangement  of  the  lungs. 
B Id  what  manner  is  tbia  vesicular  quality  of  sound  generated?  I 
aball  not  discuss  this,  more  than  other  questions  relating  to  the  mech- 
anism by  which  auscultatory  phenomena  are  produced.  U  is  gene- 
rally attributed,  after  Laennec,  to  the  friction  and  vibrations  caused 
by  the  air  expanding  the  cells  in  the  ini>pirali)ry  aet.     May  not  tho 

•  peculiar  quality  be  owing  to  the  separation  of  the  wallsi  of  the  cclhi 
or  bronchioles,  which,  to  n  greater  or  less  extent,  are  in  contact, 
and,  owing  to  the  moisture  of  the  tissues,  become  t>lightly  adherent 
during  the  partial  collapse  of  the  lung  at  the  end  of  an  expiration? 
B  We  shall  see  hereafter  that  this  is  the  most  rational  explanation  of 
an  important  and  highly  distinctive  physical  sign  of  disease,'  vis., 
the  crepitant  rale.  Tlit-  fact  that  the  air  does  not  circtdnle  freely 
in  the  air-cells  and  bronchioles  with  each  inspiratory  act,  renders 
probable  the  explanation  suggMtt'd  by  the  foregoing  inquiry. 
Other  facts  supporting  this  explanation  arc,  the  increase  of  this 
peculiar  quality  of  sound  ia  the  inspiratory  act  which  succeeds  a 


I 


*  Dr.  Ujili^  Salter  appear*  1«  iilkawcancliMlvrij  (hut  ttip  bronchloln  h*T«  more 
itodo  with  ibn  production  ot  (be  uaruur  tliin  (bu  ur-c«lls.  VuU  "Ud  ibe  Na- 
ture and  Chuic  oT  tbe  Uctptralory  Uurmun." 


134 


PHTSICAL    BXPLORATIOR    OF   TBB   OSRST. 


forced  eipirKtion  in  (he  act  or  cougliing;  tbe  dlminatioo  of  the 
qaalitj  in  cases  of  permancut  ililittalion  of  tfac  air-ccllA,  or  emptty- 
sema,  nud  tlic  1in3itation  of  the  quitlity  to  th«  insptraiorj  9omi. 
The  ifispiralory  eonnd  is  Romcvhat  longer  in  duration  tbu  tk 
triche«L  Like  tbe  tracheal  tt  is  conli&nous.  augmenting  in  idIcbv 
\Xj  from  its  comtnonccuicDt  to  its  t«nninatioD,  and  ending  ralber 
abrupt);.  It  is  notably  lower  in  pitch  than  the  tracheal  infpin- 
tJon.  As  stated  by  Skoda,  the  average  pitch  of  the  vesicuUr  iaift' 
ration  tna;  be  represented  b;  the  consonant  r  or  b,  whispered. 

lo  «  certain  proportion  of  instances,  an  eiptratorj  sound  is  sp- 
preetsblc.  In  this  respect  the  vesicular  rcepirntion  present*  a 
striking  point  of  contrast  with  the  trachoni,  the  act  of  cxpiraliM 
coneta&tl;  producing  a,  sound  within  the  trncheB.  Tfac  diflcrcMe 
is  not  less  striking  in  other  respects.  Theexpiralton.  when  prcstct 
in  the  refticolsr  respiration,  is  nearly  or  quite  continuous  with  the 
sound  of  inspiration;  not  following  «  brief,  but  distinct  interrsl, 
aH  in  the  tracheal  rcHpiration.  This  stateioent  holds  good,  ex- 
cept when  tbe  person  examined,  increasing  voluntarily  the  force 
of  the  respiratory  movement,  holda  the  breath  for  an  instant  afltr 
completing  the  act  of  innpiration.  The  duration  of  the  expiratory 
sound,  conMdcred  roUlivety  to  thnt  of  th<'  inspiratory,  is  mmell 
shorter  than  in  the  trnchi-M  respiration.  In  the  latter  it  is  »»  long 
and  not  lurrequcnlly  longer  than  tbe  sound  of  inspiration.  In  (be 
vrsiculiir  rcsjiirulion  the  expiratory  sound  is  cstimuted  by  Founiet 
to  avenigc  oiie-liftb  the  duration  of  the  inspiratory.  This  esttaiate 
is  perhnps  not  far  from  the  truth,'  but  the  relative  duration  raricB 
ooDsiderably  in  different  persons,  in  some  being  less  than  a  6ftb,  ia 
others  a  quarter,  a  half,  and  occasionally,  but  very  rarely,  except 
as  an  effect  of  disease,  bearing  a  still  larger  ratio.  The  intensity, 
as  compared  with  that  of  the  inspiration,  ia  much  less.  Acoordioj 
to  Kournel,  nuincriciilly  oxprosscd,  it  is  as  much  below  that  of  the 
inspiraiidii.  Hit  ilie  diirnlion  is  less,  viz.,  one-fifth.  The  reverse  of 
Ihii*  rule  obtains  in  the  tracheal  respirnlion.  The  pitch  of  the  ex- 
piratory sound  on  the  left  side,  certainly  in  the  great  majority  of 
instances,  is  lower  than  that  of  the  inspiratory.  It  is  represented, 
according  to  Skoda,  by  a  sound  falling  between  the  whispered  con- 


'  Bnrth  and  Rngor  and  Wiilabp  rank?  tbo  nvvrogi- duration  grater,  vis.,  oa»- 
Ihin]  thnl  vf  tlie  iiiipi ration.  The  mnitn  duralion  might  txt  obuuacd  with  mxm- 
tnuj,  but  it  ia  not  a  mattvr  uf  [imjlicKl  iDuiuuut. 


rererBe 
governs  the  tracheal  respiration.  In  thft  latlvr,  thfl  pilch  of  iKc 
expiratory  sound  is  higher  than  that  of  the  inApiraCory.  The  ex- 
pirittorj'  eoand  is  a  simple  blowing  sound,  bl^iI1g  devoid  of  the  vc> 
sienlar  quality  whic-h  characterizes  the  sound  of  inspiration.  To 
rcciipitulute,  the  distinctive  characters  of  the  tracheal  rc^iptration 
-00  the  one  hand,  and  of  the  vesicular  respiration  on  the  other  hiind, 
«8  developed  hy  the  comparison  just  made,  arranged  in  parallel 
coIaiDDK  are  as  follows: 


Tkacbbal  oa  hxKTuaKXL  RKiriBA- 

TIOK. 

Ifnipiraliim. 
1.  TVjbulsr  in  (juulitjr. 
2.  In  duration  faUingiomcwhatthort 
of  lii*  iaipimUiry  nct- 
S.  High  in  fiitcli. 
Erpiration. 
1.  UnlfDnnly  preMct  la  tracheal  rM- 
plralMn. 

12.  GmcrRlly  mora  iiilf'aM  than  iha 
iatpintlicn. 
S.  Ai  lonK  or  Innfcor  tliaa  thn  »ound 
«t  in*plratioD, 
4.  nigb«r  in  pitch  than  tho  innpira- 
tlon. 
&.  ThaiiupirntionBndrjqiiratloDanp- 
aratpd  by  an  iDtOTtiil. 


VuiCUI^H  BitiipruATiOK. 
IiupirnliiM. 

1.  T«iculiir  in  qiinliiy. 

S.  Low  In  pitch. 

Mrpiratum. 
1.  AblMit  in  about  OD*>thtrd  of  tbo 


2.  Inir-niity  much  leu  than  tiiat  of 
Uiu  innpirnlion. 

3.  Much  shorter  than  th«  nound  of 
inspiration. 

4.  Lownr  in  pitch  than  tho  Innpira- 
tion. 

ft.  Tho    ioipiration    and  expiration 
cootJnuoui. 


) 


The  resionlsr  reepiration  presents  marked  differences  in  different 
personit,  not  only  of  the  ^ame  age  and  sex,  hut  apparently  with 
cheittK  minilar  in  conformntinn.  In  inleniiity  it  ici  far  from  uniform. 
In  some  persons  it  is  with  difficulty  upprceiable,  ntid  in  tome  it  can- 
not be  heard  even  when  the  force  of  tho  rc^^piration  w  voluntarily 
increased.  In  others  it  is  comparatively  intense.  Between  theso 
eitrcntes  there  is  every  grade  of  intensity.  In  the  »Rme  person 
the  raartnur  often  differs  considerably  in  intensity  with  different 
respirations,  with  some  being  perhaps  loud,  while  with  others  it  is 
feeble,  and  Bometimeii  inappreciable,  these  fluctuations  being  ob* 
served  during  the  few  ntomenls  that  the  ear  is  applied  to  the  chest. 
In  pitch  and  quality  of  sound  the  respirations  in  the  same  person 
appear  to  he  idetiticul,  whether  feeble  or  intense;  and  forced  respi* 
rations  compared  with  tranquil  breathing,  do  not  show  any  change 


_    ;.;.  '    --   ^■-";.   ■:'"  ■'-  :;::- .  fy_    ,   i--^.;rii  .  Tfi*'T:iitii»:-;c"f.  "•i'ia 

I    .■    ;.'    .,-..-    r:\_    -,.-  -.■_...—    -  In  j^  -r  in-  ma^iii^-L   irLr.     Tm 

■■: ;  .-.;.  F—    -.-r.  _     1  ..  .•_    d     _^      -rrS    — n.    i    ir-erMTu:   Ji  f.s* 

I'---';-     .;; :    ;;—■.:     ::  ■:.-—-    -\i — :ui  lif-   a  r^:u^-Z"i    Ll.-izj:z.3 

h  •u--::ii—  :'.:-  ■■-•■-.  -  ::.,--.::...-  iii-— nr^i-.uTi.  Tjtia.  ^  :i  i-n 
1.-.  ■ '    T  :  !     .J..   ■-  ;:;   ..-      .::.::-  ij-    iir^aat—- ;   hilj  "ni    rioiirij 

tL: -:ii—  ;-    .  jiii:.. ..-..:  ■  ::---t— JL-r:'.  ti^h    r   &  iiii,iui'^Kii.r:i±  ij i; 

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if'   :<■'..  .:  "   ■■.-":  „  :;■■ — ..":    ir    pi     .11 — :  Tii:if.       ?»;i  l-  ;  4^ 

■■:■'"-  1  :.--■^,,■i  :!.iii-".i—  1  ;;.■  n.-jiri"  ir  ~ii-  '^^•n<"i':y'  '■^■^'"x. 
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-— 1  ~  ■'■•.vi..i.'   uuTi  u"    jr;-."  l.;>--i.;—' .  s  ^■■"iii'iij  ljk::t r^i-el 

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■vi'.'    ■■'  111'  I,  .•'•t'.i:  T  i.iv:   i—.;ii:w   ;i."  :.iir*rL   jtiL."*-      A:   li*  jaik 

"  .'.li*.    ■'.i>     * :  ■/■.'■f   -'-    r''i:i':     !•'■;■  'IlTr    --;l**^_'"  llvTi    Irf^I-X-f-i  isl 

.■-■■.iv      7*:.^  ---"■-•■t-' -1    uuf   ni.-.ln— L    T  lt*   ^   Lt»~:z jiiii^j « 

.'•.    :■-.-.•    ■-.■:—■::■    :;.i-.    :'.-.-:i--.~    ;.f;-r'::Hf  L-i    :""-»;tt?J  ;-  ;ae 

■. -.i.  -1  t'.-.  -.'.i  :  ■:.:■.  i:^  i.:  -..:  ■'  -n.  X-~:'~'.±'-z.^  ^  z.-^—'-iT  •:{ 
jA-.. ■'.'■.:■  :  '■.■.•A-:  .:.  :.  1.  :' :  z<^:ii-.'-t_  -.'h  --ij^.:^.  is  r^^rls 
•-•.'■'J;  '.:. t.*f.--i'-.  ",.^    ;■.■-■:  :-t"., 

".■.-•■•:  ;.  i.--,:  r:  J .  .-.!  r.:.i  7  :iT  ni^f-T^K  :f  i-LsiiTTaiLca  c-:.re 
'.,',*,'.  *,  ■.■:.  .■::  fi:.:  .:'  .:.  i.:-—  -.-  -  ::t  :i^:i:~tli  :',"i:^7\i  ;t  ptr- 
'-■.'i!  ',.-,  *?■■';•-.  :■  i  .iv:;  LL^ii,-;  ::'  -rx;':-!:::- :  :•;-,-»***  ir.  l«>th 
i.'.<"i.'.'.'-.  "ii-.i.*.:. ,:,!  :',■■,■;,  ;.=il:i.  ir^  -:;  i'.-.^zzJ.r^-ti  \j  refcrtLoe  to 
*i,/f.i'-j,  4-,--..-i';'  T^ir.U:;,^?  r^^i.-I?  ii:T-ni;:j.  f:;i:i.  eic.  bat 
t,jf  ->  '-,.';,(i*.-!' ,f:  :'.    !;.■■-  -.>  .  -!  Ui  ■■.:"  ;':.r  ci.-.?;. 

'If.':  ';/j...'«",.'v  -■,,;,!.  a:  &'.-*;i  :T  JLiiiLa:-.!.  i-eri  from  the  in^pn- 
«ii.i.'-r;r  (,',i.  i,(,;j  if,  >i  ,.■;(■>,:.,  ir.:t!.■^i:v.  a^O  p:;ch,  tut  id  qualitv.  It 
je  'U  /'.I'l  '.r  i.i,-  ■■•■■'.i-.'.iAt  •{■m.'.'.vi  «iLIi:L  eiiaraciciLzes  the  iikspiratorjr 

I'.    r'rri.>iii4  Ui  i:',n.i'l';r  the  TuriatioDd  in  the  characters  of  the 


AOeCDLTATIOIT    IX   HBALTS. 


187 


I 


I 


'respiration  observed  on  comparative  examinatiotis  of  corre«pAn<ling 

iiiuatton.4  on  thi;  (wo  sides  of  the  elie.4t  in  tlie  f>au)e  person  ;  and  the 

di&ereiit  niodifi<-atioii»  prest-nted  in  ililTt.-rcnt  regions  on  the  »ame  side. 

I  abail  proceed  to  give  the  rcDulu  of  a  sericM  of  rccon)c<l  examina- 
tiona  of  healthy  perHonn  with  reference  to  n  conipanMOD  of  the  respi- 
ratory phenomena,  firat  at  the  summit  of  llic  chext  and  aflcrvanU 
in  the  region*  elfewhere,  omitting  many  of  the  dvtuiU  contained  in 
thv  former  edition  of  this  work.  I  have  confirmed  the  correctness 
of  tbe^c  results  hy  a  great  number  of  observations  since  the  date  of 
tlie  piihlication  of  the  former  eilltion. 

Kkiiit  Aitn  LSPT  Ixpba-Clavicular  KBOlON.~Tho  respiratorj 
murmur  ha«  certsio  modifications  in  thia  region  at  uml  near  the 
ati-mo-chivicular  junction,  nhich  will  l>v  noticed  after  having  con- 
sidcrcd  the  murmur  in  the  rematniler  of  the  infra-clavicular  region 
on  the  two  sides.  Abnormal  luodificationit  of  the  miinuur  in  ibis 
region  are  of  great  importance  in  their  hearing  on  the  dingnofiis  of 
taberculous  disease ;  hence,  it  is  bigbly  desirable  to  determine  iho 
points  of  ditparitj  and  the  rariations  coiiHiatenl  iritb  health,  in  order 
tbat  thc^  may  not  be  mistaken  for  morbid  signs. 

The  inspiratory  sound  in  the  majority  of  cases  ia  not  of  equal  in> 
tensity  in  tbis  rrgiou  on  the  two  sides.  The  inU'iisity  is  aliiiosl  in- 
Tariably  greater  on  the  left  side.  This  statement  is  opposeii  to  that 
of  some  authors;'  but  the  matter  is  purely  one  of  observation,  and 
a»my  examinations  have  been  made  with  cnrc  and  with  no  expecta- 
tion of  such  a  resull,  I  am  bound  to  n^ume  their  corrcetncM.  I 
can  only  account  for  the  opinion  that  the  inspiratory  Kound  on  t]is 
right  side  U  often  more  intense  than  on  the  left  side,  hy  supposing 
that  elevation  of  pitch  has  been  mistaken  for  increased  int<-nKity. 
The  dispjiriiy  in  intensity  is  sometime.'*  marked.  The  intensity  of 
the  inspiratory  sound  i«  sometimes  notably  increased  by  forced 
breathing  on  the  left  and  less  so  on  the  right  side.  In  the  majority 
of  caseit,  there  is  a  disparity  as  regards  the  pitch  of  the  inspiratory 
sound;  the  pitch  is  loner  on  the  left,  or,  per  contra,  higher  on  the 
right  side.     The  vesicular  quality  is  more  marked  on  the  left  side. 

The  expiratory  sound  is  oftener  wanting  on  the  left  than  on  the 
right  side;  in  other  words,  it  may  be  heard  fretguently  on  the  right 
and  not  on  (he  left  side.  Not  very  infre<iuently  the  expiratory 
Bound  is  prolonged  ou  the  right  side  to  nearly  or  quite  the  length 


Butb  and  Boger  and  Uorhard. 


•*r"      -"     >  "■"     *"  "■-"   ^>^i  — :i.^-:^-w  T-:T-L,;a.    s.v-«-   -"1*1  ikt 

*r*  -■::->  -.,  ■.-.■>  ^  —  :  -it:  wu*^  ■""  :-■  rri^Si— r-i  ss^mfur 
v-'^-  ■:■*  -_».-^i>  •;  — -:.r-_-r--->*  rr-kT  rsf^Lnn--;.  Ii  ft  ^v  bif:aB«i 
I  -  i  ■  >■  *: .-.-  ;  -  ■; ^  -,-.-  >»-=-■  ^jL.  I  iJ—"JK~.  ;  STcsi'^e-j^  b«az  iif«d, 
k  ^-■,  .'.j>r^.  r,  ^.-^  '■•r.^ti  *T^.TK,  -7-  ^■--::L^t  :T»r  :i*  Vi-jie  of  dt 
.-■■-»,-  a    t:  V-  r*^  •■„     >r:i5C  *■.:;:  ■:z=  'i^irKTrT  =o«sd  in  il» 

T-.V  :y.r.''  '/  1  -z^r.-.j  z,'"r^^n'-^i  j  tie  fc~;i!iTHs;  riren.  auv  be 

V'.  ■  .«'-,.a,i-.J  .'«' x^-i^.  Vr*:- iliT  :  ixlitT  aior«  marked. 

Eipirvttrrj  Kiatd, 
Hufh  t  fie.  Left  li^. 

I'frir.i  i.t,  ti.i.  ■t.'l  r.'.t '/n  i*!fi  tld*        S«v*r  pr»»<ol  ■>n  ihi*  tide  aad  w««t- 

■  I,  •',<!,>  '  a.o.  iiiZ  -vn  th«  rizhi  ^Ide. 
fti-  B''  r  if.'''(i'i>^,  Ici'.^njilt  D-rvt-r  ^rvktO'. 

hi. I  inff''(ii'irll>  [.r-.l'.r.g'^.  Bardv  prolooted. 

till'  r-'!>J  "ifiii'Uiriin  li'tw-y-fi  th«  two         Tb^  two  scuDdi  continaooft. 

fifJIiifn. 

I'll'  li   >"iiii'lirii>''  l.iK)«-r  Itikn  lb>t  of        Pitch  more  rarelj  higher  than  tbU 
lii>|.miiiiiN.  of  inej.iration. 

Ill  iti«  Micrrio  cliiviciilur  portion  of  the  infra-cUvicnlar  region, 
Mil-  iin|>iriil'iry  murmur  In  apt  to  be  notably  modified  by  sonnds 
ciiiiiii'jr  rmtri  ilii'  bfint^liial  titbcH  exterior  to  the  lungs  and  from  the 
t.Mii'lK'11.  'I'Ik'  iMU-iiHily  iif  tlif!  murmur  in  this  situation  is  greater 
aiiriii'timi'N  tilt  llin  Idfl  and  mimetimca  on  the  right  eide.     The  pitch 


IDBCOLTATION    IK    HEALTH. 


189 


[of  tbe  inspintorr  sound  is  higher  on  the  right  sHe.    The  quality 

rof   the    inspiratory  sound  on  both  sides  differs   from  the  normal 

Innrmur  iii  oilier  situntions  in  hoing  s  compound  of  the  TeaicuUr 

[-and  luhulnr,  and  the  pilch  is  raised  in  proportion  as  the  tabular 

IqualitT  prcdi>ininBl«8.     The  expiratory  sound,  in  this  situation,  is 

sonietioiea  more  intense  than  the  expiratory.     In  tbie  respect  there 

is  oflcn  a  ilispnrity  between  the  tvo  sides,  and  the  greater  intensity 

Bof  the  expiratory  sound  is  nlways  on  the  right  side.     The  pitch  of 

I     tbc  expiration  is  genernlly  higher  on  the  right  side;  but  to  this  rale 

lher<!  «r«'  exceptions. 
■      The  respiratory  murmur  in  the  situation  now  referreiJ  to  has  been 
called  thv  normal  hroncliial  rri'i>ir<tlion.     This  nninc  impli<'S  identity 

ririth  the  morbid  sign  called  bronchial  rm^iration,  and  in  this  respect 
it  is  incorrect.  The  inspiratory  ionnd  is  not  purely  tubular  in 
quality,  ns  it  is  in  the  bronchial  respiration  of  disease,  and  as  it  b 
in  the  normal,  laryngeal,  and  tracheal  respiration.  It  is  a  mixture, 
in  THriublc  proportions,  of  tbo  vesiculur  and  the  tubular  equality, 
tbe  pitch  being  high  in   proportion  us  the  tubular  quality  prcdomi- 

» nates ;  hence,  the  characters  are  those  of  the  broncho- vesiculnr  respi- 
Tfttion  of  diKeaee  to  be  presently  described.     The  same  modifications 
extend  more  or  lew  to  the  respiratory  murmur  over  the  remainder 
of  the  infra-clavicular  region.     A  prolonged,  intense,  high-pitched 
expiratory  sound,  heard  near  tbc  sternum,  and  sometimes  over  the 
K  vbole  of  the  infrn-clavicular  region,  doubtle««  comes  from  the  tra- 
■^chea  and  bronchial  tubes  exterior  to  the  lungs,  and  if  this  kind  of 
expiratory  sound  exist  on  both  sidrs,  the  pitch  is  higher  on  the  left 
■side.     The  inspiratory  sound  is  modified  in  ■  gri-alcr  or  less  degree, 
in  different  persons,  by  the  c-tnibination   in  variable  proportions  of 
the  sound  emanating  from  the  uir-tubes  and  the  sound  produced  ia 
the  air-cells. 

t  Without  knowledge  of  the  Tncts  presented  in  the  foregoing  ac- 
count of  the  respiratory  murmur  in  the  inTra-clavicular  region,  it 
can  hardly  be  otherwise  than  that  errors  will  he  committed  by  mis- 
taking for  the  physical  signs  of  disease,  characters  which  are  found 
in  healthy  persons.  The  normal  vesiculo-tubular  quality  of  the  in- 
spiratory sound  on  the  right  side,  as  compared  with  the  inspiratory 
sound  on  tbe  left  side,  and  the  prolonged  expiratory  sound,  are  not 
—  infrequently  considered  as  denoting  a  tuberculous  deposit. 
^  The  poftclavicuiar  region  may  be  examined  by  auscultation,  ifae 
stethoscope  being  requisite  in  this  situation.     The  caution  inculcated 


140 


PHYSICAL  BXFLORATIOH  Of   TUB  CBBST. 


by  I^pnnc<!,  is  important  to  be  borne  in  mind  in  apptTinir  ilie  »t«tho- 
scope  above  llic  clavicle,  ris.,  to  avoid  presdng  tbe  iiiairuineiit  in  • 
direction  tovard  the  trachea,  ^bp  traclieal  sounds  are  liable  to  W 
eondiict«d  (o  the  ear  if  attention  be  not  paid  to  tbia  point.  Presntn 
■of  the  siteibojcope  in  thi;-  region  may  derelop  an  arterial  mumar, 
whivb  18  to  be  dijtinguiiibcd  from  a  respiratory  sonnd  by  obwrri^ 
that  it  h  syncbronoiifl  vilb  ibe  puUe,  and  persisting  when  the  mm- 
mcnta  of  ri^piration  are  rolunlarily  arrested.  Tbe  vesicular  rapi- 
ratory  found  is  readily  discovered  in  lb«  p06t-e1a\-icu]ar  region  if  it 
be  tolerably  dcvelnpiMl  below  the  clavicle  in  tbe  person  examined. 
With  respect  to  a  comparison  of  the  two  sides,  I  have  not  notod  ob- 
wrvations.  In  a  tingle  instance  in  wliicli  the  phenomena  were  n- 
cordei),  care  being  liikeii  not  to  incline  tbe  stethoscope  toward  the 
trachea,  ibe  in^ipiratory  sound  vas  more  intense  on  the  left  5tde,  and 
no  «>iind  of  expiration  appreciable  on  Ibat  side;  but  on  tb<;  right 
Mdo,  after  an  interval,  a  vrelUmnrked  expiratory  siiccvcdcd  the  in- 
spiratory 6ound,  and  higher  in  pitch. 

Jiiffht  and  Lfft  Scapulor  lirgion. — In  the  upper  scapular  re- 
gioB,  I.  ft.,  over  the  scapula  above  the  spinous  ridge,  the  r«spiratdiy 
murmnr  is  leH  intense  than  in  front,  but  it  iniiy  genoraUy  be  heard, 
ewpecially  if  Cammann's  stethoscope  be  used.  Tbe  inspiratory 
sound  in  some  persons  has  greater  intensity  on  the  left  side,  and  tbe 
vcsiculnr  quality  is  more  niiirkrd  on  this  sid«.  The  vesicular  quality, 
however,  is  less  appreciable  over  the  scapular  regions  than  in  any 
other  parts  of  the  chest.  The  expiratory  sound  is  not  infre<)uenlly 
prolonged  on  the  right  side.  In  Hliort.  tlie  murmur  on  tbe  right 
sidi;,  as  compared  with  the  left  side,  may  bore  veeiculo-tubular  char- 
acters more  or  leas  marked. 

In  the  lower  scapular  region,  t.  e.,  below  the  spinous  ridge,  th& 
respiratory  tnurmur  is  beard  pretty  constantly,  and  is  more  intense 
than  in  tbe  upper  scapular  region,  although  less  intense  than  in 
front,  the  vesicular  quality  being  less  apparent  than  in  other  parts 
of  tbe  chest.  In  thi»  region,  ms  above  the  ridge,  the  intensity  of 
the  iniipirntory  sound,  in  some  persons,  \a  greater  on  the  left  side, 
and  the  pitch  higher  on  the  right  9>ide;  the  expiratory  sound  on  tbe 
right  side  may  be  prolongcl.  und  it  may  be  higher  in  pilch  than  tho 
inspiratory  sound.  The  voiouio-tubular  characters  are  thus,  in 
some  persons,  more  or  less  marked  on  the  right  side,  as  compared 
with  the  left  hiiIp, 

Inter-tcapular  Region. — In  the  upper  und  tbe  middle  portion  of 


riCULTATIOK    IK    HBALTH. 


141 


thi»  region,  the  rcopirntory  munniir  tias  essontially  the  snmc  ohsr- 
actera  as  the  rannnur  in  the  sterno- clavicular  portion  of  the  infra- 
clavicular region,  that  is,  the  modiScations  arising  from  the  proximity 
I  to  the  bronohial  tubea  exterior  to  the  lungs,  and  the  trachea  are 
■nor«  or  less  marked.  The  differeoccs  betveeo  the  two  sides  are 
also  easentiall^r  the  same  as  in  front. 
\  The  differences  between  the  two  sidea  of  the  chest  at  the  summit, 
in  front  and  behind,  compatible  with  a  health;  condition  of  the 
thoracic  orgins,  are  generally  attribntcd  to  the  diRi?rence  in  site, 
length,  and  direction  between  the  two  primary-  bronchi.  Konrnet 
denies  that  thi:^  difffrence  is  sufficient  to  occasion  any  disparity  in 
the  auscultatory  phenomena.  But  he  also  denies  the  fact  of  the 
existence  of  any  disparity  between  the  two  sides  u  respects  these 
phenomena.  Other  causes  may  be  inrolred,  but  that  the  one  jnst 
mcntioncl,  if  not  in  itself  adequate  to  account  for  the  disparity,  is 
more  or  less  concerned  in  its  production,  is  rendered  probable  by  the 
following  experiment:  The  larynx,  trachea,  and  primary  bronchi, 
with  some  of  the  larger  subdivisions  of  the  latter  extending  an 
equal  length  on  each  side,  were  detached  from  the  pulmonary  organs 
and  removed  from  the  body.  Then,  by  means  of  a  large  pair  of 
bellows,  the  noxule  of  which  was  inserted  into  the  larynx  and  ticcureil 
by  a  ligature,  a  current  of  air  was  inude  to  traverse  the  bronchial 
tubes,  firat  on  one  wde  and  afterward  on  the  other  side,  by  com- 
pressing alternately  the  right  and  left  bronchus  with  the  linger. 
Compariiig  tlH>  »oiiniU  thus  produced,  which  were  quite  loud,  it  waa 
very  obviouti  that  the  sound  produced  by  the  current  of  air  driven 
through  the  right  bronchus  and  its  subdivisions  was  more  intense 
and  higher  in  pitch  than  that  produced  within  the  left  bronchial 
tiib<>8;  care  being  taken  to  place  the  two  bronchi  u  nearly  as  pos- 
sible in  their  natural  position  as  regards  their  angular  relation  to 
tbe  trachea.  This  experiment  was  repeated  numerous  times  in  the 
presence  of  several  medical  gentlemen,  and  also  in  the  I  eel  ore- room 
before  n  large  class  of  medical  students.  The  disparity  junt  xtuted 
WM  not  lets  obvious  to  others  than  to  myself.  When  the  current  was 
made  to  traverse  tbe  bronchial  tnbes  on  both  sides  simultaneously, 
it  was  easy  to  perceive  a  difference  in  intensity  and  pitch  on  bringing 
the  ear  in  cto»c  proximity  to  tbe  bronchial  tubes,  firvt  on  one  side, 
I     and  then  on  the  other  side. 

^B    The  result  of  this  experiment  may  seem  at  first  to  be  inconsistent 
^^rith  the  fact  tltac  the  inspiratory  sound  on  the  left  side  is  frequently 


exc«pt  in  an  incivafied  intenaitj'.  It  is  heard  vilti  greater  imeas^ 
hy  iuinieiliale,  than  !>}'  mediAte  aoscullation,  provided  the  ordiovy 
cylinder  b«  employed;  but  williCammann's  stethoscope, llie  intoui- 
tj  is  much  greater  than  with  the  ear  applied  direcllj  lo  the  cfaen.  < 
It  may  bi'  rlii'tiiiclly  a]iprei;iatH!  nith  Cammann's  stethoscope,  vbeb 
it  is  not  heard  with  the  ordinary  cylinder  or  the  nnaided  ear.  TW  I 
expiratory  sound,  which,  na  has  been  seen,  is  present  in  soau 
persons  and  absent  in  otlten,  varying  al»o  in  relative  duration,  ia 
somciiEnes  di«coven;d  by  immedinte  aiL^caltation,  when  it  is  not 
heard  with  llie  cylinder;  and  in  ««ine  instances  may  be  rendered 
distinct  by  CantmnDn's  instrument,  when  it  i*  inappreciable  by  the 
ordinary  stethoijcope  or  the  ear  alone  Kly  recorded  examiuaijou 
of  healthy  chests  conliiin  illustrations  of  thrsc  facts.  Sex  and  sgc 
exert  a  decided  influence  on  the  intensity  of  the  rcslcniar  re»)Hiv 
Uon.  In  early  life  the  intcusiiy  is  marked,  so  ihnt  a  morbidly  ia- 
tense  Tcsicular  murmur,  after  Lacnucc,  is  freqaeiitly  distinguislicd 
as  puerile  respiration.  In  old  age,  on  the  other  hand,  tlic  inlcnuily 
is  diminiabed,  a  change  to  be  attributed  to  the  attenuation  of  the 
walls  of  the  air-cells  which  attends  advanced  yean.  At  the  saae 
time  the  expiratory  sound  becomes  relatively  more  developed  and 
longer.  The  respiration  thus  modified  by  ago  is  distinguished  u 
tentU^  respiration.  In  females,  as  a  general  remark,  the  respiratory 
sounds  are  more  intense  than  in  mates.  I'his  is  true  more  especially 
of  the  rc^piratiuii  at  the  Summit  of  (he  chest. 

In  other  respects  than  intensity,  differences  are  observed  in  the 
rcKpirstory  sounds  in  diffcniit  pcrMnia,  The  degree  of  veaicnlar 
quality  and  the  pitch  arc  not  unifurm.  Auscultating  a  number  of 
persons  in  succession,  in  no  two  purliaps  will  the  murmur,  aa  regards 
these  characters,  hv  identical. 

Th(-«e  divcniities  ilu  not  impair  the  oscriilnvss  of  auscultation  nor^_ 
than  a  similar  want  of  uniformity  in  the  phenomena  obtained  by  pcC^| 
cUBsion  aflccts  the  Utter  methul  of  exploration ;   beenuMi  in  both 
instances,  deviations  from  health  arc  not  determined  by  rcrcrcncc  to 
any  fixed,  abittriict  standard,  ns  regards  intenifity,  pitch,  etc.,  but 
by  a  comparison  of  the  tno  sides  of  the  chest.  ^H 

The  expiratory  sound,  as  already  iniimated,  differs  from  the  inspi^^ 
ratory  not  only  in  duration,  intensity,  and  pilch,  but  in  quality.    It 
in  devoid  of  the  vesicular  quality  which  chaructvrixes  the  inspiratory 
sound,  and  is  feebly  blowing. 

ll   K-maius  to  consider  the  variations  in  the  characters  of  the 


AUSCCLTATIOIT    IV    KBALTB. 

Bpiratioo  obaeried  on  comparative  cx»iiiinatinn»  of  corrcfponding 
situatiotia  on  the  Iwo  thits  of  the  cht^.tl  in  the  ^aiiic  persion ;  and  the 

k^iiSc-rcTiL  niodilicitlioiift  presenleil  in  dilTi-rent  regionii  on  llie  tuine  side. 
I  iiliail  proceed  to  giv«  the  results  of  a  series  of  recorded  exsmins- 
[tioDH  of  licallhy  pi'r*on»  with  reference  t«  n  comp»ri»»n  of  tho  reopU 
ntory  plu-nonienn,  Gr)>t  at  the  fiamniit  of  the  cliest  iind  ikfterwurdx 
ID  the  tcgions  cUewhcrc,  oniitling  in»ny  of  the  delailn  eontained  in 
Ktho  former  edition  of  this  work.     I  have  eoufirrned  the  corr<-ctnc«s 
™  of  thcM;  rcBuIu  by  a.  prciit  wuinher  of  observiitions  sliiw!  ihc  date  of 

Uie  piililicntion  of  the  former  eilitiuii. 
K  RiOHT  AND  Left  Ikfra-Clavicflar  Keoion. — The  respiratory 
murmur  hits  cerlitin  [uoditiciiii')n)i  in  thi»  region  at  nnd  near  tfa« 
stern o-clavieuUr  junction,  vrhich  will  be  noticed  nficr  huving  con- 
vidervl  the  inurmiur  in  Ihc  remainder  of  the  infrn>claricular  n^ion 
on  the  tiro  sides.  Abnortnal  modifications  of  the  niurmnr  in  this 
region  are  of  great  importance  iu  their  bearing  on  the  diagnosis  of 
toberculous  disease ;  hence,  it  is  high);  desirable  to  detonnine  tho 
points  of  diepaiiiy  and  the  varialions  consistent  with  health,  in  order 
ihat  thcT  may  not  be  mistaken  for  morbid  signs. 

■  The  inspiratory  sound  in  the  majority  of  cases  is  not  of  erjuni  in- 
Wnsily  in  this  region  on  the  two  »uh».     The  intensity  i»  almost  in- 

I     Yttriably  greater  on  the  left  side.     This  statement  its  opposed  lo  that 

■  of  some  authors;'  but  the  matter  is  purely  one  of  observation,  and 
as  my  examinations  have  been  mnde  wiib  care  nnd  with  no  expectn,- 

—^  tiou  uf  such  a  rKtull,  I  am  bound  to  nssunic  their  coriectness.     I 

Hoan  only  account  for  the  opinion  that  the  inspiratory  sound  on  the 

right  side  is  often  more  intenso  than  on  the  left  side,  by  supposing 

that  elevation  of  pitch  has  been  mistaken  for  increased  intensity. 

The  disparity  in  intensity  is  Bometimcs  marked.     The  intensity  of 

Htbc   inspiratory  soand  is  sometimes   notably  increased  by   forced 

^  breathing  on  the  left  and  less  so  on  the  right  side.     In  tho  majority 

of  cases,  there  is  a  disparity  as  regards  the  pitch  of  the  inspiratory 

Booad;  the  pitch  is  lover  on  the  left,  or,  per  eemtm,  higher  on  tho 

right  side.     The  vesicular  quality  is  more  marked  on  the  left  side. 

The  expiratory  sound  is  ofieiier  wanting  on  the  left  than  on  the 

j-ight  side;  in  otlicr  word»,  it  may  he  heard  freiiucnily  on  the  right 

•nd  not  on  the  left  side.     Not  very  infreciucnily  the  expiratory 

>tttid  is  prolonged  on  the  right  side  to  nearly  or  quite  the  length 


>  Bartli  luitl  Boger  and  OMhard. 


1S8 


PRTBIOAL    BXPLOBATIOn    OF   TDK    CBIBT. 


of  ihc  itiEpirslorjr  sound.  This  is  never  »bservfd  on  tbc  left  sni) 
not  on  the  ri^lit  side.  The  [lilch  of  the  rxpintor;  tn  tomctimcs 
higher  than  that  of  the  inxpiralorj  sonnd  on  tlie  right  side;  this  is 
very  rmre  on  the  lefl  aide.  The  Bonnd  of  in* [itration  itnd  of  expirm- 
tion  are  sometimes  aeparsted  by  a  brief  interval  r>n  the  right  nde, 
and  thi»  iii  verj  rarcljr,  if  ever,  obserred  on  the  left  »idc. 

The  foregoing  points  of  dtsiparitj  between  llie  two  sides  in  this 
region.  exdni*ive  of  the  «erno-clavictiliir  portion,  show  that  the 
respiratory  murmur  on  the  right  side,  as  eonipared  with  Ih**  left,  ia 
annlogous  to  the  morbid  sign  which  will  he  considered  hereafter 
under  the  name  broneho-vcsioaUr  respiration.  In  a  few  instances 
I  have  found  in  hciilthy  persons,  Cammann's  stethoscope  being  used, 
a  prolongeii  high-pitched  expiratory  sound  over  the  whole  of  the 
infra-clavicular  region,  identical  with  the  expiratory  sound  in  the 
tracheal  or  laryngeal  respiration,  and  in  the  morbid  sign  called 
bronchial  or  tubalar  respiration.  In  these  instances  the  pilch  of 
the  expiratory  sound  was  higher  on  the  left  than  on  the  right  side. 
The  points  of  disparity  presented  in  the  account  juei  given,  in»y  be 
seen  at  a  glance  by  referenee  to  the  subjoined  table: 


COMPARltOX  or  BlOBT  «XD   LKFT  IlirKA>Cl.AT100t.AR  Rmiok. 

fmpiralury  toumd. 
Jti^t  tUU.  Uft  tidt. 

Inltntlly  Im*.  Onwti^r  IntcnMty. 

Voiiculkr  <|aiiIUj  Ich  nutrk«d.  VaiouUr  qiiulilj  mora  narind. 

ritod  blghor.  Pitcb  lower. 

Erjiimiory  loiMd. 


JiijfM  a<d4. 

PfMont  on  tbb  and  not  on  loft  sida 
In  •os)«  («■(«. 

Orfatrt  inl*n(lty. 

Knt  iiifrvqucnlly  prolong. 

InUirvol  lamMlniM  Iwlvmn  th«  two 
■ounili. 

I'lloli  *omntiii»3i  bSghfir  tliaii  ibftC  of 
tmpiralioa. 


KoTor  pr«unl  on  thii  tiit  atul  wanl- 
Ing  on  Iho  rlghl  tidu. 
InUmil;  nvrer  grtaUr. 
B^n-Iy  pro!oli|[od. 
Tbo  two  wundt  c«ntinuou», 

I^lcfa  moK  t^nij  bifhor  tlua  ibat 
of  Iiupiiation. 


In  the  stemo-claTicular  portion  of  the  infra-clavicular  region, 
the  respiratory  murmur  is  apt  to  be  notably  tnodi6ed  by  bouihIs 
coming  from  the  bronchial  lubes  exterior  to  the  lung*  and  from  the 
trachea.  Thv  intensity  of  the  murmur  in  tbta  aituation  is  greater 
Bometime*  on  the  left  and  sonieiimes  on  the  right  side.    The  pitch 


ACSCBLTATIOH    tN    HEALTH. 


1S9 


^of  the  inspiraiorv  sound  is  higher  on  the  right  siAe.  The  finality 
hof  the  inspiratory  sound  on  liolh  sides  difler?  rrnin  the  normal 
Ixaonniir  in  other  eituntions  iii  being  a  coiiipoiind  of  the  vf-sinntar 
[and  tubuUr,  Bnd  the  pitch  i»  raised  in  proportion  as  the  tubular 

juality  predominntci.  The  expiratory  Kound,  in  thtg  gituation,  is 
^Boinetimes  more  intetiRc  llian  the  expiratory.  In  this  rcipect  there 
'is  often  a  divpiirity  between  the  two  *ides,  and  the  greater  intensity 

of  (he  expiratory  sound  is  always  on  the  right  »idc.     The  pitch  of 

the  fxpinition  ijt  generally  higher  on  the  right  side;  but  to  this  rale 

Ihcre  are  exix-ptionii. 

tThc  respiratory  murmur  in  the  situation  now  referred  to  has  been 
called  the  normal  bronchial  respiration.  This  nsme  implies  identity 
%ith  the  morbid  sign  call^  bronchial  respiration,  and  in  this  respect 
3t  is  incorrect.  The  inspiratory  sound  i«  not  purely  tubular  in 
quality,  as  it  is  in  the  bronchial  respiration  of  disease,  an<I  as  it  is 
in  the  normal,  laryngeal,  and  tracheal  respiration.  It  is  a  mixture, 
in  variable  proportions,  of  the  vesicular  and  the  tubular  quality, 
the  pitch  being  high  in  proportion  as  the  tnbulnr  quality  predomi- 
nates ;  hotice,  the  characters  arc  those  of  the  hroncho-vcsiculnr  respi- 
ration of  disease  to  be  presently  described.  The  same  modifications 
extend  more  or  less  to  the  respiratory  murmur  over  the  remainder 
of  the  infra-clavicular  region.  A  prolonged,  intense,  high-piicfaed 
expiratory  sound,  heard  near  the  elernum,  and  sometimes  over  the 
whwle  of  the  infm-clavicular  region,  douhtle«s  comes  from  the  tra- 
chea and  bronchial  tubes  exterior  to  the  lungs,  and  if  this  kind  of 
expiratory  sound  exist  on  both  sides,  the  pitch  is  higher  on  the  left 
side.  The  inspirntory  ^ounil  is  modified  in  a  grenler  or  less  degree, 
in  different  persons,  by  the  combination  in  variable  proportions  of 
the  sound  emanating  from  the  air-tubes  and  the  sound  produced  in 
tbv  air-cells. 

»  Without  knowledge  of  the  facts  presented  in  the  foregoing  ac- 
count of  the  respiratory  murmur  in  the  infra-clavicular  region,  it 
can  hardly  be  otherwise  than  that  errors  will  be  committed  by  mis- 
taking for  the  physical  signs  of  disease,  characters  which  are  found 
in  healthy  persons.  The  normal  vcaiculo- tubular  quality  of  the  in- 
spiratory sonnd  on  the  right  side,  as  compared  with  the  inspiratory 
Bound  on  the  left  side,  and  the  prolonged  expiratory  sound,  are  not 

■Infrequently  considered  as  denoting  a  tuberculous  depo.'iit. 
The  iH>»t-elavieular  region  may  be  examined  by  auscultation,  the 
stethoocopc  Wing  requisite  in  this  situation.     The  caution  inculualcd 


u 


rnrsicAL  bxplokation  op  thr  chest. 


hy  linenaec.  is  importnnt  to  be  borne  id  toiod  in  applying  llie  stctlio- 
Bonpe  abovf  the  einricle,  tit.,  to  avoiil  pressing  the  instrument  in  » 
direction  toirard  the  trsohea.  The  tracheal  sounds  arc  linble  to  ho 
conducted  to  the  ear  if  atleniion  be  not  paid  to  this  point,  IVewore 
of  the  -'<tethoM!opo  in  ihitt  region  m»y  dcrelop  an  artenal  niunnur, 
wlik'li  is  lu  bo  diatinguinhed  from  ii  n-t^piratorj  sound  by  <>l»i<,'rving 
that  it  in  synvhronous  with  ihc  pulac,  and  persisting  when  the  Diove- 
menlti  of  rvxplration  nrc  volunliiHIy  arrested.  The  rosiculiir  rrt^pU 
raiory  xound  i»  rcnilily  diHoov^rcd  in  the  pOBt-olnvicuIar  region  if  it 
be  tolerably  developrti  helow  the  claviclfi  in  the  person  csomitied. 
With  r»>pect  to  a  compariKoii  of  ihc  two  side^  I  have  not  noted  oV 
serTationa.  In  a  »inglo  instance  in  vhich  the  phenomena  vero  re- 
corded, care  being  tiiken  not  to  incline  the  flleihoacojte  toward  th« 
trachea,  the  inspiratory  sound  wiis  more  intense  on  the  left  ^iile,  and 
no  wuntl  of  expiration  apprcciitbic  on  that  side;  but  on  iho  right 
side,  after  itn  iiiter\-nl,  n  well-tuarked  expiratory  aacceedod  tho  iu- 
vpirulory  sound,  and  higher  in  pitch. 

Riyht  artd  £<^  Sciipular  Htgion. — In  the  upper  seapular  re- 
gion, I.  (.,  over  the  scupula  uborc  the  spinona  ridge,  the  respiratory 
innrmtir  is  leiui  intense  than  in  front,  but  it  may  generally  he  heard, 
ettpccially  if  Caromann's  stothoscope  he  used.  The  inspiratory 
sound  in  some  permna  has  greater  intensity  on  the  left  side,  and  the 
vesicular  quality  is  more  marked  on  this  side.  The  vesicular  (iiiatiiy, 
hovcTcr,  is  Iras  appreciable  over  the  scapular  regions  than  in  any 
other  ports  of  the  ehe^l.  The  expiratory  Muml  is  not  infre^iuenlly 
prolonged  on  the  right  side.  In  »hort,  the  murmur  on  the  right 
side,  as  compared  with  the  left  sidd  nay  have  Te«iculo-tqbular  char- 
acters more  or  le«  marked. 

In  the  lower  scapular  region,  ■'.  «.,  below  the  spinous  ridge,  ibt 
respiratory  murmur  is  heard  pretty  constantly,  and  is  more  intente 
than  in  the  upper  scapular  region,  although  less  intense  than  in 
front,  the  vesicular  quality  being  less  apparent  than  in  other  pnru 
of  the  chcHt.  In  this  region,  as  above  the  ridge,  Ihc  intensity  of 
the  inspiratory  sound,  in  some  persons,  is  greater  on  the  left  side, 
and  the  pitch  higher  on  the  right  side;  the  expiratory  sound  on  the 
right  side  may  be  prolonged,  and  it  uiiiy  be  higher  in  pitch  than  the 
inspiratory  sound.  The  vcsiculo-tubular  characters  are  thus,  io 
some  persons,  more  or  leas  marked  on  the  right  aide,  as  compared 
with  the  left  tudo. 

InUr-tcapular  Region. — In  the  upper  and  the  middle  portion  of 


*5¥(ICntTATr0N    IS    HBASt&T" 


141 


region,  the  respiratory  mnrmur  ha«  essenttallj  the  same  char- 
as  ibe  murmur  in  the  sterno-ckvicular  portion  of  the  iofra- 
.ncolar  region,  that  is,  the  modifications  arising  From  the  proximity 
the  bronchial  tubt^s  exterior  to  the  lungs,  and  the  trachea  are 
lore  or  less  marked.     The  difTcronccs  between  the  two  side*  are 
.Isti  csM-ntially  the  same  as  in  front. 
The  differences  betirecn  tiic  tno  sides  of  the  chest  at  ihc  summit, 
front  and  behind,  compiitibic  witli  n  liUHlthy  conililiun  of  the 
lOntcic  orgins,  arc  gencrnliy  attributed  to  the  diffciTucc  in  size, 
Dgtli,  and  direction  between  the  two  primary  bronchi.     Foumet 
leaiM  tliat  this  difference  is  sufficient  to  occasion  any  disparity  in 
i«  Bwciiltxtory  phenomena.     But  he  also  denies  the  fact  of  the 
ixistence  of  any  dii<pnrity  between  the  two  sides  as  respects  these 
ibenomena.     Other  causes  may  bo  involved,  but  thnt  the  one  juat 
iilioncd,  if  not  in  itself  adequate  to  account  for  the  dispariiy.  is 
lOre  or  les*  concerned  in  its  prodnction,  is  rendered  probable  by  the 
following  experiment:     The  larynx,  tnichca.  and  primary  bronchi, 
with  Home  of  the  larger  subdivti^ions  of  the  latter  extending  an 
ual  length  on  each  side,  were  dctacheil  from  the  pulmonary  organs 
and  removed  IVom  the  body.     Then,  by  means  of  a  large  pair  of 
bellows,  the  noEtle  of  which  was  inserted  into  the  larynx  and  secured 
by  a  ligature,  a  current  of  air  was  made  to  traverse  the  bronchial 
tubes,  Erst  on  one  side  and  afterward  on  the  other  side,  by  com- 
rBsing  alternately  the  right  and  left  bronchus  with  the  finger. 
'ompaiiiig  the  sounds  thus  produced,  which  were  f|uile  loud,  it  was 
very  obvious  that  the  sound  produced  by  the  current  of  air  driven 
through  the  right  bronehus  and  its  subdivisions  was  more  intenso 
and  higher  in  pilch  than  that  produced  wilhin  the  left  bronchial 
tnbee;  care  being  taken  to  place  the  two  bronchi  as  nearly  as  pos- 
sible in  their  natural  position  as  regards  their  angnlar  relation  to 
the  trachea.     This  experiment  was  repealed  numerous  times  in  the 
presence  of  several  medical  gentlemen,  and  also  in  the  lecture-room 
before  a  large  class  of  medical  students.     The  diitparily  just  Hlatcd 
was  not  less  obvious  lo  otherit  than  to  myself.    When  the  current  was 
made  to  traverse  the  bronchial  tubes  on  both  sides  simultaneously, 
it  was  easy  to  perceive  a  difierenco  i»  intensity  and  pitch  on  bringing 
the  ear  in  cWe  proximity  to  the  bronchial  tubes,  first  ou  oae  ude, 
■ad  then  on  the  other  side. 

I     The  result  of  this  experiuieut  mny  seem  at  first  to  be  inconsistent 
idtb  the  fact  that  the  inspiratory  sound  on  the  left  side  is  frequently 


9^ 


^nrei 


142 


PBrEiICAL    SXPLOBAtlOS    OP   TBS    CBS8T. 


nore  intense  than  that  on  the  right  side.  It  is,  bowrer,  to  W 
borne  in  tniai,  that  it  is  the  sound  produced  within  tbe  vesela  oi 
the  left  a,ide  which  ii  more  developed  than  on  the  rigbt  side.  Tk 
respiration  on  tbe  left  side  prescnU  a  more  mark«d  resicaW  qnSiJ, 
at  tbe  same  lime  thai  its  iiitenaitj  is  gtnerall^  greater.  Tbe  ikOtt, 
iben,  it  is  fair  to  conclude,  is  due  to  some  cause  connected  vilblla 
sir><r«lhi,  and  not  viib  the  bronchial  tabes.  The  greater  intewnj 
of  the  marmur  from  tho  air-Tcsicles  at  the  Btunmit  of  the  cbe*(  m 
the  left  tide,  may  b«  explained  in  part  by  the  greater  «ixe  of  tbe 
left  primary  bronchus,  and  in  part  by  tbe  relatively  greater  doocM 
of  the  diaphrugm  on  the  left  side  in  the  act  of  inspiration. 

RiffKt  and  Left  fi\fra- Scapular  Region*. — In  the  infra-Ksp- 
nlar  region  the  respiratory  murmur  is  almost  uniformly  appreciable 
It  is  generally  well  dercloped,  and  Frequently  with  forced  breathing 
becomes  inteiiM.  Here,  as  in  other  situations,  a  marked  differcnee 
in  intensity  is  often  obserred  between  the  mnrmnr  developed  by  or- 
dinary and  forced  breathing  :  with  tbe  latter,  in  some  insunccs,  H  it 
quite  loud,  when  with  the  former  it  may  be  scarcely  beard.  Ast 
rule,  the  intensity  is  greater  than  in  the  lower  scapular  region;  tbt 
vesicular  quality  is  also  more  apparent,  and  the  pitch  somewhat 
lower.  This  rule  is  not  without  exceptionn.  Tbe  intensity  in  a 
small  proportion  of  instances  is  about  equal  in  the  scapular  and 
infra-scapular  re^on ;  so,  also,  as  regards  the  vesicular  qo&lity  akd 
pilch. 

The  variations  between  the  two  sides  arc  decidedly  less  frequent 
and  marlced  in  this  situation  than  tn  the  regions  before  compared. 
In  a  few  inatuncea  the  intt-nniiy  H  greater  on  one  side,  and  when 
tbis  is  the  case,  the  greater  intensity  is  almost  uniformly  on  tbe  left 
side.  Occnnionully  the  vesicular  quality  is  more  marked  on  the  left 
aide*  and  in  a  few  instaneos  the  pitch  is  higher  on  tho  right  side. 

Tbe  cKpiratory  sound  is  almost  uniformly  lower  in  pitch  than  tbe 
aoand  of  inopiration.  I  have  noted  an  exception  to  this  rule  on  the 
right  side,  and  in  this  instance  the  sound  wag  distant,  an  intenw 
expiratory  sound  existing  over  the  scapula  on  the  same  side.  This 
Oa»e  ahowa  tliat  it  is  possible  for  tbe  tracheal  or  bronchial  respiratory 
sound  to  be  trunitmitled  in  the  healthy  chest  to  the  ear  applied 
below  the  scapula, — a  fact  important  to  be  remembered,  since  this 
sound  in  that  situation  in  the  vast  majority  of  cases  is  evidence  of 
diseaitc. 

JiiffiU  and  Litft  Mammary  and  Infra-Mammart/  XUffhnt^ — An  in- 


ADBODLTATlOir 


143 


* 


I 


ipirttorj  80un<l  \»  alniMt  nnifonnl;  apprvcinblc  in  tho8«  regions,  but 
niffcring  consider  ably  in  inteiiMitj  in  different  individuulti.  Tbe  in- 
ten^itT  ia  lees  than  at  the  summit,  with  verjr  few  exceptions,  The 
|)itcfa  is  nniformly  lower.  The  vesicaUr  quality  is,  at  the  ?ame  time, 
Xnorc  mnrlcH.  In  iheae  three  points  of  view,  viz.,  diminished  in- 
tcDvity,  lownMTS  of  pitch,  and  more  marked  vesicular  quality,  the 
difference  on  compnrinon  with  the  summit  of  the  cheat  is  sometimes 
greater  on  one  side-  of  ihe  >;heflt  than  on  the  other  side.  This  fact 
ia  to  l>c  explained  by  (he  disparity  which  has  been  seen  to  exist  at 
the  summit  in  a  certain  proportion  of  individuals  as  regards  inten- 
sity, pilch,  and  vesicular  qaality.  Supposing  the  inspiratory  sounds 
at  the  middle  and  lower  portions  of  the  chest  to  be  equal,  a  com- 
pariKon  witli  the  sonndH  at  the  summit  will,  of  course,  not  give  iden- 
tical rcfnltH  if  the  two  tiidi-N  al  the  summit  difTi^r.  Another  <-xpln> 
nation,  applicable  to  a  certain  extent  in  tiome  iiictHnces,  is,  the 
Bounds  over  tlie  middle  and  lower  portions  en  the  Iwo  sides  arc  not 
equal.  The  latter  is  true  but  of  a  very  stimll  proportion  of  cases 
Mvo  with  rcwpect  to  intensity.  An  expiratory  sound  is  rarely  ap> 
preciablo  in  the  mammary  and  infra-aiummary  regions. 
[  Sight  and  Left  Axillary  and  Jnfra-Axiilary  Regiont. — In  th« 
axillary  and  infra-axillary  regions,  an  inspiratory  sound,  especially 
with  furceil  breathing,  is  hoard  with  as  much  and  even  more  intensity 
than  over  any  other  part  of  the  chest.  It  may  be  inappreciable  in 
boaltby  cheats,  in  some  instances,  for  reasons  that  are  apparent,  as 
wbcn  the  thorax  is  covered  with  u  very  thick  layer  of  adipose  de< 
pont;  and  ia  other  instances  when  no  cause  is  apparent.  As  in 
other  situations,  the  intensity  differs  considerably  in  different  per- 
sons. The  intensity  is  generally  less  in  the  infra- axillary  than  in 
Uie  axillary  region,  and  the  pitch  somewhat  lower.  Careful  com- 
parison of  the  two  sides,  according  to  my  observations,  shows  some 
points  of  disparity  in  the  larger  proportion  of  cases.  Thus,  of 
twelve  examinations,  in  five  no  difference  was  apparent,  and  in 
BCTen  there  existed  more  or  less  inet]uality.  The  facts  respecting 
the  disparity  in  the  seven  cases  in  which  it  was  noted,  arc  as  follows: 
the  intensity  was  gre4iter  on  the  left  side  in  three  cases,  and  on  the 
right  side  in  three  cases.  The  pitch  was  higher  in  four  cases,  all 
on  the  right  side.  The  vesicular  quality  was  more  marked  io  three 
caMS,  all  on  the  left  side. 

An  expiratory  sannd  is  heard  in  a  much  larger  proportion  of  in- 
stances than  over  the  middle  and  lower  portions  of  the  chest  in  front 


144 


PBTSICAL    BXPLORATIOK    OP    TIIK    CHRST. 


or  boltinJ.     It  is  present  in  tlie  axilla  in  eomo  inslances  kud  not  tn 
the  infra^axillary  region. 


n.   PnaxOMKXA   IRCTDKNT  TO  TRR   rOICB. 

The  phenomena  produced  in  hcaltli  hj  the  act  of  epcakinfc,  liko 
those  ini-iilcnt  to  ro^pimtiou,  differ  in  diflcrcnt  portions  of  the  res- 
piratory npparatiis;  and  the  vocal  Eoundi;  may  be  arranged  accord- 
ing to  their  situation,  into  \»t,  tboee  pradaccd  wilbin  the  Urynx  and 
trachea ;  -d,  tho«c  heard  over  the  chest.  The  hcalihjr  phenomena 
in  these  siltuttions  incident  to  tlie  voice,  not  less  tluin  those  developed 
by  respiration,  represent  e«undx  which,  by  a  ohange  of  place,  become 
the  iiigns  of  disease.  The  uioi-c  important  of  the  vocal  phenomena 
porlninin;;  to  morbid  conditions  may,  in  fact,  be  atndied  upon  the 
bealihy  living  8td>joct.  Moreover,  here,  as  in  the  case  of  the  rea- 
piralory  phenomena,  varialioni;  wilhin  the  limits  of  health  exist  in 
different  individual*,  and  in  the  same  individual  in  corresponding 
regions  of  the  two  sides  of  the  chest,  which,  without  duo  knowledge 
and  care,  are  liable  to  be  mistaken  for  the  eridencca  of  disease,  giving 
rise,  possibly,  to  serious  errors  of  diagnosis*.  The  8tudy  of  the  pbe- 
nomcna  incident  to  the  voice  lit  health,  tberefure,  merits  close  atten- 
tion, preparatory  to  entering  od  the  subject  of  auscultation  in  disease. 

In  auscultating  for  vocal  ttonndx,  in  health  and  disease,  the  ear 
may  he  applied  immediately  to  the  chest,  or  the  stethoscope  may  be 
employed.  In  general,  the  sounds  arc  hotter  approbated  and  are 
more  intense  with  tb«  naked  ear  than  with  the  ordinary  stethoscope, 
nnd  the  latter  i^  not  only  uaek-««,  but  disadvantageous,  except  when 
it  is  dc»ired  to  concentrate  the  examination  upon  a  circumscribed 
space,  or  .direct  it  to  parts  of  the  chest  to  which  tbe  ear  cannot  be 
saliKfnotorily  applied.  In  listening  to  vocal  phenomena  witli  the  ear 
alone,  or  with  the  cylinder,  tho  sounds  are  heard  better  if  the  unoc- 
cupied ear  be  closed  completely  by  pressure  with  the  finger.  By 
means  of  Cammann's  stethoscope  the  sounds  produced  by  the  voice 
are  rendered  much  more  intense  than  by  ordinary  mediat«  or  by 
immediate  auscultation.  Phenomena  are  made  distinct  by  this  ia- 
strument,  in  some  Instances,  whoa  without  It  they  arc  too  feeble  to 
be  appreciated.  The  general  rules  and  precautions  to  1>e  observed 
in  the  practice  of  auscultation  are  alike  applicable  to  the  investiga- 
tion of  vocal  and  respiratory  phenomena.  These  need  not  be  re- 
poBied.     We  may  oauae  the  potlent  to  speak  by  addressing  to  him 


HRALTH. 


145 


ft 


Iqnestionii  vbile  the  ear  is  applied  to  the  chest;  but  a  better  mode  ig 
to  request  bim  to  count,  one,  two,  tkrM,  io  a  Jinlinct  and  tolerably 
floud  voice,  directing  him  to  pronounce  each  numeral  as  nearly  as 
jbic  with  tlie  same  tone,  difltinctuesA,  and  degree  of  louduc««, 
Ijtaniiing  a  little  between  the  numbers. 

The  vocal  phenomena  of  liuiillh  and  disease  relate  to  the  loud  and 
the  vliUpered  voice.  Sounds  obtained  bv  whispered  words  have 
liitherlo  received  but  little  attention.  They  will  be  found  to  consU- 
tote  a  highly  important  addition  to  tlie  physical  signs  avaiUble  for 
iugnosis.  It  will  facilitate  the  comprehension  of  thc«e  signs  to 
consider  that  a  sound  obtained  with  tlie  whitipcred  voiov,  always 
correepond»  with  tlie  soond  of  expiration.  Words  are  generally 
ivhispcrvd  with  the  expired  breatli;  a  whispering  sound,  therefore, 
is  neitlicr  more  nor  less  Ui&n  the  sound  produced  by  a  forcible  set 
of  expiration. 


ft, 


1.  Trachbal  Voice — Laryn'okal  Voick — Tkacheophony — 
I«ART:toopHOXT. — If  the  alethosoope  be  placed  over  the  trachea 
JDSt  above  the  slernal  notch,  and  the  person  be  desired  to  count  in 
B  moderately  loud  tone,  the  ear  of  the  auacultalor  receives  a  com- 
bination of  sensations.  The  voice  occasions  a  strong  resonance, 
accompanied  by  a  concussion  or  shock,  and,  also,  by  &  freinilus  or 
thrill.  The  voice  is  concentrated  and  near  the  ear.  The  arllculiitcd 
words  are  sometimes  transmitted  so  as  to  be  heard  almost  as  clearly 
&8  when  received  from  the  lips ;  in  other  instances  they  are  convoyed 
with  more  or  less  iui^stinclness,  and  oocAsiooally  ihey  arc  inappre- 
ciable. The  resonance,  the  shock,  the  fremituB,  and  the  complet* 
or  incomplete  transmission  of  speech  arc  the  eevcml  elements  which 
compose  the  phenomena  embraced  under  the  bead  of  the  tracheal 
Toioe.  It  will  facilitate  a  clear  apprehension  of  the  vocal  phenomena 
incideDt  to  the  auscultation  of  different  parts  of  the  respiratory  ap. 
paratus,  to  consider  the  tracheal  voice  as  thus  made  up  of  different 
elements.  These  elements,  in  the  great  majority  of  instances,  will 
be  found  to  enter  into  the  tracheal  voice,  the  differences  in  different 
individuals  consisting  in  variations  in  the  degree,  ahaolute  and  re- 
lative, which  they  present.  The  resonance,  and  shock,  and  fremitus, 
are  geoerally  strong. 

These  three  elements,  as  a  general  remark,  appear  to  preserve  a 
mntual  relation ;  that  is  to  say,  they  participate  aboat  equally  in  the 
T«riatioas,  as  regards  intensity,  observed  in  different  individuals, 

10 


146 


PHY8I0AL.    KXPLORATIOX    OF    TDB    CDBST. 


Yet  the^  do  not  mvulro  the  same  phpical  causm.  The  rcMouiee' 
it  <Iuc  to  Uic  rcvcrbcrntion  of  tlic  voice  wiltiin  the  trBchenl  epaoe; 
the  shock  to  the  forcv  given  to  tho  column  of  air  by  expiration  in 
oonnectiou  with  it#  partiitl,  Hudtlon  arrest  hy  tho  act  of  BpCKking, 
ami  the  frcmittu  to  tho  vibrations  of  the  tracheal  tube,  in  eonjuoa 
tion  with  those  of  the  vocal  chorde.  Collectively,  they  arc  nor 
ttlronply  markud  in  proportion  to  the  strength  of  the  voice  and  ita 
gravity  of  tone.  Hence,  in  females  and  children,  they  arc  com- 
IMtratively  less  prominent.  If  Cammaun's  stethoecopc  be  applied 
over  the  trachea,  tho  shock  ajtd  resonance  are  fcH  vritli  pAinful 
intensity,  in  some  instances  being  quite  unendurable;  tho  articolftted 
Toiee,  or  speech,  however,  is  not  conducted  much  better  tbrougli 
this  instrument  than  through  the  ordinary  cylinder.  The  rosonanee 
of  the  voice  and  transmission  of  the  speech  are  acoustic  phenomena; 
the  »hock  and  fremitus  arc  tactile  sensutions. 

The  transmission  of  the  speech  more  or  less  perfectly  through  th« 
stethoscope  ia  an  interesting  »nd  important  element  of  the  tracheal 
voice,  from  the  fact  that  when  it  occurs  over  tho  chest,  as  incident 
to  disease,  it  conatilutes  the  sign  culled  PectfirHoqwy.  Pectoriloquy 
is  said  to  be  perfect  when  the  articulated  words  are  distinctly  heard 
with  the  car  applied  to  tho  chc-st  mediately  or  immediately.  It  ia 
imperfect  when  the  words  are  indistinctly  heard.  The  types  of 
perfect,  and  of  tho  various  grades  of  imperfect  pectoriloquy,  are  for- 
nidhed  by  auscultation  of  the  trachea.  Hence,  by  becoming  prae- 
tieally  acquainted  with  this  clement  of  the  tracheal  voice,  ths 
student  acquires,  at  the  same  time,  an  acquaintance  with  a  morbid 
sign,  the  signifieanoo  of  which  will  be  hereafter  considered.  The^ 
proportion  of  oaaes,  however,  in  which  perfect  pectoriloquy  is  repro- 
aented  by  the  tracheal  voice  is  email,  and  the  trunflmiiisioD  of  srtiea- 
lated  words  is  quite  independent  of  the  preceding  elements,  viz., 
the  resonance,  shock,  and  thrill.  This  want  of  relation  is  further 
shown  by  the  fnot  that  a  powerful  and  bass  voice,  which  is  most 
favorable  for  the  elements  last  named,  does  not  render  the  peclo- 
riloquouj*  element  more  ctrongly  marked. 

The  foregoing  vocal  phenomena  referable  to  the  trachea  are  thoii 
which  are  oocaaioned  by  the  voice  when  words  are  spoken  aloud 
When  words  are  whispered   there  is  little  or  no  shock,  nor  thrills 
Tbeee  elements  are  either  wanting,  or  comparatively  slight ;  but 
tlifi  whispered  words  are   transmitted  in  nome  instances  perfectly^! 
and  in  other  instances  incompletely.     This  is  identical  with  what  is' 


AtTBOtTLTATfOir    IK    BBALTB. 


147 


^'Cklled  «ht»pering  pcctoriloqu;^)  v\u:n  irhUpercil  norda  are  received 
TOiD  «ny  portion  of  ibu  cliMt.  The  term  pccloriloqiiy  cnnnot  of 
onrBe.  with  strict  proprii-ly,  be  appliol  to  the  tmclica,  because  it« 
igDi6cation  implies  tliut  the  speech  comes  from  the  chest.  From 
its  tleriviilion  it  signifies  cbe»t-tulking.  In  cODDCctioii  vrilh  perfect 
or  iocomplete  transmissioa  of  speech  is  a  strongly  mitrkeil  tou^  or 
blowing  sounil.  The  latt«r  follows  the  vocnl  sound,  odU  nppoars  as 
if  a  current  of  air  were  directed  into  the  ear  through  the  stethoscope. 
This  blowing  sound  is  aUo  appreciable  in  some  infttanoesiihcn  words 
■re  spoken  aloud,  It«  intenHity  is  irrespective  of  the  perfect  trans- 
mission of  the  speech.  It  is  sometimes  intense  when  the  transmts- 
iicn  of  words  is  quite  imperfect.  Whispered  words  are  ofiener 
distinctly  transmitted  than  words  spoken  aloud. 

If  the  stethoscope  be  placed  on  the  broad  surface  of  the  thyroid 

cartilage,  the  vocal  phenomena  emanating  directly  from  the  larynx 

will  be  found  to  be  resolvable  into  the  same  elements  aa  are  those 

proceeding  from  the  trachea.    The  laryngeal  voice  doea  not  present 

the  marked  differences,  compared  with  the  tracheal,  which  the  student 

is  led  to  expect  from  the  writings  of  some  authors;  and  in  some  in- 

•taocea  tlie  sounds  in  both  situations  are  very  nearly  if  not  quit* 

identical.     As  a  general  rule,  the  shook  and  vibration  commanicaled 

to  the  ear  are  leas  than  when  aiiRcultation  is  practised  over  the 

B  trachea.     There  are  some  exceptional  instances  in  which  tbey  arc 

■  of  the  same  intensity,  but  very  rarely,  if  ever,  greater.     The  Irans- 

Kmission  of  the  speech  is  oftener  perfect,  and  generally  Ices  incomplete. 

£.  NottUAL  TuoK.icic  Vocal  Rbsokaxcb — Nohhal  Bkoxciiial 
WutsfKB. — The  resonance,  over  the  chest,  of  the  loud  voice  pre- 
sents important  distinctive  traits  when  contrasted  with  the  tracheal 
or  laryngeal  voice;  certain  differences  are  frequently  observed  when 
corresponding  regions  on  the  two  sides  of  the  chest  are  compared, 
•nd  the  effect  produced  by  the  act  of  speaking  in  different  portions 

K  of  the  same  side  are  not  identical. 

'^  Fir»t,  as  contrasted  with  trachcophony,  the  resonance  is  much 
weaker;  in  other  words,  it  has  much  less  intensity.  It  differs  in 
lot  being  constantly  present ;  not  infrequently  over  portions  of  the 
cheat  DO  resonance  is  appreciable,  at  least  with  the  ordinary  stetho- 
scope and  immediate  auscultation,  and  in  some  persons  it  is  absent 
over  the  entire  chest.  The  sound  is  diffused,  and  seems  farther'rO' 
moved  from  the  ear.     It  is  rarely  accompanied  by  a  sense  of  con- 


I 


rsTBicAL  BxrLo»AXi«>  er  raa  caisx. 


M8 


Wt  n  MB*  iMtiMM,  »  eertuA  puttof  iW  dMst,  the  latter  ca»- 
eoiiUat  w  stnaglr  Marked;  sad  h  b  HBctinM  prasent  in  •  defttc 
lAid  it  o«t  of  piapcnioa  t»  tbe  mm^i  of  ntcmnc*.  Traasni- 
moa  of  the  ipMeb.  i>  mWt  ««rdt  pectarSoqaj,  docs  oM  oce« 
ID  conaectiaa  with  borttal  tboradc  teaooaacf,  mit  as  a  tctj  nn 
•xeeptioa  to  tfae  rale.  iBpesfeet  wluapefi^  peeiorilotia/  is  «e» 
mmaDjobMrral;  aad  in  aoae  pans  «f  iW  chest,  the- act  of  spcsk- 
tag  in  a  wluaper'occasioas  a  ax^  or  Uawiag  scMind,  lik*  tbtl 
wbich  attends  tke  tradMsl  and  ibe  bratMUal  Toiee,  hat  mcrck  )««* 
fBtease.  Uese  are  the  uaportaBt  psials  distn^otsluBg  tbe  plie- 
Boaaeoa  enbrsced  onder  the  appsHsiioa  of  tbe  nomal  thoracic  r»- 
soiuDce  u  contrasted  «ith  the  pheaoMcaa  caaaating  dircctlj  Cron 
the  larynx  and  trachea. 

The  thoracic  vocal  resooance  presenu  is  different  healthj  pcnou. 
eren  greater  rariauons  in  degree  than  the  vestcular  respiration,  4l^| 
to  difierenoes  in  poaer  of  voice,  graTitv  of  tone,  and  other  drcoi^^ 
■tanees  act  so  obvious.  There  is  not,  therefore,  in  the  one  cate, 
more  than  in  the  other,  a  eerUtn  normal  intcncitj  to  be  referred  t« 
u  a  standard  for  comparison.  In  both  cases,  eqnall;,  morbid  vart- 
sti«as  are  not  determined  b;  reference  to  an  abstract  criterion,  or 
to  an  average,  bitt  by  asceruining,  as  far  ae  practicable,  the  degree 
of  resonance  natural  to  the  individaal ;  and  this  !b  done  hj  insti- 
luting  a  comparison  of  corresponding  EitaatioDfi  on  the  two  sides  of 
the  chest,  taking  advantage  of  pathological  lavs,  in  conformity  with 
which,  for  (he  most  part,  diseate  is  either  confined  to  one  side,  or 
is  more  advanced  on  one  side  than  the  other.  This  rale  of  practice 
is  baaed  on  the  assnmpiion  that,  in  a  condition  of  health,  and  pro. 
vided  the  conformation  be  symmetrical,  the  two  sides  of  the  chest 
famish  the  same  phenomena  on  anscnltation.  Me&surabty  this  maj 
be  assumed,  and,  as  already  remarked,  it  is  &  fundamental  principle 
in  physical  exploration;  but  we  hare  seen  that,  as  regards  phe- 
nomena incident  to  respiration,  this  rule  is  practically  not  without 
important  exceptions.  The  same  is  also  true  of  the  phenomena  inci- 
dent lo  the  voice.  Hence,  to  avoid  the  error  of  mistaking  normal  dif- 
ferenees  for  the  signs  of  di»c»!te,  it  is  highly  importnnt  to  become 
Mqaainted  with  the  nature  and  extent  of  the  deviations  from 
equality  which  are  within  the  limits  of  health.  Fortunately,  these 
deviationx  observe  laws,  ths  knowledge  of  which  will  secure  against 
error  of  diagnosis,  which  would  be  unavoidable  if  such  laws  did  not 


AUSOULTATIOIT    IR    HBJILTII. 


I 
I 


ProceeiliRg  to  consider  tlio  vocal  re«on>nco  in  corr«sponding 
iitualions  on  lliv  two  tiitlce  of  the  chvHt,  ond  in  difTorcnt  psru  of  tbfl 
Mmc  Hide,  it  will  b«  convenient  to  purHue  tlie  eaine  course  as  in 
treating  of  the  respirntory  phenomena  under  these  points  of  view, 
tftking  np  snccessiTely  the  more  important  of  the  thoracic  regions, 
aod  giving  the  results  of  the  analvsis  of  a  aeries  of  examinations  of 
persons  presumed  to  he  entirely  free  from  any  disease  of  the  rea- 
pir*tory  apparatus.  Directing,  attention  first  to  the  summit  of 
the  chest,  the  different  regions  will  be  noticed  in  the  same  order  aa 
under  the  head  of  respiration. 

Infra-eiavicitlar  rtffion. — The  resonance  of  the  loud  voice  is  almost 
always  appreciable  in  every  part  of  this  region.  It  varies  ranch  in 
different  persons,  being  in  some  slight,  and  in  others  quite  intense. 
Vocal  vibration,  thrill  or  fremitus,  more  or  less  marked,  acoom- 
psnie8  the  resonance  in  most  persons,  but  is  sometimes  wanting;  it 
is  sometimes  more  marked  than  the  resonance. 

As  regard^  a  comparison  of  the  two  sides,  in  a  very  large  pro- 
portion of  persons  the  vocal  resonance  ia  distinctly  greater  in  the 
right  than  in  the  left  infra- clavicular  region.  This  statement  ia  op- 
posed to  Ibc  opinion  of  Foumet,'  profeHsedly  baiMtd  on  numerous 
observations,  viz.,  that  a  marked  disparity  in  this  region  bctweeo 
the  two  sides  is  evidence  of  ilisease.  And  as  regards  lliv  disparity, 
a  law  is  invariable,  viz.,  the  increased  resonance  is  always  on  the 
right  side.  The  frequent  existence  of  greater  resonance  on  the 
right  side  has  been  well  known  to  practical  auscultators  of  late  years. 
The  fact  was  first  pointed  ont  by  Stokes,  and  was  confirmed  by 
the  researches  of  Loan.*  It  is  usually  attributed  to  the  larger  siie 
of  tlie  right  primary  bronchus. 

Aa  regards  the  amount  of  disparity,  it  differs  considerably  in 
different  perxons.  In  some,  a  resonance  is  distinct  on  the  right 
side,  none  being  appreciuhle  on  the  left.  In  some  the  difference  ia 
slight,  in  others  more  strongly  marked,  and  occaaionally  the  con- 
trast is  striking. 

The  thrill  or  fremitus  Li  greater  on  the  right  side.  It  may  b« 
present  on  this  side,  and  wanting  on  the  left  side. 

With  whispered  worda,  a  aouffle  or  blowing  sound  is  in  most  per- 
sons heard  over  this  region  on  both  sides.  Its  intensity  varies  con- 
siderably  in  different  pentons.     It  is  sometimes  beard  on  the  right 

■  Dp.  cIl.  pagD  IG2,  torn.  1. 

•  Bi!cbor«bM  »ur  la  Pbthlttn,  IMS,  p.  588. 


IM         pirtiCAX.  BXPLaBAZicv  Ar  tkb  cassz. 


iW  ri^  ■«•  tkM  «  tW  Wt    A  Mniij  Wfiw<Uf»«fc» 
aba  «x«t*  >fl  ii^ri*  Am  pilch  af  tUi  m^iA.    Ii  is  hi^o-  ia  piuh 

Mtklcftndfc    Tfc»  iMif  Lii^ imi  i  rfhaahhway  UoM 

tW  wrmo/  liwiti'if  ilffi  .  Ai  j««  Mttc^  k  ■  badcr  m  Ik 
r%hc,Hia  U^bartapitafc  M  tke  Ml,«4e.  TkM  poiaU  oT  &■ 
paritj  BonwyBwi  vilh  djAnaMC  |  iitihwiy  to  the  Mpmtnj 
of  rcifmiMM  oa  th*  C»o  lUa*  in  thii  ngioo;  tliM  tami, 
I  it  €«■«  frDB  tW  tfiachi,  ia  laaJcr  •■  th«  rigbt  and  ^bv 
ia  pitdi  on  tbe  l«ft  nit. 

At  the  ■tertM»-«l»rie«lar  partiaa  ef  th»  iefr»-«)anealar  regiav,  ik 
nMMBM  af  the  loW  voiee  hae  beea  called  manmtt  inmeApplt^ 
Tbe  reao&aaee  kaa  More  iateituiy  here  thsa  ia  other  portioas  of  tfa 
regioa,  aad  the  roice,  ia  M«e  peraoaa,  it  eoacetraieJ,  near  the  eer, 
and  hi^  tn  pitch ;  ia  ether  werda,  it  haa,  nare  or  Icaa  aarhed,  Ae 
dur*et«TS  whkh  will  b«  seea  hereafter  to  dittiagmih  the  morltil 
aiga  called  broi»d><^bonj.  Tbe  broodual  whiipar  is  aonetine*  nota- 
bly more  int«iiae  here  thaa  elsewhere  orer  the  infra-oUvicalar  rcipoa, 
and  it  preacou  the  potuu  of  dup^tj,  vhea  the  two  ndea  are  com- 
pared, which  hare  beea  atated  aa  pertaining  to  the  wh<4e  ot  the  n- 
gion.  Whimpered  worda  are  aonetimea  partially  tnanailted,  ooo- 
atitating  iDcomplcU)  whimpering  peeloriloqay. 

Seapviar  rtgum- — Tbe  resonance  of  the  loud  roioe  is  generaOy 
more  or  Im«  marked  in  this  region.  It  it  mtKh  less  intense  than  at 
the  Mimmit  of  the  chest  in  front,  and  is  more  distant  and  diffused. 
It  is  more  intense  in  some  persons  above,  and  in  other  persons  below, 
the  spinous  ridge.  The  intensity  is  nniformly  greatest  on  the  right 
side.  Tlio  disparity  in  this  respect  varies  in  different  persons,  being 
aometimes  slight  and  sometimes  strongly  marked.  The  intensity  in 
this  refpon,  on  cither  side,  ^liffers  considerably  in  different  peraoos. 

Vocal  vibration,  thnll,  or  fremitus,  accompanies  the  resonance  ia 
aome  persons,  but  loss  frequently  than  in  the  infra^elnvicalar  region. 
When  present,  it  is  most  marked  on  the  right  side.  It  may  be  pre>. 
ent  on  this  side  and  wanting  on  the  left  Hide. 

The  bronchial  whiaper  is  sometimes  present  and  sometimes  want- 
tug.  Il  ma;  be  heard  on  the  right  and  not  on  the  left  side,  and 
when  heard  on  both  aides  it  is  louder  on  tbe  right  side. 

Intfr-teapular  rfffion. — The  resonance  of  the  loud  voice  in  this 
region  has  the  intensity  which  it  has  at  the  sternoclavicular  junc- 
tion in  front,  and  in  some  ponons  it  has  here  the  characters  of 


AD8CULTATI0I)    lit    ttCALTB. 


I  lironchophony,  more  or  less  marked.     The  intensity  is  greatcfll  on 
the  right  side.     This  is  true  also  of  the  bronchial  whisper.     The 
latter  is  loudest  on  the  right  side,  and  higher  in  pitch  on  the  left 
[side. 

Infra-Kfapalar  region. — In  a  large  majority  of  persons,  the  reso- 
,  Bsnce  of  the  loud  voice  la  thia  pnrl  of  the  cheat  ia  greater  than  over 
'  the  scapula.     The  resonance  in  Bomc  pcrnons  is  quite  aa  intense  in 
the  infra-scapular  as  in  the  infra-clavicular  region.     Here  not  IcM 
'  than  elsewhere,  the  intensity  varies   in  iliffercnt  in<IividunU.     Id 
,  much  the  larger  proportion  of  instances,  also,  there  is  greater  rcB- 
lonanceon  the  right  than  on  the  left  aide.     The  resonance  is  dif- 
fused, distant,  and  the  pitch  low,  these  characlera  being  in  contrast 
with  those  of  bronchophony.     A  thrill  or  fremitus  fret(iieMtly  ac- 
companies the  resonance.     It  is  almost  uniformly  more  morkvd  on 
the  right  side,  if  present  on  both  sides,  and  it  may  be  preM-nt  on 
the  right  and  not  on  the  left  side. 

The  bronchial  whisper  is  often  wanting  in  this  region  on  both 
I  sides.     When  heard,  it  is  generally  slight  or  feeble.     It  may  be 
beard  on  the  right  and  not  on  the  left  side. 

Mammary  and  ir^fra-mammary  regiimn. — The  resonance  of  thft 
loud  voice  in  thc-sr  regions  is  uniformly  less  than  at  the  summit  of 
the  chest  in  front,  and  in  the  intcr-scapular  region.  It  Js  distant, 
diffused,  and  of  low  pitch,  in  those  characters  contrasting  with 
bronchophony.  The  intensity  is  greater  on  the  right  side.  Vocal 
vibration,  thrill,  or  fremitus,  accompanies  the  resonance  in  some 
persons,  either  limited  to  the  right  side,  or,  if  appreciable  on  both 
(ides,  more  marked  on  the  right  side. 

The  bronchial  whisper  is  often  wanting,  and,  when  present,  is 
feeble.  It  may  be  present  on  the  right  and  not  on  the  left  side, 
and  'm  louder  on  the  right  side  if  beard  on  both  sides. 

Arittary  and  infra-axiUitry  rtgiont. — In  these  regions,  the  reso- 
nance of  the  loud  voice  is  greater  in  intensity  than  over  the  middle 
and  lower  lliirdt  of  the  chest  in  front,  and  in  some  persons  tb«  res- 
onance is  quite  cquni  to  that  of  the  infrn-clavicular  region.  The 
intensity  is  lei's  in  the  Iiifra-uxillary  thiiii  in  the  axillary  region. 
kit  is  greater  on  the  right  than  on  the  left  side.  The  resonance  is 
here  distant,  diflfused,  and  of  low  pitch,  in  these  characters  con- 
trasting with  bronchophony.  VocilI  vibration,  thrill,  or  fremitus, 
attends  the  resonance  in  some  persons,  in  both  regions,  but  oflencr 
in  the  axillary.     This  may  be  present  on  the  right  and  absent  on 


U2 


PRi 


THB  CBRST. 


the  left  side,  and,  if  prvsmt  od  ^ol)l  sides,  is  greater  on  the  right 
side. 

Tho  bronchial  vhi»pcr  is  in  some  perm>nii  presont  and  in  ollwt 
porcoDB  wanting.  Thi<  may  bo  prcHcnt  on  the  right  and  not  on  tht 
left  side,  und  if  present  on  both  sides  it  is  louder  on  the  right  side. 

In  view  of  the  importance,  with  reference  to  the  diagnosis  of  ili» 
ease,  of  the  points  of  disparity  between  regions  on  the  same  nit, 
and  between  corresponding  regions  on  the  two  «des  of  the  chest  is 
health,  the  following  condensed  abstract  of  the  foregoing  facts  per- 
taining to  the  respirntion  and  voice  is  appended: 


Summary  of  the  pffintt  of  di^arity  bftween  different  rtgiinu  on  tk 
tame  tide,  and  between  corretponding  refftont  on  the  two  tida  if 
th^  chetls  ill  healthy  prrtoni,  ae  retpeett  the  phcTtomena  incident  tt 
the  reapiration  and  the  voice. 

1.  Infra-elavicttlar  region. — The  inspiratory  sound  on  the  left 
side  Qsuiilly  more  intense  than  on  the  right  side,  and  the  rceicvlir 
quality  more  marked.  Thi-  inspiratory  sound  on  the  right  fide,  ai 
compared  with  that  on  the  left  side,  vesiculo-tubular  in  quiillty  and 
higher  in  pitch.  The  expiratory  sound  frequently  prolonged  od  lb* 
right  side,  and  not  infrequently  higher  in  pitch  than  the  sotiod  of 
inspiration.  In  some  persons  tho  expiratory  sound  prolonged  sad 
high  in  pitch  on  both  sides,  and  in  these  cases  the  sound  more  is- 
tense  on  the  right  side  and  higher  in  pitch  on  the  left  side.  Tk 
characters  and  points  of  disparity  just  stated  mo»t  marked  at  tk 
stcrno-cIaTicular  junction,  in  consequence  of  the  proximity  to  the 
trachea  and  Urge  bronchi,  constituting  what  has  been  called  tbe 
normal  bronchial  respiration,  more  properly  called  the  normil 
broncho- vesicular  respiration. 

The  resonanco  of  the  loud  voice,  as  compared  vitb  the  re«onanee 
over  the  larynx  ant!  trachea,  diffused  and  distant,  but,  a£  «  rule, 
more  iutcnse  thtin  in  other  regions,  excepting  the  inier-scapolsr 
region.  The  resonance  greatest  on  the  right  side,  and  in  some 
pertODS  present  on  this  side  and  wanting  on  the  left  side.  The 
resonance  greatest  at  the  sterno-clavicular  junction,  and  in  this 
situation,  in  some  persons,  the  voice  concentrntcxl,  near  the  car,  %tA 
high  in  pitch,  constituting  nonnni  bronebopliony.  The  resonaaee 
frequently  uccoiupanicd  by  thrill  or  fremitus,  which  may  be  present 
on  the  right,  and  wanting  on  the  left  side,  and,  if  present  on  both 
Bidc4,  most  marked  on  the  right  aide. 


ArseotTATioy  tif  bkaltb. 


A  Mmffit  or  blowiug  sound,  with  whispered  word*  (ihc  norroa] 

broncliial  wIiJKpor)  in  most  pcreon»  hciird  on  both  nidoa.     Present 

Bomctimes  on  the  riglit  and  not  on  tho  left  »idc,  and,  when  present 

both  eidos,  loudest  on  the  right,  and  higher  in  pitch  on  the  left 

aide. 

2.  Scapwhtr  region. — The  inspiratory  sound  in  some  persons 
more  inteDse  and  vesicular  on  the  left  side  of  the  ehest.  The  ex- 
piratory sound,  in  some  persona,  prolonged  on  the  right  side. 

The  resonance  of  the  lond  ydicfx  more  dlstnnt  and  diffuued  thnn 
in  the  infra-ctnvicular  n-gion.  The  re)«oiiance  greater  on  the  right 
■ide,  Tocal  vibration,  thrill,  or  fremitus,  if  present,  more  marked  on 
fthe  right  side. 

The  bronchial  wbi«pcr  jtomctimes  present  and  somelimea  wanting; 
ener  present  on  the  right  side,  and,  if  present  on  both  sides, 
^louder  on  the  ri^ht  ^ide. 

8.   Intrr-teapuiar    nyhn.  —  Tlie    chitruclers  of   the    respiratory 
■^urmur,  and  the  disparity  between  the  two  sides,  «!»enttally  the 
Kiame  as  in  the  portion  of  the  tiifra-clavicnlnr  region  situntcd  at  and 
Vxear  the  sterno-clavicular  junction,  that  is,  the  murmur  modified  by 
aounda  derived  from  the  trachea  and  large  bronchi,  giving  rise  to 
vbat  might  be  called  the  normal  broncho-vesioulnr  respiration. 
The  resonance  of  the  loud  voice  intense  as  compared  with  other 
pons  excepting  in  front  at  the  stcrno-elavicular  junction.     The 
oicc  in  some  persons  near  the  car,  and  conccotrated,  constituting 
lormal  bronchophony.     The  intensity  greater   and   the   broncho- 
phonic  characters  more  marked  on  the  right  tide. 
The  bronchial  whisper  more  or  less  intense;  the  intensity  greater 
FoD  the  right,  and  the  pitch  higher  on  the  left  side. 

4.  Infratcapular  rfgiun. — The  intensity  and  vesicular  finality 
of  the  respiratory  murmur  sometimes  mure  marked  on  the  left  side. 
The  resonance  of  the  loud  voice  distant  and  diffuited,  more  intense  than 
in  tlic  scapular,  and  1cm  intense  than  in  the  inter-ecnpular  region. 

tbff  intensity  greater  on  the  right  than  on  the  left  side.     The  bron- 

tcbial  whispi-r  sometimes  wanting,  and  generally,  if  present,  quite 

Irfoeble;  prevent  on  the  right  and  not  on  the  left  side  in  some  per- 

XB,  and  if  present  on  both  sides  louder  on  the  right  side.     Thrill 

'  or  fremitus,  if  on  one  side  only,  on  the  right  side. 

5.  Mammary  and  infra-mammary  region».  —  The  respiratory 
murmur  more  or  lesa  intense.  The  intensity  in  some  persons 
greater  on  the  left  side.     The  resonance  of  the  loud  voice  more 


IM 


Pn?SlCAL    BXPLORATIOV    OP    THE   CHEST. 


cliMitnt  &nd  difTiutcd  than  at  th«  summit;  the  intensity  of  the  reM- 
nnnco  grciiMr  on  tho  right  thaii  on  the  left  side.  The  bronchial 
irbiflpcr  in  some  persons  wanting,  Hrid  in  »ome  pentonii  prettent  but 
feeble;  prexcnt  in  some  pcrHons  on  tbf  right  and  not  on  the  left  titde, 
sod,  if  present  on  both  «i"Ie«,  louder  on  tbe  right  xidc.  P'ncts  with 
ropcct  to  thrill  or  fremituK  the  Knme  kb  in  tbe  infra-Mupnlnr  region. 
6.  Axillary  and  infra-axUlary  region. — The  iiitennty  of  llie 
respiratory  murmur  greater  thun  in  the  mammnry  nnd  itcapulu 
regions.  The  resonance  of  the  loud  voice  dietunt  and  diffiwed,  of 
variable  intensity  in  different  persons,  but  more  intense  on  the  right 
Bt<lc.  Pacts  with  respect  to  thrill,  or  fremitus,  the  same  as  in  the 
infra. scapular  region. 

UI.   PBBNOUSNA  INCIDENT  TO  TBS   ACT  OF   COCdBlHO. 

The  phenumcna  produced  by  coughing,  or  tussive  pbcnomeDt,  are 
comparatively  of  little  importance  in  auHcultation.  NerertheleM, 
they  undoubtedly  possets  a  certain  value  «»  physical  signs  of  di»- 
eaite,  taken  in  connection  with  those  pertaining  to  the  respiration 
and  the  voice.  If  the  stethoscope  be  placed  over  tho  trachea,  the 
act  of  coughing  occasions  a  forcible  shock,  and  a  strong  blowing 
sound.  The  same  results,  but  less  in  degree,  nay  be  observed  at 
the  parts  of  the  chest  where  the  bronchial  Kspiration  and  voice  are 
sought  for  in  health.  These  phenomena  manifested  elsewhere  over 
the  chest,  constitute  morbid  signs.  Over  the  chest  generally,  in 
health,  the  sense  of  impulse  or  shock  is  slight,  or  altogether  absent, 
but  a  feeble,  short,  diffused  sound  is  nionc  hcftrd.  The  atudy  of  tbe 
tussive  phenomens  in  different  persons,  and  in  different  portions  of 
the  chest,  did  not  enter  into  the  exnniinalioiis,  the  results  of  the 
analysis  of  which  have  been  presented  in  the  foregoing  pagea. 


II.   AOSCniTATION   IN  DiSEAaR. 


fl 


Having  studied  the  phenomena  whioh  auscultation  of  tbe  healthy 
chest  discloses,  wc  are  prepurrd  to  investigate  those  incident  to  di>- 
easo.  In  prosecuting  the  Utter  investigation,  the  general  objects 
areas  follows:  1.  To  determine  what  are  morbid  sounds  and  in  what 
particulars  they  differ  from  those  incident  to  health'.  2.  To  ascer- 
taiD  the  connection  between  individual  morbid  sounds  and  the  phys- 
ical  conditions  of  which,  in  consequence  of  this  conneotJon,  they 


AD8CCLTATI0K    tR    DI8BABB. 

th«  eigns.  3.  To  explain,  as  fnr  as  practicable,  the  manner  in 
''whieh  morbid  pby^ical  conditiooB  give  rise  to  the  phenomenn  em- 
.braccd  under  the  head  of  Auscultation  in  Disease.  Of  these  throe 
objects  I  shall  conuider  at  length,  in  the  remainder  of  this  chapter, 
the  first  and  second,  devoting  to  the  third  relatiTely  but  little  atten> 
tioD.  As  already  remarked,  knawledge  of  physical  signs,  as  re- 
gards their  significance  and  value  in  diagnosis,  is  not  dependent  on 
onr  ability  always  to  furnish  a  complete  exposition  of  the  raochan- 
ista  of  their  production.  Persons  may  difier  in  opinion  as  to  the 
rationale  of  certain  signs,  and  yet  be  entirely  agreed  respecting 
their  spedal  meaning  and  importance,  the  latter  being  based  on  the 
uaifonn  relation  found  by  observation  to  exist  between  tlic  signit 
present  daring  life,  and  the  pathological  changes  ascertiiitiitl  after 
death.  It  is  certainly  very  desirable  to  explain  satisfaolorily  that 
•onnection  sob-iiating  botweon  physical  nigna  and  physical  condi- 
tiODS,  bj  virtue  of  which  the  former  represent  the  hitter;  hut  with 
[our  present  knowledge,  this  branch  of  the  Kuhject  of  phyitical  ex* 
>loration  contains  many  points  not  fully  settled.  In  a  work  in- 
nded  to  be  practical,  it  would  be  out  of  place  to  di.<cuiis  opinions 
ind  theories  relating  to  questions  which  arc  us  yet  open  for  specu- 
[lation;  and  I  shall  therefore  content  myself  with  giving,  as  con- 
ci&ely  as  possible,  different  views,  without  attempting  a  full  consider- 
KtioD  of  their  respective  merits. 

In  treating  of  auscultation  in  disease,  as  in  health,  the  phenomena 
incident  to  respiration,  the  voice,  and  the  act  of  coughing,  are  to  be 
OODsidered  under  separate  heads. 


FHRNOHBKA   INCIDBNT  TO   ItBSPIRATION. 

The  morbid  phenomena  incident  to  respiration  admit  of  a  natural 
Idivision,  which  it  is  convenit^nt  to  observe,  into.  First,  the  normal 
.KBpiratory  sounds  more  or  less,  and  variously,  modified;  Second,  new 
or  adventitious  sounds,  t.  «.,  sounds  having  no  existence  in  the  healthy 
chest.  Of  the  phenomena  embraco'l  in  the  first  of  these  two  classes, 
several  are  repreacnled  by  types  existing  in  health;  and  with  these 
the  student  who  has  studied  faithfully  the  normal  respiratory  sounds 
is  already  familiar.  They  are  to  be  found  in  different  parts  of  the 
respiratory  apparatus  when  entirely  free  from  disease,  and  they  be- 
come signs  of  abnormal  conditions  by  a  change  of  situation.  The 
phenomena  embraced    in    the  second  class'  have  no  oounterpartn 


156 


PHTBIOAL 


:PLORATIOn    OP   TBB    OBBST. 


amoBg  the  sounds  iDcid«nt  to  Dormal  respiration,  knd  pertdn  ex- 
clasively  to  the  changea  produced  bj  disease.  We  will  consider 
tbe&e  two  divisions  separately. 

I.  MODiFiKD  ItesMBATORY  SoDNDd. — ^Limitiog  the  stteaticau 
the  vesicular  murmur,  exclusive  of  the  traeheal  and  lazyngfal  ret- 
piration,  the  changes  which  it  undergoes  in  oonneclion  with  diiliereal 
forms  of  disease,  are  resolvable  into  various  kiiid^  of  aberralioa. 
Its  inlemtity  may  be  increased,  or  diminished,  or  it  may  b«  sop- 
pressed.  Its  quality  may  be  altered,  the  vesicular  character  givui| 
place,  partially  or  completely,  to  tubularity  of  sound.  The  pitd 
may  be  raised  or  lowered.  The  inspiratory  and  expiratory  sounds 
may  be  modified  .leparalely,  or  oonjoinlly.  The  inspiratory  soiud 
may  he  shortened  in  duration,  and  the  expiratory  prolonged.  Their 
rhythmical  succession  may  be  dlHturbod.  It  is,  however,  iinnece^ 
sary  to  treat  of  nil  theee  varied  modifications  separately.  They  do 
not,  M  n  general  remark,  occur  in  connection  with  di«caM  singtj, 
but  several  are  usually  presented  in  combination.  A  ja^aou 
ola^i  Real  ion  of  the  different  modifications,  comprising  more  otImi 
of  the  foregoing  aberrations,  is  important;  and  for  all  practical  pB^ 
poses  the  following  arrangement  suffice!!.' 

1.  Modifications  of  the  intensity  of  the  vesicular  murmor,  con- 
sisting of,  a,  increased  intensity ;  f>,  diminished  intensity ;  e,  sof- 
pression  of  respiration. 

2.  Modi6cations  of  the  quality  of  the  respiratory  eounds,  ano(i> 
ated  with  alterations  in  pitch,  duration,  end  rhythm.  This  division 
will  consist  of,  <t,  bronchial  respiration;  fi,  broncho-vesicular,  ooii- 
monly  called  rude  respiration;  c,  cavernous  respiration. 

3.  ModiRcalions  of  rhythm,  consisting  of,  a,  shortened  inspiration; 
i,  prolonged  expiration;  c,  interrupted  inspiration  or  expiration. 

I  shall  consider  all  those  physictl  signs,  derived  by  auscultation, 
which  are  modified  respiratory  sounds,  as  embraced  under  the  fore- 
going divisions  and  subdivisions;  and  I  shall  proceed  to  describe 
them  under  distinct  heads  in  conformity  with  this  arrangement. 

1.  Increased  Intentiti/  of  ike  Veticufar  Murmur— Ezaggarattd 
Rtipiration, — The  vesicular  murmur  is  simply  increased  in  intensity, 
or  exaggerated,  whenever  its  loudness  is  augmented,  the  normal 

<  Thii  diviainn  aocoidii  with  ihn  BrrnngcmRDt  hy  Barth  and  Soger.  T1i«  tu^ 
dirisionii  diffbr  fruui  tbuau  wliicb  llit'y  adujit. 


etcn,  in  other  respects,  mnxiDing  unchanged.  The  sound 
fifty  be  more  intense  than  natural,  with,  at  the  uamo  time,  alteration 
in  quftlitj,  pilch,  and  rhythm.  The  modifications  will  then  fall  under 
other  dirtsions.  Merely  exaggerated  rct^pinttion  preserveti  the  uormal 
cbarsctera  as  regards  vesicular  quality,  pitch,  and  rhythm. 

Il  has  been  seen  that  the  intensity  of  the  normal  vesicular  murmur 
differs  greatly  in  different  persons.  How  then  are  we  to  decide 
whether  «  certain  loudness  he  normal  or  abnormal  ?  If  thi»  loudness 
be  found  orer  the  whole  chest,  the  presumption  is  that  it  is  natural 
to  th«  individual,  and  it  ia  not  to  be  regarded  as  a  sign  of  disease. 
But  if,  on  the  other  hand,  it  exist  on  one  side  of  the  cheat  only,  it 

fay  be  presumed  to  be  a  result  of  disease. 
An  exaggerated  veaicular  murmur  does  not  proceed  from  diseased 
long,  but  from  healthy  lung  situated  cither  near  or  remote  from  the 
seat  of  disease.  Whenever  the  lung  on  one  side,  or  a  considerable 
portion  of  it,  is  rendered  by  disease  incompetent  to  fulfil  its  part  in 
the  respiratory  function,  the  lung  on  the  other  side  takes  on  an  in- 
creased action  to  supply  its  place.  Hence  an  increased  intensity  of 
the  respiratory  murmur,  corresponding  in  degree  to  this  augmented 
activity,  the  increase  of  intensity  being  most  marked  at  the  superior 
and  anterior  portion  of  the  cho»t.  The  exaggerated  respiration 
ondcr  these  circumstances  is  vicarioui^,  or  supplementary,  nnd  it  has 
l>Mn  called  by  some  writers  gapplfmentaiy  respiration,  Laennec 
»pplie<l  to  it  the  name  purrih  rmpiration,  from  its  resemblance  to 
the  naturally  loud  respiration  of  early  life.  JIffper-veticutar  respira- 
tion is  another  appellation. 

Any  di8<-a»e  which  compromises  to  much  extent  the  respiratory 
function  of  one  lung  occasions  an  increased  functional  activity  of 
tbe  other.  The  physical  sign  of  this  increased  activity,  viz.,  an 
increaaed  inten.iity  of  the  vesicular  murmur,  thus,  is  indirect  evi> 
dence  of  the  existence  of  disease  in  the  opposite  side,  but  it  does 
not  slTord  any  information  as  to  the  particular  form  of  disease  which 
exists.  The  pulmonary  affections  with  which  it  h  oftene^t  associated, 
and  in  the  most  marked  degree,  are  piicumonitii*  and  picuritis.  In 
the  former  of  these  affections,  occurring  in  the  adult,  generally  an 
entire  lobe  and  sometimes  an  entire  lung  is  rendered,  for  a  time, 
nearly  or  quite  incompetent  to  take  part  in  htcmatosis,  in  conse- 
quence of  the  oclU  being  Riled  with  inQammalory  exudation :  in 
^e  latter  affection,  the  lung  on  one  side  is  more  or  Ices  reduced  in 
rolume  by  tlie  compression  of  effused  fluid  within  the  pleural  sac. 


1&8 


PHTSIOAL    BXPLOHATIDS     OP    THE     CHBST. 


Obatrnction  to  tlic  entrance  of  air  into  one  long  from  the  presence 
of  a  foreign  bo<l^,  pressure  of  an  enlurgeil  kronchisl  gland,  ete^ 
will  al&o  give  rlae  in  tbe  other  lung  to  exnggerated  respirsttoa. 
Considerable  d<'iio»it  of  tubercle  on  one  side  uiav  produce  tt;  ud 
aliu>  ^olidirication  from  extravasated  blood,  (larcinomx,  etc 

It  i^  8tated  \>y  Fournct'  ibat  cxnggernted  respiration  eosiMS  is 
lieallli^p  lung  »itnated  in  the  immediate  vieinity  of  •  local  affectioe 
vhich  compromises  or  uboliitlK'S  the  function  within  «  limited  fpaee. 
For  example,  around  n  niiws  of  tubercle  he  tliinks  the  vesieaUr 
■lannur  is  unduly  intense,  ui<],  indeed,  ho  auerts  that  an  abnor- 
nally  increMcd  vesicular  murmur  in  the  snrroanding  hpalthj  por- 
tjon  of  lung  is  greater  in  proportion  to  its  prozimitj  M)  tho  point 
of  locul  diecdsc.  Whether  this  statement  be  correct  or  otherwise, 
i»  not  easily  dclormined,  nor  is  it  of  importance  with  rcfercnot^^H 
diagDOsis;  for,  nssuiuing  that  the  vesicular  murmur  docs  bcoiMV 
more  intense  in  the  healthy  lung  surrounding  a  diseased  portion,  for 
example  in  tuherculuus  disease,  the  respiratory  sound  is  at  the  same 
timu  more  or  less  modified  by  the  diseased  portion  in  other  respects, 
presenting  the  character  of  a  bronchial  or  broncho-vesicotar  roq>ir»- 
tion.  In  canes  of  solidification  of  an  entire  lobe  from  pneumonitis, 
according  to  Fournet,  tbe  veaicalar  murmur  proceeding  from  the 
other  lobe  or  lobea  of  the  aifectcd  Hide  iei  exaggerated,  and  in  a  more 
marked  degree  llian  that  proceeding  from  the  healthy  side.  I  sbodd 
express  a  different  opinion.  »pcitking  from  the  impressions  dicrived 
from  my  own  experience.  I  am  certain  that  in  some  cases,  at  leu^ 
the  vesicular  murmur  over  the  healthy  lobe  or  lobea  of  the  affected 
side,  is  notably  less  intense  than  on  tbe  opposite  side,  and  even  below 
the  normal  intensity. 

When  tho  vesicular  murmur  is  abnormally  exaggerated,  the  dura- 
tion of  tho  inspiratory  sound,  as  a  rule,  is  somewhat  increased. 
This  is  because  the  murmur  is  heard  during  the  entire  act  of  in- 
apiralion,  whereas,  if  the  intenHity  be  not  increased,  the  sound  is  too 
fe<-hle  to  be  beard  at  the  beginning  of  tbe  act  when  tbe  intcn«ty  ti 
the  leust.  The  expiratory  sound  is  also  much  oftcncr  heard,  and  b 
cumparit lively  longer  in  duration.  This  Ih  due  to  the  fact  that  the 
exaggeration  alfccting  equally  the  sounds  of  inspiration  and  expira- 
tion, the  latter  becomes  appreciable  when,  with  ordinary  normal 
breathing,  it  is  too  feeble  to  be  heard;  and  for  the  same  reason  it 


R«ivbcruh«4  CllniquM,  otc. 


ADSCnLTATIOH    IV    DISBASR. 


169 


$ 


I 


k 


aaqnires  i  longer  Hnralion.  In  pitch,  rbylhm,  and  quality,  the  exfi- 
ntory  sustains  the  same  relation  to  the  inspiratory  eound,  as  nhen 
the  two  are  not  exaggerated.  Thin  is  a  fact  important  to  be  borne 
in  mind  if  wo  would  not  be  led  astray  by  the  greater  loiidncRS  and 
longer  duration  of  the  expiratory  sound,  the  latter  being  a  promi* 
nent  feature,  aa  will  ht>  seen  hereafter,  of  the  bronchial  rctpiralion. 
In  simple  exaggerated  respiration  the  expiratory  sound  i»  lower  \a 
ibsn  the  inspiratory,  and  Jt  ia  continuous  with  the  xounil  of 
■ilea,  those  being   the  cliaractvrs  belonging  to  the  vcaicuhir 

urmur  when  its  intensity  is  not  incrcnsod.  In  each  of  these  pointo 
it  diSers  from  the  bronchial  respiration.  With  due  attention  to 
these  poiiitji  of  difference,  the  two  need  never  be  confounded,  an 
error  which  Barth  and  Roger  state  is  liable  to  be  committed,  and 
examples  of  which  have  fallen  undtir  my  observation. 

Alt  abnormal  intensity  of  the  vesicular  murmur  is  attributable, 
as  has  been  stated,  to  an  incrrnscd  activity  of  respiration,  by  way 
of  compensation  for  suspended  function  in  a  portion  of  the  pul- 
monnry  organs.  This  increased  activity  can  only  proceed  from 
an  expansion  of  the  chesl  beyond  the  limits  of  ordinary  normal 
breathing,  and  with  greater  force  than  is  employed  in  health,  in  con- 
sequence of  which  a  larger  quantity  of  air  is  drawn  into  the  bronchia) 
tub«s,  giving  rise  to  a  more  powerful  expansion  of  the  lung;  and 
under  these  circumstances,  a  larger  number  of  cells  are  dilated  than 
in  ordinary  breathing.  Hence  the  exaggeration  of  the  respiratory 
sonnd,  the  intensity  of  which  depends  on  the  conditions  just  men- 
tioned. And  the  fact  that  in  plcurltis,  pneumonitis,  and  tubcrculons, 
the  movements  of  the  affected  side  are  more  or  less  Restrained,  while 
tboce  of  the  opposite  eide  are  increased,  would  lead  us  to  anticipate 
what  (in  opposition  to  the  opinion  of  Fournet)  I  believe  clinical 
observation  shows  to  be  true,  nz.,  that  in  these  affections  the  exag- 
gerated  respiration  is  limited  to  the  opposite  aide  of  the  chest. 

As  a  physical  sign  of  disease,  exaggerated  respiration  does  not 
poACM  great  importance.  Isolated  from  other  signs,  it  would  be 
insignificant  in  diagnosis.  Taken  in  connection  with  other  signs,  it 
ia  deserving  of  attention. 

2.  IHmirmked  Intenaity  of  the  Vetitfular  Murmur — Feebie  or 
Weak  Rftpiratmi. — The  effect  of  disease  is  much  oftcner  to  dimin- 
ish than  to  increase  the  intensity  of  the  vesicular  murmur.  Feeble 
or  weak  respiration  is  an  abnormal  modification  of  frequent  occur- 


160 


PHTSIOAL    KXPLOnATION    OV   TB B    CBBST. 


renoe,  and  it  in  a  phjajcal  tign  iaciilent  to  oumeroits  sod  nnd 
morbid  conditions. 

This  species  of  modification,  like  that  just  considered,  eonnsttif  a 
grciLter  or  U-.ss  diminution  in  loudness  of  the  respiratory  soond,  Ife 
distinctive  ctinrnct<TS  of  the  vcsiculur  murmur,  pertaining  to  quslilj, 
pitcl),  and  rhythm,  remaining  unaffected.  A  respiratory  aound  vuj 
be  leSMoed  a«  well  as  increased  in  inlensitir,  vith  at  the  same  tinK 
alteration  in  quality,  pitch,  and  rhytlim,  in  which  case  the  «bem> 
tion  would  not  fall  under  the  present  head,  but  under  tho«e  bcloo;- 
ing  to  other  divisions  of  abnormal  sounds.  In  duration,  tbc  inspln- 
torj  sound  is  frctiuently  shortciied  when  it«  intenMly  is  abDonoallj 
diminished,  the  explanation  being  precisely  the  convcn>D  of  tliat  rf 
the  longer  duration  when  the  murmur  \»  exaggerated.  An  eipirator; 
sound  may  or  may  not  be  beard.  In  one  form  of  disease  diaracter- 
izei]  by  feeble  respiration,  it  is  frequently  present  and  prolou^td, 
the  diminutioo  of  intensity  being  less  marked  than  in  the  inspira- 
tory sound.  Excrpt  in  this  affection  (emphysema),  an  expiratory 
sound  is  rarely  heard,  nod  is  not  prolonged,  provided  the  modifica- 
tion consists  in  n  simple  weakness  of  the  murmur,  exclostve  of  any 
other  change, 

The  variotia  morbid  conditions  which  may  induce  abnormal  feeble- 
ness of  the  vesicular  murmur  produce  this  reenlt  by  four  different 
modes,  singly  or  combined,  vis.:  1.  By  obstructing  the  passage  of 
air  in  some  portion  of  the  air-tubes ;  2.  By  obstructing  or  over-dis- 
tending  the  air-veslcles ;  8.  By  removing  the  longs  from  the  thoraeii) 
walls ;  4.  By  restraining  the  movements  of  the  chest.  Under  these 
several  heads,  I  will  proceed  to  mention  the  more  important  of  the 
affections  in  which  simple  diminution  in  intensity  of  the  resicular 
murmur  may  be  expected  to  occur,  premising  that  alone,  this  sign, 
a*(  well  an  exaggerated  respiration,  fails  to  fumbh  information  r» 
epccting  the  nature  of  the  affection  of  which  it  is  an  effect.  To 
determine  the  latter  point,  it  must  be  taken  in  connection  with  other 
signs  and  with  symptoms.  In  this  respect,  however,  it  differs  from 
exaggerated  respiration,  vis.,  it  often  indicates  directly  the  seat  of 
disease;  in  other  words,  the  diminished  intensity  of  the  mtinnitr 
corresponds  in  its  situation  to  the  locality  of  the  affection  upon 
which  it  depends. 

a.  An  obstruction  in  any  portion  of  the  air<tubes  lessens  the  loud* 
ness  of  the  vesicular  murmur  by  rt-ducing  the  quantity  of  air  which 
expands  the  cells.    Laryngeal  affections,  for  example,  croup,  oedema, 


AUSCULTATION    IX    niSBASB. 


161 


or  ihe  glottis,  vegeUlion^  wliicb  contract  tlic  otlibrc  of  the 
canal  in  ibis  situation,  produce  tlii«  <'flV-<:t.     Tliexe  ciiukcs  dimlDiEh 
the  oiurmur  c<|ually  on  both  sides  of  the  chvM.     An  obatriiclioR, 
l»Oire»ei,  msj  be  seated  in  one  of  Ilic  prinmry  bronchi,  utiii  then  the 
effect  u)>on  tlic  rcApiratory  murmurs  will  lie  liiiiiu^il  to  the  correspond- 
ing side.     This  obtniiin  when  a  foreign  body  iit  lodgvd  in  one  of  the 
Ibroncliial  divisions,  vbich  occurs  oftener  on  the  right  side.     A  for- 
eign body  within  the  iiir-pa^nges  sometimes  change*  its  place,  being 
at  times  thrown  iipwitnl  into  the  tmchea,  and  uecasioiislly  trunif- 
ferred,  allVrnately,  from  one  bronchns  to  the  other.     The  nhnormul 
feeblent-K.s  of  the  vesiculnr  murmur,  under  thcttc  circnmstauccis  nil) 
»b«  presrnt  now  on  one  side,  and  now  on  the  other  side  of  tlic  chest. 
This  alTords  evidence  that  the  physiciil  sign  is  due  to  a  movable 
body,  and  hence  it  i»  a  point  of  importance  in  the  diagnosis.     The 
Bilnation  of  the  «ign  on  one  »idc,  also,  when  the  presence  of  a  foreign 
body  in  the  air-puKinges  is  ascertained,  points  to  its  situation  in  one 
Kof  the  bronohi,  and  iodicatejt  the  particular  bronchus  (the  right  or 
9  left)  in  which  it  is  situated.     The  bronchial  lubes,  within  the  pul- 
f  nionary  organs,  are  liuble  to  be  oburucted  by  the  swelling  of  thoir 
lining  mciiibninc,  incident  to  inflKniiualion,  and  from  the  presence  of 
the  inQammatory  product-i,  mucus,  pns,  and  congulable  lymph.    The 
respiratory  murmur  may  he  diminished,  in  consequence,  on  one  or 
Bboth  aidee.     Insemucb  as  in  primary  bronchitis  the  bronchial  tubes 
on  both  side*  are  equally  affected  (this  being  one  of  the  symmetri- 
cal diseases),  when  the  obstruction  depends  on  swelling  of  the  mem- 
■  braoe,  the  effect  on  the  murmar  is  equal  on  the  two  sides.     Hence, 
abnormai  feebleness  of  respiration  on  the  two  sides  of  the  chest  is 
one  of  the  physical  signs   incident  to  bronchitis.     On  the  other 
B  hand,  vhen  the  obairuction  depends  on  an  accumulation  of  the  pro- 
ducts of  inflammation,  it  may  be  limited  to  one  side,  or  he  greater 
on  one  side  than  on  the  other,  with  a  corresponding  effect  on  the  re- 
H  epiralory  murmur.   Spasm  of  the  bronchial  muscular  fibres  U  another 
B  morbid  condition  dimini-^hing  temporarily  the  calibre  of  the  bronchial 
B  tubes.     Permanent  contraction  of  the  tubes,  or  stricture,  may  exist 
^  a«  a  structural  leeion.     An  enlarged  lymphatic  glsnd,  or  other  tu- 
mor, way  pre.is  upon  one  of  the  bronchi  exterior  to  the  lungs,  or  on 
one  of  their  subdivisions,  and  occasion  a  feeble  vesicular  murmnr 
.  cither  over  the  whole,  or  a  part  of  one  aide.     The  clinical  discrimi- 
nation between  thcHe  various  causes  is  to  be  made,  if  practicable,  by 

11 


162 


PBTSIOAL    BXPLOEATIOK    07   TBB    CBBST. 


neanfi  of  Uie  8jinp(Ani.t  nti<I  circumstanccn  aBaoeiat«d  in  iodindiul 
OKWs.     It  iH  not  ntwiiya  easy,  nml  somriiintjs  impracticable. 

A.  The  cause  of  nn  iibiioriDiilIjr  fwWc  mommr,  when  seat«j  io 
tlic  vcsicleM,  niiiy  cnimi^t  in  h  mnrttiil  ilt^jMKtit  blocking  ihem  np  to  a 
grcntor  or  less  v^itcril,  nii<I  excluillng  tin*  air.  Thus,  in  tuberculoeb; 
pncumonititt,  extravasntton  of  kliKxl,  a»lema,  tie.,  the  pb^ncal  >iga 
ioci'lcnl  to  rc(<pinition  may  lie  simple  foclilcndss  of  the  T^^nlar 
EQunDur.  ('rctn-rally,  liowcvcr,  Ju  tlicse  alTociions,  either  the  reepirv 
tory  sound  \»  8upprc«seit,  or,  vith  or  williout  feebleness,  it  is  Don 
or  \ef*  chnngei)  in  qniiHly.  pitch,  nml  rbytltm.  Ofer^d  is  tension  ind 
enlargement  of  tlit-  vtrtticleit  ctiitAtitutc,  virtually,  an  obstruction,  tkc 
oclU  rvinairiihg  filled  with  air,  the  renewal  with  the  sacces^re  respi- 
ratory acts  taking  place  iinpcrfcctly,  and  hence  ibe  pbyeica)  coodi- 
tione  for  the  production  of  the  ve^icubr  mumiur  urc  impaired.  At 
abnormully  feeble  vesicular  inurtiiur,  therefore,  characteriuea  tlie 
nflecticn  called  emphysema,.  In  this  nflcclion  the  expiratorj  aoand 
is  frequently  proloiiged,  in  consequence  of  the  slowness  with  whirii 
the  lungs  collapse,  nnd  of  the  obstruction  to  the  p«*Aag«  of  air  in 
the  bronchial  tubes  which  often  coexists,  arising  from  bronchitis  and 
spasm.  Prolonged  expiration  will  be  consi')rrc<l  .under  n  (li«tinct 
head.  I  may  rcranrk  here  that,  occurring  under  the  circnmstanen 
just  mentioned,  it  is  to  bo  distinguished  from  its  occurrence  under 
circunis'tiinceM  in  which  its  pathological  signlficnnce  is  quite  different, 
by  the  Attcndiint  circumstances,  and  by  its  preserving  the  nomil 
relation,  an  rc»pect»>  pitch,  to  the  inspiratory  sound. 

nie  physical  signs  derived  by  percussion  in  the  two  forms  of  ob- 
struction within  the  vesicles  just  noticed,  vis.,  from  morbid  deposit 
»nd  over-inflation,  are  directly  opposite  in  character.  In  the  former 
inst&nce,  whether  the  deposit  be  tubercle,  coagulable  lymph,  etc.,  the 
percussion-sound  is  more  or  leas  dull.  In  the  latter,  the  resonance 
is  usually  ahnormully  intense,  TL-siculo-tyuipnnilio  in  quality  and 
higher  in  pilch  tliiin  the  normal  vesicular  resonnncc.  This  suffice* 
for  the  discrimination  between  these  two  kiudd  of  ^'ccicular  obstnio- 
tion. 

c.  If  the  lungs  arc  removed  at  n  certain  distiinec  from  the  thoracic 
walls,  the  intensity  of  the  murmur  is  diuiinishcd.  Under  thcsv  eir^ 
cnmstnnces,  the  sound  conveys  to  the  mind  the  idea  of  distance;  it 
doefl  not  seem  to  be  produced  in  cloee  proximity  to  the  ear,  but  tv 
come  from  a  source  somewhat  remote.  The  appreciation  of  distance, 
which  undoubtedly  belongs  to  the  perception  of  impressions  received 


ACSCO^TATIOtr    IK    DTSBABE. 


168 


I 


I 


I 


I 


iroogh  the  senw  of  heariog,  in  other  instanced  than  this,  wit)  be 
Toond  to  farniith  «  charar^ter  of  physical  signa.  The  1ang>>  must  not 
be  removfid  beyond  a  certain  limir,  else  the  respiratory  murmur  will 
fail  to  b«  transmitted.  The  feeble  respiration  produced  in  lliifl  vAy 
occurs  wben  there  cxiHiM  a  small  nr  moderate  quantity  of  U<]iiid 
effusion,  of  air,  or  gas.  within  the  pleural  sac.  and  when  the  pleural 
snrfaeM  are  covered  with  a  thick  layer  of  coagulable  lymph.  When 
it  is  due  to  the  presence  of  liquid,  the  feebleness  is  at  the  lower  part 
of  the  cheiti,  provided  the  poMiiun  of  the  patient  he  upright,  und 
il8  «ituntion  niny  be  found  to  vary  with  the  different  positional  which 
the  pxlirnt  n^sumcs.' 

d.  The  intensity  of  the  vesicular  murmur,  other  things  being  equal, 
depends  on  the  extent  and  force  of  the  respiratory  movements.  Any 
morbid  condition,  therefore,  which  limits  these  movements  renders 
the  respiratory  sound  abnormally  feeble.  For  example,  in  a  case  of 
incomplete  general  paralysis,  which  recently  came  nnder  my  obser- 
vation, the  respiratory  muscles  wore  in  a  measure  involved.  The 
respiratory  movements  were  wnntinf;  in  sireiigtb.  and  the  vesicular 
marmnrwascorrc^^pondingly  fcrbU-  on  both  wide-».  In  some  caiicB  of 
hemiplegia,  this  effect  obtains  on  the  paralyzed  indf:.  In  plcuritis, 
before  effuaion  has  taken  place,  and  in  intercostal  neuralgia,  the 
pain  occasioned  by  the  expansion  of  the  chest  on  the  affected  aidft 
leads  the  patient  instinctively  to  restrain  the  movements  on  tliat 
side.  Hence,  abnormal  feebleness  of  the  vesicular  marmor  belongs 
equally  to  both  these  affections,  irrespective  of  the  cause  already 
mentioned  as  incident  to  pleurilis  at  a  later  period.  The  move- 
ments of  the  cheat  on  one  side  may  be  restrained  mechanically,  in 
consequence  of  pennancnt  contraction  aa  the  sequel  of  chronic 
ptenritis,  of  morbid  pleuritic  adhesions,  of  injury  to  the  thoracic 
walls,  and  deformity  from  any  cause. 

Whenever  by  any  of  the  modt-x  ju*t  named  the  vesicTitar  murmur  ta 
rendered  abnormally  feeble  on  one  side  of  the  chest,  the  respiratory 
sound  on  tbe  other  side  is  likely  to  become  exaggerated,  and  the  em- 
trast  between  the  two  sides  is  thereby  enhanced. 

It  is  needless  to  state  that  in  order  to  judge  of  abnormal  feeble- 
nesa  of  the  resiculnr  murmur,  us  of  most  of  the  physical  eigna,  there 
IB  no  ideal  standard  to  which  reference  is  to  be  made,  btit  it  is  d«- 


)  Tbst  a  thin  Rtratum  o{  liquid  mB>-  bo  e(|Ually  diffiuod  ovor  tlic  lung,  u  con- 
leuled  bj  WnllloK,  may  Inlrlv  tw  doubted. 


lU 


PBTSICAL  EXPLORATIOB  OF  TOE  CHEST. 


l^TiniiiiNl  bv  «  coinpiiriiwn  of  corresponding  regions  of  two  side*  of 
till?  chrvt.  In  driiwing  infcrvncce  from  the  results  of  this  comparisoD, 
it  is  sometimes  bighly  important  to  bear  in  mind  the  fact,  that  ■ 
indindunls  in  good  health  and  with  cheats  well  formed,  a  naivtil 
disparity  exists  as  regards  the  intensity  of  the  vesicular  mnnnot. 
Thi»  fnct  h&s  appeared  in  the  portion  of  this  chapter  devoied  (e 
nuMuItatiou  in  beiilth.  A  natural  disparit;  may  mislead  the  ant- 
Ciiltator,  the  greater  relative  feebleness  on  the  one  hand,  or  on  the 
Other  hand,  a  norma]  exaggeration,  being  attributed  incorrectly 
to  disease  existing  on  one  or  the  other  side.  This  Uabili^  lo 
error  is  not  to  be  lost  sight  of.  especially  in  the  diagnosis  of  taber- 
colous  disease,  a  disease  in  which  slight  deviations  from  ec]ualitT  of 
the  two  sides  at  the  summit  of  the  chest,  provided  they  are  abDormtt, 
are  justly  I'egarded  as  highly  significant.  The  results  of  examina- 
tions of  the  healthy  chest  not  only  enforce  the  caution  jofltgireiL, 
but  lead  lo  another  very  important  conoideralion.  In  much  the 
larger  proportion  of  inHtnnce.i  of  rel»tive  feebleness  of  the  vesicular 
murmur  on  one  sidi^  compatible  with  hoallh,  it  ia  observed  OD  the 
right  side.  It  follows  from  this  fact  that  comparative  feeblciien  n 
the  right  sidt?  is  much  lo^s  likely  to  be  the  result  of  disease  thaa 
when  it  iii  found  to  exist  on  the  left  side.  A  relatively  feeble  murmur 
on  the  left  side  in  the  great  majority  of  instances  denotes  disease; 
but  exii^tlng  on  the  right  side,  if  the  relative  feebleness  be  slight,  it 
may  be  due  to  a  natural  disparity. 

Diminished  intensity  of  the  vesicular  murmur,  when  it  is  evidently 
attributable  to  a  morbid  condition,  as  already  remarked,  alone,  gives 
little  or  no  information  respecting  the  particular  condition  upon 
which  it  depends.  Isolated  from  other  aigns,  therefore,  and  froin 
Bymptoma,  its  diagnostic  value  would  be  small,  but,  asaocialed  with 
the  information  derived  from  other  souroes,  it  becomes  a  valuable 
sign. 

3.  SupprfMed  rit»j)traiwn. — The  respirntion  is  said  to  be  snp- 
prc«sed  when  no  miiriuur  is  Hppreciiiblc  by  au^otiltatiou ;  the  rei^> 
nilory  acts  lake  place  without  giving  rise  to  any  audible  sound. 
Tlii«  effect  may  be  produced  by  each  of  the  four  modes  wluch 
have  liccn  itoen  to  occasion  abnormal  feebleness  of  the  respira* 
tory  murmur :  their  operation  being  pushed  to  a  certuio  extent) 
the  sound  is  abolished.  Suppression  is  therefore  liable  to  ocour  in 
oonneetion  with  any  of  the  various  morbid  conditions  which  indnce 
feebleness  of  respiration.     This  being  the  case,  it  is  only  necessary 


J 


rATlOK    IK    DISBASB. 


1C5 


If. 
I 


I 


:nder  tliia  head  to  r«pe«t  sd  cnnmeration  of  tfie  affections  vliich 
were  mentioned  in  connection  with  the  sigB  last  conHidered, 

Obstruction  of  the  larynx  from  inflammatory  exudation,  rodema, 
egetationa,  spasm,  or  the  presence  of  a  foreigo  body,  may  extin- 
guish atl  Honnd  over  the  entire  cheet.  A  foreign  substance  lodged 
in  one  of  the  bronchi  may  produce  this  effect  on  the  corresponding 
side,  giring  rise  to  exaggerated  respiration  on  the  other  side.  Ab- 
seDC«  of  all  sound  obtains  in  some  cases  of  bronchitis,  from  the 
■welling  of  the  membrane.  Its  temporary  absence  over  a  portion 
of  the  chest,  owing  to  an  accutnulalion  of  mucus  in  some  of  the 
bronchial  lubes,  is  occasionally  ohservcil  in  that  afTnction ;  and  under 
these  circumstances  it  is  sometimes  abruptly  ri^stored  in  coDM-qui'nce 
of  the  removal  of  the  obstruction  by  an  act  of  cou^hinj;;.  Pressure 
of  sD  enlarged  bronchial  gland,  or  tumor  of  any  kind,  on  a  bronchial 
ttibe,  may  he  sufficient  for  complete  absence  of  sound. 

In  some  cases  of  pneumonitis,  tuberculosis,  pulmonary  apoplexy, 
pnlmonary  oedema,  etc.,  the  respiration  is  suppressed.  The  vcxic- 
alar  mnrmur  is  generally  abolished  in  connection  with  these  affec- 
tions over  the  solidified  portion  of  the  lung,  but,  as  will  be  eucn 
presently,  the  murmur  frequently  is  replaced  by  a  respiratory  sound' 
modiRt-d  in  quality,  etc.,  viz.,  the  hroucliial  or  the  hronchif- vehicular 
re)>piraiiun.  In  some  case*  of  emphyi*euia  no  rccpiralory  oound  is 
appreciable.  In  thi)>  afTcelion  the  in>»piratory  sound  may  be  sup- 
prew*<i,  and  the  expiratory,  more  or  less  prolonged,  remain.  The 
expiratory  sound  is  ulsu  alone  upprocinble  under  other  circumstances, 
which  will  be  noticed  under  other  heads. 

Again,  when  the  lungs  are  removed  beyond  u  very  limited  space 
from  the  thoracic  walls,  either  by  the  presence  of  liquid  effusion  in 
pleurisy  and  hydrothorax,  of  air  or  gas  in  pneumothorax,  or  of  both 
conjoined  in  pneumo-hydrotborax,  the  murmur  of  respiration  ia 
generally  extinct. 

Finally,  from  contraction,  deformity,  injury,  or  paralysis,  the 
movements  of  the  chest  may  be  insufficient  to  produce  a  respira- 
tory sound. 

Suppressed  respiration  is  a  barren  sign  as  regards  special  signiG* 
c«nc«,  disassociated  from  other  physical,  and  from  vital  phenomena. 
Thus,  when  absence  of  sound  exists  on  one  side  of  the  chest,  it  may 
be  incident  to  pneumonitis,  emphysema,  pleurisy,  or  pneumothorax. 
Of  coarse  no  inference  can  be  drawn  from  the  isolated  fact  of  the' 
absence  of  respiratory  sound,  as  to  which  of  these  several  affections 


166  PBTSICAIt    BXPLORATIOK    OF    THB    CQGST. 

is  preaent.  Bat  assoaated  with  tho  i-vidcncc  Bflonlod  by  percoiuM, 
and  other  methuds  of  phjsieal  vxplomtioii,  in  coimcclion  wttli  k>iiip- 
lOmH,  ih«  diagnwue  i»  uifuitUy  Dot  »t(cnde^  witli  diflicaltj'.  In  point 
of  freijiii-iicv,  absence  of  respirntory  souod  oftcner  proceeds  from 
liqaid  efTuiiioD  witliin  the  clicsC  llian  from  any  other  morbid  conditioiL 

Thv  respiration  will  fa«  feoble  or  suppressed  ib  certain  eases  *f 
diseii^o  according  to  tlie  acnteness  of  hearing  of  the  aascultator.  A 
[wrson  with  a  delicate  perception  of  sound  will  sometimes  apprecist* 
a  weak  respiratory  murmur,  when  another  person  whose  aaditoty 
perceptions  are  more  obtuse  will  fail  to  diHCorer  any  sound.  TW 
node  of  exploration  will  also  affect  the  result.  A  muriDur  may  be 
appreciable  by  immediate,  and  not  by  mediate  auscuUatioD ;  and 
with  Cammann's  stethoscope,  the  respiratory  sound  is  dittioct  in 
some  instances  in  which,  with  the  ordinary  cylinder,  and  the  nafc<d 
ear,  it  cannot  be  perceived. 

The  foregoing  moiificntions  relate  to  deviations  from  healthy  r«- 
piration  as  respects  intently,  including  the  abolition  of  sound. 
Those  to  be  next  considered,  inToUe,  either  with  or  without  these 
deviations,  a  change  in  the  quality  of  sound,  associated  with  abnor- 
mal changes  in  pitch,  duration,  and  rhythm.  This  class  of  modifi- 
oations  embraces  signs  of  great  importitnce  in  phyaiml  diagnosis. 

4.  Bronchial  or  tubular  retpiration. — The  name  bronchiitl  respira- 
tion imports  that  the  sound  corrcM)H>nds  to  that  heanl  over  the 
bronchi  rn  the  healthy  cheat.  This  mcuning  of  the  trrio,  )u>wever, 
involves  an  error.  The  normal  respiratory  murmur  over  tkc 
bronchi  is  not  identical  with  the  bronchial  respiration  of  disease,  but 
It  exemplifies  a  broncho- vesiculur  renpimtion.  A  morbid  broncfait) 
respiration  may  be  defined  to  be  n  respiratory  sound  essentially 
identical  with  the  normal  Inryngo-treaclieal  renpirntioii,  iupplnnttog 
the  vesicular  murmur.  With  this  definition,  Um  student  familiar 
with  the  characters  which  distinguish  the  truchcol  and  laryngeal 
sounds  from  the  resicular  murmur,  which  have  been  considered  fully 
under  the  hcftd  of  Auscultation  in  Health,  will  have  no  difficulty  is 
underitiuiidiiig  and  jiractically  rccogniting  the  bronchial  respiration 
incident  to  diKcasc.  In  describing  the  essential  tnits  pertaining  lo 
morbid  hriiiic-hial  respi rution,  it  is  only  neevsunTy  In  reproduce  the 
description  already  given  of  the  tracheal  and  laryngeal  sounds  con- 
trasted with  the  vesicular  murmur.  The  distinctive  characters  are 
as  foIlowH  :  an  inspiratory  sound,  tubular,  in  place  of  the  peculiar 
character  to  which  reference  in  the  foregoing  pages  has  frequently 


FaTIOH    IK    DI8KAER. 


167 


I 


itde  under  tfa«  name  TestcuUr  quality;  shorter  in  flura- 
I,  i»minon(.-iiig  with  the  beginning  of  the  inspiratory  act,  and 

ding  Wfore  the  act  is  completed  ;  the  pilch  of  the  sound  higher. 

D  expiratory  sound,  prolonged,  frequently  nearly  or  quite  as  long, 
and  Mnictimes  even  longer  than  the  infipiratory,  succeeding  (be  in* 
Bpiratory  ttoand  after  an  intervnl,  owing  to  the  fact  that  the  inspira- 
tory »onnd  ends  hefore  the  completion  of  the  inspiratory  act ;  the 
pitch  of  i>«und  higher  than  that  of  the  inspiratory,  and  the  intensity 
generally  greater.  The  student  is  again  requested  to  impress  on 
the  memory  these  several  points  of  distinction,  with  reference  to  the 
discrimination  of  bronchial  ref'piration,  not  only  from  the  vesicular 
murmur,  but  from  another  modification  included  in  this  class,  called 
thv  cavernous  respiration.  At  the  risk  of  incurring  the  charge  of 
a  nvedlcss  repetition,  in  order  that  the  points  distinguishing  the 
bronchial,  may  be  again  contrasted  with  the  characters  belonging  to 
the  normal  vesicular  murmur,  the  latter  are  reproduced  in  this  con- 
nection. They  are  as  follows :  an  inspiratory  sound  characterised  by 
the  vehicular  quality ;  lower  in  pitch  than  the  tracheal  or  laryngeal 
inspiration.  An  expiratory  sound,  when  present,  much  shorter  in 
duration,  less  inten;9e  and  lower  in  pitch  than  the  sound  of  inspira- 
tion. These  are  the  chuructcrs  of  the-  normal  vesicular  murmur, 
certain  modifi<^» lions  cxlKting  nt  the  Auiumit  of  the  vhci't  which  have 
been  considert-d  under  the  bend  of  Au»cultntion  in  IlciiUh. 

Contrusled  wiih  the  vesicular  murmur,  the  brunohini  expiration  w 
taid  to  be  characterized  by  greater  hardnttt  and  drr/ntni.  These 
Icnna,  although  in  vogue  since  tlie  time  of  Lncunec,  do  not  Hcem  to 
me  to  express  properties  of  sound,  of  which.  In  this  conlratt,  the 
mind  receives  a  very  distinct  idea.  The  distinctions  pcrtnining  to 
intensity,  rhythm,  quality,  and  pitch,  are  much  more  definite,  and 
•re  sufficient  for  the  discrimination.  I  shall  therefore  dispense  with 
tbe  u«c  of  the  former  terms  aficr  this  allusion  to  them.  They  ap- 
pear to  mo  to  he  rendered  superfluous,  especially  by  attention  to 
rurialions  in  pilch,  an  aspect  under  which  respiratory  sounds  have 
hitherto  been  but  little  studied. 

The  inleusity  of  the  brtiiichial  respiration  varies  greatly,  not  only 
ID  different  affcctiona  to  which  it  is  incident,  but  in  difl^erent  cases  of 
the  mine  disease.  It  ia  not  distinguished  by  its  intensity,  but  by 
the  characters  which  have  been  named,  and  the  latter  may  be  present 
and  sufficiently  marked,  when  the  sound  is  feeble,  as  well  as  when  it 
:i8  loud.     The  intensity,  however,  in  certain  affections,  pneumonitis 


168 


PHTSIOIL  IZPLOBATIOR  07  THE  CBBST. 


enpt'ciallv,  ia  nfd^n  gr«»t,  bnini;  pqn*!  to  and  al  tlnieH  exc«ediDg  llol 
of  the  nonnnl  irnclienl  respiration.  In  ^mne  instance:*  of  inteitw 
broncbiiil  respiration,  the  itouaii,  in  adtlition  t«  a  stronglv  toarkel 
tubular  ijiialitj,  has  ■  peculiar  ringin;;  tone,  like  that  prodncd  hj 
blowing  tbroiigU  a  tube  of  inctsi,  and  hence  called  a  metallic  intoaa- 
tion.  It  it  oflcner  marked  in  the  cxgiraturj  than  in  the  >n^tnts<7 
tound.  Tlie  normal  tracheal  respiration  occasionally  presents  tUt 
character  in  forced  breathing.  This  is  an  incidental  featnre  of  llw 
bronchial  respiration  occurring  in  certain  cases  of  pneamonitU,  and 
not  poesesBing  special  diagnostic  significance. 

Id  other  respects  than  inionaity,  the  bronchial  respiration  rartes. 
The  pitch  is  not  the  same  in  all  cases,  hut  this  difference  obtains  io 
different  persons  an  respects  the  tracheal  and  laryngeal  Bomtda. 
Both  the  inspiratory  and  the  enpiralory  sound  vary  in  duration,  as 
well  U  in  their  relative  intensity.  Either  may  be  present  wilhont  rbe 
odier.  ,In  some  instances  the  sound  appears  to  be  produced  in  el«M 
proximity  to  the  ear:  and  sometimes,  indeed,  the  air  appears  to 
enter  and  again  emerge  from  the  meatus.  This  was  the  ground  of 
Laennec'a  dirisiAn  into  bronchial  and  blowing  respiration,  the  latter 
term  heinj;  applied  when  (be  ani^nltator  experiences  a  senaatiwi  a* 
if  the  breath  of  the  patient  actually  traversed  the  Methnseope.  It 
BulRccft,  however,  to  consider  this  as  simply  nn  incidcntat  feature  of 
the  hrunchini  and  also  of  the  cavernous  respiration.  In  some  in- 
stances in  which  this  is  strongly  marked,  the  illusion  is  almost  com- 
plete, and,  quoting  the  language  of  Laennec  "it  is  only  from  the 
absence  of  the  feeling  of  titillation  and  of  warmth  or  coldness  which 
a  blast  of  air  so  impelled  must  necessarily  occasion,  that  we  are  held 
to  doubt  its  reality." 

In  other  cases  the  sound  gives  the  impression  of  emanating  tnm 
a  source  more  or  less  distant  from  the  walls  of  the  chest,  ll  18 
important  to  be  borne  in  mind  that  not  only  is  the  bronchial  respira- 
tion, in  diSerent  cases  of  disease,  thus  variously  modified,  but  that 
all  the  characters  which  serve  to  distinguish  it  from  the  vesienlar 
respiration  are  by  no  means  uniformly  present.  The  existence  of 
an  inspiratory  without  an  expiratory  sound,  and  vite  rena,  direst* 
it  of  several  of  the  distinctive  traits  which  arc  a830ciale<i  when  a 
sound  accompanies  both  acts  of  respiration.  In  sncli  instances  va 
are  to  determine  that  the  respiratory  sound  is  bronchia)  by  the 
characters  which  remain.  The  bronchial  respiration,  like  the 
tracheal,  differs  in  intensity,  and   in  other  respects,  with  dili?T«ot 


adsohltatiox  iir  disbasb. 


Imecmire  respirations,  always,  however,  preserving  certain  cbarao* 
IrrixiioK.  8k»i)h  cantvmls  thiit  it  ix  mn  intermittent  sign,  fretjuenlly 
CPBving  for  s  series  of  rc^piriitionti,  an<l  then  reappearing.  This 
doct  not,  hovevrr,  cccord  with  l)ic  experience  of  others,  the  Istler, 
to  far  n»  m;  obs«rrkttoiis  go,  being  correct  as  the  general  rule.  lu 
occasioniil  cessation  and  reftppcarance  after  coughing  and  expectora* 
Uon,  is  n  fact  which  I  have  observed. 

With  what  physical  condition  of  the  lungs  is  the  bronchial  respi- 
ration aMociatcd?  Thu  queilion  ni»y  be  explicit);  answered.  It 
reprfrAcnts  oithwr  complete  or  considcrahte  solidificniion  of  the  pwl. 
mouarj'  structure.  Whenever  the  bronchial  respiration  is  present 
it  donoles  this  condition.'  The  convor**  of  this,  however,  is  not 
truw,  vis.,  that  nbenever  lung  is  Bfdidified,  it  give*  ri.*ft  to  bronchial 
respiration.  The  sign  always  denotes  the  morbid  physicol  condition 
just  stated,  but  the  physical  condition  may  exist  without  giving  riso 
to  the  sign.  Solidtficntion  of  lung  is  incident  to  discuses  which 
induce  condensation  by  pressiiro.  This  eflTect  follows  the  accumuls-' 
lion  of  li<|uid  nitbin  th&  plonral  $nc,  within  the  pericardium,  and  th? 
development  of  tumors  encroaching  on  the  thoracic  space.  Much 
oftener,  however,  it  proceeds  from  a  morbid  deposit  within  the  pnl- 
moiiary  structure.  Bronchial  respiration,  tliereforo,  may  be  a  sign, 
on  the  one  band,  of  pleuriny,  or  hydrolhorax,  or  hydro- pericardium, 
of  aneurismal  and  other  tumors ;  and,  on  the  other  hand,  of  pneumo- 
nitis, tuberculosis,  carcinoma,  and  pulmonary  apoplexy.  Of  the 
several  alTectioDs  last  mentioned,  it  is  more  constantly  present  in  the 
two  first,  vix.,  pneumonitis  and  tuberculosis.  On  this  account,  and 
owing  to  the  frequency  of  these  affections,  the  sign  is  especially  tm> 
portant  with  reference  to  their  diagnosis.  IJeforc  directing  ftirlher 
attention  to  it  in  oonncction  with  these  affections  respectively,  wc 
will  inquire  how  doe«  the  solidification  of  lung  incident  to  different 
forms  of  disease  give  rise  to  a  bronchial  respiration  ?  To  this  in- 
quiry I  shall  devote  brief  consideration. 

The  explanation  of  bronchial  respiration  offered  by  liaennec,  and 
up  to  the  pre.«ent  lime  generally  accepted,  is  that  the  sound  is  in  fact 
a  normal  bronchial  respiration,  which,  owing  la  conditions  of  disease, 
is  transmitted  to  the  ear,  disconnected  from  the  vesicular  murmur. 
Ute  bronchial  respiration  appears  in  connection  with  physical  con- 


>  A>  m  apfwrent  •Krjiiitin  ■»  ibif  tii'rmcaii,  dilnBiinn  of  t)ir  bmiif-hial  (ubm  migbl 
hf  chied.  [hIaiBiion  »,  howevFt,  u  will  t*e  tevn  licrealter,  aJwafs  autvUlnl  with  in- 
ctcaxd  denail}  cT  tun|[. 


4 


m 


raTfliCAk  BXPfcoftATios  or  tsb  cbbst. 


€«Mim  whicb  nT«If«  ■fpitanMi  of  tW  vcainkr  mraBr.  Ik 
kalti^  the  btur,  m  U  «erc  Miflc*  Mvniit  law—line  or  prop^tvrf 
friNi  Um  braacfanl  t^M.  MmArrr,  the  tna^  «bva  iu  iateitf  it 
ncmwi},  has  Im««  ■^ppowJ  to  IweoM*  ■  Bodi  bvtwr  eoo^acMr  of 
mwmI  ihsn  ur-miela  filled  witk  sir.  Thaw  trnv  eJTcmmanntn, 
Tix.,  aboGiioti  of  tb«  *e«icaiar  manaar,  uid  Uw  tnasfortmtjuii  rf 
the  pdaonary  aabsUocc  into  ■  bctur  eowlactv  of  tanad,  acoonlaf 
to  IfBtc  an  raficient  to  Mconat  for  the  bronchial  mpiratica, 
the  i>oiirc«  of  the  Maad  being  the  large  ami  anall  broocfaial  tidm. 
Tbo  HtSdenc;  of  ibis  eipUaatioa  b«»  beea  called  in  qaoatioo,  ia 
coaaeqaeoce  of  tbe  broncbial  rapiration  beiag  soactiiDea  SMiro  b- 
Unse  ihftQ  e«eo  tbe  tracbeal  Moads ;  and  diSerit^  fron  tbe  tradMa) 
and  «hat  hi«  beeo  called  tbe  norinsl  hroDchial  respiration,  in  how 
cases,  in  c|Daliij-  and  jMicb.  The  fact  that  aolidificaiii^Q  of  lan^, 
when  tbe  broncbial  tubea  are  free  fron  obotrvetioB,  ia  not  inrariabl/ 
associated  aitb  tbe  braaebial  reapiration,  bnt  in  Miae  tDstaoces  gire* 
fiae  to  sopprcMion  of  all  found,  U  thoogbt  to  militate  against  the 
bjrpotbesaa  of  Laennec.  Again,  when  tbe  lung  M  aolidified,  aa  ia 
caivo  of  pneainonitia,  it  is  doubted  by  some  wbetber,  owing  to  in 
inabiliij  to  colUpM  and  expand  with  tbe  two  revpiratory  aeU,a 
current  of  air  cireolates  in  the  pnlinonary  bronchial  tabes  with  auB- 
cient  force  to  give  rise  to  soand.  Finally,  according  to  8kotU. 
increased  demity  of  tbe  long  does  not  render  it  a  better  conductw 
ofsoind.  Tbe  latter  statement  is  ba«ed  on  comparative  experiments 
nade  irith  the  puiraonary  organs  remored  from  ibe  body  in  a  healthy 
condition,  atii)  whfn  lutlidificd  by  disease.  Other  observers,  hoveteri 
from  tiinilar  experiments,  do  not  arrive  ac  the  sane  conclnaioa. 
Walshe  8tate«,  aa  the  results  of  experiments  made  by  hinsel:^ 
that  sound  mny  i*e  coDduct<-d  *riih  great  intensity  by  solidified  lung, 
but  not  invnriubly ;  and  that  as  regards  the  condacting  power,  vhen 
the  pliyitical  conditlonit  lo  all  appearances  are  the  aame,  differences 
arc  found  to  exi)>t  which  it  is  not  easy  to  explain.  That  a  current 
of  air  i)t  not  rccciTeil  inlu  the  pulmonary  bronchial  tnbes  by  the  act 
of  inspiration,  nnil  expelled  by  expiration  with  sufficient  force  lo 
generate  a  tubular  sound,  n  anumed  rallicr  than  established.  Tho 
novements  of  the  dinphrngm  and  walls  of  the  cheat  on  the  affected 
•idff,  in  discs  of  pneumoniiis,  wiih  solidi6catiOD  of  one  or  more  lobes, 
nrc  not  nbolisht>d;  and  it  seems  probable  that,  notwithstanding  the 
eomparative  incooipressibilily  of  tlic  luTig,  the  broncbial  tubes  re- 
maining unobstructed  undergo  altcruntc  contraction  and  dilatation. 


AnSCULTATIOjr    IS    DISBABB. 


171 


The  opinion  of  Andrni,  that  tbe  obBtraction  to  lh«  entrance  of  atr 
into  the  air-cells  b;  arresting  suddenly  the  current,  and  increasing 
tbe  pressure  of  the  air  npon  the  bronchial  tubea,  tends  to  develop 
an  exeggorated  sound  therein,  although  repudiated  by  high  an- 
thority,  i^  not  disproved,  and  seenia  rational.' 

Wiih  regard  to  the  greater  intensity  of  lliv  bronchial  than  even 
the  tracheal  respiration,  in  some  cases,  and  variations  in  pitch,  it  ia 
certain  that  dtfierences  as  respects  these  characters,  do  exist  in  a  ea- 
tain  proportion  of  cases.  A  morbid  bronchial  respiration  issometimes 
more  int«-nse  than  the  sound  emanating  from  the  trachea  of  the 
■arae  person  and  higher  in  pitch.  It  may  also  present  a  metallic 
quality,  vrhen  the  tracheal  sound  of  the  same  person,  at  the  same  time, 
ia  devoid  of  ibis  quality.  Nevertheless,  as  respects  the  distinctive 
characters  which  (he  tracheal  respiration  presents  in  contrast  wilb 
the  vesicular  murmur,  they  bi-loiig  (-(jually  to  the  bronofaial  respira- 
tion. The  latter,  when  strongly  insrki^d,  as,  for  example,  frequently 
in  casee  of  pnciimonilis,  iit  identieiil  with  the  tracheal  respiration  as 
regards  tubularity,  duration  of  the  inHpiraiory  and  expiratory  sounds, 
the  rhythmical  succession  of  the  latter,  and  their  relative  inletiaity 
and  pitch,  theu  constituting,  as  has  bMii  teen,  the  trails  by  which 
the  bronchial  respiration  is  distinguished  from  the  vesicular  murmur. 
This  being  the  cas«  for  the  production  of  the  bronchial  respiration, 
the  tracheal  respiration,  it  is  reasonable  to  infer,  must  either  be  rcpro- 
daced  within  the  bronchial  tubes,  or  conveyed  to  the  ear  bycondiio- 
tion.  Circumstances  incidental  to  their  manifestation  in  disease 
produce  in  certain  cases  the  variations  in  quality,  pitch,  and  inten* 

|Bity  to  which  reference  haa  been  made.  According  to  Skoda,  tbe 
sounds  may  be  rt^produeed.  He  attribniea  the  origin  of  morbid 
bronchial  respiration  in  certain  cases,  to  the  principle  of  consonance. 

[Tbe  air  contained  in  the  pulmonary  bronchial  tubea,  according  to 
tbis  view,  undergoes  vibrations  consonaling  with  thoM*  caused  by 
respiration  within  the  trachea  and  lar^o  bronchi,  in  the  Mamc  way 
that  musical  notes  are  repeiited  upon  the  strings  of  a  violin  or  piano- 
forte  when  corresponding  notes  from  another  instrument  in  itD 
vicinity  are  produced.  This  fanciful  bypoibe&is,  which  appears  to 
be  readily  received  by  many,  I  shall  notice  somewhat  more  fully  in 
connection  with  the  explanation  of  vocal  signs.  The  simple  fact 
that  the  loudness  of  the  bronchial  respiration  of  disease  is  often 


1  ThU  vliw  b  advocated  by  Dr.  Qnbatd.    DiMa»«ortb«Cbest.    1H&. 


172 


rHTSICAL   SIFtOtATtOS   OV  TBE   OSBST. 


eq^toi 


to  Apme  k,  lor  ft  I 


id  rqwodseed  br  coBMNisDee  ii  dvqi 

mnA  \em  iittens*  thka  ibt  vkidi  onpumtM  it.  Tlie  wutiaD  n 
pilcfa,  wkidi  b  MMMiiBn  ofatired,  k  abo  Cual  to  th«  hjpciWM, 
for  %  eontemtiag  mmaA  »  alaays  is  miww  viih  llw  pnakm 
MDikd.  Wnboat  dcBjiag  ibal  ioaorww  ribnuio&s  widira  ihe  f«t 
Boaarj  brandnti'  tito  may  <aa«w>le  villi  iboee  vbich  take  fbte 
in  tbe  rrthf  smI  brger  bnacUal  t«b«s,  (be  disparity  in  piteb  ad 
JaleMJty  dbprotea  tbe  Taltdity  of  tbe  espIaBaiion  uader  ama- 
ManoM  in  «b>cfa,  M«or£&g  to  Skoda,  the  principle  of  oOBSODtM* 
i»  pftiitcvUrly  sppltcabW.  tis..  vben  tbe  br«ttcttial  res{Hnti<n  iao- 
dental  to  disease  is  inieofielr  dereloped. 

Begarding,  ibett,  tbe  bronchial  respiration  w  consisting  of  true- 
milted  sovnda,  iber  are  prodaced  within  the  trachea,  the  prinarr 
bronchi,  and  prohablv  aUo  within  the  snhdivisiotts  of  the  Utter,  and 
are  coodncted  by  tbe  air  ia  the  tnbce  and  tbe  solidified  lung  to  tk 
ear  of  the  anscaJtator.  In  what  proportion  they  are  doe.  reepM- 
tivety,  to  the  trachea,  and  the  larjje  bronchi  exterior  to  the  Innp, 
«>d  towhat  extent  sounds  generated  within  the  pulmonary  bronchial 
sabdirifions  may  be  combined,  are  points  not  easily  dfllertained.  ll 
ia  not  diScolt  to  cono<^ive  that  the  sounds  emanating  from  tbr 
trachea  nay  be  convevc<I  with  conuderable  intensity  to  diSereoi 
parts  of  the  che«t.  after  applying  the  MethoROope  on  the  back  of  tbe 
neck,  and  luitening  to  these  Donnds  in  that  Mlualion  transmitted 
tlirough  the  Tcrtcbr«  and  mass  of  miu«le  which  intervene  between 
the  ear  and  the  trachea.  The  cnodnction,  howerer,  of  the  soundi 
generated  within  the  trachea  nnd  the  bronchi,  sa  in  ihe  oooditiooi 
of  henlth,  will  not  inffice  to  explain  the  inten^tificalion  of  soand 
which  sometimes  characterixes  the  bronchial  rc«piratioD  in  disease, 
nor  the  disparity  in  pitch  which  is  obscrvei].  Thewe  tlifferencei 
must  be  owing  to  some  agencies  pertaining  to  the  bronchial  tubes 
within  the  Inngs,  or  to  the  pulmonary  structure.  Sonorous  ribratioos 
propagated  to  the  pulmonary  bronchial  tubes  rendered  firm  and  m> 
yielding  by  Hiirrvnntling  solidification,  according  to  Fouraet,  Bartb 
and  Bogcr,  and  othcr»,  arc  reinforced  and  Hlreuglhened  by  rovti^ 
bcration,  and  thnii  acquire  an  increa.4i*d  intensity.  Other  physical 
influences  are  doiilitlenM  involved,  which  are  not,  as  yet,  salisfacto- 
riiy  explained.  The  fact  that  frcquenlly,  in  thv  affections  to  whidi 
bronchial  respiratifiii  is  incident,  ibe  respiratory  movements  are 
made  with  an  abnormal  <)uickne«is  and  fvi-ce,  will  acoount  for  the 


AUSCHLTATIOS    IN    DI8BASE. 


173 


I 


ironebia)   respiration   being  more  intense  tlian  the  tracheal  with 
rdinary  breathing  in  a  healthy  person,  bnt  not,  of  course,  for  an 
tensity  greater  than  the  trachea]  sounds  of  the  pa,tient  at  the  time 
if  the  examination.     It  has  been  seen  in  connection  with  the  fiuh- 
|eoi  of  auscultation  in   health,  that   ihe  intensity  of  the  tracheal 
ounds   ia  greatly  iiioreased    when   the   respiration   is  voluntarily 
breed.     It  is  therefore  to  be  home  in  mind,  that  the  intensity  of 
he  tracheal  respiration  nilh  ordinary  breathing  in  health  J9  not  a 
riterion  by  which  to  judge  whether  the  bronchial  respiration  incident 
;to  disease  is  iuteti-iitied  by  same  cause  or  causes  within  the  pul- 
.onary  organs,  bat  tbe  proper  standard  of  comparison  is  the  trtt- 
eheal  n-spiration  of  the  patient  which  is  incident  to  the  »ame  cir- 
cumstances under  which  the  bronchial  respiration  is  observed. 

Some  of  the  circumstances  accounting  for  differencea  in  different 
•CMScn,  ht  regards  the  intensity  of  the  bronchial  respiration,  are  ob- 
vious. Other  things  being  equal,  the  greater  the  degree  of  density 
■the  more  complete  is  the  conduction-of  sound.  If  the  solidificatioo 
1>e  continuous  from  iho  larger  bronchial  tubes  to  the  exterior  of  (he 
lung,  the  intensity  will  be  greater  than  if  the  continuity  bu  inlcr- 
•ropted  bj  healthy  structure,  not  only  because  air-vesicles  contsiniag 
ftir  conduct  sound  more  imperfectly,  but  also  from  tbe  fact  that  tbe 
strength  of  sonorous  vibrations  is  impaired  by  passing  from  one 
medium  to  another.  With  the  same  amount  of  solidification,  the 
greater  the  proximity  to  the  larger  tubes,  the  louder  will  be  the 
sound;  hence,  the  bronchial  respiration  is  more  strongly  marked 
when  the  physical  conditions  favorable  to  its  production  are  situated 
near  the  root«  of  the  lungs,  in  proximity  to  tbe  trachea  and  large 
bronchi,  and  surrounding  the  immediate  subdivisions  of  the  latter. 
In  so  far  as  the  sign  may  be  dependent  on  the  passage  to  and  fro  of 
■ir  within  the  bronchial  tubes  distribnted  through  the  lunj;,  and  on 
the  conduction  by  the  air  within  the  tubes  (the  latter  perhaps  enter- 
ing considerably  into  the  mechanism),  it  will  of  course  bo  alTectcd 
by  obstruction  of  these  tubes  from  the  accninuhiUon  of  inucuti  or 
other  morbid  products.  In  addition  to  these  circumstances,  ihorc 
ftre  others  which  are  not  fully  undi-rKtood,  and  which,  in  some  carets 
oocmIod  suppression  of  all  respiratory  sound  when  the  conditions 
favorable  for  tbe  bronchial  respiration  appear  to  be  present.  The 
c«Biplvlcnc»  and  intensity,  on  the  other  hand,  with  which  this  sign 
will  be  presented,  will  depend  on  the  concurrence  of  all  the  circum. 
slances  iovolvcd  in  ius  development  and  transmission. 


374 


PBT81CAL    EXPLOBATIOX    OT    THE    CBBST. 


The  affection  in  which  the  bronehimi  respiration  ia  moft  oonstndj 
present,  as  well  as  oftoneat  inlense,  and,  as  regards  tb«  union  of  in 
dutinotive  cbaraclera,  most  complete,  is  pneoraonttia.  As  thisafllBiy 
tion  is  gcnerallj  seated  In  tlie  inferior  lobe,  and  extendi  owr  the 
entire  lulie,  a  well-marked  broncbial  respiration  conjuiDcd  witbdol- 
nees  on  pereu-tston  over  the  lover  seapalar  and  infrft-ecspalar  r^ 
gionit,  and  with  tbe  sjnptoins  of  intra-thoracie  in  flu  to  mat  Ion.  ii 
concltuire  evidence  of  tbe  presence  of  that  disease,  advanced  to  lit 
arcond  stage,  or  the  stage  of  solidification.  The  transition,  on  tW 
nrfscc  of  tbe  cbest,  from  the  Tceicalar  murmur  to  the  bnmcAiil 
rexpiration  ia  abrnpt,  and  il  ia  generally  easy  to  determine,  with  die 
slclbosiMpe,  the  line  of  demsrcaii»n  bciwoea  the  two.  This  Mtte, 
marked  on  the  cbest.  will  be  found  to  pursue  the  direction  of  the 
interlobar  fiAsnre.  If  this  line  have  been  previously  determined  \j 
pereusaioii,  aiincultation  will  thus  afford  confirniation  of  it»  correct- 
DfM.  A  sufficiently  large  collection  of  cases  of  pncnmonitis  will 
present  every  nhade  of  intensity  of  the  bronchial  respiration,  tni 
the  different  variniions  in  other  characters.  In  some  cases  an  in- 
spiratory sound  will  alone  be  heard,  and  in  others  the  expiratory; 
in  pitch  the  sound  may  be  more  or  less  acute,  and  it  may  or  may 
not  pottsess  a  metallic  intonation.  In  a  itmall  proportion  of  cases  it 
is  absent,  and  there  is  suppressed  respiration :  while,  therefore,  tbe 
bronchial  respiration,  in  connection  with  the  circumstances  above 
mentioned,  is  positive  proof  of  the  existence  of  the  second  stage  of 
pneumonitis,  the  abolition  of  all  respiratory  sound,  in  conneeliOD 
with  the  same  oirctimstancea,  is  not  proof  that  pnenmonili.*  doc*  not 
exist. 

Next  to  pneumonitis,  as  refrarda  the  frcqnency  with  which  the 
bronchial  revpirution  isassociated,  is  tuberculofis.  A  mans  of  tubrr- 
ele,  situated  nt  the  summit  of  the  chci'l,  in  proximity  (o  some  of  the 
large  bronchial  niibdiviiiions.  niiiy  give  rise  to  a  well-marked,  and 
sometimes  an  intense  bronchial  respiration,  rarely,  howerer,  M  in- 
tense as  attends  ihe  consolidation  from  pneumonitis.  Existing  at 
the  summit  of  the  chest  on  one  side,  over  a  space  not  extensive, 
eonjoined  with  dulness  on  percussion,  and  certain  symptoms,  soeh  as 
Imb  of  weight,  pallor,  accelerated  pnlse,  and  especially  hsmoptysia, 
the  diagnosis  hardly  admits  of  doubt.  Often,  however,  in  connec- 
tion with  a  tuberculous  deposit,  the  respiratory  sound,  altboagh  dis- 
tinctly modified,  is  not  sufficiently  so  to  constitute  a  well-marked 


J 


AC8CP1TATI0S    I3T    DISBABK. 


>ronc)iial  roHpi ration,  and  the  modification  vill  fall  nntlcr  the  head 


iilcroil. 


to  be  next  eunKJiI 

In  cedi'ina  of  the  lungs  the  branchinl  respiration  ma^  he  prcMnt, 
bill  not  strongly  marked,  and  never  presenting  lh«  intensity  observed 
in  some  cases  of  pneumonitis.  The  same  is  trne  of  pulmonary  apo- 
plexy and  carcinoma  of  the  lungs.  These  forms  of  disoiisp,  more 
vspiwially  the  two  last,  are  extrotnely  rare,  and  their  diagnosis  in- 
Tolves,  on  the  one  hand,  the  presetioe,  and,  on  the  other  hand,  the 
Mbsence  of  signs  and  symptoms,  to  <nhich  reference  will  be  made 
hcrcBft«r. 

Id  plenrisy  affecting  the  adult,  a  wdl-marltcd  bronchini  rcupirntion 
is  observed  in  a  certain  proportion  of  cases.  Of  twenty-»ix  cn)>o«, 
selected  indiscritninntcly,  in  the  wards  of  the  bosipitals  Iliitel  Dicu 

tknd  La  CharitS,  ut  Parifl,  Burth  and  Roger  stnto  that  it  existed  in 
Dine,  and  was  absent  in  seventeen.  It  is  incident  to  this  afl^ection 
nuvh  more  frequently  in  children,  it«  coexistence  in  them  bcin^  the 
rale  according  to  Swett.'  Occurring  in  pleurisy,  it  i*  due  to  con- 
densation of  the  lung  from  compression  by  the  li'^uid  cff'tisir^n  within 
the  pleural  sac,  and  is  usually  limited  lo  the  summit  of  the  chest, 
tbe  pressure  of  the  fluid  pushing  the  lung  upward,  except  in  some 
instances  in  which  it  is  prevented  from  yielding  to  the  force  of  tbe 
pressure,  in  this  direction,  by  morbid  attachment  of  the  pleural  sur- 
faces, tn  some  cases,  however,  it  ia  more  or  less  diffused  orer  the 
chesit.  Kuch  cases  are  met  with  much  oftener  among  children  than 
adults.  When  heard  below  tlic  level  of  the  fluid  it  is  nirely  intense, 
and  tbe  sound  seems  to  come  from  n  distance.  In  the  grcnt  majority 
of  the  cases  of  pli-uritis,  c<Tt«inly  among  adults,  the  respiration  ia 
suppressed  over  the  chest,  below  the  level  of  the  liijuid  elTusioo. 
This,  in  fact,  is  the  rule,  the  inetnuccs  in  which  a  diffiincd  distant 
bronchial  rcspirntion  is  apprcciiibic,  being  exceplions. 

The  physical  conditions  in  hydrothorax  are  the  same  os  in  pleor 
risy,  so  far  as  concerns  their  effi-'Ct  on  respiratory  sounds;  but  inas- 
touch  as,  in  this  affection,  liquid  efi'uKion  Inkea  place  in  both  sides  of 
the  chest,  the  quantity  necessary  lo  produce  complete  or  consider- 
able solidification  of  both  lungs  is  hardly  compaiible  with  life.  Oc- 
casionally, however,  bronchial  respiration  over  a  limited  space  is 
produced  on  one  or  both  sides. 

'  a  already  stated,  compreiision  of  the  pnlmoiiaiy  parenchyma  by 


>  DiseasM  of  Uie  Cbett,  etc 


180 


PBT81CAI.    BXPLORaTIOS    OP    THB    CHEST. 


In  general  ierms,  th*  lironcho-vi'wculiir  respiration  repr«CTitt  ill 
the  diSercnt  ilcgrcvs  of  nolulificjitivn  of  lung,  falling  short  of  eon- 
plete  or  constdcrnblc  noli<ii6cati<Hi,  the  latter  being  rrprcseattd  b; 
the  bronchial  respiration.      The  character*  of  the  «igti  tmrj  acrOTd- 
ing  to  the  degree  of  Holidificalton,  and,  by  means  of  tbcse  variation^ 
it  may  be  determined  whether  the  volidifivation  be  »l>ght,  niodcnu^ 
or  nearlr  enough  to  furnish  the  bronchial  re«piration.   For  cxsiBpIt, 
let  it  be  nupposed  that  there  is  a  slight  incr«a*«  of  dcnnty.  9n«h  u 
entMtA  in  a  small  deposit  of  tubercle,  the  eharaoters  of  the  broncho- 
TMienlar  respiration  denoting  this  condition  are  m»  follows:  1W 
inspiratory  sound  is  a  little  h-»t  vesiciilar  than  in  health,  a  Ittik 
tubular  quality  is  adiU-d,  and  the  pitch  U  ■  little  higher:   the  expt- 
ratory  sound  is  somewhat  proionjied,  the  intensity  »oincwhat  greater, 
and  the  piteh  higher  thnii  in  health.     These  characters  denore  wbn 
may  be  callcl  n  slight  broneho-vesiculnr  renpiralton.     On   the  other 
hand,  let  it  be  supposed  that  the  solidification  falls  bnt  little  sbsrt 
of  the  amount  sufficient  to  furnish  hrotichinl  re-'<pir»tiun,  the  cbaia^ 
tcTS  rlenoticig  this  condition  are  as  follows :  The  inspiratory  sound  a 
almost  purely  tubular  in  quality,  only  a  little  vesicular  quality  is  pe^ 
oeived,  and  the  pitch  ia  high;  the  expiratory  sound  b  prolonged,  ik- 
tense,  and  high  nearly  to  the  same  degree  as  in  the  bronchia)  rupi- 
ration.     Now,  bclwccn  these  two  extremes  of  the  broncho* veueabf 
re<Bpiration,  every  degree  ofgrndittiun  may  be  presented  id  diflereu 
cases.     In  proportion  ns  the  increase  of  deninty  of  lung  is  gmnll,  tW 
^aracters  of  the  nornml  vesiculiir  miinnurwill  predominate  orcrlfe* 
characters  of  the  bronchial  or  tubulur  respiration ;  and,  on  the  otbtf 
hand,  in  proportion  ns  the  solidification  uppronches  the  amount  re- 
quired to  furnish  bronchial  respiration,  the  characters  of  the  UtUf 
will  predominate  over  those  of  the  normal  resicular  murmur. 

The  respiration  is  broncho- vesicular,  not  purely  bronchial, 
wherever  the  vesicular  quality  is  appreciable,  however  slight,  ia 
the  inspiratory  sound;  and  the  respiration  is  broncho-resicular,  not 
normal  vesicular,  wherever  there  it  an  abnormal  diminution  of  ihf 
vesicular,  and  addition  of  tubular  quality,  no  matter  how  slight,  ia 
the  inspiratory  sunrd.  In  proportion  as  the  vesicular  quality  pre- 
dominates in  the  iiispirnlory  sound,  the  increase  of  density  of  long 
is  small,  and  the  elevation  of  the  pitch  of  the  insptratorr  sound  is 
slight  in  proportion  ns  tho  vesicular  quality  predominate*.  Pc 
eontra,  in  proportion  as  iho  tabular  quality  in  the  inspiratory  sonsd 
predominates,  the  density  of  lung  is  greater,  and  the  pilch  of  the 


aPSCTJLTATTOK  IS   DISEASB. 


object  or  plijsieal  fsplorntion,  he  will  find  a  singular  want  of 
FnrnvAit  in  the  tniiiiner  in  which  thi«  Bigo  is  ii»unlly  (iefinctl ;  and  it 
is  «xc«-dingly  diflicnlc  for  tliv  student  to  form  a  correct  idea  of  what 
ta  intended  to  be  indicated  by  the  term  rude  respiration.  All  concur 
in  saying  that  the  rude  respiration  mergrs  insensibly  into  the  bron- 
chiol  respiration.  It  is,  in  foct^  neither  more  or  less  than  imper- 
fectly developed  bronchial  respiration,  which  in  the  process  of  certain 
(diseases,  as  will  be  eccn  presently,  it  may  both  precede  and  follow. 
Analyzed  it  consists  of  elementary  charucters  approximating  to 
tboee  of  the  bronchial  respiration,  an  essential  point  of  difTerence 
being  that  the  vesicular  quality,  although  impaired,  b  not  lost. 

In  describing  the  distinctive  characters  of  the  broncho-veflicutar 
respiration,  as  contrasted  with  the  normal  vesicular  marmur,  the  in- 
epiratory  and  the  expiratory  sound  are  to  be  considered  separately. 
Id  determining  these  characters  clinically,  in  cases  of  diseuiie,  of 
course  comparison  is  made  of  corresponding  regions  on  the  two  sides 
of  the  chest;  the  normal  vesicular  murmur,  or  an  approximation 

•  thereto,  being  presumed  to  exist  on  one  side.  This  comparison  is 
necessary  in  judging  of  a  broncho-vesicular  more  than  in  determin- 
ing the  presence  of  a.  bronchial  respiration,  for  the  distinctive  char- 
acters in  the  latter  are  more  marked.  As  stated  under  the  head  of 
_  Anocultation  in  Health,  in  tjuality  and  pitch,  as  well  as  in  intensity 
f  of  the  normal  respiratory  sounds,  marked  dilferences  exist  in  differ* 
ent  individuals.     The  natural  respiration  in  some  persona,  enmparecl 

I  with  that  in  others,  might  be  said  to  be  broncho-vesictilar. 
The  intensity  of  the  inspiratory  sound  in  the  broncho- vesicular 
respiration  may  be  cither  greater  or  less  than  in  the  normal  vcxicular 
murmur.     The  intensity  is  not  a  distinctive  feature.     This  sound  is 
frequently  shorter  in  duration  than  in  the  normal  vesicular  murmur, 
ft  ending  before  the  close  of  the  inspiratory  act ;  in  other  words,  being 
unfinished.     It  has  less  of  the  vesicular  quality,  with  more  or  less 
of  the  tubular  quality  added,  as  the  name  imports.     It  is  higher  in 
pilch.     The  latter  is  a  feature  highly  distinctive,  easily  appreciated, 
and  which  is  therefore  of  considerable  importance.     It  is  a  feature 
to  which  attention  had  not  been  called  prior  to  the  publication  by 
H  the  anthor  to  which  reference  has  alreatly  been  made.*     I  am  per- 
H  cnaded,  however,  that  practical  auscultators  have  been  accustomed 

^H   t  Oa  Vftriniion*  of  Fitch,  ftc.,  Priie  Eway. 
:       Ai»(Wl«Uon,  1862. 


TmnRaottotu  uf  Am.  Medical 


178 


7BT9IDAT,    KXTLOBATIOX    Or    TUB    CDB8T. 


to  recognize,  unconsciously,  what  they  have  culled  &  rude  respira- 
tion, in  a  great  uciitiurc  by  the  eleration  of  pitch.  I  »*y  uncon- 
Bcioiisly,  for  it  is  evident  that  sounda  maj  be  discriiDin»t«d  practi- 
'C^ljr,  without  n  full  knowledge  of  the  special  chnrnctcni  bjr  which 
they  are  distinguished,  this  knowledge  being  obtained  only  by  car»- 
ful  and  accurate  analyais.  In  comparing  sounds  on  the  two  aide* 
of  the  chest  which  differ  but  slightly,  it  is  cn«ier  to  appreciate  «  t»- 
rialion  in  pitch  than  a  difference  in  the  amouiil  ofvcHioular  quslitj, 
although  each  involves  the  exifttence  of  the  other. 

The  expiratory  sound  may  be  present  or  abtient.  It  is  mueb 
oftener  present  than  in  the  normal  vesicular  inunaur.  It  is  often 
prolonged,  being  nearly  or  rguite  as  long  att  the  sound  of  inr^piration, 
and  aometimea  longer.  From  the  fact  that  iho  in«pirnlory  souihI  is 
unfinished,  an  interval  tioparnte.*  the  two  aounds,  m  in  the  bronchial 
respiration.  In  the»c  soveriil  [ioint»  the  reader  will  not  fiiil  to  notice 
the  approximation  to  the  bronchial  respiration.  This  holds  good 
still  farther.  The  expiratory  Hound  is  higher  in  pilch,  and  frequently 
more  intense  than  the  inspiratory.  It  was  obserTc^l  by  Jackson 
(who  Srst  called  attention  to  tbo  importance  of  the  expiratory  sound 
in  physical  diagnosis),  and  the  fact  wns  confirmed  by  Fournet 
and  others,  that  in  the  development  of  the  rude  respiration  the 
morbid  alteration  generally  first  appears  in  the  expiration.  It  be- 
comes more  intense  and  prolonged.  The  fact  that  the  pitch  bceomea 
higher  than  that  of  the  inspiratory  sound,  reversing  in  this  rc«p4ie( 
the  condition  of  health,  appears  to  have  escaped  observation.  This 
fact  is  of  considerable  importance  to  be  borne  in  mind;  for,  nnder 
other  eircumstances,  when  the  expiration  is  prolonged,  indicating 
physioal  conditions  differing  from  those  which  give  rise  to  the  brun- 
cho-vesicular  respiration,  the  pitch  of  the  expiratory  sound  does  not 
become  higher  than  that  of  the  inspiratory. 

To  recftpituUtc  the  eharactcrs  of  the  broncho-vcsiouliu-  respira- 
tion: Itupiration  prcxonting  the  vesicular  and  the  tubular  quality 
combined;  sbortencd  in  duration;  pitch  raised;  intensity  variable; 
sometimes  alone  prcs.ciiU  Kr-iiiratiun  prolonged;  occurring  after 
an  interval ;  pitch  higher  tliao  that  of  inspiration,  and  often  the  iii< 
tensity  greater. 

Keeping  in  view  these  distinctive  characters,  it  is  not  diffionlt 
to  determine  clinically  the  existenuo  or  non-existence  of  the  aij 
under  consideration.  It  should  be  discri minuted  readily  from  ex^ 
aggcrated  or  puerile  respiration,  after  a  little  experience  in  pby>>^ 


AVBOVLTATIOV    lit    tilSBASE. 


183 


ports  mojificationtt  of  tlic  rcRpiratory  Roumls  due  to  tlif  prcACSM  of 
caverns  or  excavations  within  tlic  cho»I.  Tlic  fonnBtion  of  cavities 
of  greslrr  or  less  «ixp  belongs  to  tliv  nnturni  liistory  of  tobcrculoitis 
of  the  lungs;  they  result  also  from  abscess,  as  a  rare  termination  of 
pneumonitis;  also  fron  circumscribed  gangrene,  and  from  pcrfoni- 
tton  cetnblishing  a  fittnlous  communication  between  the  bronchial 
tubes  and  the  pleural  sac.  The  cavernous  respiration  consists  of 
the  sounds  caui^ed  by  tlie  entrance,  with  the  net  of  inspiration,  of 
air  into  the  cavities  incident  to  the  several  uHoctions  just  oaincd, 
and  its  expulsion  willi  the  act  of  expiration.  Laennoc  dowribcd 
this  KOtind  b»  revcniMing  that  of  the  bronchial  respiration,  but  dis- 
tingnishcd  bj  the  air  seeming  to  penetrate  a  larger  space  than  that 
of  a  bronchial  tube.  The  difference  between  the  cavemoas  and  the 
bronchial  respiration,  is  certainlj  not  very  clearly  de&ned  in  this 
description ;  and  the  two  sounds  arc  novp  conadercd  by  many  to  bo 
cwcntially  identical.  Skoda  takes  this  view.  The  laryngo-traeheal 
wunds  arc  frequently  referred  to  by  writers  on  this  subject,  as  offer- 
ing equally  a  type  of  the  bronchial  and  cavernous  respiration. 
This  view  is  incorrect.  The  cavernous  respiration  ia  a  distinct  phys- 
ical fcign,  and,  whi.-(i  wrll  injirked,  U  diitcriminatcil  from  the  bron- 
chial respiration  without  difficulty,  by  characters  which  are  quite 
distinelivc.  These  chncactcrs  relate  to  intensity,  quality,  pitch,  and 
rapidity  of  evolution.  The  intensity  is  variable.  It  may  be  fe*ble, 
or  more  or  less  intense,  but  rarely  acquiring  the  great  intensity 
which  sometimes  characterises  bronchial  respiration.  It  ia  rarely 
the  case  that  it  presents  the  character  of  the  blowing  reapir«tion  of 
Lnenncc,  vis.,  the  air  appearing  to  enter  and  emerge  from  the  car 
of  the  auseullator.  The  quality  of  sound  is  n on- vesicular,  in  other 
words  blowing,  using  thiti  terra  as  denoting  a  quality  different  from 
that  denoted  by  the  term  tubular.  The  quality  conveys  lo  the  ear 
the  idea  of  a  hollow  space.  The  differetieo  in  iliis  respect  betn'i,-«n 
the  cavernous  and  the  bronchial  r^-spiration  may  be  illuHtrsled  by 
blowing,  lirait,  into  a  cavity  formeil  by  the  two  bands,  and  aflerwanl 
ihrongfa  a  lube  formed  by  the  6ug«rs  and  palm  of  one  band.  The 
pitch  is  low,  coinpareil  with  that  of  the  traclienl  or  the  bronchial 
respiration.  An  expiratory  HOiiml  may  be  present,  and  if  so,  the 
pitch  ia  lower  than  that  of  inspiration.  Finally,  the  inspiratory 
•oond  ia  evolved  more  slowly  than  in  the  bronchial  respiration;  in 
other  word*,  it  does  not  so  promptly  nucompany  the  beginning  of 
the  respiratory  act.  Of  the  characters  just  mentioned,  those  which 
arc  specially  distinctive,  as  contrasted  with  the  bronchial  respirn- 


leo 


PHYSICAL   BXPtORATIO!!    OF   TBB    CBBST. 


Id  genersl  terms,  the  broRchoTeaiciilnr  respiration  rcprrcirDts  lU 
the  (lifTerent  ilogreefl  of  solidiGcation  of  lung,  falling  short  of  ocn- 
plete  or  considerable  solidifiAtion,  the  latter  being  represeotcd  ij 
the  bronchial  respiration.  The  characters  of  the  sign  varj  Mcctd- 
ing  to  the  degree  of  solidificnlion.  and,  by  means  of  ihese  T&riatiM^ 
it  ma;  be  detennined  whether  the  solidi6cation  be  slight,  modenii; 
or  ne*rl;  eoongli  to  furnish  the  bronchial  respiration.  For  exaupb, 
let  it  be  supposed  that  there  is  a  slight  increase  of  densitv,  tmckm 
exists  in  a  smnll  deposit  of  tubercle,  the  characters  of  the  broD(li»- 
vesicnlsr  respiration  denoting  this  condition  are  aa  follows:  TW 
bspiratory  sound  is  a  little  less  vesicular  than  in  health,  a  liltk 
tubular  <]ualitT  is  added,  and  the  pilch  is  a  Utile  higher;  the  exp- 
ratory  sound  is  somewhat  prolonged,  the  intensity  somewhat  greater, 
and  the  pitch  higher  than  in  health.  These  characters  denote  «W 
maj  be  called  a  slight  bronoho.Tesicular  respiration.  On  the 
hand,  let  it  be  supposed  that  the  solidificaiion  falls  hot  little 
of  the  amount  sufficient  to  famish  bronchial  respiration,  the  efaatic- 
ters  denoting  this  condition  are  as  follows :  The  inspiratory  sound  is 
almost  purely  tubular  in  quality,  only  a  little  vesicular  quality  is  pet- 
oeived,  and  the  pitch  is  high;  the  expiratory  sound  u  prolonged,  it- 
tcn.se,  and  high  nearly  to  the  ume  degree  as  in  the  bronohial  respi- 
ration. Now,  between  these  two  extremes  of  the  broncho- vesicnlar 
respiration,  every  degree  of  gradation  may  be  presented  in  diflereU 
cues.  In  proportion  as  the  increase  of  density  of  lung  is  small,  the 
characters  of  the  normal  vesicular  mDrmorwill  predominate  ovcrtiw 
characters  of  the  bronchial  or  tubular  respiration ;  and,  on  the  other 
hand,  in  proportion  as  the  solidiRcation  approaches  the  amount  re- 
quired to  furnish  bronchial  respiration,  the  characters  of  the  latter 
will  predominate  over  those  of  the  normal  vesicular  murmitr. 

The  respiration  is  broncho- vesicular,  not  purely  bronchial, 
wherever  the  vesicular  quality  is  appreciable,  however  eltght,  ia 
the  inspiratory  sound:  and  the  respiration  is  broncho-vesicular,  not 
normal  vesicular,  wherever  there  is  an  abtinrmal  diminution  of  the 
vesicular,  and  addition  of  tubular  quality,  no  matter  how  slight,  in 
the  inspiratory  sound.  In  proportion  as  the  vesicular  qualiiT  pr^ 
dominates  in  the  inspiratory  sound,  the  increase  of  density  of  long 
is  small,  and  the  elevation  of  the  jiitch  of  the  inspiratory  sound  is 
alight  in  proportion  as  the  vesicular  ijuHlity  predominate*.  Pfr 
eontra,  in  proportion  as  the  tubular  quality  in  the  inspiratory  soond 
predominates,  the  density  of  lung  \»  greater,  and  the  pitch  of  tlie 


181 


bspirator;  aouml  is  raiwd  in  proportion  se  tiie  tubular  quality  pre- 
flominales.  The  expiratory  sound  TarieH  in  correspondeDce  with  the 
TftriationR  of  tlie  iiiHpirntory  souDtl.  It  is  leas  prolonged,  lesa  in- 
|bnsc,  >nd  ]v»h  liigh  in  proportion  as  the  vesicular  quality  predomi* 
'n»i«3  in  the  inHpiraloryAound;  and,  pi-rcontra,  it  iaiiiorvpri>loiij:;ed, 
uiorL-  intense,  nml  higher  in  proportion  aa  thu  tubular  quality  pre* 
dominates  in  the  inspiratory  souiiil.* 

bThe  broncho- vesicular  respiration  i»  important,  u»  a  phyiiicnl  sign, 
pcciully  in  the  diagnosis  of  pulmouary  tuberculosis  in  its  early 
1^.  In  this  relation  it  is  a  sign  of  great  value.  When  the  nniount 
of  tuberculous  deposit  is  small  or  iDodemte.  eo  far  as  the  phenomena 
determinable  by  auscultation  are  concerned,  this  is  the  sign  most 
likely  to  be  produced;  hence,  in  conjunction  with  other  signs  and 
symptoms,  it  is  often  very  signi&csDt.  In  fact,  the  diagnosis  may 
binge  upon  the  question  nbether  a  well-marked  broncho-vesicular 
respiration  be  present  or  not.  In  this  connection  it  is  to  be  borne 
in  mind  (as  has  been  stated  already),  that  all  the  several  characters 
which  distinguish  this  sign  from  the  healthy  vesicular  murmur  ore 
bv  no  mexna  invariably  present.  An  inspiratory  sound  only  may  be 
appreciable.  If  this  be  leas  vesicular,  higher  in  pitch,  and  shorter 
in  duration,  with  a  greater  or  Ip»»  degree  of  intensity,  ihun  the  in- 
spiratory sound  at  the  summit  of  the  che.-<l  (wher^i  the  tuberculous 
Beposit  first  takes  place),  at  a  corresponding  point  on  the  opposite 
side,  the  respiration  is  broncho-vosicular.  as  clearly  almost  as  if 
there  were  added  the  characters  pertaining  to  the  expiratory  sound. 
>Q  the  other  band,  a  prolonged  expiratory  sound  higher  in  pitch 
hsn  either  the  inspirfttory  or  expiratory  sound  on  the  opposite  side 
lay  be  added. 

In  the  diagnosis  of  tuberculous  disease,  before  Attributing  to  a 
lorbid  source  the  sign  under  consideraiion,  we  arc  always  to  Inquire 
4iether  it  may  not  be  ineidont  to  a  healthy  condition;  in  other 
rords,  whether  the  points  of  disparity,  which  may  be  observed,  do 
lot  belong  among  the  variations  which  are  frequently  found  in  per- 
itonH  free  from  pulmonary  ditteaste.  This  question,  in  some  instanceit, 
Kives  rise  to  more  room  for  difficulty  and  doubt,  than  a  deci&ton  m 
ifds  the  reality  of  tlte  characters  which  distinguish  the  broncho- 


j  1  Dt-  Daocata,  in  hit  work  on  Diai^noBif,  propniM  th«  oiiTuu  Tcaioulii-bruucLial 
1  i>r  bronctK'-vndculiir.    The  two  tcrnn  might  bp  lun-d,  the  flnl  to  denoU 
aminaDM  of  the  voiuular,  and  thv  lultor  a  jirvdonilnaoce  of  th«  broncbla) 
jactcr>. 


in 


ratBicAL  axFLOBATio  or  tbi  chbst. 


latioa  IB  HMhk,  Au  the  MMrd 

MJlbghuBlfcllLMlril 

mm  eertaia  prBpwtJBB rf fcMhfcy 
This  bet  cUTMt  ke  laM  Mk>  of 


thebevlof  Am 
iatovUcfc  tkebrtftdnl 
nMlnUe,  are  to  W  fmuj 
as  tW  MiBBit  of  the  (kft 
the  fialc  of  grave  cfmo  a 
£ogfM>«.  Erron  pretoW/  oAes  ooear  fnm  the  vmnt  of  a  fttftt 
sppreciatioB  of  this  fatt.  The  feaahi  of  ezauBatioBa  of  the  At* 
n  a  eeneo  of  heakhv  |Hje<iue  lead  la  a  rale  ahich  aRbrda  greil  w 
■inaace  in  setlting  the  qofMioa  jast  BeMioBed.  If  the  readtfaiD 
refer  to  the  tamfantam  of  the  r^imt  ai  the  R^mtt  of  the  chMi 
tti  health,  aa  reipeett  the  phcaaafaa  jaciilreT  to  nspiratioa,  he  ail 
■ee  titat  coBitiaratira  fiaiaaliM  af  rwAeJkr  qnalitj  and  elovatioa  <f 
pitch  of  th«  hiFptratorT  fioncd.  a  atote  frcqimit  pnvcaee  of  tk 
Mood  of  expiration  with  or  aithoat  the  bupiratorr  eonad.  proloa^ 
tion  of  the  Utter  with  gmter  iateantT  and  elevation  of  pitrh,  m 
points  of  dispam;  peculiar  to  the  right  side^  In  other  words,  a  ttb- 
th-o  broaelio-veaiciitar  respiration  ia  natural  to  the  sammil  of  ib 
chpst,  in  front  and  behind,  in  a  cenain  proportioa  of  indirideali.* 
This  being  the  csM,  it  foUowB  that  the  qneaiion  as  to  this  modiiica 
tWB  of  the  respiratory  aotnid  being  doe  to  disease,  pertatna  to  iu 
preaeoee  on  ih«  right  aide  of  the  cheat.  A  aell-taarhed  relatirt 
broncho- vesicular  re«piration  on  the  right  aide  may  not  mdteaW 
more  than  a  natural  dltiparicv.  To  be  considered  a  morbid  ag»  <n 
thia  >iclc.  it  mast  be  associated  wiih  other  signs,  and  with  sTmpKiv 
poiiiling  empbaticall;  to  the  existence  of  tnbercalons  disease.  At 
an  isolated  sign,  reliiiDcr  mnst  not  be  placed  apon  it  in  that  sitnattoa. 
NoD-observanoe  pf  this  rale  exposes  the  practitioner  to  a  false  disj- 
noais.  On  the  left  side,  boverer,  the  probnbilities  of  (he  sign  being 
ddc  to  a  norusl  disparity  are  very  few.  In  this  situation,  it  is  of 
ttvelf  po«!tive  evidence  of  a  taberculons  deposit,  when  other  cireimi- 
•lanoitt  create  a  snspicion  of  the  existence  of  phthisis;  and  tt  is  of 
lesa  importance,  with  reference  to  the  diagnonis,  that  it  be  associated 
with  other  sigOK,  anii  wiih  symptoms  denoting  the  existence  of  tnber- 
enloua  diacik«c  when  it  is  sitoatcd  on  the  left  side. 

The  term  bronolu>>vei>icular  owes  its  pertineocy  to  the  use  of  the 
lenn  bronchinl  us  applie<l  to  the  sign  previously  conndered.  Vcwe- 
nlo-lubular  reapirution  would  be  preferable,  if  the  bronchial  respi- 
ration  be  cnllei)  tubular. 

6.   t'averiwH*  and  Amphoric  rfapiratum, — ^The  tens  caverDons  ha- 

*  B}'  thp  iNui  rfbttivt,  I  mean  tlic  roUiion  or  one  tid«  ot  tbo  dicM  to  the  otbw 
tU«,  In  c'irm ponding  roglon*. 


i 


AOSODLTATIOH    tS    MSBARB. 


188 


Qioi]!fi cations  of  the  mpirutory  tiountls  due  to  (he  pronence  of 
learemH  or  cxcnvations  witbin  tho  chest.     The  fonnntion  of  cuvitics 
[of  greater  ur  Uft  size  belongs  to  the  natural  hiHtory  of  tuberculosis 
[of  the  lungs;  they  result  also  from  abscess,  as  a  rare  termination  of 
nenmonitis ;  also  from  drcurascribed  gnngrenc,  and  from  perfora- 
Itioo  eetabliebing  a  Ei^tnlous  communiciition  between  the  bronchial 
Ittibes  anil  the  pleural  sac.     The  cavcrnuus  respiration  consists  of 
'the  sounds  caused  b_v  the  entrancf.  with  the  act  of  inspiration,  of 
;  air  into  the  c»viiic(i  incident  to  the  scveru]  tilTcetions  justt  named, 
tnd  its  expulsion  with  tbc  act  of  expiration.     Luenneo  described 
this  sound  as  resembling  that  of  the  bronchial  respiration,  but  'lis- 
nguished  by  the  air  seeming  to  penetrate  a  larger  space  than  thnt 
tof  m  bronchial  lube.     The  difference  between  the  cavernous  and  the 
broDcliiftl  respiration,  is  certainly  not  very  clearly  defined  in  this 
description;  and  the  two  sounds  arc  now  considered  by  many  to  be 
eflscntially  identical.     Skoda  takes  this  viow.     The  laryngo-tracheal 
sounds  are  frequently  referred  to  by  writers  on  this  subject,  as  oSer- 
ing  eqnally  a  type  of    the  bronchial   and  cavernous  reapiration. 
This  view  ia  incorrect.    The  cavernous  respiration  is  a  distinct  phys- 
ical Bign,  and,  when  well  marked,  \n  ili.HcriminHtcd  from  the  bron- 
chial respiration  wiiliout  difficulty,  by  clianictcrs  which  are  quite 
dietinctire.     These  characters  relate  to  intensity.  i|unlity,  pitch,  and 
rapidity  of  evolution.     The  intensity  is  variable.     It  may  be  fi'eble, 
or  more  or  less  intense,  but  rarely  acquiring  the  great  intensi^ 
which  sometimes  characterizes  broDcliial  respiration.     It  is  rarely 
[  the  case  that  it  presents  the  character  of  the  blowing  respiration  of 
Laennec,  viz.,  the  air  appearing  to  enter  and  emerge  from  the  ear 
of  the  anseultalor.     The  quality  of  sound  is  non-vesicular,  in  Other 
votiIb  blowing,  using  this  term  as  denoting  a  quality  ditTerent  from 
that  denoted  by  the  term  tnbulnr.     Tlic  quality  conveys  to  the  ear 
the  idea  of  a  hollow  epace.     The  differenen  in  thitt  rcHpeet  between 
the  cavernous  and  the  bronchial  respiration  may  be  illuMtrated  by 
blowing,  fintt,  into  a  cavity  formi'd  by  the  two  hands,  and  afterward 
ifaroagh  a  tube  formed  by  the  lingent  and  palm  of  one  hnnd.     The 
;  [Mtch  is  low,  compared  with  that  of  the  tracheal  or  the  bronchial 
respiration.     An  expiratory  sound  may  be  pre?^rnt,  and  if  so,  tbe 
pitch  is  lower  than  that  of  inspiration.     Finally,  the  inspiratory 
\  sound  ia  «roIv«d  more  slowly  ilmn  in  the  bronchial  respiration;  in 
other  worilH,  it  does  not  s»  promptly  iiccompimy  the  beginning  of 
the  respiratory  act.     Of  the  chnruciers  juBt  mentioned,  those  which 
arc  specially  distinctive,  as  contrasted  with  the  bronchial  respira* 


184 


FBTSICAL    SXPLOBATIOS    OF    TBB    CHKilT. 


tioD,reUle  lotb«pUcb  and  qiulilj  of  sonsd.  The  iDCpizmtei^  mid 
it  lover  io  pitch  than  in  the  bronchul  rcspiratSoD  aad  LI-.*.-* 
The  BODod  of  expiration  is  blowing  and  lower  th«a  that  of  i&ifnn- 
tioD,  the  rererse  obtaining  to  ibe  broncitial  respiration.  This  Hal»- 
nent  is  based  on  nanieroas  obserrationa,  in  wkidt  th*  ptieno»tn 
were  noted  dnring  life,  and  the  eiistence  of  cavities  is  Uw  ntv- 
dons  where  the»e  cbaraciere  of  the  respiration  hw]  been  flt«£s^ 
b«iag  demonstrated  after  death. 

In  detennining,  clinicallv,  the  existence  of  the  caremotu  rc»pin- 
bon,  other  circtun&iances  than  its  intriosic  characten  maj  be  ukm 
into  account.  It  is  beard  orer  a  circunkscrihed  ar«a,  which  com- 
sponds  to  the  sixe  of  the  cavii;.  It  is  an  intemiiitent  sien,  bciag 
absent  wlicn  the  cavity  is  filled  with  liquid  morbid  prodncts,  4r 
when  the  tabes  leading  to  it  are  obstructed.  Occurring,  in  the  not 
majoritjr  of  the  instances  in  which  it  exists,  in  the  progrcsi  rf 
tabercnlosis,  it  is  found  at  the  sumniit  of  the  cheat ;  the  caritia  b 
that  afffction  being  formed  at  or  near  the  apices  of  the  lungv.  It 
may  be  aitsociatcd  with  other  eavcrnou.-t  signv,  rji.,-  amphoric  or 
cimckcd-mctal  resonance,  csvcmout  whisper,  gargling,  and  metallic 
tinkling.  Freqitentl;,  the  symptoms  aflord  strong  corroboratin 
erideoee  of  the  esbtcnoe  of  a  cavity. 

When  a  caritr,  or  cavities,  exist  in  the  lungs  in  connection  with 
either  of  the  affections  which  have  been  named,  the  presence  of  ike 
Gsvemons  respiration  depends  on  certain  conditions.  The  cavkj 
must  be  empty,  or,  if  purtially  fillc*!,  the  opening  or  openings  with 
which  it  commanicates  with  the  bronchial  tabes,  must  be  itiinaltd 
above  the  level  of  the  liquid  contents.  Intermittency  arises  from 
the  fact  that,  at  different  periods  of  the  twenty-four  hoara,  a  carjly 
may  be  completely  filled,  partially  filled,  and  entirely  empty.  Il 
in  less  likely  to  be  beard  at  an  early  hour  of  the  morning,  becaase 
liquid  cr>nu'nts  usually  accumulate  daring  sleep,  and  are  renond 
by  effort*  of  expecloralion  more  or  le*»  prolonged,  or  rcpcaltd, 
after  waking.  The  cavity,  of  course,  mii^t  comiiiuuicate  by  one  or 
more  openings  with  the  bronchial  tubes.  The  fixe  of  tiic»e  opca- 
ings  will  affect  the  »ign,  in  the  firnt  place,  directly,  the  int^-nsity  of 
the  sound,  other  iLtngs  being  ciiual,  being  proporti  innate  to  the  free- 
dom with  which  the  itir  is  admitted  to  the  cavity ;  and,  in  the  second 
place,  indirectly  by  favoring  the  removal  of  the  liquid  contents  by 
expcctorntiuD.  The  opening,  or  openings,  arc  liable  to  become  tem- 
porarily or  permanently  obstructed.  Their  form  and  sim  sometitiiea 
are  such,  that  tbc  current  of  air  in  passing  to  and  fro,  gives  rise  to 


[ON    IK 


185 


iTtnlitious  sounds,  which  rentier  the  cavernous  respiration  inap- 
prcciibli>.  The  bronchial  tubes  leading  to  the  cavity  must  be  un- 
nbstructed,  and  free  from  loud  adventitious  sounds  which  iire  frc- 
laentlv  generated  within  them.  The  walla  of  the  cavity  muHt  not 
be  BO  rigid  and  unyielding  as  not  to  collapse  and  oxpnnd  with  the 

Itemate  acta  of  insplraliuu  and  expiration;  othcrwino,  it  will  not 
be  sacccssivcly  filled  with  nnd  emptied  of  air.     The  cavity  roust  be 
Fof  a  certain  «ixe,  and,  other  things  being  equal,  the  cnvernini'*  rcMpi>^ 

ttion  will  be  lunrkeil  in  proportion  to  its  tniignitiide.     The  prcft- 

soe  of  the  ttign  will  depend  on  the  situation  of  the  cavity.  Situ- 
•ted  aupcrlicially.  or  near  to  the  exterior  of  the  lung,  the  gimiid 
may  be  apprcriable  when  it  would  not  have  reached  the  car  through 
■  layer  of  pulmonary  parenchyma. 

The  condition  of  the  lung  surronnding,  or  in  the  vicinity  of,  the 
cavity  is  ai>  important  circumstance,  generally  there  is  more  or 
Ic»s  solidification,  giving  rise  to  tho  bronchial  reapiration.  This 
sometimes  assists  by  contrast  in  determining  the  presence  of  a  cav- 
ernous mpirntion,  but  in  other  instances  it  drowns  the  latter  and 
prevents  it  from  being  appreciated.  In  consequence  of  its  depend- 
ence on  so  many  contingencies,  it  is  only  in  a  certain  proportion  of 
the  cases  in  which  a  cavity  or  cavities  exist,  that  auscultation  suc- 
ceeds in  discovering  a  well-marked  cavernous  reiipiration ;  nnd  fre- 
qaently  in  the  instances  in  which  it  is  discoverable,  it  is  found  onl^ 
after  repeated  explorations.  Fortunately,  as  a  physical  sign,  it  is 
of  less  importance  practically  than  other  signs  involved  in  the  ding- 
noeis  of  the  affections  to  which  the  formation  of  cavities  \a  incident. 
A  successful  search  for  a  cavity  requires  aonie  care  and  patience. 
The  object  is  to  loenline  within  a  clrunmscrlhcd  space  a  non -vesicular 
taspiralory  sound,  blowing  or  non<lubular  in  quality,  and  low  in 
pitch,  evolved  somewhat  slowly,  and  an  expiratory  souml,  blowing, 
and  lower  in  pitch  than  the  inspiratory.  Tho  lowncss  of  the  pilch 
of  inspiration  compared  with  the  bronchial  respiration  Is  mentioned 
hy  Walshe  and  others;  but  the  rehiiive  lowness  of  the  pitch  of  ex- 
piration compared  with  the  inspiration,  was  not,  to  my  knowledge, 
pointed  out  prior  to  the  publieattou  of  my  prize  essay  in  18iJ2.  This 
constitutes  a  highly  distinctive  characteristic  of  the  cuvernous,  as 
distinguished  from  the  bronchial  respiration;  and  it  is  rendered 
especially  important  hy  tho  fact  that  other  signs  of  a  cavity,  for- 
merly considered  to  he  distinctive  (I  refer  more  particularly  to  the 
vocal  sign,  pectoriloquy),  have  now  justly  ceased  to  he  regarded  in 
that  light.    The  fact  of  a  non-vesicular  sound  being  restricted  within  a 


186 


PBT6ICAL    SXPLORATIOK    OF   THE    CHEST. 


ciTcnm!~Rrib«d  9]inc«,  ia  hy  do  means  reliable  u  DufBcient  erid«aee 
that  t!ie  respiration  ia  cavernous.  They,  who  consider  the  bmt- 
ohial  and  caremotu)  respirations  idcntica]  in  character,  are  ob1i|td 
to  base  the  discrimination  on  that  otrcuni stance.  Hut  a  brotichnl 
respiration,  at  the  summit  of  the  chest,  is  not  tu)fre<]uentl^  circim- 
scribed  within  narrow  limiU;  hence,  crron  of  diagnottis  are  neecfr 
aarily  incident  to  reliance  on  this  point.  I  huve  known  mistaka 
arhiing  fVmn  thi»  »Ofirc«  to  be  committed  by  experienced  «u»calu- 
tor*.  Taken,  howerer,  in  connection  with  other  point*,  it  b  rf 
con«ideriib1c  importance;  and  in  order  better  to  circumscribe  the 
aren  whence  MiindH  arc  received  by  the  car,  the  Methoscope  >hoaU 
be  »»c<l  in  preference  to  immediate  naecnltation.  To  determine  tbe 
non-veniciilnr  (junliiy  of  the  Hotind  at  a  saspectcd  point,  a  compari- 
aon  may  be  mndc  of  the  oonnd  at  this  point  with  that  beard  enr 
portions  of  the  cho»t  where  the  vesicular  quality  is  dinlinclly  p«- 
nerved.  To  determine  that  the  pilch  ]»  lower  than  that  of  Ik 
bronohial  rcspiralioti,  in  cn^cx  of  tutierculoi'i.'*,  the  sound  at  a  IW- 
peeted  point  mny  fre<iuently  1>c  controfited  wiih  that  at  otlicr  point* 
at  the  summit  of  the  chest,  where,  owing  to  the  presence  of  cni^ 
tubercle,  the  bronchial  respiration  ia  well  marked.  Or,  if  thU  ctm- 
parison  be  wanting,  it  may  be  conlraated  with  the  sounds  heud 
over  the  trachea.  In  some  inflnnceii,  owing  to  the  cavity  bang 
surrounded  by  solidified  lung,  the  cavernous  respiration  will  be  pre- 
sented in  strong  contrast  to  the  bronchial  respiration,  which  oa  lU 
sides  defines  the  boundaries  of  the  excavation. 

In  a  case  in  which  1  localized  a  cavity,  the  following  tutfrestisj 
circumstance  w;is  noticed.  At  the  beginning  of  the  inspiratory  act 
the  sound  was  tubular  and  high  in  pitch,  but  at  about  the  middle  sf 
the  act  the  pitch  iibruptly  hecnme  low,  and  the  qoality  blowing.' 
The  iiiMpirntion  was  followed  by  n  feeble  expiratory  sound  low  is 
pitch.  In  ihiB  ease,  a  poi<t-mortcm  cxiimiiintion  revealed  a  nviiy 
comrannicating  at  the  point  whi-re  this  peculiarity  was  observed  will 
a  bronchial  tube  of  the  f'lte  of  a  goose-quill.*  This  instance  ei- 
empli6ed  a  combination  of  the  cavernous  and  bronchial  re.Hpi ratios. 
This  combination  I  have  rcpeotcdiy  noticed.  The  characters  of 
the  bronchial  and  the  cavernouB  respiration  mny  be  intermingled  in 
varied  proportions.  The  combination  of  the  Iwo  sign*  may  bees- 
pressed  by  the  term  hrotieho-eavervout  rttpiration. 


>  Tho  rckdcr  ii  romindcd  that  I  uu  th«  Urui  blmring 
whidi  >-  nvillx-r  liibiilnr  iior  Tt^lculnr. 
■   Vidt  Aiijiundix  to  Eoa;  aa  Variationi  ia  Pitch,  elo. 


d«nollnf  a  qoalitf 


ACBOntTATIOlT    JV   DIflRASB. 

Of  the  seTcral  affections  >n  which  n  cavernous  ri'spirstion  mny  he 
[)Berre«l,  tuberculosis  is  the  one  in  which  it  occurs  in  the  vnst  mn- 
of  instances.  The  other  affections  ore  extremely  rorc.  In 
iioiBcrihed  gangrene  and  abscexs,  moreover,  the  cvnditioDS  ro- 
|uire4  for  the  production  of  the  sign,  ore  much  more  infrc<|iiently 
Dmbined  than  in  the  cavcmons  stage  of  phthisis.  Skoda  stntcs 
that  in  the  few  instances  in  which  an  excavation  results  from  pneu- 
monitis, the  space  in  so  conntantly  filled  with  pus  and  sanies,  that  it 
atmost  never  gives  rise  to  dintinctive  sounds,  determinable  either  by 
percnsaioD  or  auscultation.  I  have,  however,  observed  well-marked 
cavernous  respiration  in  a  cavity  formed  by  an  abscess.  In  pneu* 
mo-hydroihorax  the  pleural  Kac,  which  may  be  more  or  \c»»  circum> 
scribed  by  morbid  «ilhc»i(in»,  constitutes  a  cavity  in  which  the  air 
may  enter  with  inKpirvlton.  and  be  expelled  with  expiration,  through 
the  fistuIouK  comTniinication  with  the  bronchial  tuhc!>.  There  i*  »liH 
another  mode  in  which  a  cavity  may  be  formed  within  the  chei^t, 
vis.,  by  means  of  a  pouch-like  dilatation  of  a  bronchial  tube.  Tbis 
i»  very  infrequent,  but  it  is  to  be  borne  in  mind  as  «  possible  con- 
dition giving  rise  to  the  sign  under  consideration.  In  view  of  the 
nstty  greater  ratio  of  tiiberoulous  excavations  to  those  incident  to 
ft]|  other  aSectiona,  when  the  fact  of  the  existence  of  a  pulmonary 
cavity  is  determined,  it  might  be  attributed  to  phthisis,  almost  by 
the  lair  of  probabilities  alone;  but  the  situation  of  the  cavity 
affords  additional  evidence.  A  tubcroutoux  excavation  in  forty-nine 
out  of  fifty  oases  is  situated  at  or  near  one  of  the  apices  of  the 
long,  while,  on  the  other  band,  cavities  from  gangrene,  abscess,  or 
perforation,  are  more  likely  to  occur  elsewhere. 

As  a  sign  indicating  the  nature  of  the  disease,  in  indiridua!  cases, 
csvernona  respiration  is  of  minor  importance.  It  is  discoverable 
in  only  a  certain  proportion  of  the  cases  in  which  cavities  exist. 
Tubercnlou*  excavations  arc  very  frequent.  They  are  found  after 
death  in  most  subjects  dead  niih  jihlhi-^is,  »nd  the  prevalcncu  of  this 
fatal  disease  in  all  countries  ia  well  known.  Yet,  in  cases  of  ad- 
vanced phthi-iis,  a  well-marked  cavernous  respiration  is  by  no  means 
always  discoverable,  even  after  repeated,  careful  explorations.  And 
when  canities  are  formed  in  the  progress  of  any  of  the  affections 
named,  but  especially  in  tuberculosis,  occurring  at  a  late  period  of 
the  disease,  the  diagnosis  has  already  been  determined  by  other  signst, 
together  with  the  concomitant  symptoms;  hence  a  cavernoas  rcspi* 


PKTIICAL    KXrLOBATIOK    Of    TBS    CflSSt. 


-<y 


id 


Sfaraorer,  tsMdrf 
jwrh  litr  iHlrtirinn  rf  «!*»- 
cUal  tobe,  llii  iig,M  ■MlijiB|iliiwi.  iin«|iiilin  iiir<ini^<pi  iiniii 
tiea,  are  ■■Krifl  to  rcndn-  tbe  fagoaw  ca«7  ud  (Mdre^  m  iki 
thm  htur  k  redoadnt,  aad  «uc)K  as  a  matter  of  mit  aiifa  laMml, 
MMtliam  harJlj  eaapcantea  for  the  paina  aeraMaiy  f^BHwak 

Aoaboonna)  nodikatioii  of  tlw  reaptratsry  aoaad  ■*  ealM  w- 
fimr  rnpmfMa.  It  a  tncideat  to  a  cantj  eqaaDj  vitk  tke  m- 
craooa  rwpirilioo,  and  boib  are  lotaetinea  eoMfcJatd,  ilthnagb  it 
HieclnniMi  of  tbeir  prodactioo  b  «» tbe  aaac-  It  aafcw  to  repri 
tk«  ampttoric  ai  a  rarietj  of  the  eavenooa  resfOiatiMt.  If  a  fu- 
son  blow  geoilj  npoo  tbe  open  moutb  of  aa  etaptjr  vial,  a  GMadii 
produce-^  which  ha*  a  natical  iatOQatioo.  TUi  womad  im  maakgiM 
to  tliat  which  eharmcterize*  tbc  ampboric  rcopAratioa;  is  etl»ef  *«rii^ 
wbenerer  a  rettpiratorj  teoad  preaenu  a  musical  tone  it  is  said  to  bt 
amphoric.  Tbi*  aoniKi  U  rariable  a>  re^rds  inleitai^.  It  has  bcci 
beard  evvo  wbeit  the  ear  is  remored  at  a  little  disuiiM  fraa  tbt 
chest.  It  is  geoerall;  couSued  lo  a  circumscribed  space,  bat  il 
•ametimea  diflnsed  more  or  less  over  tbe  chest.  It  majr  accoapujr 
either  rerpiratorj  set.  The  mode  of  its  prodaciiOD  within  the  ebed 
is  probably  the  umv  as  in  the  illiutnitioo  aiciitioaed.  It  b  ul 
caused  by  tbe  frev  eircttlstion  of  air  within  a  cavity,  bat  bj  tbe  current 
of  air  in  the  bronchial  tubes,  acting  upon  tbe  air  contained  withia 
the  cavity.  In  this  rvspt-ct  it  difTtT?  frvm  urdiosry  cavernous  revpi* 
ration.  Tbc  special  conditions  which  it  requires  are,  a  cavity  of 
COBsidcrable  diu-.  of  courM,  partially  cir  oniirely  free  from  Uqnid 
contents,  and  the  witlls  of  tbt-  cavity  sufficiently  firm  not  to  andergo 
complfie  collapse  ond  cupniision  with  expiration  and  twipiratioo. 
In  numc  in^tnncrN  a  partial  <liHplucriiii'nt  of  air  takcd  place  in  conse- 
quence! of  a  ccrlaii)  amount  of  colUp»c  and  citpausivn  of  the  walls 
of  the  cavity,  and  then  there  may  exist  an  ordinary  cavernous  res- 
piration with  iht'  Ktiiphoric  sound  ftuperiidded. 

It  is  rarv  that  nn  excavation,  except  it  proceed  from  tubvrcnlout 
disease,  in  of  ttufBcivnl  siz<;  and  provided  with  walls  KulEcicntly  firm 
to  fulfil  the  requisite  pliy«icnl  conditions.  It  is  n  rare  itign  in  tuber- 
culous di^-ane.  The  conditions  itre  mo«t  likely  to  exist  in  pnrumo- 
hydroihorax :  and  hc-ncc,  when  the  sign  is  present  it  generally  do* 
notes  that  affoction.  It  is  stilted  by  Skoda  tliat  for  the  production 
of  an  amphoric  sound,  a  free  cammanicBtion  between  the  bronchial 


AOSCDtTATIOS    15    IH8BABB, 


I 


ibes  and  the  pleural  sac  or  a  palmonarj  citcaT-ntioii  i»  not  ncwssarj. 

e  ihinkfl  that  the  sonorous  vibrations  may  be  communicatod  to  the 
.ir  contained  wJttiin  the  cavity,  by  the  column  of  air  in  the  tubes, 

rough  an  intervening;  septum  of  pulmonary  tiitttue.  This  opinion, 
ms  remarked  by  Bnrth  und  linger,  is  supported  by  the  fnct  that  the 
experiment  of  producing  an  analogouti  Round  by  hlowiug  into  a  de- 
canter or  wator-croft,  ia  aucceesfnl  vlien  the  mouth  of  the  vessel  is 
covered  by  a  very  thin  diaphragm,  for  example,  a  single  layer  of 
l«tter-pap«r.  The  aound,  under  these  ciroumstanceii,  is  more  feeble, 
and  more  forc«  in  blowing  iit  required. 

Amphoric  respiration,  when  present,  indicates  very  positively 
either  pncumo-thorax,  or  a  cavity  wiihlo  the  lungs,  lis  absence, 
however,  is  not  evidence  that  one  or  the  other,  or  both  morbid  con- 
ditions, do  not  exist.  Tbi«  remark,  applicable  to  ordinary  cavern- 
ous respiration,  is  still  more  so  to  the  amphoric  variety.  Considei^ 
ing  its  infreqaency,  and  in  vivw  of  tlie  fact  that  the  diagnosis  of 
the  affections,  in  connection  wiih  which  it  occurs,  is  in  uowiKe  de- 
pendent upon  it,  the  sign  is  interesting  more  as  a  clinical  ouriosity 
than  for  its  practical  vala«. 

The  three  forms  of  morbid  respiration  just  considered,  rii.,  the 
IronchiaU  the  broncho- vesicular,  and  the  cavernouR,  constitute  signs 
embracing  abnormal  modifications  in  quality,  pilch,  etc.,  of  the  nor- 
mal rcfpiratory  sounds.  In  place  of  a  summary  of  the  distinctions 
which  have  been  described  in  the  preceding  page«.  the  subjoined 
tabular  view  is  appcndi^d,  by  means  of  which  ihc  render  may  review, 
ftt  »  glance,  the  distinctive  characters  pertaining  (o  the  three  forms 
of  morbid  respiration  just  named,  and  compare  them  with  the  char- 
acters which  belong  to  the  healthy  vesicular  murmur. 


yu»  0/  (A«  Di»lin<tnt  Charactm  t^  Ou  BronaKiai,  (Ac  SrmwAo-oHicM^ar, 
onrf  tie  Cbwnotu  He^iratimt. 


KoauAL  TBsicriAa  Muruve. 


tiupimlvtit. 
||lar  in  •jiulUy.     I>ow  in  |iltcb. 
bui  cipimlion  •«  6  ta  1. 


KipiratiiM. 

Short  in  iluratiuD,  BTPrts'iS  about 
|lb  IvQgth  or  iDipirttion.  Low  in- 
trnae  Uian  ihc  iiiipintl«n.  Ottin  tb- 
•♦ni.  P'Mti  lower  Xhtui  that  of  iiupini- 
tion.  Inipiration  and  •xplr*li«n  con- 
Unaoiu. 


rBisiOAL  ixriOBATioB  at  ima  chizt. 


LSnmiTMv. 


f^f '■■"'■' 


iboruMd  In danuWa.    Bapi>dl7  *T«(r-    huti  ika  the  iwpinfiaa.    Gtac- 
d.     Ow»i(wDj    pfmat   withovt    •    kIIt  bom  taliBia  tkaa  tbe  «spbUli& 

«f  Ika  iw)<mi— ■  An  inWrral  U- 
!«•••  lai|iliMlin  Bad  ezfrinlBKi 
Saaatiaei  pirw««  vitbout  ••Mudif 
tifiraliiiK. 


SboruMd  In  danuWa. 
pi,    Ow»i(wD]r 


BKOXCStt-vmcTTLAB  BsaMkAnav. 


Tkc  tubular  ki>d  lb«  vMl««hr  qoalilf 
oombincd  in  varied  propanioMi,  and 
ih«  ^tck  ntbad  In  jvopovtlaa  la  Ik* 
•moakt  of  tabular  qu«lit]r.  Daratioo 
ft»q(ieatl7*hoii«*ied.  UomiaiuD j  pra- 
■oit  witboat  a  Muiid  of  vxpiratiOD. 


Prolonfnd.     UttttrallT  (Bora  Ul 

tfaan  tbr  i»ipi'raiiaa-  UKialljr  { 
l^t«k  Boaawhat  hi|,hai  than  tkal  *t 
iniptrBlion-  Ad  intcrral  ba<«a(«  ia> 
•piralloH  aa^  vipuatlon.  SoaiadBa 
prawBl  «itbout  a  soand  of  latjinA*. 


/■upirafim,  Espii^km. 

BloinBi,i.«.,  noo.TctictilM' and  ana-  Qnalitf  bUiwing.    Piieh  lover  titti 

tabular  is  qualily.    Pilcb  lo«.   8lo«ly  that  of  Inapinliob.      SoumUibm  ■•■ 

CToUod.     SomctiiDci  ampfaoric.  pfaorie. 

The  r<MDsin!ng  division  of  tbe  tntxlificatio&s  in  qualitr.  cte.,  of 
respiratory  soundu,  coioprisrs  those  relating  to  rhytlin.  Tlie  mhA 
virions  ani)<T  tb»  liend,  nve  one,  are  among  the  constilnent  etc- 
mrats  of  the  signs  which  have  been  considered.  A  brief  notice  «f 
them  will  therefore  sufGoc  in  the  prc«cnt  connection.  The  modifi- 
cations in  rhjihin  which  arc  of  imporlnnce  in  diagnosin  arc  three  in 
number,  vix.:  1,  shortened  inspiration;  2,  prolonged  expiration;  i, 
interrnpted  respiration.  The  two  first  hare  received  attentioa  a 
eoniieclion  with  exaggerated,  feeble,  bronchial,  and  broncho-vcaca- 
lar  respiration. 

7.  Shortetied  trw^n-irfiOTi. -^Abnormal  shortening  of  the  insptr»- 
tory  sound,  occurring  as  one  of  the  elements  entering  into  s^ns 
irhicb  have  been  considered,  is  of  two  kinds.  As  it  is  presented  id 
the  feeble  respiration  iiioidcnt  to  emphysema,  it  forma  what  is  called 
deferred  inspiration.  Tbe  inspirator;  sound  does  not  ooDunenee 
prior  to  the  middle  or  toward  the  close  of  the  inspirator;  tet. 
Ilcnce  the  propriety  of  the  term  deferred.  With  the  ear  applied  to 
the  chest,  tbe  expansive   movement  is  frequently  felt   for  eome 


fATIOH    IK    DI8SASB. 


191 


im«  before  any  flounil  is  heard.     Ttie  nuirmur  is  heard  in  healtb 

fitfa  on  intensity  incronninf;  from  the  beginning  to  the  end  of  the 

liratorjr  act.     Whtni,  therefore,  the  sound  become*  abnormally 

eble  in  cinphy^eaia,  it  is  ioaudible  antil  the  inteustty  increases  to  a 

ertain  point.     In  this  way,  with  the  progre*:"  of  the  disease,  it  is 

some  instances  at  length  extinguished;  the  suppression  estenda 

>re  and  more  toward  the  end  of  the  act  of  inspiration,  until  the 

>and  entirely  ilisnppcnrs.     The  duration  of  the  inspiratory  sound 

<  diminished  in  a  different  manner  in  the  bronchial  and  the  broncho- 

vesicular  respiration.     The  sound  is  quickly  evolved,  comnteneing 

bcarly  nt  the  commencement  of  the  act  of  inspiration,  and  ends  be- 

^re  the  close  of  the  act.    The  inspiratory  sound  in  this  ca«e  is  said 

to  be  unSnufied.     The  difference  in  these  two  forms  of  shortened 

ioapiration,  it  will  be  observed,  correaponds  to  the  difference  M 

respects  the  situation  in  which  the  sound  is  generated.    A  re:AiciiIar 

inspiratory   murmur,    when   shortened,   is   deferred ;   a   shortened 

ttroDcbial  inspiration  is  always  unfinished.     Another  point  of  dis* 

Unction  is  involved  in  the  foregoing,  viz, :  a  shortened  bronchial  or 

unfinished  inspiration  is,  at  the  same  time,  notably  changed  in  quaU 

Htj  and  pitch;  a  shortened  vesicular  or  deferred  inspiration  offers 

nuch  lea  change  in  other  respects.     To  treat  here  of  the  diagnostic 

signiGeaaoc  of  this  rhythmical  modification,  would  be  to  repeat  whtt 

has  been  already  fully  prcientcd. 

As  the  ooDHcqucncc  of  an  unGniitlied  inspiration,  an  iutcrval 
occur*  between  the  inspiratory  and  the  expiratory  sound.  Tho 
dorntioQ  of  this  interval  is  proportionate  to  the  extent  to  which  the 
inspirstion  is  shortened.  Regarding  this  as  a  distinct  modifiealion 
of  rhythm,  it  is  called  dixridrd  respiration.  Division  of  the  two 
sounds  of  respiration  is  one  of  the  several  elements  of  the  bronchial 
and  the  broncho-vesicular  respiration.  It  is  a  change,  however,  en- 
tirely dependent  on  the  unfinished  duration  of  the  inspiratory  sound, 
aud  it  suffices  to  notice  it  as  incidt-ntal  to  the  latter, 
fc  8.  Prolonged  expiration. — Although  Laenneo  did  not  overlook 
^Ite  fact  of  the  existence  of  an  expiratory  soand  in  health,  the  iin* 
portance  of  its  abnormal  modifications  escaped  the  allenlion  of  the 
illustrious  discoverer  of  auscultation.  His  observations  of  the  phe- 
nomena of  disease  referable  to  modified  respiratory  sounds  were 
confined  to  those  pertaining  to  the  inspiration.  The  honor  of 
having  first  called  attention  to  the  value  of  the  expiration  in  physi- 
il  diagnosis  belongs  to  an  American  physician,  arrested  by  the 


bsad  or  4mA  at  A*  tkrofcaU  of  > 
of  Btfcal  iriiirii  Is  18SS,  Dr.  J. 
a*  tfcattae  proMCsUng  hb  •(■£(•  a  hrk,  eaaaaHCMed  'faf 
to  the  S$tim  Ml^itmL  ^OJmnmlMm,  —  Iha  w^JM  of  »  praloigii 
ezpimory  toaad  as  as  cariy  asl  pramaiai  fiBatare  of  dte  bnaoMil 
rtaptatMO,  aad  M^atally  aMHtetiag  aa  iapai  mil  p^wal  ap 
«f  the  fnc  Mage  of  piMlMn.  ¥nm  tUa  cpack  bst  bv  dated  tb 
e—mefHM  of  obaerTattoea  w}aA  bare  waitoed  tbr  expintMj 
cearwly  mfmor  lo  tbe  htspintonr  sowkd,  ra  iu  relaiioM  lo  Am  fi»- 
tmciirt  ehmneum  of  tlw  broaehial,  Ae  Ww ct  B-Te»euUi-.  and  lb 
aareraoaa  Rapintioo.  Aa  nmJtr  hat  ooIt  to  |^aaoe  ai  iW  tat*- 
lar  fie«  of  tke  character*  ilJBfiagaiilii  iig  sereralljr  tbo  agas  jal 
mcBtiooed,  to  pcreeiro  the  bnportaoee  of  tte  ahaonaal  ^angm  ii 
Apalioe  aa  well  la  in  the  iotPDntj  ud  fiteb  of  the  sooud  at  o- 
piiatioa.  A  proloaged  cipiTaiion  has  been  alao  aeea  to  aotcr  iw 
tlw  cbaracten  distingaishiDg  exag^ntcd  respiralioD,  aod  to  eoa- 
atinite  a  atriking  festare  of  tlia  oppo*n^.  ria.,  feeble  mptratiw  n 
Mtcnplified  io  eertain  casea  of  emfbjieat^ 

Diflemic«a  in  other  partknUrs  than  daratioo,  and  <«pcc)allj  mI^ 
ationa  in  pilch,  are  important  to  be  conaidered  in  eooaectioa  wilk 
prolongation  of  tbc  inxpiratory  aomnd.  Tha#,  in  bmiMAial  ttafin- 
tion.  the  expiration,  while  it  is  ioereaMd  tn  length,  is  more  inleoM 
and  hije;her  in  pitch  than  the  sonnd  of  infpirutioo.  ^e  aame  difl^ 
eoee  holda  good,  to  a  greater  or  less  extent,  in  broacho-TeneBhr 
reopiration.  On  tbe  other  hand,  in  caverooiu  respiration,  the  ei- 
piratorf  Honod  i»  generallir  feeble  and  lower  in  pitch  than  the  aooal 
of  inapiralion.  In  exaggerated  respiration,  tbe  expiration  b  km 
rolenae  than  tbe  inspiration,  and  the  relstireljr  lower  pitch  wlueh 
tbe  latter  baa  ta  normal  respiration  is  preserved.  Tbe  same  is  am 
of  tbe  prolonged  expiration  in  emphysema:  at  all  eTenia,  it  d»a 
not  present  the  elevation  of  pitch  which  characterisea  the  expirator; 
■onnd  io  bronchial  respiration.'  These  varistiooB  in  the  pitch  of 
the  expiratory  noand  have  hitherto  been  but  little  etnilied,  and  tbe'ir 
significance  haa,  therefore,  not  been  snfficienily  appreciated.  Thej 
appear,  from  the  facts  jiut  stated,  lo  eiBtain  relations  to  the  difler- 

■  Tb«  prolongad  MpAratitw  in  unph  jinma  oftati  aMDraa  a  faiKli.pltcbcd  ton* 
in  eoiiM^o«D<w  ef  eoexining  brODchitii.  Uodpr  ih«ae  «ircumit«aoM  it  caana 
10  hn,  prnfivrif  OOiuldertd,  S  niodiflnd  rntiilralor;  tound,  but  b««oa:i<a  a  Hie. 
Tliii  dittlnction  b  to  be  oU«Tvcd  in  verifying  bj  obierrati«n  tba  itaiaOMnt 
m*di>  ab«v«. 


AV-SODtf AtlOir    IS    DiaiCABB. 


Ids 


nces  in  the  physical  conditions  under  which  the  duration  of  the 
^xpirstorr  sound  is  increased,  which  it  is  both  interesting  and  im- 
rtant  to  note.  When  the  pitch  is  raised  in  the  bronchial  and  the 
nncbo- vesicular  respiration,  the  prolongation  is  due  to  increased 
»Dsity  of  lung ;  whereas  in  exaggerated  respiration  there  is  no 
Borbid  change  in  (he  part  of  the  lung  whence  the  sound  emanates, 
but  simply  an  increased  functional  activity,  and  under  these  circum- 
tances  the  pilch  is  not  raised,  but  continues,  as  in  health,  lower 
ban  that  of  the  inspiration.  In  emphysema,  owing  to  the  dimin- 
shed  elasticity  of  the  lung,  the  cells  collapse  and  expel  their  ccn- 
nu  more  slowly  than  in  health.  In  this  case  the  pitch  is  not 
'"notably,  if  at  all  raised.  The  same  is  true  when  the  prolongation 
arises  from  any  obstruction  to  the  pa-isngc  of  air  from  the  cells  to 
the  larger  bronchial  tubes.  If  these  statements  be  correct, — and 
observation  will  confirm  their  correctiies.i, — ihc  pitch  of  the  expira- 
tory sound,  taken  in  connection  with  iu  prolongation,  affords  i^ 
means  of  determining  whether  the  latter  is  an  indication  of  tuber- 
culous or  other  morbid  deposit,  or  only  an  clfect  of  a  retardation  of 
the  current  of  air  from  the  cells. 
■  A  prolonged  expiratory  gonad  in  some  instances  ie  the  eole  or 
chief  alteration  of  the  rcHpirution  which  an  examination  of  the 
chest  di*clos«s,  the  iuspirutory  sound  not  presenting  any  distinct 
morbid  change  in  quality,  intensity,  pitch  or  duration.  Now,  what 
is  the  diagnostic  value  of  a  prolonged  expiration  under  such  circum- 
etaooes  ?  The  importance  of  this  question  relates  to  its  practical 
bekriog  on  the  diagnosis  of  incipient  phthisis.  Is  a  prolonged  ex- 
piration  under  such  circumstances,  to  ho  reganled  as  a  .*ign  of  tu> 
berclc?  These  inquiries  suggest  some  considerations  to  which  I 
will  devoto  a  little  space.  The  earliest  and  must  obvious  of  the 
aoBCultatory  eridonccs  of  tubercle,  in  a  certain  proportion  of  cases, 
undoubtedly,  are  incident  to  the  expiration.  On  this  point,  the  ob- 
servations of  Dr.  Theophilns  Thomson  are  interesting.'  This  author 
stAtes  that  among  2000  consumptive  patients,  a  prolonged  expira* 
tory  murmur  was  the  most  remarkable  of  the  physical  signs  in  288, 
or  a  proportion  of  about  one  to  seven.  In  a  large  majority  of  these 
eaaea.  the  concomitant  signs  and  symptoms  were  not  such  as  to  ren- 
der the  diagnosis  positive ;  and,  hence  Dr.  Thomson  is  led  to  con- 
clude that  a  prolonged  expiratory  murmur  frequently  takes  preoe- 


■  Clinical  LectiuiM  on  Pulmooar;  CoiuuinpUon. 
13 


IM 


PHYSICAL    SXPLOBATIOK   Of   THE   COSST. 


daaco  of  othor  i-hArnctf  ristic  signs ;  nn  opinion  according  villi  '3m 
kdnnocil  by  Jucktton,  in  his  memoir  on  this  sntjecL  But  a  |ii»^ 
longod  vxpiratorj  murmur  is  found  to  exist  frcqaentl;  in  &  kea))^ 
dIimU  Tiiii  is  sliown  bj  the  results  of  «  scries  of  g»»min»ticM 
given  under  tho  facttd  of  Auscultaticiii  in  Health.  A  certain  >Da*- 
RBC0  is  to  bo  mndc  for  this  fact,  which  was  not  axcertained  vImd 
JMkwn  first  cnlled  ottontlon  to  the  importance  of  the  expinuoBa 
dikgDOsis,  and  hence,  he  m*  nnturnlly  led  to  oterrat«  the  inmiae 
significance  of  tho  sign  under  oonudcration.  There  i»  reaam  Id 
atupMt  that  in  some  of  tho  cases  exnmined  by  Dr.  Thomson  the 
prolonged  expiration  oiay  have  been  nonnal.  The  subjects  weretlii 
outpatients  of  an  hospital,  and  it  is  not  staled  bow  large  a  prefo- 
tloa  rwoMoed  lutder  obMrvation  till  the  evidences  of  tubefcoliB 
dtM*M  were  BBeqairoeally  declared.  A  naturallv  prolonged  ex]w- 
ation,  bowerer,  occurs  only  on  the  right  side.  The  questioa  whttW 
it  bo  nonnal  or  morbid,  therefore,  arises  only  when  it  is  foud  » 
the  right  side.  Existing  on  the  left,  and  not  on  the  right  side,  lb 
•ignificance  is  rastly  greater  than  vben  the  reverse  is  the  case,  or  it 
is  foand  oo  botlt  sides.  It  is  needless  to  saj  that  its  significance  if 
a  aign  of  tabercle  depends  on  its  shnation  at  the  sranout  of  thr 
dtwU  If  it  exist  Bore  or  less  «t'»  tlie  entire  chest  on  one  tUt^ 
still  more  on  both  sidw,  it  b  dse  to  other  caoMs  than  tsbereijett 
dis«*Mk  *Bd,  if  not  nomaL,  deaotw  cBphT^enu.  Tfae  more  arena- 
scribed  the  »pac«  onr  vUA  it  is  beard  ai  the  rammit,  the  greater 
IW  Jiaf  aWlB  «Tid«Me  if  t^ecele.  TW  eridcDee,  alto,  il  nhaiKeJ 
tf  it  be  (Wi4  t»  a  rire— ■crihii  spao*  in  the  iafn^daricalar  r^ioa 
at  Mwe  i&taacf  tnm  iWpeot  atsUckaaanaal  broncho-vesieahr 
nvfiralM*  it  mW  •av^for^aadis  ■«>« marked  ikan  ia  the  latter 
MHaaliwfc.  Fiullr,  iW  aknbM  tt  fitek  is  to  be  taken  into  ae- 
MUM.  If diefi*Abft>iiiwi,»fi Jmgtde»piralian  indieatM 
Md;  obrti atrial  «ii(4,  it  n  b«^  maj  be  inadeBl  to  tubercle,  Iw 
tfcas^atb  as  a^MT  ea—M  mar  Uaoe  ibatiaitiM.  tbe  endam  af 
ybtbwis  is  ha*  if  Ae  |iMk 

«bi«k  a  ralirwiwi  4wHt  iifHi  trim,  m.  aart  be  exceediaglj 

iexfisatiaa. 

******* ;h^\*»»fc    ■■■■«>^^.,      iV-m,    AUgm^,^^AU 


'     ■' 


AUttCITLTATIOX    tX    DliEASU. 

■O-Tceicalkr  rcsprrution,  of  which  modifications,  when  it  coexista 
lib  tnbercle,  it  is  to  be  regarded  as  a  constituent  clement. 
It  is  nccc«»ury  to  eiiution  the  inexperienced  auscaltator  against 
ikiag  for  n  prolonged  cxpiriitory  murmur  the  sounds  originating 
tbe  mouth,  throat,  or  nusa)  passages,  entering  the  ear  not  applied 
the  chest,  and  uppcuriiig  to  come  from  the  chest, 
9.  Inttrru}ited  rrspiratton. — This  rhythmical  aberration  has  re- 
ired  several  names,  such  as  Jerking,  wavy,  ootfged-wkeeL*     The 
>und,  instead  of  being  continuous,  i»  broken  into  one  or  more  parts, 
may  hv  iaiit*tcd  in  the  mouth  by  drawing  in  the  breath  with  a 
rica  of  disconnected  inepiratory  efforts,  instead  of  a  single  uniform 
Bt  of  iiupirattou.     It  is  very  rarely  observed  with  expirstion. 
The  inspiratory  sound  may  bo  interrupted  in  connection  with 
irious  affections,  nbiclt  may  bo  arranged  into  two  classes,  &ccord- 
Ig  to  the  mo<lc  in  which  llii-y  produce  this  eigii.     In  one  of  thcso 
iis-'MM  the  interruption   lakt-s   pluce  in  consequence   of  a  corr«- 
nnding  vant  of  eontinuousness  in  the  cxpiujire  movements  of  the 
lioracii'  walls.     This  occurs  in  pleuriKy,  pleurodynia,  and  intercos- 
si  neuralgia,  in  eonscqucnec  of  the  pain  oeen»ioned  by  expunding 
be  chest.    The  patient  instinctively,  as  it  were,  shrinks  from  the 
lovements  necessary  to  h^matoeis,  and  hence  sn  irregular  series  of 
r-OTta  instead  of  a  steady  expansion.     Thus  produced,  an  inter- 
ipt«d  inspiratory  sound  will  pervade  the  entire  chest.    In  the  other 
the  catiae  is  seated  in  the  pulmonary  organs.     In  the  latter 
fease  the  sign  is  limited  to  a  part  of  the  chest.     When  the  cause  is 
Imonary,  it  is  of  a  nature  to  oppose  nn  obstacle  to,  but  not  to 
revent,  the  free  expansion  of  a  portion  of  the  lungs.     Partial  ob- 
struction of  a  bronchial  tube,  cither  from  spasm,  tuberculous  deposit, 
or  bronchitis  confined  within  circumscribed  limits,  is  probably  com- 
nt  to  produce  this  effect.     Adhesions  of  the  pleura,  also,  may 
irolvc  the  ucve^snry  physical  conditions. 
This  exists  an  a  norniul  peculiarity  in  a  certain  proportion  of  in- 
dividuals, who,  irrespective  of  this  sign,  are  apparently  free  from 
pulmoiuiry  di«ca»e.     1  met  with  it  in  two  of  twenty-four  cxsmina- 
tiont.     I  hare  observed  it  on  the  healthy  side  in  lobar  pneumonia. 
Incident  to  health,  it  is  sometimes  »  transient  or  intermittent  pecu- 
liarity, but  in  some  instances  is  pcrsistunt.     In  health  or  disease  it 


t  Callod  b;  Laonniw  inspiration  fnfrecaufiif,  nod  hy  Frnoch  writer*  of  tbe  pres> 
pt  day  retpirali™  taetadtf. 


196 


PBTSK 


tRATtOX    OF   TKB   OHBST. 


is  ofWner  obsorrod  on  the  left  ttiAn  on  the  right  side,  uid  io  nrrij 
found,  fxcluKire  of  the  cases  in  irhich  it  extends  over  the  vheAe 
cfac«t,  elsewhere  than  nt  the  eumniit  in  front. 

The  importance  of  llii.«  »ign  practicull;  maj  he  said  to  have  refer* 
cnco  ftololy  to  the  diugnoMi*  of  incipient  phthisis.  Obserrationa  flio* 
tlwi  it  io  preHent  not  iiifretiueDtly  in  enscs  of  tuberculous  dbease,  U 
an  early  period,  while  the  ntwociutcd  physical  indications  are  sl^L 
Under  these  eirciiinslaiious  it  tany,  in  t^omc  instances,  be  doe  to  tke 
obstruction  cauited  either  hy  the  pressure  of  the  tubercles  on  l)w 
bronchial  tubes,  or  by  circumscribed  bronchitis;  and  in  other  is- 
Rtances  to  mechanical  reotmiitt  exterior  to  the  lun;^.  such  as  is  inci- 
dent to  pleuritic  adhesion:*.  Its  signiGcance  or  ralue  as  a  diagneetie 
sign  of  phthifiis  of  conrsc  depends  on  the  frequency  vith  vbioh  it  it 
observed  in  Ihiit  iifTectton,  and  its  infrequent  occurrence  in  heahk 
or  in  connection  with  other  formi*  of  disease.  Dr.  Thcophilns  Thoa- 
son,  who  ba8  made  thin  ttign  the  Kubjoct  of  special  statistical  re- 
search, recorded  lO-l  caries  in  which  it  wan  found  to  be  prasCDt.*  Of 
theae  caxes,  in  32  there  were  grontids,  irrcspectirc  of  this  sign,  fiiT 
B08p«oting  tuberculous  disea^.  Of  the  remainder,  many  were  eif 
tJrcly  free  from  other  evidences  of  any  affliction  of  the  lungs.  Dr. 
ThoiDKOu  adds  that  in  feveral  insiaiioeH  he  has  watched  the  pcrvisu 
cncy  of  this  sign  for  years  without  ili»  becoming  coinplicateti  with 
any  other  indication  of  dinea^e. 

In  TiL-wof  the,<M}  fade  an  interrupted  inspiratory  sound  cannot  be 
considered  to  afford  more  thnn  a  certain  amount  of  presompUTC  en- 
dcnce  of  phthisis.  As  an  isolated  sign  it  is  entitled  lo  but  little 
weight.  Assoclnted  with  other  sigiin,  such  as  diilness  on  percnssica, 
prolonged  expirattc^n,  etc.,  being  ])resent  at  the  situation  vbere  tbe 
latter  are  observed,  and  ihia  siliiatton  being  a  circumscribed  space  st 
the  summit  of  the  chest,  it  adds  to  the  amount  of  collective  proof  of 
the  existence  of  a  tuberculous  deposit. 

II.  Advkntitious  Ukppiratouy  Sounds. — Thus  far,  in  treating  of 
the  morbid  phciionienii  incident  t<)  respiration,  the  sounds  which  have 
been  considered  are  abiioriTml  modifications  of  those  which  pertain 
to  health.  It  remains  to  consider  certain  phenomena  which  hare  no 
existence  in  the  healthy  chest,,  and  are  therefore  distinguished  as  new 
or  adventitious  sounds.     The  greater  part  of  these  sounds  origiostt 

'  Op.  cit.,  p.  161. 


AXJ8C17LTATI0K   IS    0I8BA8B. 


197 


either  ill  tlie  Hir-tul>c»,  the  rcsictes,  or  within  catitieB  formed  in  the 
igs.  DifTerent  iiiimcs  bsvc  boon  applied  to  these  adTenlit:<^ui4 
UD<J8.     Lacnncc  cftlW  them  rSlgg,  a  term  fltill  in  vogup  wiiK  the 

'rCDch,  and  also  with  medical  writers,  and  in  conversational  lan- 
lage,  to  a  considerable  extent  in  other  countries  than    France, 

ther  names  by  which  they  are  collectively  distinguished  are  rhomrhi 
i)  raltiet.  The  two  latter  terms  are  not  only  wanting  in  euphony, 
bot  their  signification  is  inappropriate  when  applied  to  some  of  the 
sounds  embraced  in  this  cla«s.  In  the  absence  of  a  satisfactory  aub- 
Btitute,  either  of  classicnl  derivation  or  from  our  own  language,  it 
seems  to  me  preferable  to  retain  the  title  adopted  by  the  discoverer 
of  auscultation.  I  shall  accordingly  make  use  of  the  term  r<}te  in 
the  sense  in  which  it  was  employed  by  Laennec,  viz.,  to  denote  any 
abnormal  sound  produced  with  the  acts  of  respiration  in  the  air- 
tubes  and  Yeoicles  of  the  lungs,  or  within  cavities  formed  in  these 
organs.'  Proceeding  at  once  to  a  consideration  of  the  rales,  the 
points  to  be  first  settled  arc,  the  number  which  are  to  be  recognized 
as  constituting  individual  signs ;  the  method  of  classification,  and 
the  names  by  which  they  are  to  be  distinguished  severally  from 
each  other.  Iiaennec  determined  the  rales  by  their  audible  charac- 
ters, and  defignated  thetii  afier  resemblances  to  other  well-known 
sounds.  Mo4t  of  the  rnleit  discovi^red  by  him  are  still  recognized, 
and  the  same  names  arc  gcncrully  retained.  Andral  proposed  to 
divide  (he  rales  after  their  anatomical  location  in  the  air-tubes,  vesi- 
eles,  or  cavitieH,  and  to  distingni.ih  them  from  each  other  by  their 
eonveying  lo  the  car  the  ttvnsntiim  either  of  the  presence  or  absence 
liquid,  the  former  being  called  moist,  and  the  latter  dry  ralerf.* 

t  a  basis  of  clnksiiScntiun  this  is  convenient  and  advantageous.  The 
mes,  however,  in  comnioii  use  since  the  time  of  Laennec  will  con- 
tinue to  b^  employed,  and  they  are  ho  interwoven  in  medieal  litera- 
ture that  it  would  be  undesirable  to  endeavor  to  substitute  others, 
even  wen'  they  in  some  respects  preferable.  Following,  then,  the 
plan  of  distribution  according  to  situation,  certain  rales  arc  produced 
within  the  air-tubes,  the  larynx,  trachea,  the  two  primary  bronchi 


•  If  l)i«  FrvDCli  term  rSU  Ih-  iul<>plfMJ,  it  nbuuld,  I  thluli,  ba  angUaised,  and  I 
_4llsll  bcfsBAcr  uic  h  lu  an  EngUih  word. 

H^   *  Skoda  rmtHclt  the  appKcation  of  Ihn  l«rni  r»l«  ta  Iha  noundi  [irodacnd  hj 

^blquidi    The  dry  thIvh  bit  culU  timpty  auunda.     Tlii^  UUtiide  o[  «igiiiflcation  «c- 

^Borded  to  the  r«Iu  moj,  howRTcr.  bo  irtlU'd  fnirly  lij  cAnvcntional  umxe,  *nd 

Ibnro  U  a  wnvoDknco  In  s  g«n«rio  Icrm  appliMl  to  all  new  or  iidv«iitit!ou<  tuutid*. 


MS 


FBTilCAX.    BXPt«KATI»S    »t   TBK    CBB9T. 


the;  •enr,  execpliag  vbcn  th^  ue  tnasMsl,  only  aa  aa  ifta 

»  AMM^acaae  af  Mmied  paof- 
TW  tnchMl  raJea  sre  tboa- 
for*  ehirielLriilie  of  the  ■wrihmi  atete.  or  iadicMe  gattnSj  iht 
Aii  atat«  ta  m^  at  kaaiL  CowMilaliag  «kat  it  papalarl j  kaom  u 
At  "ie^th-nxtltt,"  tfay  are  ■Jrieaily  lood  to  be  beard  oTuaali 
MMdcfabk  di<uii«e,  aad  iixlkate  to  tbe  csr  tbe  preatpee  of  Bqvl. 
They  ara  eiUjEi^nted  typea  of  eertaia  ^  ibe  Moiat  ralca  pro^asti 
iritlua  tbe  palmonary  air-l^cak  Dry  ralea  nay  be  prodneeil  villia 
these  M«tion8  of  the  air-paaaagea  when  there  exiata  contraotiMi  M 
tbe  glottis  fnm  spurn,  ttiemx,  eiadatioa  of  ^ap^t  etc^  or  «b«. 
from  the  preasure  of  a  inmor,  the  preaenee  of  a  lare^  body,  mot- 
bid  depoaiu  or  growths,  tbe  calibre  of  tbe  tabe  is  diminished  us 
point  below  tbe  glottis.  They  consist  of  wheeung.  wbistHsg,  «r 
erowing  aovods,  inoro  or  I«aa  iDtense,  vhich  may  be  aodible  at  a 
^stance,  witboot  stethoscopic  esaintnation.  Tbeac  mwhU  also  repre- 
sent, on  a  large  acale,  tbe  dry  rales  prtKloced  within  tbe  pvlaoaaiy 
organs,  and  inroire  limilu'  physical  cooditioas.  Aascnltatiofi  «f 
the  larynx  or  trachea  will  MKoeiiowa  reTcs)  dry  ralea  not  otberwiM 
sndtUe.  and,  in  either  cii>c.  nay  be  a»cful  in  delermining  tbe  preeiaa 
seat  of  ao  obatraction.  Kalc^  produced  within  the  larynx  or  tnebea 
msy  be  propa^tod  to  tbe  cfaest  and  heard  in  the  latter  sitoation.  It 
is,  tbereforCi  nc4:etii'arT  tiomelinieii  to  auscultate  the  larynx  and  tra- 
chea in  order  to  detonikine  whether  sounds  heard  over  tbe  chest  are 
transmitted  from  theao  sections  of  the  air-tubes.  It  is  chiefly  in  tbe 
two  points  of  riew  just  named  that  tracheal  rales  are  of  importanoe 
in  diagnosis. 

Adventitioas  sounds  produced  within  the  primary  bronchi  and 
their  subili visions  are  called  the  Bronchial  Rata.  These  arc  of  two 
kindi),  the  one,  indtciitin|!  by  the  character  of  ihv  sound,  the  prtaence, 
and  the  other,  the  absence  of  liquid  in  the  bronchial  tubes.  The 
former  are  called  moist,  and  the  latter  dry  rales.  The  dry  bron- 
chial rales  ore  subdivided  into  two  varieties,  called  the  M^ntant  and 


J 


AVBOJStTATlOS    IN    DI8BABI. 


riMiv.     The  distinction  betveen  tbe  sibilant  and  eonorous  rates 
insists  mainly  in  a  difference  of  pitch.     A  sibilant  rale  is  high- 
pitched,  and  as  the  name  imports,  is  a  irhistling  or   hissing  aoond. 
sonorous  rale  is  low  or  grave  in  tone.     The  former,  in  general,  is 
produced  in  the  smaller,  and  (he  tatter  in  tlif  lar^«r  bronchial  tube». 
Joth  are  sometimes  distinguished  as  the  vibrating  rale*.     -Most  of 
be  moist  bronchial  rales  are  usually  styled  mucoiu  raltt,  the  liquid 
Dncemcd   in   their  prodnction  being  generally  inncus.     They  are, 
however,  produced  equally  by  other  fluids,  viz.,  pus,  softened  tuhcr- 
loQs  matter,  serum,  or  blood.     They  are  subdivided  into  coarse 
tnd  fine  rales.     The  sound  in  the  former  instance  conveying  to  the 
'ear,  the  idea  of  large,  and  in  the  latter  of  small  bubbles.     These 
variations  are  found  to  correspond  to  differences  in  siie  of  tho  bron- 
tchial  tubes  in  which  the  sounds  are  produced.     In  contrast  with  the 
tterm  vibrating,  applied  to  the  dry  rales,  the  moist  are  sometimes 
[called  bvhhtiKg  rales. 

A  moist  rale  prodaeed  in  the  minute  bronchial  diriAions,  is  dis- 
'  tinguisbed  as  a  tufhcrepUant  rak.     The  sigmficaooe  of  this  title  is 
derived  from  resemblance  to  a  sound  produced  within  the  vc!iioU'«,to 
which  reference  will  shortly  be  made.     Tbe  snb-crepitant  is  an  im- 
portant variety  of  the  fine  moirt  bronchiiil  rules, 

The  only  rale  attributed  to  tlic  air-vc»iclcs  is  called  the  crepitant 
tor  crepitating ;  so  vailed  from  the  peculiar  character  of  tbe  sound. 
This  is  a  hif^hly  important  phyucal  sign. 

Gvrgling  is  a  name  applied  to  a  peculiar  sound  produced  by  bub- 
bling,  and  the  agitation  of  liquid  contained  in  a  cavity  of  consider- 
able  tixe. 

Id  addition  to  the  several  rales  just  enumerated,  there  are  certain 
nonds  occasionally  heard,  undetermined  as  regards  their  location 
and  the  moilc  of  their  production,  as  well  as  somewhat  varic<i  in 
character.  These  may  be  embraced  under  the  title  indeUrminate 
rslet. 

By  reference  to  the  subjoined  tabular  view,  ihe  reader  will  be  able 
ito  see  at  a  glance  the  number  and  names  of  the  several  pulmonary 
jnlos  which  arc  to  be  eubsequently  considered,  arranged  in  the  order 
tin  which  they  have  just  been  briefly  described. 


rVTflCAL    KXPLftftAlfAS    •»   TBB 


aWwrf  rcb.— Abj  bn^AU  aond,  not  •  mafifation  of  A> 
rt^inboB.  la  odwr  vvHs,  aay  idTtnthio—  »Mad  or  nk, 
vfaidi  eoafjw  t«  Um  mt  the  ffwrttfiw  of  drjncM,  uad  if  acste  « 
h^pitdMd.  bib  nder  this  ilB«<»M»riwi  Frt^a^ntlj  th«  Mod 
hM  a  aonol  looe,  reaefflblisg  sanetUMS  the  crj  of  •  jonog  aaiaiL 
Um  ehirpini;  of  birds,  etc.  1b  other  iniuaccs,  h  is  •  thxrp,  cliddBf 
•otmd.  OccuiooaUj  it  u  not  oolike  the  vhiuUof  of  wntd  thro«fh 
B  crevice  or  key-hole.  Without  bdjt  oitifoniiiij  as  mpccU  tone,  or 
rcaeinbUnc«  t«  parliciilar  wetl-kDown  eooDcU,  a  sibiUnt  rale  b  eha^ 
acterixed  by  it*  drjmess  and  eleTation  of  [utch.  With  this  defini- 
tion, notwithstaoding  its  direnilies,  it  tit  appreciated  without  £S- 
enllj'.  The  respiratory  murmar  may  c«ntina«  to  be  beard,  the  nla 
being  •uperadded,  or  the  fortaer  loay  be  marked  by  the  Utter.  It 
may  accompany  the  inHpiralory  or  the  expiratory  act,  oftener  the 
forB>er  when  confined  to  one,  but  it  winetiines  attends  both  acta. 

A  libilaiit  rale  ia  freqoently  Tanahle,  occorring  not  with  oachsoe- 
eeMive  respiration,  but  at  irregular  intcrrnls,  coiitiinjing  perhaps  for 
a  few  momentMy  then  ceasing,  and  again  reappmring.  It  is  variable 
aa  regards  intenaity,  aa  well  aw  other  characters.  It  may  be  often 
■tupended  by  an  ad  of  oonghing.  It  is  apt  to  vary  also  in  sitnation, 
being  heard  at  one  moment  in  a  certain  part  of  the  chest,  and  the 
noit  moment  in  another  part;  thus  changing  its  scat,  it  may  be, 
fre(| 0(^1  Illy,  within  a  short  space  of  time.  The  rale  may  be  more  or 
less  diffused  over  the  entire  chc:)t,  or  confined  to  one  side,  or,  again, 
limited  to  a  circumacribud  space. 


201 


The  eibil&nt  nie  is  produced  within  the  ninaller  bronchinl  lobcft. 
ThiflJs  the  rule,  vUb  exceptional  instances  in  which  it  originaieH  in 
the  larger  tubes  in  consequence  of  their  calibre  being  diminished 
by  tnorbid  changes.  Lscnneo  attributed  its  production  to  ltie»paoe 
irithin  the  tubes  becoming  contracted  at  certain  poIntA  b^*  awolling 
of  the  macoDS  membrane.  From  itit  variability,  however,  and  the 
fact  that  it  frequently  disappears  after  an  act  of  coughing,  it  is  prob* 
■blj  due,  in  many  ioBtancea,  to  tenacious  roucua  adhering  to  the 
walb)  of  the  tubes  with  sufficient  firmness  to  occasion  a  partial  obsta- 
cle to  the  carretit  of  air,  and  give  rise  to  sonorous  vibrations  witli- 
out  bubbling.  This  explanation  is  sustained  by  the  fact  that  the 
rale  is  observed  especially  at  ibe  commencement  of  inflammation 
of  the  mucous  membrane  lining  the  smaller  tub<>s,  when  the  mucns 
secreted  is  small  in  quantity  und  adhesive.  The  swelling  of  the 
membrane,  greater  in  tome  pnrlionv  than  in  others,  reilitcing  thereby 
the  capacity  of  the  tubes,  not  untfornily,  but  irrcgiilnrly,  may  also 
give  rise  to  dry  rales,  whioli,  under  ihe-te  cireumstanees,  are  more 
persistent.  Spamm  of  the  muscular  fibres  iudiiucs  the  rcquiitilc  phy». 
ical  condition,  and  the  mle  is  louder  and  more  iliffu»cd  in  imthmn 
than  in  any  other  affection.  The  pressure  of  a  tumor  on  the  tubes, 
diminishing  their  size,  and  changing  their  direction,  but  not  suffi- 
ciently to  produce  obi^truction,  may  occasion  this  rale. 

In  the  majority  of  instances  a  sibilant  rale  is  a  sign  either  of 
Mthmu  or  of  bronchitis  seated  in  the  smaller  tubes.  If  it  be  heard 
more  or  less  over  the  chest  on  both  sides,  and  associated  with  sab- 
Mernsl  8orenc«s  and  febrile  movement,  the  evidence  is  very  strong 
oTtbeearly  stage  of  bronchitis  occurring  as  a  primitive  affection;  for 
primary  bronchitis  is  one  of  the  symmetrical  diseases,  which  is  not 
true,  to  the  same  extent,  of  diseases  in  which  bronchitis  is  liable  to 
oooor  u»  n  secondary  affection.  On  the  other  hand,  if  it  be  con- 
fined to  one  side  of  the  cheat,  it  may  be  due  to  bronchitis  occurring 
as  a  secondary  affection,  for  example,  in  connection  with  pneuinon- 
iiis.  If  it  be  restricted  to  a  circumscribed  spaoo  at  the  summit  of 
the  chest  on  one  side,  taken  in  connection  with  other  facts,  it  infer- 
cntially  points  to  the  existence  of  phthisis;  for  bronchitis  thus  oir* 
enKis«ribi'd  rarely  occurs  except  m  the  immediate  vicinity  of  a  tuber- 
culons  deposit,  and  it  is  ftt  the  summit  of  the  chest,  near  the  apex 
of  the  lung,  that  this  deposit  usually  takes  place.  The  sign  is  prtrjtviit 
I  in  a  marked  degree  in  asthma,  proceeding  from  spa&in  of  the  bron- 


SOS 


PHYSICAL   BXPLOBATIOa    OF  TBI  OBBST. 


cbial  tabes,  gtn^rnlly  ■»»MUtc<1  with  pulnonMj  eaUrrii  or  facw- 
chitiit;  snd  it  is  elill  more  mnrkvi)  if  the  catarrh  or  bronehittt k 
Msocintcd  with  cmpliyBenut.  Under  the  eircumaUnces  Ust  taoi* 
tionc^l,  it  maj  b«  marked  in  the  expiration,  owing  to  tbc  mat 
01UM  wliich  occasion  a  prolongcil  expiratory  murmur,  rix..  is- 
paired  elasticitj  of  )Dng,  and  the  neccttitj  of  iocn'ased  moscahr 
power  to  czp«l  the  air  from  the  over-dvslcndod  cellx.  Altbongh, 
therefore,  the  presence  of  the  sign  generally  dcDot«B  either  inflam- 
Diation  or  Bpasm  affecting  the  smaller  tabes,  thv  diagnosU  wmU 
oftoD  be  incomplete  were  not  other  signs  taken  into  aeeoant,  as  «e9 
08  svmptoma  which  disclose  the  coexistence  of  other  afTcctionft,  rii^ 
pneumonitis,  tubercle,  and  emphysema.  It  is  only  after  excloding 
lhe«e  several  affections  bj  the  absence  of  their  diagnostic  criteria, 
that  the  sign  denotes  a  morbid  condition  pertatDing  solely  to  the 
bronchial  tubes. 

3.  Sonoroiu  rate, — Thia  term,  which  the  French  apply  to  the  dry 
broDchial  ralea  collectively,  by  English  writers  is  limited  to  a  rale 
diatingntshed  from  the  sibilant  rale  by  gravity  of  tone.  A  sonorou 
rale  may  be  defined  to  be  any  dry  adrentitious  soand  produced  within 
the  bronchial  tub«8,  not  acute  or  hi^h  in  pitch.  The  exaci  lino  o( 
demarcation  between  the  sibilant  and  the  sonorous  rale  eannai  be  de- 
fined in  words,  nor  is  it  necessary  to  make  the  distinction  wiih  rig- 
orous exactitude  in  practice.  A  sonoroos  rale  is  duo  to  the  Mme 
physical  conditiouH  as  the  sibilant,  the  only  difference  as  n^ardt 
their  production  pertaining  to  location.  Tbesonorous  rate  proceed* 
from  the  larger  bronchial  tubeo.  !n  audible  characters  it  is  not 
more  uniform  than  the  Hibilaiit  rale.  Among  the  diversity  of 
sounds  to  which  it  may  be  compared  are  tJie  snoring  of  a  perns 
sleeping,  heard  at  a  distance,  the  humming  of  a  mosquito,  the  cooing 
of  a  pigeon,  a  note  of  a  bass-viol  or  bassoon,  etc,,  etc  The  tone 
b  oftener  more  distinctly  musical  than  that  of  the  sibilant  rale. 
The  sound  ia  also  louder  and  stronger,  being  sometimes  beard  at  a 
distance,  without  anscnltnlion,  and  producing  a  ribration  or  thriQ 
perceived  by  placing  the  band  on  the  chest. 

The  remarks  in  connection  with  the  sibilant  rale  &a  to  Tsriable- 
ness  of  intensity  and  peculiarity  of  tone,  change  of  place,  cessation 
and  reappearance,  and  sii.tpenHion  by  acts  of  coughing,  are  equally, 
and,  indeed,  even  more  applicable  to  the  sonoroos  rale.  Like  the 
sibilant,  the  Honorous  ntle  may  accompany  cither  act  of  respiration, 


I 


AVBOUtTATIOlf  iH   DtSBASB. 

both  acts.  When  confined  to  one,  it  is  more  *pt  to  be  produced 
bj  expiration,  in  this  particular  difTering  from  the  HibiUnt  rale. 

A  aonoroua  rale  occarK  in  aflthtii^  and  in  bronchitis  aflVcting  the 
l&rger  bronchial  tubes;  the  latter  inaj  be  pn'marT  or  a  coinpliciUion 
of  other  diseases,  vis.,  pncumonitiR,  tubercle,  emphysema,  etc.  The 
coexistence  of  other  nffections  is  to  be  determined  bj  the  associ- 
ated signs,  ID  conjunction  vith  symptoms.  Occurring  in  connection 
with  other  sffcciions  wrhich  arc  limited  to  one  side  of  the  chest, 
whereas  primary  bronchitis  is  bilntcrtil,  it  yrill  bo  confined  to  the 
eidc  sffoctcd;  siid  henec,  when  present  on  both  sides,  it  is  presomp> 
live  ovidcnee  that  the  bronchinl  affoetion  is  primnry. 

The  sonorous  and  the  sibilant  rule  are  often  heard  in  combinstion; 
that  is,  the  sonorous  existing  at  some  parts  of  thu  chest,  and  the 
sibilant  at  other  pnrts  at  the  iMimo  moment;  or  the  two  alternate 
at  irregalar  intervals  with  successive  acts  of  respiration  in  the  same 
silnation ;  or.  again,  both  arc  appreciable  at  the  same  instant,  some- 
times  commingled  together,  and  sometimes  succeeding  each  other  at 
diflerent  pcnoils  of  a  single  respiration.  When  combined,  it  is 
evidence  thut  the  bronchial  affbetion  is  seated  both  in  the  larger  and 
smaller  tubes.  The  sonorous,  like  the  sibilant  rale,  ia  espcciallj 
marked  in  paroxysms  of  a-ithma.  The  sounds  are  sometimes  so  in- 
tense as  to  be  heard  at  a  distance.  On  applying  the  ear  to  the 
chest  during  a  paroxysm  of  asthma,  frequently  a  great  rarietj  of 
muHJcal  tones  are  heard,  which,  if  auscultation  be  continued,  are 
foDud  to  undergo  con^ttant  mutations.  They  are  sometimes  continu- 
ous, not  only  during  the  two  acts  of  respiration,  but  uninterrupted 
by  the  interrats  b»-lween  successive  reapiraiions,  the  contraction  of 
the  lung  prolonging  the  sounds  with  expiration  after  the  visible  ex- 
piratory  movements  have  ceased. 

The  discrimination  of  bolh  vnrieliesof  dry  rale  from  other  sounds 
emanating  from  the  chest  ii*  attended  with  no  difficulty.  A  mere 
description  of  their  varied  characters  suffices  for  their  recognition 
when  heard  for  the  first  time.  They  are  quite  unlike  any  of  ilic 
modifications  of  the  natural  rei^ptratory  sounds,  and  tire  distin- 
guished by  points  not  less  striking  from  other  rales.  As  dingnostic 
signs  they  arc  important,  indicating,  as  has  been  stated,  in  the  great 
majority  of  instances,  the  early  stage  of  bronchitis,  or  a  paroxysm 
of  asthma,  uficctions  of  frequent  occurrence.  As  denoting  these 
afleetions,  tlieir  signification  is  almost  positive;  and  if  they  are 
present  extensively  on  both  sides  of  the  chest,  together  with  the 


204 


PaTKICAL    EXPLOBATIOH    OF    TRR    OHKST. 


iiegntirc  ovidcncc  afforded  by  tlio  absonce  of  the  sigoB  of  olber  da- 
«u»r8,  the  (Itagno»iti  u  cumploto.     Bronchitis,  liowerer,  Dol  unfre*, 
<|tii-iitly  uccura  us  a  complication   of  other  pulmonary  sffeciiona.' 
UBilcr  those  circumetancm  it  te  often  confined  to  one  side  of  the 
choHt,  or  is  still  inori!  circutnscribod,  vfll(^rc«s  the  reverse  is  the  rute 
when  it  is  iiliopBiIiic  or  primary.     But  the  fact  of  its  exbtence  m  %' 
complicntion  is  to  be  eetablishcd  by  the  concomitant  signs  and  synip- 
tomfl  of  the  coexisting  nffcctions. 

S.  Sfueout  or  bttbfiUng  radt. — The  mucoiis  rales  »re  the  moist 
bubbling  sounds  produced  in  any  portion  of  the  bronchial  tree  ex- 
cept the  minute  branches,  the  sounds  in  the  latter  situation  consti- 
tnting  the  sub-crepitant  rale.  The  term  mucous  is  here  used  in  a 
generic  sense  to  comprehend  sounds,  essentially  similar  in  character, 
which  arc  due  to  the  presence  of  any  ltf|utd  in  the  subdivbiont  of  ■ 
the  bronchi.  Miieus  i»  the  kind  of  liquid  oftenest  present;  bot 
other  kinds  are  pus,  blood,  softened  tubercle,  nnd  serum.  Whenever 
either  of  these  liquids  is  contained  within  the  bronchial  tubes,  the 
currents  of  air  with  the  lospiratory  acts  cause  explouve  babbles, 
which  fjivc  rise  to  sounds  more  or  le«i  intense.  Thcae  Munds  hare  ft 
bubbling  chariietcr  which  is  ditttinctire.  In  contrast  with  the  rale 
alrea'ly  considered,  they  nffurd  intrinsic  evidence  of  the  presence  of 
a  liquid ;  in  other  words,  the  cnr  appreciates  at  once  the  fact  that 
they  arc  moist  rales.  Diffcrcnecs  in  the  quality  of  the  Uqnid,  as 
respects  viscidity,  kc,  doubtless  affect  somewhat  the  character  of 
the  sound.  The  variations,  however,  due  to  this  source,  arr  nut  suf- 
ficiently deBnod  to  serve  as  the  basis  of  well-marked  distinctions. 
So  far  as  the  audible  chnractera  are  concerned,  the  only  inference 
to  be  drawn  is,  that  liquid  of  Bome  kind,  in  greater  or  less  abun- 
dance, ia  contained  in  the  bronchial  tubes.  Generally,  the  kind  of 
liquid  is  determined  demonstratively  by  an  examination  of  the  naUJ 
ter  of  expectoration.  The  mucous  rales  may  bo  imitated  by  blow-* 
ing  through  a  tube  introduced  into  any  liquid. 

The  character  of  the  sounds  indicates  the  size  of  the  tubes  in 
whicli  they  nre  produced.  In  the  larger  tubci*,  the  bubbles  appear 
to  be  of  greater  volume  :  perhaps  the  iltflcrcncG  is  in  part  owing  to 
the  space  in  which  the  explosions  occur.  At  all  events,  the  bab- 
bling soumls  differ  perceptibly  acconling  to  the  dimensions  of  tho 
bronchial  subdivisions  in  which  they  are  produced.  This  has  been 
shown  by  experiments  in  which,  after  death,  sounds  differing  ae- 
oording  to  tho  aisc  of  the  lubes  arc  produced  by  ii^cctJng  fluids 


ADBCrLTATton    IV    DT8RA8B. 


[uito  different  SDClions  of  tho  bronchi,  nnil  nfCcrwards  introducing 
'  currents  of  air  by  inflution.'  These  difference  »re  cxprcdsed  by 
the  terina  coarse  and  fine;  and  the  different  degrees  of  coareeneM 
,  ftnd  Rneness  are  expressed  by  words  of  quantity,  such  as  very,  can- 
titit-rahie,  jno<fi-rattr,  etc.  These  expressions  are  sufficiently  precise 
for  practical  pnrposes.  The  coarsest  mucous  rales,  then,  are  pro- 
duced in  the  lar);est  bronchia]  tubes ;  they  lose  this  quality  grada- 
»lly  ID  the  Bubdivisions  of  these  tubes,  until,  in  the  smaller  ramifi- 
cations, before  reaching  the  minute  branches,  they  assume  the  quality 
of  finen«!i9 ;  and  this  fineness  merges  into  the  still  finer  Gub-«repi- 
tant  rale.  It  would  be  difiicult  to  determine  the  particular  locality 
at  whieh  the  sounds  cease  to  be  coarse  and  become  fine,  and  it  ia 
equally  difficult  to  draw  the  line  of  demarcation  between  the  two 
elaawfl  of  •ftundit  with  exactitude;  but  such  precision  is  of  no  con- 
•eqncocc  in  diagnoaia. 

The  mucouit  mivs  resemble  the  dry  rales  in  vaj-iableness.  They 
•re  liable  to  appear  now  here  and  now  there,  shifting  their  scat  from 
one  part  to  another  part ;  occurring  not  with  each  reKpiration,  hut 
intermiltingly  in  the  same  locality,  and  are  often  removed  for  a  time 
by  nn  act  of  expectoration.  The  bubbling  #«undit  henni  at  (he  same 
moment  in  a  single  spot  may  not  hi-  uniform.  Tiuhbles  of  unequal 
Tolnme  appear  to  be  commioglctl  together.  The  sounds  may  be 
heard  with  inspiration  or  with  expiration,  or  with  both  acts.  Fi- 
nally, they  may  exist  on  both  sides  of  the  chest,  or  on  one  side  only, 
or  in  a  circumscribed  space  on  one  or  both  sides. 

Mocoaa  rales,  more  or  less  diffused  on  both  sides  of  the  chest, 
constitute  the  physical  sign  of  bronchitis  advanced  to  the  second 
stage,  or  the  stage  of  mucous  secretion.  The  rales,  other  things 
being  equal,  will  be  diffused  orer  the  chest,  and  abundant  in  proper- 
tion  to  the  extent  to  which  the  inflammation  pervades  the  bronchial 
□lucouB  membrane,  and  the  abundance  of  the  mucus  secreted  in  con- 
srqaencc.  If  fine  and  coarse  rales  are  intermingled,  which  is  not 
infrequently  the  case,  it  is  evidence  that  the  affection  of  the  mem- 
brane is  not  confined  to  the  larger  tubes,  but  extends  to  tho.i©  of 
smaller  size.  In  the  progress  of  the  affection,  the  dry  rales  may 
gradually  disappear  and  give  place  to  the  moist ;  but  it  is  not  infre- 
quently the  case  that  the  former  do  not  entirely  ceaae,  and  the  dif- 
ferent varieties  of  the  dry  and  moist  rales  are  combined  in  vurioas 
and  constantly  varying  proportions. 

<  Bartb  uid  Rog«r. 


rBTSICAI.    IXPlOBATIQir    Or    THB    CHKST. 

h  Tie*  «f  As  biK  that  a  priBarjWoBcUtii  aiiMla  ike  bnadill 
tabes  o«  both  adca  «f  tbe  cbwt  ajsillj,  if  matooB  nlea  arc  band 
on  ib«  twa  ndea,  and  MpecUIly  towwd  the  lower  |iart  of  tbe  Am 
behind,  tke  eridaweaf  ibiaafeetMn  is  alnok  cancteaira.  Tbenlo 
are  iBMC  apt  to  be  praaeat,  «r  to  be  aora  nacfced  fat  the  oitaatiin 
jost  raentioBcd,  *iz^  at  the  tonr  pan  of  tbe  deet  behiiMl,  oa  acmot 
of  the  greater  aaoont  of  iBlanmatioo  ia  tUs  ■taaliow,  tbe  bigcr 
■imber  of  brcttchkl  aabdiTOiocia,  and  beeaaae,  (nm  ibeir  powtiaa, 
tbe  renoT&l  of  their  Uqnid  oootenu  is  effected  leea  aaalj  than  bm 
the  labee  at  the  superior  portioB  of  tbe  laaga. 

If.  on  tbe  other  band,  the  rales  are  eonSned  to  one  side  of  ikt 
chest,  they  denote  a  bronchial  affection  not  prinitire,  box  secondarj, 
occurmg,  for  example,  u  a  complication  of  pneamooitia.  Or  tbty 
ma;  b«  prodooed  bv  the  presence  of  litjnid  ia  the  bronchial  tdiea 
irrespective  of  a&T  sffection  of  the  tobea  thfelves.  Thos,  pa>  is 
this  eitnatioD  ma;  be  derired  (rom  the  pleoral  cavity,  the  liver,  or 
an  abscess  formed  viihio  tbe  pulmonary  parenchyma ;  the  tahca 
maj  contain  blood  in  cases  of  bsmoptiffiis,  or  pntmonarj  apoplexy^ 
or  aervm  in  bronchorrbtea  and  oedena.  In  all  sndi  instance*,  the 
nature  of  tbe  disease  to  which  the  mucous  rales  are  incident  ia  to  be 
determined  hj  other  associated  signSi,  and  b;  ajuipioms. 

If  tbe  rales  are  confined  to  a  circorascribed  apace  at  the  anrnnut 
of  the  cheat,  or,  even  if  the;  are  more  narked  in  this  aitnstioa, 
and  cdpeciail;  if  they  ar«  either  present  on  one  side  only,  orper^ 
sisiingly  more  markc<l  on  one  side  than  on  thu  other,  they  are  sig- 
nificant of  phthiVi*,  bccunse  tbev  denote  a  bronchitis  confined  to  a 
small  section  of  the  bronchial  tnbee.  Thus  restricted,  bronchitis  is 
nerer  primitive,  but  dependent  on  a  prior  local  affection,  which  afleo- 
lioo,  when  the  circumscribed  bronchitis  is  situated  at  the  summit  of 
the  chest,  in  the  vast  majority  of  eaaes,  is  ttiberculosis.  Mucoos 
rales  are  apt  to  attend  tubcrculoas  diacase  in  all  stages  of  ita  pro^ 
ress,  being  produced  not  alone  by  bronchitis  occurring  as  a  compH- 
cation,  but  by  the  pr«<cncc  of  liquid  derived  from  lubcrculoos  exca- 
TstioDS.  Moreover,  the  bubbling  of  the  liquid  contents  of  small 
esviliea  occasions  rales  wbiob  cannot  be  dtsbnguisfacd  from  those 
produced  within  the  large  bronchial  lubes.  In  generni,  mucous  rales 
do  not  accompany,  in  a  marked  degree,  tnbtrcutous  disease  prior  to 
tbo  stage  of  softening  and  excavation. 

Definite  information  respecting  the  condition  of  the  lung  snr^ 
rounding  the  bronchial  tubes  within  which  mucous  rales  are  pro* 


AUSCCLTATIOK    IS    DtSiASB. 


207 


I 


is  afforded  by  the  pitch  of  the&e  ral«8.  If  the  buhbling 
iinds  ftrc  produocd  within  tubes  surrounded  by  solidified  luog, 
pitch  is  hi^h  ;  tlie  elevation  of  pitch  ia  in  proportion  to  the 
degree  of  Holidlfioittion.  On  the  other  hand,  the  pitch  of  these 
rales  u  low  if  iho  lung  be  not  eolidiiied.  The  pitch  of  the  rales 
correcponda  to  that  of  the  bronchial  or  broncho- vesicular  respiration, 

tbe«e  signs  of  solidification  are  present.  It  is  practicable  to 
determine  the  existence  of  solidiGcntiou,  «»d  its  degree,  by  the  pitch 
oF  these  r«lcs,  in  the  absence  of  other  oigiia;  or  to  determine  that 
eolidificatioD  does  not  cxtst.  In  tlus  point  of  view,  the  sif^nificsncc 
of  these  rales  is  interesting,  and  in  some  cai^cs  highly  important. 

4.  Sub-^rrepitant  rale. — By  soiiio  vrritcrs,  ull  the  moist  bronchial 
nl«s  are  embraced  under  this  name;'  and,  on  the  other  band^  tho 
sub-crcpitant  might  with  propriety  be  regarded  as  a  variety  of  mu- 
cous rale.  The  only  reason  for  making  it  a  separate  physical  sign 
that,  approximating  io  certain  of  its  characters  to  the  rale  pro- 
duced within  the  air-vesicles,  it  is  important  to  be  diaoriminatcd  from 
the  latter.  The  name  expresses  the  resemblance  just  referred  to. 
The  Bub-erepitant  rale  forms  an  intermediate  link  between  the  mu- 
cous and  the  crepitant  rales.  It  is  distinguished  from  the  mucous 
rales  by  its  greater  degree  of  fineni-^t.  It  is  produced  in  the  minute 
broDcbial  ram ifica lions.  Its  locality  accounts  for  ita  being  finer,— 
that  ia,  for  the  bubbling  being  smaller  than  in  other  bronchial  rales. 
The  bubbling  character  of  sound  is,  however,  preserved;  the  Sensa- 
tion conveys  the  idea  of  the  presence  of  a  liquid  in  tabes  of  small 
dimensions.  The  bubbling  sounds  are  generally  unequal ;  in  other 
vords,  they  seem  to  be  made  up  of  bubbles  uniformly  small,  but  dif- 
fering in  volume.  This  character  is  due  to  the  fact  that  the  subdi- 
visiODS  in  which  the  rale  is  produced,  although  minute,  are  not  of 
tli«  same  calibre.  It  is  hoard  in  inspiration  and  expiration,  with 
either  act  alone,  or  with  both  acts.  It  may  continue  during  the  whole 
duration  of  the  inspiratory  or  the  expiratory  sound,  or  be  heard  only 
during  a  small  portion  of  one  or  both  of  the  respiratory  acts.  As 
regards  persistence  it  presents  somewhat  of  the  irregularity  and 
want  of  uniformity  which  characterise  the  mucous  rales,  but  its 
variableness  is  less  marked.  These  few  points  are  important  to  be 
borne  in  mind  with  reference  to  its  distinctive  characters  tg  con- 
trasted more  particularly  with  the  crepitant  rale. 


Bsrlti  nnd  Soger. 


rSTffCAt.  SX*t«BATI*S    •»    TBS  CBSft. 


— ■-   ii     if  II   M  ^^Li  —  j-iJM  M    -  -*■  ^  *L^B  «-  a.  (^ 

■Me,  nBCMn^  ■  MiMeiSMcar  a  cao  m  imib  vMnM^    tMW 

M  Aeihif  ifttn  rf  ike  nle  are  cBMccned,  h  a  iwfWMUt  ttfc- 

ikmhy  Ike  MWe  «f  Ike  B^Bd  gnisg  me  to  the  fcdU^ 

nil  aiHTtiaa  i>  m  «ff«>taM  M  de  news  of  Fmrwt,  «b 

inmlH  T  -*'r' '-^ -*-  ''''*^ 1 — '-rrrtMM  JMlBiil 

la  tUe  kc  W«  Bol  kc«B  Utimwtd  \j  otWr  a— lutori,  vke  rc«4 
tfcf  rmie  m  aetgliBlly  iitwiCifl  m  mti^miAamf^hj  mo  mtmmt  waj&tm 
m  evety  napccc,  «kb  ia  Afecal  cmc*,  akd  at  £liereiit  periodi  «f 
tknae  ctcctMB.  Ikt  inwiiiiiwttwB  of  the  £irrrat  «rc«tMi 
ckmeiemed  br  tke  prance  «f  tkis  Mf^  b  to  be  beecd,  »ot  oa  £( 
jereaeee  in  ibe  dianeten  prrui&tBg  to  ■■■ad,  b«s  ■■  otker  oft^ 
■IMMM  i«  vkiek  1  ek>n  bmi?  sIMe. 

In  etpilbrj  bronekitiB  tke  ■!■  hriae  tbnng  ibe  BBote  knaflid 
W—dw  M  the  teet  of  iiAiweriott.  Tke  inluuMiMn  my  fe 
timitH  CO  tbU  Bedioa  of  tbe  braodtul  lobeft,  or  tl  mmj  sSrct,  n 
Ike  naw  time,  (be  larfErr  sebdimMttft.  Tbe  nb-ereplMit  nie  m 
tkM  dtaease  is  dnc  to  tbe  prceeoee  of  Bacaa.  It  aaeeeed*,  mad  ma; 
be  more  or  t«aB  interiniiiglcd  witb,  tbe  libilaiit  nit,  mi  if  tke  alee- 
lion  be  Dot  confined  to  the  minote  bninrhni,  abo  with  tbt  soooroes 
and  mnooiu  nlea.  Capillary,  as  well  aa  ordinarT  broa^tia,  aiect- 
iag,  wben  primary,  both  aidea  of  tbe  cHeet,  the  rale  will  be  preecnl 
on  the  two  oidra,  and  eapeoUlly  at  the  base  of  the  ehest  briii&d. 
Thia  is  an  important  diagnostic  poinL  inasmach  aa  the  other  afl<e- 
tioHH  to  which  the  rale  ia  tncident,  are  usually  confined  to  one  side 
of  the  cheat.  A  aub-crepitant  rale  at  th«  baae  behind  on  both  sktes 
ia  almoal  conclueiTe  eridcncc  of  capillnry  bronchitis,  as  diattngniabed 
from  pncutnonitts,  in  which  the  crepitant  rule,  in  tbe  great  Diajorily 
of  caaca,  i»  preaent  on  one  side  only.  But  other  evidence  derind 
from  physical  exploration  may  be  broapht  to  bciir  on  (he  differential 
diagnoRt)),  fuclusive  of  the  charactern  distingninhing  the  crepitant 
from  tbe  aiib-erepitant  rale.  In  capillary  bronchitis  the  percaasiotH 
reaonanco  coiitinueH  clt-ar,  while  in  pncnmonitia  it  bveomes  dall.  In 
the  former  the  sub-crepitant  rale  contiaaos,  and  ia  replaced  by 


aoscultatiok  in  disease. 


SO!) 


[Teajcular  marmur;  in  the  latter  the  crepitant  rati-  in  nio»t  cnxcfl 

noon  dirainisliea  or  coases  entirely,  nntl  givc«  place  to  the  bronchial 
respiration.  These  circuiD^t.-knccit  will  aiil  in  nrriving  at  a  pnsitive 
conclasioQ  in  iniitnnces  tn  which,  judging  from  (he  intrinific  char- 

[acters  pertaining  to  the  rale,  there  might  be  room  for  doubt. 

The  sub-crepitant,  however,  ti»  well  im  the  crepitant  rale,  belongs 

[to  ibe  natural  historj  of  pneumonitis.     It  occurs  in  »  certain  pro- 

I  portion  of  cases  during  the  stage  of  resolution,  having  been  preceded 

[Ity  the  crepitant  rale,  nod  the  phjificnl  signs  of  snlidilication  of  lung. 

["Wlih  the  latter  signs  it  is  moreover  associated.  Under  these  cir- 
cnin*tunoe8  it  oon!)titute«,  in  some  cades,  the  r/toncfiua crepitans  redux, 

[or  the  returning  crepitant  rule  of  Lacnnec. 

In  pulmonary  ceilenia  the  oub- crepitant  rale  is  due  to  the  prexence 

'  of  verous  fluid  within  the  minute  bronchial  branchen.  Occurring  in 
oonnc«tioii  with  thia  form  of  diHease,  it  ia  preaent  on  the  posterior 
surfacA  of  the  cheat;  it  is  accompanied  wiih  more  or  lenit  dulness 
on  pcrcii»>ion,  and  i)  found  in  connection  with  the  morbid  condi- 
tions upon  which  tJic  production  of  <edcma  depcndii,  viz.,  disease  of 
ticart,  or  of  the  kidneys,  and  blood  changes  leading  to  stasis  in  the 
pulmonary  capillaries  (as  in  fovcrs),  or  favoring  serous  transudation. 
These  circnmsunces,  together  with  the  absence  of  more  or  less  of 
the  physical  eigni  of  pneamonits,  in  addition  to  the  characters  dis- 
tinguishing the  sub-crepitant  and  crepitant  rules,  enable  u»  to  cx- 
cladc  the  latter  affection. 

In  philiiiiiii  a  sub-crepitant  rale  may  be  due  to  circumscribed  cti- 
pillary  bronchitis  in  the  vicinity  of  tlie  tubcrculoua  deposit,  or  it 
nay  proocot)  from  the  presence  of  liijuelied  tubercle  in  tho  minute 
tubes.  In  the  first  instance,  it  may  occur  enrly  in  the  disease;  in 
the  latter,  not  until  a  Inter  period,  after  softening  has  taltea  place. 
In  either  case  its  significance  depends  on  conditions  similar  to  those 
which  render  a  sibilant  or  a  mucous  rale  a  sign  of  tuberculosis,  viz., 
its  situation  at  the  summit  of  the  chest,  within  a  cireurascribod  space. 
With  these  conditions,  a  sub-crepitant  rale  is  strongly  indicative  of 

[  the  existence  of  phthisis. 

In  bsemoptysis  and  pulmonary  fipoplezythe  presence  of  licjuid  blood 
in  the  minnte  hronchiai  branches,  may  give  rise  to  a  sub-crepitant 
rale.  It  is,  however,  by  no  menus  u  sign  constantly  attending  these 
affcctionR.  It  is  obncrved  in  but  a  certain  proportion  of  cases,  and 
is  of  tiniall  value  in  their  diagnosis.  Blood  escaping  from  the  pul- 
monary vessels  cither  passes  into  the  larger  tubes,  and  is  expecio- 

U 


S06 


PHYSICAL    IZPLORATIOIC    OF    TAB    CBBST. 


In  view  of  tbe  fact  tlint  ■  priiniirjr  bronchitis  KfTecta  ibe  bronchtri 
tubes  on  botb  Mtdcs  of  tbe  chest  e<)iuU;,  if  macooa  rklcs  are  fonni 
on  the  twn  sidm,  »nil  cxpccinlly  towarii  the  lower  part  of  th«  obM 
behind,  tbe  evidence  of  tbi^aScction  is  almost  eoncbuive-  Tbcnlti 
are  nio§t  apt  to  be  present,  or  u>  be  more  mHrked  in  the  »itaiiwi 
JQSt  mentioned,  vis.,  at  the  lower  purt  of  tbe  cheat  behind,  on  accossl 
of  the  gmaler  amount  of  influmra&lion  in  thvs  situation,  the  \uftt 
nuiobiT  of  bronchial  fubilivixions,  and  because,  from  their  posiliM, 
tbe  removal  of  their  liquid  contents  is  effected  less  easily  than  fion 
the  tabes  nt  tbe  superior  portion  of  the  longs. 

If,  on  the  other  baud,  the  mles  nro  confined  to  one  side  of  Ibt 
chest,  ihcy  denote  a  bronchial  affection  not  primitive,  but  sccondaij, 
occurring,  for  example,  an  a  complicalioR  of  pneamonitis.  Or  (fclf 
maj  be  produced  hy  the  prenenoe  of  liquid  in  the  bronchial  tabei 
irrespective  of  any  affection  of  the  tubes  themselves.  Thus,  pus  in 
this  situation  may  be  deriveil  from  the  pleural  oavitj,  the  liver,  or 
an  absccHS  formed  within  the  pulmonary  parenchyma ;  the  tubes 
may  contain  blood  in  cuscs  of  hiemoptyais,  or  pulmonary  apoplexy, 
or  scrum  in  bronchorrhoea  and  oidema.  In  all  such  instances,  tb« 
nature  of  the  disea-te  to  which  the  mucous  rales  are  incident  is  to  be 
determined  by  other  associated  »ign»,  and  by  symptoms. 

If  the  rales  arc  confined  to  a  circumKvribcd  spnoc  nt  the  summit 
of  the  chest,  or,  even  if  they  arc  more  marked  in  this  situation, 
and  especially  if  they  are  either  present  on  one  side  only,  or  per- 
sistingly  more  marked  on  one  side  than  on  the  other,  they  are  wg- 
nificant  of  phthisis,  becaose  they  denote  a  bronchitis  confined  to  a 
small  section  of  the  bronchial  tubes.  Thus  rt>stricted,  bronchitis  is 
never  primitive,  but  dependent  on  a  prior  local  nffcction,  which  aSeo- 
tion,  when  the  circnmHcribed  bronchitis  is  situated  at  the  samtnit  of 
tbe  chest,  in  (lie  vast  majority  of  cases,  is  tuberculosis.  Mucoits 
rales  are  apt  to  attend  tuberculous  disease  in  all  stages  of  its  prog> 
rcs^  being  produced  not  alone  by  bronchitis  occurring  as  a  compli- 
cation, but  by  the  presence  of  liquid  derived  from  tnberculoos  exca- 
vations. Moreover,  the  bubbling  of  the  liquid  contents  of  small 
cavities  occasions  rales  which  cannot  be  distinguished  from  ihoM 
produced  within  the  large  bronchial  tubes.  In  general,  mucous  ralM 
do  not  aocompniiy,  in  a  marked  degree,  tubarculoBS  disease  prior  10 
the  stage  of  soflening  and  excavation. 

Definite  information  respecting  the  condition  of  tbe  long  8wr> 
ronndiog  the  broiicliial  tubes  within  which  mucous  rales  are  pro- 


AV80CI.TAT10K    IS    DISEASE. 


207 


foeert,  is  sfforded  by  the  pitch  of  these  rales.  If  the  hubbling 
Boandd  are  produced  witliin  tubes  surrounded  by  solidified  lung, 
their  pitch  is  high ;  the  elevation  of  pitch  is  in  proportion  to  tbe 
pegree  of  solidification.  On  the  other  hand,  tbe  pitch  of  these 
ral«a  ia  low  if  the  lung  be  not  solidified.  Tbe  pitch  of  the  rales 
gMrreapondfl  to  ihut  of  the  bronchial  or  broncho* vesicular  respiration, 
it  tho*c  »tgm  of  solidification  are  present.  It  is  practicable  to 
4et«nni»e  (he  exidtenoe  of  solidttlcntion,  and  its  degree,  by  the  pitch 
'of  th<4e  rale8,  in  the  absenoe  of  other  signs;  or  to  determine  that 
.soli<)i  Scat  ion  does  not  exist.  Id  tbis  point  of  view,  tbe  significance 
of  thcM  rales  is  interesting,  and  in  souc  cui^cs  highly  important. 

4.  SuifcrepitanC  ralr. — By  some  writer^  all  the  moist  bronchial 
:nlH  are  crobmccil  uudcr  this  name ;'  and,  ou  the  other  band,  the 
Bub'Crepitant  might  with  propriety  bo  regarded  us  a  variety  of  mu- 
cous rale.  The  only  reason  for  mnking  it  a  separate  physical  sign 
.  ic,  that,  approximating  in  certain  of  its  characters  to  the  rale  pro- 
duced within  the  air-vesicles,  it  is  important  to  be  discriminated  from 
the  latter.  The  name  expresses  the  resemblance  just  referred  to. 
The  sub-crepitant  rale  forms  an  intermediate  link  between  the  ma- 
couH  and  the  crepitant  rales.  It  is  distinguished  from  tlie  mucous 
rales  by  its  greater  degree  of  finenetiti.  It  i»  produced  in  the  minute 
bronchial  ramlficatioiM.  Its  locality  accounts  for  its  being  finer, — 
that  is,  for  the  bubbling  being  smaller  tlian  in  other  bronchial  ralea. 
Tbe  bubbling  character  of  sound  is,  however,  preserved;  the  sensa- 
tion conveys  the  idea  of  the  presence  of  a  liquid  in  tubes  of  small 
dimensions.  The  bubbling  sounds  are  gencrnlly  unequal;  in  other 
words,  they  seem  to  he  made  up  of  hubbies  uniformly  small,  hut  dif- 
fering in  volume.  This  character  \»  due  to  the  fact  that  the  subdi- 
visions in  which  the  rale  is  produ(;ed,  allbougb  minute,  are  not  of 
the  same  calibre.  It  in  heard  in  initpiratiou  and  expiration,  with 
either  act  alone,  or  with  both  acts.  It  may  continue  during  the  whole 
daralioD  of  the  inspiratory  or  the  expiratory  sound,  or  bo  heard  only 
during  a  small  portion  of  one  or  both  of  the  respiratory  acts.  As 
regard)!  persistence  it  prcacnts  somewhat  of  the  irregularity  and 
want  of  uniformity  which  characteriie  the  mucous  ralea,  but  its 
variableness  is  less  marked.  These  few  points  are  important  to  be 
borne  in  mind  with  reference  to  its  distinctive  characters  as  con- 
,  trusted  more  particularly  with  the  crepitant  rale. 


■  BoTlh  and  Kog«r. 


208 


P0T8ICAI.    RXPLOBATIOM    OF    THE    CBBST. 


The  sub-crcpitnot  tkIc  attends  ttiose  affections  to  wbiefa  s  liqoM  a 
present  in  tb«  minute broncbiit]  branches.  The  liquid  is  differenlB 
different  foTins  of  dreeue,  presenting  tbe  same  rarietiea  u  in  tk 
cow  of  the  mucous  rmleii,  viz.,  mucus,  pus,  serura,  softened  tub«rcl«, 
blood.  Those  different  liquids  are  present  in  the  mmuie  broui^l 
branches,  in  capillary  bronchitis,  pneumonitis,  cederoa  of  the  laap, 
phthisis,  hiCmoptyMs.  and  pulmonary  apoplexy.  The  sab-crejMlUI 
rale,  therefore,  is  liable  to  occur  in  each  of  these  disew«9.  S<tbt 
as  ifae  characters  of  the  rale  are  concerned,  it  is  tmpowible  t«  it- 
termine  thereby  the  nature  of  the  liquid  giving  rise  (o  the  babbliig 
sound.  This  assertion  is  in  opposition  to  the  views  of  Fournet,  ■b* 
deacribed  a  distinct  rale  for  each  of  the  several  affccliond  just  namci 
In  this  he  has  not  been  followed  by  other  auttcultntorK,  who  regird 
the  rale  as  cRsentially  iiicnlicul  in  all,  altliotigli  by  no  means  nnifora 
in  every  re«pect,  even  in  different  ca«e8,  and  al  different  periods  of 
the  sxme  affection.  The  discriminatioo  of  the  different  affection* 
characterised  by  the  preeenoc  of  this  sign,  w  to  be  based,  not  on  dif- 
ferences in  the  characters  pertaining  to  Hounit,  but  on  other  circvn- 
stances  to  whicb  I  shall  briefly  allude. 

In  capillary  bronchitis  the  membrane  lining  the  minute  bronclHil 
branches  is  the  seat  of  inflammation.  The  inflaramation  may  be 
ItDiiied  to  tbis  section  of  the  bronchial  tubes,  or  it  may  affect,  >t 
the  same  time,  the  larger  subdivisions.  The  sub-crepitant  nle  in 
thix  disease  is  duo  to  the  presence  of  mucus.  It  succeeds,  and  may 
be  more  or  less  intrriningled  with,  the  sibilant  rale,  and  if  the  oflce> 
tion  be  not  confined  to  the  minute  branches,  also  «ith  the  sonorou 
and  mucous  rales.  Capillnry,  as  well  as  ordinary  bronchitis,  affeet> 
ing,  when  primary,  both  sides  of  the  chest,  the  ralo  will  be  present 
on  the  two  sides,  and  especially  at  the  base  of  the  chesi  behind. 
This  is  an  important  diagnostic  point,  inasmuch  as  the  other  affce- 
tions  to  which  the  rale  is  incident,  are  usually  confined  to  one  side 
of  the  chest.  A  snb^crepitant  rale  at  the  base  behind  on  both  sidn 
is  almost  conclusive  evidence  of  capillary  bronchitis,  as  distinguished 
from  pneumonitis,  in  which  the  crcpilani  rale,  in  the  great  majority 
of  cases,  is  present  on  one  side  only.  But  other  evidence  derived 
from  physical  explornlion  mny  bo  brought  to  bear  on  the  differential 
diagnosis,  exclusive  of  the  characters  distinguishing  the  crepitant 
firom  the  sub-crepitsnt  rale.  In  capillary  bronchitis  the  percnssioo- 
resonance  continues  clear,  while  In  pneumonitis  it  becomes  dull.  In 
tbc  former  the  sub-crcpitsot  rnlc  coutinnoii^  and  is  replaced  by  ' 


AUSCULTATIOX    IS    IH8BA8K. 


vo9iciilar  inurmar;  in  tb«  latter  the  cicpitant  rale  in  most  cmm 
«wii  iiiini[iish<>8  or  ceases  entirely,  and  gives  place  to  tbo  broncliial 
roApi nttioD.  These  circumHtances  will  aid  in  arriving  ai  a  positive 
oonoluiiion  in  instances  in  which,  judging  from  the  intrinsic  char- 
acters pertaining  to  the  rale,  there  tnljiht  be  room  for  doubt. 

The  sul>-erepitant,  however,  as  well  ns  the  crepitant  rale,  belongs 
lo  ihe  naiural  history  of  pneumonitis.  It  occurs  in  a  certain  pro- 
portion of  cases  during  the  stage  of  resolution,  having  been  preceded 
by  the  crepitant  rale,  and  the  physical  signs  of  solidification  of  lung. 
With  the  latter  signs  it  is  moreover  associated.  Under  these  cir- 
CuiDMlancPS  it  consiitntet),  in  some  caaes,  the  rhonrkua ercpitetni redox, 
or  the  returning  erepitimt  rale  of  Laennec. 

In  pulmonary  (udema  the  »ub-crcpitant  rale  ia  due  to  the  presence 
of  iK-rous  fluid  within  thv  minute  bronchial  branohcfl.  OceurriTig  in 
connccliou  with  thin  form  of  di«ea««,  it  h  present  on  the  po.ttenor 
surface  of  the  chest;  it  is  accompanied  with  more  or  less  iluliie^ 
on  percussion,  ind  is  fonnd  in  coimeclion  with  the  morbid  condi- 
tions upon  which  the  production  of  (cilema  depends,  viz.,  disease  of 
heart,  or  of  the  kidneys,  and  blood  changes  leading  to  stasis  in  the 
pulmonary  capillaries  (as  in  fevers),  or  faroring  serous  transudation. 
These  eircuinalancea,  together  with  the  absence  of  more  or  less  of 
the  physical  signA  of  pneumoniij),  in  addition  to  the  characters  dis- 
tJDgaisliing  the  sub-cropitunt  nod  crepitsnt  rftlcs,  enable  us  to  ex- 
clude the  latter  afiTectiou. 

In  phthisis  a  suh-crepit»nt  rale  may  be  due  to  circumscribed  ca* 
pillsry  broachi^s  in  the  vioinity  of  the  tuberculous  deposit,  or  it 
may  proceed  from  the  presence  of  liquelicd  tubercle  in  the  minnto 
tubes.  In  the  first  instance,  it  msy  occur  early  in  the  disease;  in 
the  latter,  not  until  a  later  period,  after  softening  has  taken  place. 
In  either  case  its  significance  depends  on  conditions  similar  h)  those 
which  render  a  sibilant  or  a  mucous  rale  a  sign  of  tuberoulosiii,  vis., 
its  situation  at  the  summit  of  the  chest,  within  a  circumscribed  apace. 
With  these  conditions,  a  sub-crepitant  rale  ia  strongly  indicative  of 
the  existence  of  phthisis. 

Id  Itiemopty^iB  anil  pulmonary  apoplexy  the  presence  of  liquid  blood 
in  the  minute  bronchial  branches,  may  give  rise  to  a  sub-crepitant 
ra1c.  It  is,  however,  by  no  means  a  sign  constantly  attending  these 
affections.  It  is  observed  in  but  a  certain  proportion  of  cases,  and 
is  of  small  value  in  their  diagnosis.  Blood  escaping  from  the  pul- 
monary vessels  either  passes  into  the  larger  tubes,  and  is  expeoto- 


210 


PHYSICAL    BXPLORATIOX    OP    THK    CHR8T. 


rated;  or  it  coagnlatee,  constitutiDg  apoplectic  cxtravaulion  ;  haUd 
reaulu  doing  aw»;  wich  the  ])hy9icBl  condition))  acoi»«*Tj  lo  dcrelop* 
the  rale  under  consideration. 

The  sub-crepitant  rale  is  an  inipormnt  phjrsicnl  sign.  From  th| 
mucous  rdee  it  is  dislingitiKlicd  cliicfljr  bj  tbc  sensslion  whidi  it^ 
conrejrs  of  a  liner  bubbling  sound.  Tli«  charact«rs  wbioh  will  bo 
presently  found  to  mark  tlie  distinction  from  the  crepitant  rale  are, 
the  s<>nse  of  a  liquid,  incqualii;  in  volume  of  the  bubbles,  its  pres- 
ence somcttmeH  with  cxpiraliun,  uit  well  us  inspirsttou.  In  wme 
iastunoes  the  approximation  is  so  close  to  the  crepitant  rale  that,  it 
muHt  be  confessed,  judged  by  intrintiic  charnct«r»,  it  i«  not  emsj  to 
make  tbe  <liatluotion. 

As  n-gard^  pitch,  the  sub-crepitunt  rale  has  the  samo  sipiiGeaaa 
u  the  mucoUD  rales.  The  pilcli  is  high  if  the  lung  be  sotidifiv^l,  and ' 
comparntirL-ly  low  if  soliditicatton  does  not  cxiift.  Thus  in  cspil- 
lary  bronchitis  the  pitch  is  low,  and  iu  pneumonitis,  before  resolution 
has  taken  phice,  the  pilch  Is  high.  By  means  of  the  pitch  of  the 
rale  the  condition  of  the  lung  with  respect  to  the  existence  of  solid- 
ification, or  othenriee,  may  be  ascertained  in  cases  in  which  the 
modiGeations  of  the  respiration  and  voice  which  represent  this  con- 
dition are  absent. 

a.  Orepilant  rale. — The  crepiunt,  also  culled  tbe  crepitating  and 
erepitous  rale,  is  distinguished  from  tlie  rales  already  considered  by 
its  origin.  It  is  a  vesicular  rale ;  but  it  is  not  produced  exclusively 
within  the  vesicles.  The  anatoniicu]  relations  of  the  air-cells  and 
the  ultimate  bronchial  tubes,  or  bronchioles,  are  such  that  ibey  g*e 
Itardly  bo  isolated  from  each  other;  and,  in  fact,  tbe  physical  eon>^ 
ditioiis  giving  rise  to  the  crepiuiut  rule  pertain  equally  to  both. 

The  chnracler  of  the  sound  is  well  expressed  by  the  term  crepi- 
tating. Laennco  compared  it  to  the  ntiisu  producc<l  by  Halt  in  a 
heated  vessel.  Banli  ami  llugcr  liken  it  to  the  crackling  of  a 
moistened  sponge,  expanding  ulose  to  the  ear  after  being  forcibly 
compressed.  Dr.  Williams  hua  suggested  an  oxcelleJit  imitation 
via.,  the  sound  caused  by  rubbing  a  lock  of  hair  between  the  tbutnl 
and  finger  close  lo  the  ear.  Other  illustrations  might  be  cited,  bat 
these  are  sufficient,  and  llie  one  la«t  mentinncr<l  is  available  at  aaj'j 
moment.  Opportunities  for  studying  the:  rule  itself  arc  suiBcient]/ 
abun<Unt  everywhere,  and  after  a  description  of  iu  oharaclers,  with 
the  comparisons  just  mentioned,  tlie  student  will  have  oo  difficulty 
in  recognising  it  the  first  time  it  is  prcscntci)  to  his  notice.     As 


AtlSOVLTATIOlI    TIT    DISBASB, 


211 


e»*ly  stated,  it  bears  a  resembUncc  to  Uic  *ulw:rcpil»nt  rale, 
■two  rales  npproxinint«  in  their  mxliblv  clinroctcrs,  but  uctiiilljr 
hej  are  distinguislied  Iij  tlicir  intrinsic  differences  alone,  and  sIwats 
ith  the  aid  of  coIlat<-ral  circumstance^-  Tbc  peculiar  traiu  b; 
which  the  crcpiianl  rale  is  ebanicteriz.cd  may  be  be«t  exhibited  by 
eontriu'ting  il  with  the  »iib-crepitant  rnlc.  The  «onnd  in  the  crcpt- 
tnnt  rale  i»  a  true  crepitation,  nhile  in  the  xub-crepitant  rale  it  is  a  fine 
bubbling,  approaching  to  a  crepitating  character.  With  the  common 
iden  that  in  both  imtlancex  tho  ^ound  is  caused  bjminoto  babbles,  it 
is  usual  to  say  that  the  crepitant  is  a  finer  rale  than  the  sub  crepitant. 
It  will  prexcntly  bo  seen,  however,  that  agreeably  to  the  most  rational 
explanation  of  the  crepitant  rale,  it  is  not  a  bubbling  sound.  The 
crepitant  rale,  in  fact,  so  far  as  the  sound  ia  concerned,  belongs 
Ipmong  the  dry  rales.  It  does  not  convey  to  the  ear  the  sensation 
of  the  presence  of  a  liquid.  Laonneu  regarded  it  otherwise,  and  in 
conformity  with  the  prevalent  opinion  reiipceting  ita  mode  of  pro- 
duction, it  is  included  in  the  division  of  moiftt  rale«.  Lacnncc,  how- 
ever, undoubtedly  confounded  the  crepitant  and  sub-crepiliint  rales, 
the  points  of  distinction  between  the  two  having  been  iudiout«d 
BtDoe  his  time.  He  designated  the  crepitant  as  the  moitt  crepitant, 
but  in  describing  its  characters  in  connection  with  the  diagnosis  of 
pneumonitis,  be  says,  it  "seems  hardly  to  possess  the  character  of 
humidity."  Auscultators  at  the  present  day  who  attribute  the  sound 
to  bubbles,  nevertheless  enn^ider  dryne!*s  as  one  of  its  distinctive 
features.  The  sound  appears  to  be  made  up  of  a  large  number  of 
minute  crepitation)*,  in  all  respects  equal.  In  this  point  of  view  it 
differs  from  the  sub-orcpitnnt  rale,  which  is  composed  of  unequal 
sounds,  owing  to  the  bubbles  taking  place  in  tubes  differing  con- 
tidcrably  in  calibre.  The  equality  of  the  minute  sounds  which 
fcombinc  to  form  the  crepitant  rale  is  due  to  the  fact  that  the  spitces 
in  which  they  are  produced  arc  more  uniform  in  »he.  The  crepi- 
tating sounds  arc  rapidly  evolved,  occurring,  «a  it  were,  in  puiTfl, 
IresembUng  the  noise  produced  by  ignition  of  a  small  train  of  gun- 
powder, to  which  il  has  been  aptly  compared.  The  sub-crepitant, 
as  well  as  the  mucous  rales,  take  place  more  slowly. 

In  addition  to  the  foregoing  points  which  pertnin  to  the  audible 
[characters,  there  are  others  not  less  distinctive.  The  crepitant  rale 
I  is  not  variable.  It  continues  constantly  for  u  certain  period,  not 
[changing  with  different  respirations,  save  in  intensity,  and  this  is 
[iisaally  proportionate  to  the  force  with  which  respiration  it  per- 


m 


PHTSICAL    BXPLOBATION    OF   THE    CHEST. 


formed.  It  ic  sometimes  ilevelopod  hy  forced  fireitliing  when  it  ii 
not  otherwise  appreciable.  It  is  not  suspended  bj  coughing  »i 
expectoration.  On  the  contrary,  after  an  set  of  coogbing,  tli«  res- 
piratory movements  immediately  succeeding  being  more  forcible,  it 
becomes  more  intense.  Finally  ic  is  heard  with  the  inspiratory  aa 
cxctuntvi'Iy.  This  is  certainly  the  rule,  and  probably  there  are  lo 
exceptions.  This  Inst  point,  to  which  attention  was  first  called  by 
Dance,  is  eminently  distinctive,  the  sub- crepitant  rale,  as  well  as  tbt 
mucous  rales,  being  present  freijuenily  in  the  expiratory,  as  wellii 
the  inspintlory  act.  This  point.  a»  will  be  seen  presently,  bu  u 
important  bearing  on  the  explanation  of  the  mecbaniam  by  wbidh 
the  riilc.i*  produced." 

Lnonnvc  regarded  the  crepitant  rale  a»  almost  pathognomoBte  if 
pneamoniti.t.  At  the  pre~-<ent  time,  its  distinctive  characters  baring 
been  more  clearly  defined,  it  ia  even  more  sigiti&eant  as  a  <IiagDO*tk 
»)gn  than  heretofore,  A  true  crepitant  rale  is  very  rarely  obccr*fd 
except  in  pneuinoDttis.  Moreover,  it  is  mrcly  the  case  that  it  i> 
ubi<ent  during  the  career  of  that  dixcase.  Tlie  opinion  of  Skoda  ii 
ID  opposition  to  the  latter  statement.  He  declares  tbut  not  only 
lias  he  failed  to  find  it  present,  but  he  has  not  often  observed  it. 
This  is  one  of  the  extraordinary  asscrtione  enunciated  by  tbst 
writer.  It  is  at  varianco  with  the  ob«ervations  of  others,  vfawe 
opportunities  for  studying  this  disease  hare  been  qmte  as  extenaiTb 
For  example,  Griaolle,  who  has  contributed  the  results  of  the  nnmer 
ical  investigation  of  a  large  number  of  cases  of  pneumonitis,  aSnoa 
that  this  sign  was  wanting  in  only  four  instances.  M.  Aran  failed 
to  discover  it  in  only  one  of  fifty  cases.  That  it  is  not  invariably 
pre.ient  is  undoubtedly  true,  but  the  experience  of  most  aiucaltatota 
is  united  on  the  fact  of  its  existence  being  the  rule  in  pneuinonitii. 
Not  only,  therefore,  is  it,  as  originally  claimed  by  the  founder  rf 
auscultation,  almost  pathognomonic  when  pre.'tent,  but  its  couMaiM^ 
mnkes  it  highly  v.iluable  as  a  diagnostic  criterion. 


1  A  pleural  Motion-ton nd  Moietiuiea  brurs  a  rer;  cl«««  reMnbUnoft  to  tb* 
crepitant  rale,  so  that,  judged  br  tbc  audible  chnrt)ct<-n  Rlnnn,  lh»  former  nuj 
be  niiiiakcn  for  th<'  Inil^r.  Thlt  I  »lnl«  IVuiii  uxpericncc.  Bartb  and  R«k*t  aUlt 
ihi*  liability  to  urrur.  ns  foltuws :  "  11  ml  na  autrn  bruit  <)al  pourralt  farfbimonl 
indutro  on  irrrour  unooreille  |)ou  cjii^rcSp:  \«/rvHfaunlfiUurttifiutMt  purtcatma- 
atilu^  [«r  uut.'  «iSrie  ilc  jwlita  cruitUKiumta  aucccHib,  par  unc  capteo  d*  cttf  italioB 
inagkla,  que  la  mpprochc  du  viritnblc  rfariDchiia  vrjipltnnt.  C'Mt  *aiu  dout«  c«tM 
nriotj  de  bruU  qui  a  fuit  din-  qu'il  i-xiBlail  un  rSU  erfpllMnt  dant  la  plairfiir.' 
P.  I«. 


AUSCULTATION    IN    UIPBASB. 


218 


It  is  uftiuilly  diiteovcrcvl  uliortly  nfHT  the  attack  of  pneumonitis 

adult.'i;  hut  thin  rtilt-  iH  \c*s  uniform  thnn  its  existence  at  amnt 

riod  of  the-  discnKc.     In  mot-t  catcs  oF  frank  pneumonitis,  it  is 

trongly  marked  prior  to  the  phjitical  evidences  of  sal!di6catioa, 

is^  notable  diilncss  on  pervusHion  nnd  the  bronchinl  rosplrution.    As 

eganU  its  niiiount  mid  intennity,  howerer,  different  cates  differ. 

Then  itbiindiiiit,  it  \»  henrd  during  nearly  the  whole  of  the  intpira- 

[lotyMt.     If  prodnce^l  throughout  an  entire  lobe,  or  within  the  cella 

It  the  eitcrior  portion  of  the  lung,  it  ie  loudly  developed,  and  ^cems 

rerj  near  the  ear;  but  when  confined  to  a  central  situation,  healthy 

iBg  int«n-ening  between  the  affected  part  and  the  thoracic  walls, 

is  compnraiively  feeble  and  distant.     In  these  respects  every 

shade  of  diversity  is  presented  in  a  aufSciently  large  namber  of 

Frequently  it  continues  more  or  leflH  during  the  stage  of 

solidification,  and  sometimes  it  does  not  a^ipenr  prior  to  this  stage. 

»It  is  then  associated  generally  with  the  bronchial  respiration;  and, 
Bnder  these  circumstances,  it  is  obseryed  only  at  the  end  of  the  in- 
spiratory sound.  It  is  often  develojied  hy  a  forced  inspiration, 
when  it  is  not  appreciable  with  ordinary  hreaihing.  The  situation 
ID  which  it  \»  found  in  the  mikjority  of  the  caHCs  of  pneumonitis,  is 
the  posterior  nurface  of  the  chest,  expccinlly  bi-low  the  scapula,  the 
disease,  a»  a  general  role,  affecting  the  inferior  lobe.  It  bt  oflener 
found  «n  the  right  than  the  left  side,  because  the  lower  lobe  of  the 
right  lung  is  loorc  frequently  attacked.  Its  existence  on  one  side 
of  the  chest  i»  an  important  diagnostic  circumstance;  for  pneuninn- 
itis^  in  the  great  majority  of  cnses,  is  confined  to  one  side.     On 

■  the  contrary,  capillary  bronchitis,  as  uniformly  affecting  both  sides 
equally,  the  sub-crepitant  rale  is  heard  on  both  sides.  This  dis- 
tinction, aside  from   the   distinctive   characters   pertaining   to   the 

■  crepitant  and  the  snb-crepitant  rales  respectively,  suffices,  in  gen- 
Heral,  for  a  differential  diitj:nosis.  A  rale,  concerning  which  we  may 
^UiaTC  some  doubt  whether  to  regard  it  as  a  crepitant  or  sub-crepilnut, 
Hlf  it  be  present  on  the  posterior  sarface  of  the  chest  on  both  sides  is, 

in  all  probability,  a  sub-crepitant;  but  if  confined  to  the  posterior 
surface  on  one  side,  the  chances  are  equally  great,  that  it  is  a  crep- 
itant rale. 

Pneumonitis  may  be  complicated  with  general  bronchitis.     This 
coincidence  is  not  frequent,  hut  of  occasional   occurrence.      The 
!  vesicular  rale  and   the  bronchial   raifs  will  then  be  likely  to  be 
I^Tariomly   combined.     Capillnry   bronchitis    and    pneumonitis   are 


S14 


PHYSICAL    KXPLORATIOX    OF    THK    CHRST. 


■omctimes  associated.  In  a  case  of  this  deecription  which  recmtij 
eMii«  ander  my  observation,  the  fscl  of  the  concurrence  of  tbe  m 
dJMaiies  having  been  demonstrated  after  death,  tbe  sub-crepitui 
rale  existed  on  bolb  sides,  but  on  one  side  the  sab-crepiuni  lai 
crepitant  raks  irere  distinctlj  appreciable  during  the  e»me  ioqan- 
tion,  the  former  during  the  first  part,  and  the  latter  at  tbe  dote  if 
the  act. 

The  returning  crepitant  rale,  described  by  Laennoc  as  charscler- 
ising  the  resolution  of  pneumonitis,  included  the  sub-crepiiant  nk. 
A  true  crepitant  rale  occurs  not  infrequeolly  in  this  stage  of  ibt 
disease;  but  it  is  apt  to  be  associated  with  the  snb-crepilant.uiiil 
the  latter  may  he  present  without  the  former.  The  cooibinaiioii  cf 
the  crepitant  and  the  sub-crepitant  rale  has  probably  led  to  the 
opinion,  b«Id  by  some,  that  the  crepitant  rale  is  sometimes  heard  ii 
the  expiratory  act. 

In  the  vast  majority  of  cases,  tbe  crepitant  rale  denotes  pnesiB»- 
niiifl.  It  is  not,  however,  true  that  it  never  occurs  in  any  other 
affection,  it  is  sometimes  observed  in  oidema,  ond  in  pulmonary  he*- 
orrhage.  In  these  aflvotions,  the  rale  is  generally  a  sub-crepiuu, 
bat  Uie  prcsieiice  of  !<crum,  and  perhaps  of  blood,  in  the  aifoeUt) 
may  give  ri#c  to  a  rule  essentially  simitar  to  the  true  crcpiunt  «f 
pnoumonititi.  In  oates  of  hemorrhage,  the  expectoration  of  blood 
settles  the  dijignonis.  Moreover,  in  tliwe  caties,  the  rnle  will  W 
found  at  the  »uniuiit  of  the  oheiit  in  front,  and  not  on  the  posterior 
surface,  as  in  the  larger  proportion  of  cum-m  of  pneumonitis,  ]>«»• 
optysis  being  generally  incident  to  tuberculous  diMraae.  The  differ- 
entia)  diagnosis  of  pneumonitis  and  (udema,  is  lo  be  baiHtl  on  the 
associated  cireumstunccs,  which  will  UHually  ftufiice  for  diBtcriminultOD 
vitbout  much  difficulty.  GUdcma  oecim  in  certain  pathological 
connections,  and  is  unuttcnilcd  by  the  symptoms  which  luinlly 
accompany  an  attack  of  pneumonitis. 

A  crepitant  rale,  nt  the  summit  of  the  chest  on  one  side  in  froni, 
confined  within  a  circumscribed  space,  is  a  significant  sign  of 
phthisis.  Primitive  pneumonitis,  in  the  sdult,  us  alrewly  staled, 
generally  inrades  an  entire  lobe,  and  in  the  majority  of  instance), 
an  inferior  lobe.  When  situated  toward  the  apex  of  the  tang,  and 
extending  over  a  smuU  area,  the  pneumonitis  is  secondary,  and  tbe 
antecedent  affection  ia  probably  tuberculosis,  inSaromation  baring 
been  developed  in  the  immediate  vicinity  of  the  tuberculous  deposit. 
This  rale,  under  the  circumstances  Just  stated,  becomes  a  si^ 


AtrsCTTLTATIOir    lit    DIBKABB. 


2lfi 


\ 


I 


hthitii  like  the  sibilant,  the  macoas,  and  the  stib-crepitant  nlcs, 
der  similar  circumstances. 

The  cx|i  in  nation  of  the  mechanism  by  which  the  crepitant  rale  is 
roducctl,  given  by  Laenneo,  and  generally  received  at  ihc  prciicnl 
imc,  altribtilvR  U  to  ibo  formation  of  miiiiilft  bubbles  within  the 
Tcsicle*,  ami  terminal  bronchial  tubes.  According  to  this  theory 
e  mecltanism  is  precisely  similar  to  tbut  involved  in  the  produo- 
tion  of  the  mucoiiit  and  sub>crepitant  riiles,  the  dilTereiicu  in  the 
Aadible  characters  being  supposed  to  be  owing  to  the  smaller  siic  of 
lithe  spaces  in  which  thi?  bubbling  takes  ptuce.  Thi»  explanation  it 
unsatisfactory,  in  view  of  several  facts  pertaining  to  the  characters 
distinctive  of  the  crepitant  rale.  The  absence  of  humidity,  in  other 
words,  tlio  dryness  of  the  sound;  the  constancy  of  the  rale  during 
the  period  of  its  continuanee,  and  especially  its  aeeompanying  ex- 
clusively the  net  of  inspiration,  militate  strongly  against  the  doc- 
trine commonly  held.  To  meet  these  objections.  Dr.  WaUhc  sug- 
gested that  the  M>und  may  be  due  to  the  sudden  pressure  exerted 
on  exudatioB-mattcr  between  the  vesicles,  by  tlie  expansion  of  the 
long.  But  the  exudation  in  pneumonitis  is  within  the  air-eelU,  and, 
facnoe,  in  to  far  as  the  sound  depends  on  this  result  of  inflammation, 
it  rouHl  be  intra- vesicular.  Th?  mo^t  rational  theory,  and  the  one 
which  meets  best  the  objections  to  that  of  Lncnncc.  was  offered 
sevenl  years  ago.  by  the  late  Dr.  Carr,  of  Canandaigua,  N.  Y. 
Dr.  Canr  attributed  the  production  of  the  sound  to  the  abrupt  sepa- 
ration of  the  walls  of  the  celts,  which  had  become  adherent  by 
toeana  of  the  viscid  e.iudation  incident  to  the  early  stage  of  inflam- 
mation.* That  ibis  explanation  accouiits  for  the  peculiar,  dry,  and 
crackling  sound,  as  rt-innrked  by  Dr.  C.  a  simple  experiment  nMI 
serve  to  illustrate.  If  the  thumb  and  finger  be  moistened  with  n 
little  paste,  or  solution  of  gum  antbic,  and.  while  held  near  the  car, 
alternately  pinched  together,  anfl  s^-parated,  an  imitation  of  the 
crepitant  rale  is  produced  more  perfect  even  than  rubbing  a  look  of 
lisir,  as  proposed  by  Dr.  Williams.  A  viscid  exudation  within  the 
cells  and  bronchioles  belongs  among  the  local  phenomena  of  the  dis- 
ease;  and  aa  it  is  not  readily  removed  by  expectoration,  but  accumu- 
lates till  the  cells  are  filled,  and  the  lung  solidified,  the  constancy 
of  the  rale  for  a  certain  time  is  intelligible.     Its  occurrence  with. 


'  N«»  PiplanatlAn  of  Iho  ornplWnl  rhofichin  of  pnniimorU,  hy  U.  A.  Cut, 
U.D. — Amoricui  Juuriial  uf  Mnlivnl  tk'it>nv<.ii,  Octulwr,  1843. 


rutstciL  sxrtoBAti*!  •»  tmm  chest. 


I  vkk  tsiptntitm,  al  ifcc  aaaot  vfca  tfae  ■gglitJailii 

vitkibe  ety» 
;  l>r.  Cut'*  eitlk' 
1  ikMi  tk  MMil  vmU  W  preaai  it. 
^eair  a  dns  M^a  a«iU  eatnng  Iht 
,  aearly  or  Mlirelj,  ia  pwyti» 
M  tke  exicM  aad  MaftacMS  of  tbe  nUefwat  aoUdifiotiN. 
nc&M  tku  wha  MBfifiEaiiM  hM  ttla  plaee  »  eertaiB  nate 
«r  edb  ««  MC  OM  «iik  iW  bmW  «niuiaB,  ud  vwua  b  At 
wJitioa  Mioek  eliiramiiiw  all  tbe  ecOt  m  ibe  earljr  ku^ «t- 
fboM  tbc  ptnitttaet  «f  tW  nit  m  mmc  euca  dariog  t^  i 
«ae«af  fiiMawti>,m»d  its  bang  4«vclopcd.  uder  tbc*e< 
■f  ca,  bj-  fmttA  iwyrati—a,  nd  ■■piBiRy  »t  the  cad  af  tfc* 
iaiyireterj  act.  Tkc  tkc«f7  af  Dr.  Oht  m  alio  «)oanj  applieaUe 
ta  ibe  eases  of  (adesa  sad  hKaay^w,  ta  ^kk  tW  crepitaot  tale 
■  abatnred.  le  tkese  afcebaa*  the  air-veaidea  eoataia  a  glatnioBS 
Eqibd.  altlkoa^  in  a  kaa  Maifccd  dc^TC*  dna  ia  pocimoaitn;  ud 
ire  eaa  wffly  aiidnWaad  tkat  dw  aipwaary  phyaieal  c<e^doM 
•re  pcaaant  aaoiliMBa,  bat  aot  eaaataatl/, aa  acaoaat  of  de  greatv 
bdlitj  Tith  vbidi  lb«  liqaid  eeeapw  fraai  tbc  cHls  mto  tb»  braa- 
(Ual  tabea,  ginag  rise  to  tbe  babUiag  raits — tbe  sA-ercfitaet  aad 

Ib  view  or  tbe  patbogooMoaic  ^aracter  or  tkr  crrpitani  rale,  aal 
tbe  ODifoimiiT  inth  which  ii  aneads  tbe  eadjat^a  of  paeananli^ 
it  vas  jiuUj'  couKiercd  hj  Laeoaec  la  be  aae  af  tba  Boat  osportHt 
af  ibe  phjraiea]  agae.  la  its  diagnoebe  Talne  as  aa  taobted  aiga,  h 
is  entitlMl  to  the  first  rank  aaoag  tW  yhcaomnia  foraisbed  hj  sas- 
ealuiion. 

The  pitch  of  the  crepiuat  ral«,  as  wetl  aa  tbat  af  ibe  sab-crefHtaat 
aad  tbe  mnoooa  ralea,  repeeaeots  tbe  oondition  of  tbe  lang  a»  regard 
•obdifieation.  Tbe  pit«b  u  compiu^tively  lov  in  tbe  fint  Mage  ef 
paemMMitU  before  soli<lificati<m  lix9  taki'n  place;  tbe  pilch  i*  railed 
ia  tbe  wooad  alsge,  if  the  rale  coottnae  into  tiiia  sta^,  aad  Uie 
piteb  of  the  reloniing  erepiUni  rale  ia  lowered  in  pniportiva  at  tea- 
olation  goes  on. 

In  feeble  patients  confined  to  the  bed,  a  transient  crepitant  rale  a 
iOiBttiBkrs  heard  when  tbey  are  raised  np,  and  the  car  or  stetho9C«f)e 
applied  to  ihc  posterior  sod  inferior  portion  of  the  chest.  It  mtj 
proceei],  under  these  eircatastances,  from  the  slight  sgglatinatioa  of 


AVSODLTATIOK   IK    DISRASB. 


217 


lir^ells  and  bronchioles,  wtich  from  re«ainbenc^  od  the  bnck  and 

Feebleness  of  the  brenthing,  have  been  for  some  time  unoxpaixlril. 

[The  n)e  is  gcoerallj  heard  on  both  tii<lea.     It  (ltMippe»rA  after  ii  few 

■forced  respirations.     Under  theae  cireumflCanccH,  it  18  not  n.  sign  of 

jpneumonitia  nor  of  any  pulmonary  alfeetion.     The  yonng  iiii»cii1- 

itor  ia  to  he  cautioned  against  mistaking  a  sound  caused  by  the 

aorements  of  the  pectoral  extremity  of  the  stethoscope  upon  the 

cheet  covered  with  hair,  for  a  crepitant  rale.     The  rcsembhince  of 

lie  aonnd  thus  produced  to  the  crepitant  rale  ia  aometinies  striking. 

6.  Caeemotis  raltt,  or  ffUTfflinff. — The  entrance  of  uir  into  a  cavity 

[{larliully  filled  with  liquid,  gives  rise  to  a  sound  resembling  a  mucous 

trale  (trodiieed  within  the  larger  of  the  bronchiiil  tubes,  from  which 

'it  cannot  nlirays  be  distinguished;  and  hence,  according  to  sonio 

wrilcrd,  it  it)  needless  to  describe  a  cavernous  nile  as  iin  independent 

physical  sign.     In  some  instanccn,  however,  the  sound  is  sufficiently 

.     distinctive  to  indicate  very  clearly  the  existence  of  a  cavity. 

H     A  cavernous  rale  is  a  moist  sound,  conveying  very  distinctly  the 

^tdea  of  a  liquid.     It  is  produced  partly  by  bubbles,  and  in  part  by 

the  agitation  of  the  mass  of  liquid.     The  bubbles,  in  cases  in  which 

the  charact eristic  sound  is  well  marked,  appear  to  be  larger  in  size 

»than  the  coitr>esl  mucous  rule,  and,  Ht  llie  same  time,  fewer  in  number. 
The  liquid  thrown  into  agititciun  by  the  impulse  of  the  nir,  causes 
a  round,  of  which  the  best  idea  is  coiircyed  by  the  term  gurgling. 
It  may  be  compared  to  the  sudden  commotion  which  occurs  from 
^^timc  to  time,  when  a  liiguid  is  brought  ncnrly  to  the  point  of  ebulli- 
HKod.  The  latter  is  an  occasional  variety  of  the  eavcrnons  rale,  and 
is  presented  in  the  most  marked  degree  when  the  communicntton  of 
ihc  cavity  with  a  bronehiiil  tube  is  fuHiciently  large  for  a  column  of 
air  of  considerable  sise  to  enter  with  force,  other  favorable  physical 
conditions  also  coexisting.  The  movements  of  the  lung,  irrespective 
of  the  entrance  of  air  into  the  cavity,  it  is  probable  may  suffice  to 
produce  a  gurgling  sound,  but  less  in  degree.  The  impulse  of  the 
beart  sometimes  causes  sufGcient  agitation  of  the  liquid  to  give  rise 
to  a  rale,  which  is  detennineil  by  observing;  that  it  continues  when 
respiration  is  momcnliirily  su-^prndt-d,  and  is  synchronous  with  the 
palse.  This  curious  fact  has  been  repeatedly  noticed  when  the  cav- 
ity was  seated  in  the  left  lung,  but  Dr.  Slokes  has  observed  it  even 
ontlicpo«lenorsurfnccof  the  right  side  of  the  chest.  Thebubblingand 
gurgling  sounds  may  take  placid  with  in.ipiration  and  expiration,  con* 
jointly  or  singly,  and  when  with  cither  separately  oftener  with  the  for- 


■ 


TW  pfc JIM  ■)  BoaditiMi 

'.  nk.  vhoi  At  cantj  is  fw 

the  earitj  » 

wS  ifcairfiiii  W  fc— d  in  eertaJB  caMtk 

I  TJW  III  n  ■tmHj  nil  iiafiiw  i  nli 

«f  B  CKfity,  ia  hjmm 

It  £MODT«i^ltb     ^le  caritj  mM 

haai,  mr  oo  tlw  vAot  haad,  eoaffatelf  fflcd.  1W  eooiiBBiikstiM 
with  the  broadiBJ  tabes  ■•£!  be  Mow  tkt  level  trf  tbe  liqtad.  Tfa» 
oomaauestioa,  ft»d  tke  bmaeUal  tabca  the»ielrea,  Bim  not  be 
ctmirmatAhjmaAiiifnimtU.  IV  eaaanTcne*  oT  thew  eoaditwH 
c»B  only  be  eipcetcd  to  obtaht,  now  aad  thta.  ao  tlui  «e  m; 
att;tcalut«  for  ilu*  logn  repeMcdly,  in  cum  ib  vhiefa  «  caviir  or 
antics  exist,  witboot  wKcttf.  Tbe  raise  oT  the  ngn  in  diagnosis, 
therefore,  ia  altogether  poeitire;  negmtiTel;,  it  b  of  little  or  no 
value :  that  a,  we  are  not  aatfaorised  to  infer  tbe  Boo-exislence  i>f  s 
eavit;  from  the  absence  of  the  tiga. 

Other  tiling?  being  eqaal,  tbe  nxc  of  the  babbles  uh)  the  load- 
Dcss  of  the  gurgling  will  be  proportionate  to  the  magniiade  of  the 
carity.  When  the  rale  closeW  rcsemhles  the  mucous,  but  retains 
the  cavernous  characters  enSciebtlT  to  be  distinguished  fron  the 
latter,  it  has  been  called  aatrmulotu,'  and  Bopposed  to  indicate  the 
existence  of  sinall  excAvations.  This  distinction,  however,  is  diai- 
cally  unimportant. 

As  hu  bciin  slated,  a  well-marked  cavernous  rale  at  the  snatnit 


'  Thd  title  «M  Dm  appllMl  hf  U.  Hirta,  of  StrMbourc. 


AUBC1TLTATI0K    IN   DISBASK. 


219 


W 


tbc  chv^t  dciiDUa  almost  with  certsinty  an  excavation  proceeding 
ta1>crcii)Dna  dim-as^?.  But  the  rale  may  he  present  io  cases  in 
'faich  cavitiem  arc  olhorwisc  formed,  vix.,  from  circumscribed  gao- 
e,  abscess,  and  pouoh-like  dilatalion  of  a  bronchial  tube.  It 
aj  alao  exist  in  caaes  of  perforation  of  the  lung,  wiih  accumulation 
if  li^iuid  in  the  pleural  sac, )'.  e.,  in  pneumo-hydrolhorax.  The  di> 
osis  of  each  of  these  affectiona  muat,  however,  be  baaed  mainly 
in  other  signa.  The  infre(|uency  with  which  this  rale  is  discovered, 
e  difficulty  in  many  instances  of  diftcriminating  between  it  and 
le  mucous  ralea  (the  two  being,  moreover,  frequently  commin- 
),  together  with  the  fact,  that  it  generally  ooours  at  a  period  of 
isease  and  nnder  circumstances  when  the  diagnosis  is  siiSictently 
lasy,  and  haa  probably  bevn  already  made,  render  it  a  etgii  of  minor 
practical  consequence. 

7.  JndeUrminaU  r«?«.— Under  this  head  may  be  emhravcd  cer- 
in  adventitious  sounds,  not  clearly  referable  to  either  of  the  fore- 
going divisions,  and  of  which  the  situation,  as  well  as  the  manner  of 
production,  are  matters  of  doubt.  Notwithstanding  this  uncertainty 
88  respects  their  locality  and  cxplnnuiion,  some  of  these  itoiindx  are 
>j  no  means  without  value  as  phy^icul  signs,  obffcrvalion  having 
CstabliKhrd  their  pathological  relations. 

Laennt-c  dv»cribcil  a  distinct  i^ound  which  he  designated  by  the 
somewhat  contradictory  phrase,  "  Dry  crepitant  rale  with  largo 
bubblcB"  (rale  crepitant  tec  <)  grosaei  huUei).  This  sound,  accord- 
ing to  Laennec,  "conveyii  tho  impresffion  ax  of  air  entcrin};  and 
distending  lunge  which  bad  been  dried,  and  of  which  tho  cells  hud 
been  very  unequally  dilated,  and  rcsemhles  the  sound  produced  by 
blowing  into  a  dried  bladder."  tic  regarded  the  HOund  thus  de- 
scribed ai!  characteristic  of  empliy«emu  of  the  lungs.  Most  aus- 
caltators,  «inco  the  time  of  Lacnnec,  have  failed  to  discover  a  rule 
with  well-marlccd  characters  of  the  kind  jtmt  ntuted ;  and  multiplied 
observationa  in  cases  of  emphysema  do  nul  cntMhli^h  \\n  connection 
with  any  each  sign.  It  is  probable  that  in  inatiluting  this  rale 
Laennce  was  influenced  by  preconceived  notions.  At  nil  events,  if 
•  rale  such  as  Laennec  described  exists,  in  view  of  the  ilitlieulty  of 
appreciating  it,  and  its  indefinite  signification,  it  ia  practically  una- 
jTsilable  in  diagnosis. 

f    Putnumary  erumpiing. — Under  the   title  of  frotasetnent  pufmo- 
nam,  rendered  as  above,  Fournet'  embraced  a  variety  of  sounds 


Op.  dl. 


220 


FBTSIOAL    BXrLOBATlOX  OF    TBB    CBBST. 


not  bearing  t«  each  otfaer  d«Pe  rcsemMnnee,  Mv-fr  ttat,  knorimi 
to  this  obscrrn-,  an  impreauOQ  b  eonvrTcd  to  tlic  mind  of  tbe  ut- 
calutor  of  th«  "pulmonarj  tiMnie  forcibly  «ra|Egling  against  mm 
iropeditnenl  to  it*  es|Wii>ion."  One  varittj  he  compares  to  the  a«v 
leather  rrictioo  Mood  (ftrui/  A  cuir  nrv^f)  heard  in  perieardu; 
another  ts  a  plaintirc  moaning  Mund.  irith  rarioas  intonatiooi ;  » 
oth^r  is  lik«  th«  Roand  produced  bj  blowing  apon  lisstie-pifar. 
These  sounds,  diflie ring  no  mueb  in  (bcir  audible  cbaracten,aiJ!iiil4f 
being  classed  together  ouly  a*  indeterminate  rate«.  The  b«»J  if 
omon  stated  b;  Koiimet  ma»t  be  regarded  as  fanciful.  The  soand 
resembling  the  crampltng  of  tiwuivpaper,  and  that  of  new  leather, 
may  be  veritable  pleural  friction  sounils.  The  variooa  moaniif 
sonndx  are  probably  sonorous  bronchia)  rales.  Fonmet  e&deann 
to  establish  points  of  distinction  between  them  collectively  and  oAft 
rales,  but  the  chief  characteristic  is  that  by  which  they  are  pland 
in  the  same  category,  ris.,  tlie  impression  conveyed  to  the  ear  ef  t 
Btrnggle  against  an  obstacle.  Such  impressions  ar«  so  apt  to  origi- 
nate within  the  mind,  that  they  are  to  be  trusted  but  to  a  litoiud 
extent  in  forming  opinions  respecting  the  explanation  of  aiucvltalsiy 
signs. 

It  is  chiefly  with  reference  to  the  diagnosis  of  tuberculou  duteftK 
that  the  sounds  regarded  by  Fournci  as  dependent  on  pohnmiafy 
crumpling  nrc  of  practicnl  importance.  And  their  diagnostic  ini> 
porlance,  in  this  relation,  is  irrMpcctive  of  the  question  whether 
they  are  properly  varieties  of  the  same  sign,  nnd  of  any  hyputhcM 
as  to  their  mwie  of  production.  Foumet  stntes  that  he  has  observed 
a  bruU  de  frotMfment  in  the  proportion  of  about  one-eighth  of  p«T> 
eons  affected  with  phthisis.  Occurring  at  the  summit  of  the  chest, 
frequently  if  not  generally  limited  to  one  side,  nnd  confined  within 
circumi!erilM-d  limits,  a  rale  resembling  cither  of  the  sounds  above 
described  belongs  among  the  varied  physicnl  signs  which,  from  their 
situation  and  limitation,  taken  in  connection  with  symptoms,  poiiii 
to  the  existence  of  a  tuberculous  deposit.  Accunling  lo  Foumet, 
these  sounds  are  observed  in  the  CJirly  stage  of  phthisis,  and  the 
acute  form  of  the  iliscasc,  or  tuberculous  infiltration,  is  cspeeiallj 
favornble  for  their  development. 

This  sign  is  not  infrequent  in  healthy  persons.  If  Cammann't 
stethoscope  be  naed,  it  is  not  uncommon,  in  healthy  persona,  to  hear 
pretty  loud  crumpling  sounds  at  the  end  of  a  deep  inepiratior. 
They  are  hoard  particularly  at  tlic  summit  of  the  chest  in  frool. 


AUSOPLTAIION    IX    D13EA38. 


221 


cb 

>        vnr 


<  of  their  being  hoard  on  both  8i<lv»  of  the  cheet,  taken  is 

bniiPctioD  with  tbr  absence  of  other  signs  of  diitunvc,  will  enable 

kueenltator  to  nroid  the  error  of  considc-ring  tbeR-  feounds  a» 

Borbid. 

J*uimoiian/  waekUing. — A   crackling   sound,   presenting  certain 

rietiee  (rdUa  tie  cra^tifnieHt),  like  the  preceding,  has  been  particu- 

rly  described  bjr  Fournol,  and  is  recognised  a»  u  distinctive  nus- 

Itstory  sign  by  most  writers  on  the  subject  of  physical  exploration. 

lie  varieties  of  Ihis  sound  arc  arrunged  in  two  classes,  viz.,  dnf 

jrraekitiig  and  moitl  crackling.    Like  tlie  eo-ci>lted  crumpling  sounds, 

liey  belong  among  the  physical  signs  of  phthisis,  and  are  entitled 

'to  some  weight  in   the  diagnosis  of  that  disease.     Their  diagnostic 

significance,  like  that  of  several  other  signs  of  tubercle  already 

tDentioned,  depends  on  their  being  observed  at  tho  summit  of  tlie 

chest  within  a  circumscribod  space  on  one  !<ide. 

Dry  crepitation  bears  a  close  reseniblnnec  to  the  crepitant  rale, 
jike  the  latter,  it  appears  to  be  made  up  of  distinct  crepitations,  but 
much  fewer  in  number,  frequently,  according  to  Fournet,  not  exceed- 
ing two  or  three.  Like  the  crepitant  rale,  it  occurs  almost  exclu- 
sively with  inipirntion.  The  mechanism  of  the  sound  is  generally 
considered  doiihtful.  The  mo^l  rational  e^upposilion,  os  it  seems  to 
nie,  is,  that  it  is  produced  in  the  same  way  as  the  crepitant  rale,  viz., 

I  by  the  »brupt  separntion  of  the  witlbs  of  u  few  cells  which  beeome 
adherent,  when  the  lungs  are  collapsed,  in  consequence  of  the  pre.-'- 
•noe  of  a  small  quantity  of  glutinous  exudation.'  Tlie  sound  is 
occasionally  observed  during  a  few  respirations  in  the  healthy  chest- 
It  U  A  sign  of  rather  frequent  occurrence  in  the  early  stage  of 
phtbiua,  and  under  these  circumstances  is  usually  constant  during 

»tlie  period  of  its  persistence.  Of  fifty-five  cases  in  which  it  was 
observed  by  Fournet,  its  constancy  was  noted  in  all  hut  nine  in- 
■tances.  The  crackling  appears  removed  from  the  surface  of  the 
htng,  not  near  the  ear, — n  point  which  serves  to  distinguish  it  from 
a  pleural  friction-sound. 

>tni»t  crackling,  according  to  Fournet,  is  developed  at  a  later 
stage  of  the  disease.  The  dry  sometime!)  merges  into  the  moist 
rale.  Moist  crackling  appears  to  me  to  be  neither  more  nor  less 
than  a  sub-crepitant  rale.     As  the  title  imports,  it  dlifei's  from  dry 


'  Tfati  (xplanftlion  scconla  with  Ui"  dMcrlptlnn  of  thn  rharsctfr of  lb*  wand 
I'Vf  Poaraet;  "It  (lonaUtv d«n>  uno  euiuitlian  toute p»rti«u1iir«  ilu  rapturt," Stio. 


222 


mrSJCAJ.    BXPLORATIOK    OF   TRB    OBBST. 


crackling  in  ita  conveying  the  senaation  of  the  presence  of  >  ti^ci 
It  is  not  confined  to  inspiration,  bnl  occora  also  in  expiration,    liii 
Bdpposed  by  Foumet  to  indicate  the  transition  of  crude  tubercle  to 
softening,  dry  crackling  i>ertaining  to  the  period  of  crudity.    It  a 
probably  doe  to  the  presence  of  fluid  in  the  smaller  braocbes  of  tin 
bronchial  tubes,  and  this  fluid  may  be  softened  tuherculoas  matter, 
or  niDcoas  secretion   from  bronchitifl  affecting   the   Bmalter  iuli» 
within  a  limited  area.     The  occurrence  of  the  (vo  kinds  of  crad- 
ling in  regular  sueccit^ion,  and  the  uniform  relation  of  each  to  a  (Af- 
ferent Btage  of  tuberculous  disease,  are  theoretical  conclusions  whi^ 
obaerration  has  not  conclusively  established. 

The  foregoing  are  the  adventitious  sounds  included  within  tlted^■ 
nomination  of  rale.s.  The  subjoined  table  contains  a  recapitulation 
of  the  distinctive  characters  and  diagnoatio  indications  pertainiogU 
them  respectively. 

DniU  ExMbitiitg  tfu:  Dittinctive  Ckaracters  aitd  JKaynostic  biport  if 
the  Different  Raies. 


SHULAXT. 

Drj  *nun^,  high  In  pitch;  trhUlllnd, 
fafwitig,  or  clicking;  tvmutiinoi  muii- 

Varinbt?  in  oonlinuiine*,  iiil«iiiiitj, 
Intonalion,  aai  Mlaatlon. 

PrMVut  with  fniipiriiUoD,  or  expira- 
tion, or  both ;  ofloner  with  iorpiratioii. 

ir  proiCDl  on  both  *i<liw,  indicatlia 
of  primilivc  broncbilU  Bffccting  the 
«iiiallcr  tiilin*,  nr  of  bronchlnl  •('Mm. 

ConfitipU  to  oiic  tiJt',  IcJIcativf  of 
brnnftiilia  cnniplicating  pnoumomtU  or 
plcufi'J. 

Limiwd  to  a  circumicribod  ipaca  at 
Uie  •UDimlt  of  tho  ohf«l,  Indioatlvu  of 
tnfaerculoMt. 

Often  ONiiMiatRd  with  tho  lonoroiM 
and  iauoi)u«  rslM. 

Hucon. 

Muitit,  h(il>bli[ig  eounda.  Coane  or 
Biie,  in  pruportion  to  the  »i«ii  of  tho 
hrnnchinl  lubini  in  which  thcv  are  pro- 
daovd. 

Vnrinble  in  continuance,  intenrity, 
ditiiation,  *nd  doicrno  of  oonrtt'nue. 
8uJipendu>I  by  uzptKUralion. 


Soxoaova. 

Dry  •oDiid,  gT»v«  Id  ton*.  (Mmm 
muiiciil  than  tli«  •ilnluit;  louder  anl 
tlrong*T. 

Varisble  la  conlinuaoce,  fnlMrii;, 
ta  ton  alia  Q,  and  Mtaation. 

PrN»nt  with  iMpirallofi  and  eipir*- 
tioD,  oftt-nc^'  the  1alt«r,  and  «ith  botk 

If  prsMnl  on  botb  iIiIm,  ladkatif* 
of  pTimitivc  tironchitie,  or  of  btmctol 
■pum. 

Con&n«d  to  oae  lid*,  Ii>d1callve  •( 
(ocondary  hronchtti*. 

Limitnd  to  a  eircDnncribcd  ipaeatt 
the  nun  mi  I,  iadlcatlvo  of  tubercaloll 

CMlait  aModatcd  with  tU  ribiUal  vti 
Riucuus  rales. 

CATiaxoiTs. 
A  mobt  Mund,  aonv«vtng  the  Un- 
prcMion  of  vorjr  largo  bubhiea,  uid  lb* 
■citation  nf  a  mam  of  liquid  (gorgliii^, 
occaiionallj  ■juchronou*  with  the 
hfarl't  impulKL 


AV»OVLYATIOlt  IH    PIBBABK. 


al  wltb  tntpiration,  or  Riplrn- 
,  or  both. 
Co*r*a   and    flna    nics   often   com- 

If  pf  MFOI  on  boUi  (ido  Dt  the  inferior 
•taricir  jiiirtion  uf  cbvit,  fiidifHUTt'  of 
gnd  >tag«  of  primitive  bronchitis ; 
li«  Ccon'ni'u  or  flnnnnu  denoting  «x- 
ant  of  br[>r>GliiBl  tul>i<t  alTt'ctcd. 
Conflncd  to  one  (ido,  indientira  of 
^ttotidarj'  bTi>nchltl',  or  th«  [rrrd'tiru  of 
a,  aeruiUiOr  blood  in  broncliial  tuba. 
Llanilpd  to  a  Mrramirrtbnd  apace  at 
th«  Mimnil,  or  mora  muki'd  in  thftl 
•lluatlt>a,  IndlcatJTfl  of  tuhorculoab 
tnon.-  or  Ibh  Hdranced. 

31a;  be  aiiociatod  with  (JbilanC  and 
•onoToun  tkIbd. 

ni£h  or  low  ici  pitch,  aei^ordinic  to 
^^U>i>  eiutcDou,  or  otherwiM)  of  Mtiditt- 
^^kation  of  lung. 

m } 

1: 


Dry,    cr«Tpjtating    sound.      Evolved 
rilh  rapidity,  in  pufls.     Cuualant,  not 
Ivsriabl*^    Not  tiupendcd  by  coughing. 


Pr«MBt  with  inaplratlon  sscliuivdy. 
Vitrf  rarely  exiiling  on  botli  >idea. 

Almoat  pathognomonic  of  jmeumnni- 
tb ;  frt^uenlly  Continuing  through  the 
diieuc,  or  givifig  placQ  to  a  iiab-crRpi- 
tant  rain. 

Occur*  occHaloDall;  In  wdama  and 
faaRxioptyui. 

Idnittd  to  a  clrcuntcflhed  tjutcn  at 
lbs  •nnimit  of  the  chc*t,  indicutivu  uf 
tnbercutous. 

High  or  low  in  pitch,  according  to 
the  cxiil«ncc,  or  otfaerwiae,  of  lolldifl- 
oulon  of  lung. 


Preicnt  with  imptration,  or  Pipira- 
tiun.or  bitb,  ceppcinlly  with  innpirulton. 

Kometimci  amphoric,  and,  If  not,  thu 
pitch  low. 

Generally  nituntcd  at  tha  lumfnit  of 
the  c1i<!*i. 

Alternnting  or  combined  witb  ca*- 
emoiia  rrapiratlon. 

Cenid  and  roiurna  al  irregular  inter- 

I  iidlostlvo  of  Inb^roulouD  oicaTalion* ; 
cavities  following  HbsceM,circuinitcrit>ed 
glintrr''ne,  and  pouch-like  dilatation  of 

bronchial  UthM. 


SlIB-CBBPlTANT. 

Moist  aoiind,  giving  Iraprcuion  »r 
very  tinall  bu)>blM,  Bubbloa  touiewhnt 
unequal.  More  regular  and  conalant 
than  mucoiu  ralm.  L<Mt  llki<ly  to  hi? 
auapended  by  e»pec[orBtion. 

PrMiint  with  intipirnlluu,  or  expira- 
tion, or  both. 

If  prctnnt  on  both  lidc*  at  poitcnor 
inferior  pwt  vf  I'liwI,  liidloallve  of  prliii- 
ilive  CBpillary  bronchitis, 

Ucuura  In  pncumonitla,  at  period  of 
reiolution ;  ul«o  in  u>d«nia,  and  pulmo- 
nary ap'rploiy,  or  hsmoptyMa. 

Limited  to  a  circum«crib*>d  apace  at 
till'  lUinmil  of  lh«  obc»t,  indieativo  of 
luberculosia. 

High  or  low  in  pitch,  according  to 
the  t^iiiilruci',  ur  ulborwlt*,  of  toUtlifi- 
callon  ft  lung. 


1.  Pulmonury  (Turiipllng. 
S.  Palmonnry  crackling. 


Attrition,  on  Pleural  FBtorios-soCNDS. — With  lie  act  of  in- 
Ispinitiot)  the  ihoracic  space  is  enlarged  miiinly  by  depression  of  the 


224 


pnT;S[CAL    EZrLOKiTIOir   OF   TBB   CB8ST. 


•ImpbrnfTii,  «n<1  the-  I'lcrntiuo  Df  the  rib*.  The  long,  rxpuxltng  U 
fill  tlic  au<;Ri(.-»tc(l  cnpncitjr  of  iho  diMl,  inoT««  in  n  vcrtieitl  din«- 
tioD  (lowDwnrd,  while  t!iv  wnlU  of  ttift  cttut  asonitl;  an<l  kctice  n- 
salts,  of  necc«sit}',  a  certain  esu-nt  of  friction  of  the  plesnl  at- 
been,  which  is  repented  nith  the  revcrH  moTenieotE  of  expirktioB. 

Kormal  plenrxl  friction  takes  place  eilentljr,  as  sbovn  hy  eipen- 
mcnts  on  inferior  Hiilmals  and  auscuItatioD  of  the  hcalthj  cheM. 
This  is  undoiibu-illv  oniiig  to  the  Mghly  poluh«d  and  uuMUMi 
condition  of  the  DiL-inbrane.  When,  however,  the  surfaces  are  m- 
dered  irrogulitr  und  rough  by  morbid  exudation  or  other  eaiaei, 
there  exist  the-  phj-nieal  condition*  for  the  production  of  ailvcntitim 
sounds,  to  whicli  arc  applied  the  nantci*  attrition  or  friclion-«o<ia4L 
The  mechunisin  of  their  production  U  sufficicnti;  intelligible;  tht 
points  of  inquiry  which  suggest  llieimH-lvci  are,  the  diversity  of  ik 
sounds  thus  produced;  their  distinctive  cltarncters,  and  thv  dmmi 
by  vhich  they  are  to  be  distingntvhed ;  the  disoMes  to  whici  l^ 
are  incident,  and  tlic  circumstances  on  which  depends  their  (Iiagn<»- 
tic  sign ifi can cc- 

Tbe  intrinsic  differences  of  friction-sounilg  are  such  that  they  nay 
be  divided  into  several  varieties.  These,  however,  do  not  indirtds- 
ally  Hustsin  pathological  and  clinical  relation  so  distinct  and  in- 
porlaiit  MS  to  claim  separate  consideration.  A  delicate  graxing  n 
one  vnriety,  occurring  when  the  opposing  movements  are  not  forcible, 
or  the  physical  conditions  are  not  the  most  favorable  for  the  produc- 
tion uf  sound.  Another  Variety  is  a  more  distinct  mhl'ing,  chielj 
denoting  greater  force  of  attrition.  A  greater  degree  of  harshoen 
of  sound,  dependent  on  greater  roughness  of  the  pleural  Eurfacee. 
constitutes  the  variety  called  ratpoiif  or  grating.  A  creakinff,  like 
new  leather,  ia  still  another  variety.  These  diversities  of  sound  are 
dne  to  differences  which  are  in  a  certain  sense  accidental,  and  may 
be  presented  in  different  cases  of  the  same  affection,  withont  famUh- 
ing  any  special  indications  as^espects  either  the  nature  or  degree o( 
the  disease.  The  grazing  and  rubbing  sounds,  which  are  the  varie- 
tie»  onlinarily  prefli^ntetl,  may  be  exactly  imitated  by  placing  the 
palm  of  the  left  hand  over  the  ear,  with  Rnn  pressure,  and  moving 
slowly  over  the  dorsal  surface  the  pulpy  portion  of  a  finger  of  the 
right  hand. 

A  friction -80 und  may  accompany  both  respiratory  act«,  or  the  act 
of  inspiration  alone.  It  is  frequently  heard  with  both  acts,  but  very 
rarely  limited  to  the  act  of  expiration.     When  it  acoompanivs  hoth 


AirSOULTATIOK    IS    DTS8ASR. 


» 


ets,  it  b  more  dieliuct  with  inspiration.  It  ia  seldom  continaom 
during  tlic  wliole  of  the  inspiratory  or  expiratorj  act,  but  it  occupiea 
■  portion  onljr  of  its  duration.  Ordinarily,  it  is  either  a  single 
und  of  brief  duration,  or  there  occurs  a  oeries  of  sounds  succeed* 
ng  each  other  with  more  or  leas  rapidity,  resembling,  in  ihia  partic- 
lar,  interrupted  or  jerking  respiration.  Occurring  in  tht»  ninnuor 
t  BomotiiDcs  bears  a  very  close  resemblance  to  the  crepitant  rale, 
nd  mij  be  mistaken  for  it.  In  aooie  instances  it  continues  unin- 
rruptcd  through  the  act  of  inspiration,  and  may  even  be  prolonged 
through  the  expiratory  act,  giving  rise  to  a  oouslanl  rumbling  aouud. 
Ja  the  great  majority  of  cases,  the  sound  is  manifestly  dry;  but  it 
may  euggcst  the  idea  of  moisture.  This  occurs  when  false  mem- 
branes, situated  OQ  the  pleural  surfaces,  become  infiltrated  with 
eertun.  Under  these  circumstances  a  sound  may  be  produced,  which 
Walshe  characterizes  aa  tquathy.  The  intensity  is  variable.  It 
may  he  so  slight  aa  to  be  but  just  appreciable,  or  it  may  be  so  loud  ua 
to  he  beard  at  a  distance.  Several  instances  have  fallen  under  my 
knowledge  in  which  it  was  so  intense  as  to  be  a  source  of  annoyance 
to  the  patient,  during  convalescence  from  pleuritis.  Between  these 
extremes  there  i»  every  degree  of  intensity.  It  is  nsually  confined 
to  a  small  space,  but  it  may  be  more  or  less  diffused,  and  occasion- 
ally is  heard  over  the  entire  cbest.  In  the  latter  case,  it  may  be 
produced  within  a  limited  space,  but  its  intensity  causes  it  to  be  ap- 
preciable at  a  greater  or  less  distance  from  its  source.  The  sitiia* 
tions  where  it  is  beard  are  usually  the  middle  and  lower  portiona  of 
the  chest,  oftener  laterally,  or  posteriorly.  Ae  exceptions  to  the 
general  rule,  it  is  sometimes  heard  at  the  summit,  and  thus  situated, 
it  has  a  special  dingnostto  significance,  which  will  b«  presently  men- 
tioned. The  sound  always  appears  to  be  superficial,  not  emanating 
from  beneath  the  superficies  of  the  lung.  This  is  a  distinguishing 
feature.  So  superficial  does  it  sometimea  appear,  that  it  seems  to 
tie  Busc'nltator  to  be  produced  upon  the  integument,  and  he  is  led 
by  the  apparent  nearness  of  the  sound,  to  Btupcct  that  a  portion  of 
the  dress  comes  in  contact  with  the  ear  or  stethoscope.  In  some  in- 
stances, a  friction-sound  is  beard  with  each  respiration,  hut  oftenor 
H  i«  variable  in  this  respect,  accompanying  some  respirations,  but 
absent  in  others.  It  is  sometimea  appreciable  only  with  forced  res- 
piration, and,  on  the  other  h.^nd,  it  is  somotimcs  strongest  when  the 
breathing  is  lran<iuil.  The  sound  is  sometimes  increased  when  firtn 
pressure  is  made  with  the  stethoscope.     Its  continuanco  is  varia- 

IS 


FBTBtCAl.    IXPLOBATIOS    »W   TB  >   OVBST. 


bl«.  It  Bsj  be  tnasTBt,  or  h  bbj  coatnac  for  i 
period.  Id  »  cauc  rvportad  k;  Aadnl,  it  hated  for  thre* 
b  ii  •bcerred  ia  sooe  hksuneei  to  iktfi  iti  Mat,  hting  ftt  ooc  tiai 
Ward  at  a  eertain  potnt,  kmI  at  aaothcr  tta«  ia  a  diflercat  aitaatii^ 
aad  Ibeae  ekaagn  mar  x»ke  ptaee  wptaleflj.  Inlarwttaa^  il 
■aotker  poiut  of  rariabUit;.  It  aaj  W  preift,  disappear,  aai 
ag«n  rcB[^ear,  and  theae  aheratioiis  naj  oeew  more  tlun  oa«e  it 
lb*  progFCia  of  dte  aaae  diaease.  I  bare  ttftttHj  obaerrcd  U  N 
diaappcsr,  tenporarilj,  after  fordUe  rc^iraliMia  b*Te  bcea  em- 
ttuwd  for  loiDe  tine  for  tbe  pnrpaae  of  itlaslratiBg  the  nga  M* 
ABmber  of  parsona  in  8iieee8S)o&.  Finallv,  if  a  frictioo-aoaad  W 
•troog,  and  capeciaDj  if  it  be  rough,  a  Tibratiea  or  fretnilas  ia  po^ 
ccptibli!  to  the  touch,  on  placing  tbe  hand  over  tbe  aid« ;  aad  ■ 
thia  wajr  patients  tbcmselTea  become  avare  of  a  mbbiog  witbia  tbf 
cbeeL 

The  dutinctirc  cbnrsctcrs  of  a  plcarnl  rriction-soand,  are  ntk 
that  its  di  scrim  illation  U  not  gencralljr  attended  with  difficultjr.  Tit 
sound  itaclf  conrcjH  the  idea  of  ila  being  produced  hy  friction,  b 
addition  to  this,  ila  dr^ncw,  it4  acoompanjring  freqnentlr  both  i^ 
■pirator;  acts,  and  nipectally  tt«  superficial  situation,  aerre  to  dis- 
tinguish it  firom  other  adventitious  soands.  As  already  suted, 
sometimes,  irbeu  interrupted  and  limited  to  inspiration,  it  niaj  be 
mistaken  for  a  crepitant  rale.  The  insunces,  howerer,  in  vhieb 
tbia  rrscmblance  exists  are  rare,  and  tbe  afisociated  circumsUnccs 
will  generally  prevent  the  error  into  which  the  ausculutor  mi^t 
fall,  were  he  to  limit  his  attention  solely  to  the  character  of  the 
»ound.  In  determining  the  existence  of  a  friction-souml,  in  all 
canes  tie  are  aided  by  tbe  coexistence  of  other  signs,  and  of  symp- 
toms involved  in  tJie  diagnosis  of  the  diseases  in  which  it  is  knon 
to  occur. 

Dr.  Stokes  has  called  attention  to  the  fsct  thai  a  frictioD-aound 
may  be  duo  to  the  movements  communicated  to  the  atyaccnt  portion 
of  lliD  pleura  by  the  impulse  of  tbe  heart.  In  this  case,  a  friction- 
sound  will  be  found  to  be  synchronous  with  the  beating  of  the  heart, 
or  the  pul^-,  and  will  continue  when  the  rcspiriitory  movements  are 
voluntarily  suspended. 

A  pleural  friot!i>n>sounil  wnn  rognrded  by  Lacnncc  as  a  pathogno- 
monic sign  of  interlobular  emphysema.  He  did  not,  however,  profMS 
to  have  established  this  opinion  on  the  evidence  afforded  by  aatopdcal 


J 


AtfSCCLTATIOH    IK    DISEASE. 


227 


I 


•minations,  in  cases  in  which  tho  sound  hnd  bcon  notc^  during  life, 

orcnrcr,  in  l(i«  two  instnnci'S  given  by  him,  in  which  he  hnd  ob- 

Tvvil  thi»  Mgn,  ihc  patients,  if  sifi-clod  with  intorlobalar  etnphy- 

i«,  wero  iiIko  nffcctCMl  with  pleurii>y;  nnd  it  is  remarkable  that  its 

nncction  with  the  Utter  affection  ehould  not  have  presented  itself 

thv  reflections  of  the  discoverer  of  auscultation.     Subsequent  ob- 

rTftlioo  hmt  shown  that  in  the  interlobular,  as  well  as  the  ordinary 

Ibrm  of  emphTFcma,  and  also  in  that  vanetT  in  which  air-blebs 

c  formed  by  the  elevation  of  u  portion  of  the  pulmonary  pleura, 

friction-sound  is  an  exception  to  the  general  rule.  Dr.  Walshe  has 

lOtod  the  occurrence  of  the  eign  in  a  few  instances  of  the  varie^ 

it  named.    With  exceptions  so  infrequent  that  thuy  belong  among 

le  curiosities  of  cliDical  experience,  n  friction-sound  is  indicatire 

if  pleuritis.     It  is,  however,  by  no  means  a  sign  constantly  or  very 

eqnently  present  in  that  aScction,  and,  indeed,  it  is  observed  but 

in  a  small  proportion  of  cases.     It  may  occur  in  different  stages  of 

plcoritJe  influDmation :  /ir»t,  in  the  early  stage,  before  the  pleural 

surfaces  »re  separated  by  liquid  effusion:  and  steond,  at  a  later 

period,  after   absorption    of  the   liquid   has   taken    place,  and    the 

Ictiral  surfaces  are  again  brought  into  contact  witli  each  other. 

In  the  early  period  of  ihe  disease  it  is  due  to  the  presence  of  co- 

agulable  lymph,  with  which,  to  a  greater  or  less  extent,  the  surfaces 

of  the  pleura  are  covered ;  and  according  to  Stokes,  to  abnormal 

dryness  of  the  membrane,  prior  to  the  exudation  of  lymph.     Thnt 

abnomial  dryness  precedes,  as  a  general  rule,  the  exudation  of 

lymph,  is  not  certain,  and  that  it  is  alone  capable  of  giving  rise  to 

a  friction- sound,  miiy  be  doubted.     But  however  this  may  be,  it  ia 

certain  cither  or  both  thcite  physical  conditions  so  seldom  give  rise 

to  a  friotioD-sound  in  the  first  stage  of  pleuritis,  that  it  scarcely  po»> 

•ees«s  any  importance  as  a  aign  to  be  relied  upon  in  the  diagnosis 

prior  to  the  occurrence  of  effusion.     Instances,  however,  arc  oeca^ 

sionally  observed  in  which,  notwithstanding  a  con iiidc ruble,  or  even 

Isrge  accumulation  of  liquid  in  the  pleural  sue,  n  friction -sound  is 

apparent.    Dr.  Stokes  wan  the  first  to  report  a  citse  of  thi»  de^erip- 

ttOD,  and  others  have  been  subsequently  reported.    The  explanntion 

of  tho  presence  of  tho  sign  under  these  eircum»tanc«s  is,  the  lung 

having  become  attached,  not  closely,  but  by  means  of  bridles  of  false 

membrane,  to  the  thoracic  walls,  the  pleural  surfaces  con^noe  to 

«ome  into  contact  over  s  greater  or  less  extent  of  surface.     This 


SS8 


PHTSICAL   tXPLOKATIOS    OP   Tlllf  CBBST. 


msj  obuin  sntcriorlj',  while  the  whole  poMerior  snr&oe  of  tiie  1n{ 
is  Hcparated  from  the  waIIh  oT  the  diett  bj  a  large  quaatitjr  of  imi; 
and,  under  lhe««  circomManoeti,  the  physical  tigns  pOAteriorl;  Aat 
the  prc««nce  of  liqatd,  wliibt,  anieriorly,  a  fnclion-Mand  nayk 
obeerrcd.  Of  the  instancen  in  which  a  frict!vn-«oand  ocean  ii 
plearitis,  in  bj  far  the  larger  proportion  it  appear*  to  a  later  atag^ 
after  abaorplion.  The  pleural  surfaces  coming  again  into  eofitact, 
«r«  roughened  by  dense  Ijmph.  This  i»  so  disposed  in  diffemi 
cawa  M  lo  give  rise  to  simple  robbing,  lo  a  roaglicr  qulitj  ti 
•onnd  distinguished  as  grating  or  rasping,  to  creaking,  or,  oeca- 
siunall;,  to  a  sound  conveying  the  impresfion  of  a  liquid.  Tbnr 
dirersities  in  the  audible  characters  do  not  fnrni:>h  any  indicatisM 
as  to  the  quantity  of  exodation,  or  the  gravity  of  the  affection,  hot 
simply  denote  differences  pertaining  to  the  disposition  of  the  aoiM 
exndiition,  together  with  variations  of  dryness  and  fiminesa,  etc.; 
and  simple  scarcely  appreciable  rubbing  may  occur  in  cases  'a 
which  the  lymph  is  more  abundant  and  the  disease  more  severe  ttiu 
in  other  caMS  in  which  the  loudest,  rongheat  sounds  arc  discovered. 
The  sounds  are  heard  over  the  middle  and  lower  portions  of  tht 
chest  in  primary  ploiriiis,  becanse,  although  the  morbid  condition 
may  not  be  more  marked  here  than  at  the  summit  of  tbe  cheat,  llw 
respiratory  opposing  movements  of  ascent  and  descent  are  great«r, 
especially  in  the  male.  The  friction -sotmds  are  not  produced  solely 
by  the  rubbing'togclhcr  of  tbe  pulmonic  pleura  and  costal  pleort, 
but  probably  oftcncr  and  with  greater  intensity,  by  the  contact  of  tbe 
diaphragmatic  pleura  and  costal  pleura.  The  situation  of  the  sip 
is  sometime*,  in  fact,  not  over  the  lung,  but  over  the  diaphragH, 
ris.,  over  the  sixth  and  seventh  eartilago.'  Ijut  even  after  absorp- 
tion a  friction-sound  is  not  of  very  frequent  occurrence  in  plevrilil. 
This  ia  probably  owing  to  the  fact  that  agglutination  of  the  pleutal 
BorfKea  generally  takee  place  directly  they  are  brought  into  contact. 
It  is,  however,  not  improbable  that  the  sound  is  diHOovcrabte  at  sona 
points  ofteiicr  than  is  supposed,  because,  inasmuch  as  the  diagnoM 
of  pleuritis  is  sulIicicDtly  established,  in  the  large  majority  of  eases, 
long  before  the  period  arrives  when  the  phyncal  conditions  are  &- 
vorable  for  the  production  of  this  sign,  it  is  not  always  sought  for 
with  care  over  all  parts  of  the  chest.  Occiirriug  subsequent  to 
absorption  in  the  progress  of  plcuritis,  although  not  of  importancs 

'  Sibton't  Hfdioal  Anatcmj. 


AOSCDLTATIOIf    IV    DIBBA8B. 


229 


I  rcapects  the  diagnosis,  vhich  it  is  to  be  iircsiimed  ha«  l>i;en  alrctidy 

Bade,  it  is  useful  as  evidence  that  the  surface  of  the  lungs  is  id 

DDtaot  with  the  vails  of  the  chest.     As  stated  b;  Fournel,  in  some 

this  evidence  in  the  more  valuable,  becanae,  owing  to  the  thick- 

<  of  the  lasers  of  morbid  deposit,  [i«rcus.«ioii  and  the  aiisciiltalioii 

>f  the  respiratory  »oiind  tany  b«  inxiitliciftit  to  determine  the  fact  (hat 

■the  liquid  is  absorbed.     At  this  period  of  the  disease  the  sign  is  of 

[good  omen,  denoting  progress  toward  restoration. 

A  friction -sound  may  ftccoinpnny  pleuntis  ilevcloped  ms  a  compli- 

ktion,  or  an  intercurrent  aflTcclion.    In  pncuiuonilis  it  ii  occniuoniilly 

observed,  being  due  horo  to  tlic  pleuritic  complication,  and  produced 

I  in  the  same  manner  a*  when  the  pleuritis  is  priamry.  It  is  also  one 
of  the  signs  which,  inferentinlly,  point  to  tuberculous  disease.  Oc> 
eurring  in  connection  with  tuberculosis,  it  may  ongiunlc  in  two  wiiys: 
^iVX,  The  deposit  of  small  isolated  tubercles  beneath  the  pulmonary 
pleura,  may  occasion  an  irregularity  of  the  surfAcc  sufliciciit  to  give 
ri«c  to  a  strongly  marked  sound  of  attrition.  Foumct  gives  an  iu- 
tlnnce  of  this  kind;  and  a  striking  case  was  reported  several  years 
1^  by  Prof,  Lftwjson.'  Senomi,  It  is  due  to  intercurrent  pleuritis, 
eonfincd  to  a  circumscnbed  space,  situated  over  the  luberculoas  de- 
posits.  Saccessive  attacks  of  pleurilis,  attended  by  the  exudation 
of  lymph,  without  liquid  (dry  pleurisy),  and  followed  by  adhesion 
Kof  the  pleural  surfaces  over  the  space  affected,  as  is  well  known, 
are  so  constant  as  to  form  a  portion  of  the  natural  history  of 
toberculoos  disease  of  the  lungs.  A  friction -sound,  by  no  means 
uniformly,  but  occasionally,  accompanies  these  attacks.  Under 
these  circumstances,  the  sign  is  con&ned  to  a  small  area  at  the  sum- 
mit of  the  chest,  and  is  of  the  grazing  or  rubbing  variety,  never 
presenting  the  rougher  qualities  of  sound.  With  this  character,  and 
tbns  situate<l,  i.  e.  at  the  summit  of  the  chest,  it  is  indicative  of  cir* 
camecribed  pleuritis.,  which  is  incidental  to  tubercle,  and  therefore 
it  becomes  a  physical  sign  of  the  latter  disease.  It  is  discoverable 
in  only  a  small  proportion  of  the  oases  of  tuberculosis,  and  its  ab- 
■enee  is  not  entitled  to  any  weight  as  negative  evidence;  hut  when 
present,  it  is  a  sign  of  c»UE>idcrablu  dingno«tic  imporUnce.  Occur, 
ing  in  this  connection  it  is  of  brief  duratiou,  usually  continuing  for 
i^y  or  two  only,  being  suspended  by  the  adhesion  of  the  surfaces 
the  space  in  which  it  wiitt  produced.     And  as  Ibis  adhesion  pre- 


>  WNtcrn  Lsnml,  CIoctnDati,  Oct.,  ISGO. 


S80 


raTBIOAL   BXPLOBATIOK    OF  THB-CIIBST. 


eludes  tlie  continuance  of  movpincnts  nccessBrj  for  iho  prmltictinn 
of  the  HonD<l,  it  is  not  likely  lo  occur,  eavc  at  ikt  fin>t  nltack  of 
plouritiB.  It  is  probiible,  but  I  nm  not  nw»re  of  it«  having  hten 
clinically  establiHlied,  that  a  friction-sound  indicative  of  tab«rculoaii 
die«as«  is  more  apt  to  be  observod  in  females  than  in  maU-»,  utring 
to  the  greater  part  which  tho  superior  costal  typo  of  rcspiratton 
performs  in  thoir  respiratory  movcmonts. 

FinsUy,  tk  frictioD-sonnd  is  occasionally  observed  in  certain  .tiruA-' 
turnl  affections  giving  rise  to  asperities  or  irregularities  of  the  p1<-tinl 
surfaces,  such  as  cancers  and  tumors  of  different  kinds.  These  affec- 
tions are,  however,  very  infre(|oent;  and  in  its  diaf;noiflic  relntions 
to  them  the  sign  is  of  very  little  value.  The  8i;^ii  ht'rv,  and  in  all 
cases,  merely  indicates  that  th«  pleurnl  surfaces  arc  rottgbened.  It, 
in  connection  vtth  the  sign,  there  nrc  the  symptoms,  past  or  pr>>fir-nt, 
of  intra-tboracic  inBammution,  ond  the  sign  be  situated  at  the  middle 
or  inferior  portion  of  the  chest,  it  indicates,  in  forty-nine  of  fifty 
cases,  pleuritis,  either  primary  or  secondary.  If  it  exist  At  the 
summit  of  the  chest  within  a  circumscribed  space,  and  is  anociated 
with  symptoms  leading  to  the  suspicion  of  tnberculosis,  it  is  highly 
significnnt  of  lliiit  nlTectioi).  Ami  if  it  be  found  under  ctrcnmat«nc«t 
in  which  neither  pleurisy  nor  tubercle  are  evinced  by  associated  signs 
and  symptoms,  it  proceeds  from  emphysematous  tumors  or  other  sf- 
fections,  the  nature  of  which  may  not  be  determinable.  Dr.  Wnlshe 
states  that  intra-thoracic  friction  is  BOroetimes  simulated  by  ihe  move- 
ments of  the  scapula  in  breathing.  I  have  met  with  several  examples 
of  this  fact. 

The  discovery  of  a  pleural  friction-sound  as  a  physical  sigUt  wu 
made  by  M.  ilooor^.  a  contemporary  with  the  discoverer  of  auscul- 
tation.' Ue  brought  to  Laennec  a  patient  presenting  the  sound  to 
which  tlic  latter  applied  the  title  of  the  rubbing  sound  of  ascent  and 
descent  (bruit  lie  froiUment  nsrertdant  H  deacendant).  Lnennco,  fauw- 
ever,  as  already  stated,  failed  to  perceive  its  ooniiection  vith  pleo- 
ritis,  but  attributed  its  production  to  interlobular  emphysema.  The 
merit  of  pointing  out  more  fully  its  characters,  and  determining  its 
true  pathological  significance,  belongs  to  a  Frendi  observer,  M. 
Raynaud.* 


>   ViJt  TtmIUc  on  Mi!dUtG  AiiacullBliiriii  ote.,  bf  Lacflnw. 
*  yidi  Biirlb  and  Roger. 


Ji1l8Ct)LTAII01!I    IK    DI8BA8K. 


281 


PIIRSOMKNA   IKCIDENT  TO  TUB  VOICB. 

With  a  previous  knowledge  of  ihe  vocal  phenomena  pertaming  lo 
I  different  portions  of  the  respiratory  sjstem  in  health,  the  abnormal 
moilificationti  nre  readily  apprehendi-d.     The  roori:  important  of  th« 
vocal  K)gn$  of  iltM-iUie  arc  dintingiiiiihed  by  chariiot.criKticN  of  the 
normni  tracheal  Ar  laryngual  voio«,  transferred  to  eituntions  wher* 
.  tbey  srv  not  found  in  health.    Two  important  vocitl  mgns  are  culled 
I  exaggerated  vocal  rtinmanee  and  hrimrhiiphuny.     In  tlii;  firFtt  of  tliese 
two  eigns,  the  intensity  of  the  rt^sonance  of  the  lond  voice  i«  mor- 
bidly in(!r<'ased  without  nntable  alteration  in  other  respects;  In  the 
I  second,  with  or  without  increase  of  intensity,  the  resonance  \*  alttTtid 
fas  regards  apparent  proximity  to  tha  ear,  concentration,  and  pitch. 
Correnponding  signs  relate  to  the  whi.^pered  voice.     The   norma] 
bronchial  whisper  nndergoea  moditicationa  representing  the  name 
morbid  conditions;  and,  employing  simitar  names  to  designate  thcw 
signs,  they  may  be  called  the  exaygerattrd  bronchial  tehitjier,  and 
tchitptrring  krone hophony. 

The  normal  vocal  resonance  may  be  diminished  and  suppressed. 
Morbid  changes  in  this  direction  will  constitute  other  vooal  signs, 
Tiz.,  ditninifhal  and  »uppri!»ned  pooa!  rtatmanee. 

In  treating  of  auscultation  of  the  voice  in  health,  it  wn«  seen  that 
when  the  atethoscope  is  applied  over  the  trachea  or  larynx,  frcqui;ntly 
srtioulate  nonU  are  found  to  enter  the  ear,  sometimes  perfectly,  and 
in  other  instances  partially.  Thi*,  wliich  very  rarely,  if  ever,  occurs 
over  the  chcsl  in  health,  is  someiiincM  ohservcd  in  dii<eiL8c,  and  cod- 
stitutt^s  a  fign  called  peetoriliiifuff.  This  will  elaim  separate  consid* 
eralion,  and  cOMHtiliiles  the  thin)  of  the  division*  of  abnormal  vocal 
phenomena.  Pectoriloquy  ha«  relation  both  to  the  loud  and  whis- 
pered voice.  A  modification  of  the  pitch  of  the  whUpcrvd  voice, 
withodt  transmission  of  the  speech.  consUtutes  «u  important  sigD  of 
•  cavity.     This  sign  may  be  called  lite  eaerrnotu  whuper. 

Another  vocal  ifign  coniiKts  of  a  tmni<mii»ion  of  the  voice,  elevated 
in  pitch,  and  tremulous;  which,  after  Laennec,  i»  called,  front  it«  re> 
semblance  to  the  bleating  of  the  goat,  ayaphong. 

Agreeably  to  the  foregoing  divisions,  the  phenomena  incident  to 
the  voice  in  disease  may  be  arranged  under  the  following  heads: 
1.  Exaggerated  resonance,  and  bronchophony.  2.  Exaggerated 
bronchial  whisper,  and  whispering  bronchophony.     3.  Diminislied 


282 


raY8ii;jiL  sxploration  op  thb  chbst. 


ADi]  suppreeaed  vocal  resouance.    4.  Pectoriloquy.    6.  CitTcrnoiis 
whisper.     6.  iSgoplionj. 

1.  ExAOiiBRATRi)  VoCAi.  Rksoxaxck,  AND  BRoxcnopnoxT. — 
With  die  «r  applied  to  most  parw  of  llio  hvallliy  choHl, — for  ex- 
ample, the  infra-clavicular  region  in  front,  or  the  infn-scapaUr 
behind, — the  act  of  npcnking  occasions  a  diflTiiscd  resonance,  tlio 
eound  appearing  to  come  from  a  dUtonce,  And  noconipiDnir<l  with 
more  or  less  Tibraljon  or  thrill.  Tliis  is  the  normal  Tocal  reso- 
nance. Xow.  this  resonance  may  1>c  rendered  by  ditnM  oiore  in- 
tense, in  other  characters  thitn  intensity  remaining  the  uune  as 
in  hcnlth.  The  vocal  reeonnnce  ia  then  simply  exaggerated.  The 
reverberation  of  the  voice  la  abnormal,  and  there  is  usoally  mora 
vihratiflii  or  thrill  felt  by  the  ear;  but  the  sound  is  still  diiunt, 
and  ilifTiued.  If,  buvrevcr,  well-marked  bron<;))ophony  become  de- 
veloped, the  intensity  may  or  may  not  be  increased,  but  the  voice 
Hc«nis  concentrated  and  neor  the  car,  the  pit«h  is  high,  and  the  ao- 
coupuDying  vibration  may  bo  diminished.  The  distinction,  ibus, 
between  simply  exaggerated  resonance  and  well-marked  bronch- 
ophony is  real,  and  the  tvro  signs  may  bo  clinically  discriminated 
from  each  other  withoai  difficulty.  It  ia  not,  therefore,  correct  to 
eay  thac  ihey  are  essentially  identical.  But  it  is  true  that  both  pro- 
ceed from  similar  physical  and  pathological  conditions,  diflering  only 
in  degree.  Moreover,  exnggeraied  reeonance  not  infrcfiuently  merget-, 
into  bronchophony;  and  again,  the  latter,  in  the  progress  of  the  asni 
diMftsc,  may  give  place  to  tlie  former.  The  vibration  or  thrill,  it  is 
iniportiint  to  note,  does  not  increase,  but  in  general  is  diminished, 
when  brondiophouy  exists.  But  with  exaggerated  vocal  resonance^ 
the  fremitus  is  sometimes  proportionately  increased.  In  degree, 
both  exaggerated  vocal  resonance  and  bronchophony  present,  in  dif- 
ferent oaMw  of  disease,  great  variatione.  The  intensity  of  the  tho- 
racic voice  may  exceed  that  of  the  normal  laryngeal  or  tracheaL 
These  VQcat  signs  continue,  certainly  in  the  large  majority  of  c«m^^ 
continuously,  that  is,  they  are  always  found  on  auHCuliation,  so  l0D| 
as  the  pathological  conditions  of  the  lung  to  which  they  are  incident 
continue;  in  other  words,  they  are  not  intermitting  signs,  like  the 
bronchial  rales,  now  present  and  now  absent,  but  they  steadily  per- 
«tst  for  a  oortain  period,  in  this  respect  resembling  the  crepitant  rale 
and  the  bronchial  respiration.  This  lust  statement  is  in-opposilioK'] 
Lo  the  statement  of  Skoda,  who  nminuins  that  the  altcrtialo  absenoft ' 


ACSC0LTATIO!r    IV    DISSASR. 

laA  pro<M?noe  of  th«  thoracic  voice  ia  &  well-known  and  a  coronion 

'occurrence,  am)  that  broiiclKtphonj  may  appear  and  disap|>ear  eev- 

Larnl  timet!  io  the  course  of  a  few  miiiute:^'     Tlie  ([ueBtion  ia  one  to 

be  settled  pnrel;  bj  obwrration,  and  the  experience  of. others  does 

lot  sustain  Skotla's  anicrtion.     Intermit  ten  cj  ia  an  important  point 

the  support  of  certain  theoretical  rtewn  entertained  by  Skoda, 

rhich  will  be  briefly  noticed  presently;  and  this  circumstatice,  it 

Fmaj  be  remarked,  does  not  tend  to  enhance  confidence  in  the  accu* 

^T«cy  of  the  ob»er'rations  on  which  his  opinion  is  professedly  based, 

Firithout  inteoding  by  tbis  remark  to  convey  an  imputation  of  want 

of  good  faith. 

The  recognition  of  exaggerated  vocal  resonance  and  bronchoph- 
ay,  practically,  involves  no  difficulty.  It  is  sufficiently  easy  to  de- 
termine, on  comparison  of  the  two  sides  of  the  chest  in  corresponding 
tciluaitons,  a  disparity  in  the  degree  of  resonance,  and  the  characters 
pertaining  to  bronchophony.  There  i»  no  liability  of  confounding 
tlic«e  with  other  signs.  As  regards  exaggerated  vocal  rcttonance, 
the  only  error  to  l>c  gunnlcl  a^jainxt  is,  attributing  to  dtseii:<e  differ- 
enccs  between  the  two  sides  which  exist  DormallT.  Under  the  bead 
of  "Auscultation  in  Ucallh,"  it  has  been  seen  that  a  normal  difler- 
enee  in  intensity  is  observed  in  a  large  proportion  of  persons.  The 
dilTcrenco,  however,  observes  a  regular  law,  viz.,  the  greater  relative 
■intensity  is  on  the  right  side ;  and  Ihia  is  found  to  be  the  case  over 
'  all  the  regions  on  this  side,  but  it  i»  especially  marked  at  the  summit 
in  front.  Prom  this  fact,  it  follows  tliat  tlie  resonance  on  the  right 
aide  mnst  be  considerably  greuter  than  that  on  the  lef^,  to  warrant 
the  inference  that  it  proceeds  from  disease;  whereas  a  slightly 
greftter  rejtonance  on  the  left  than  on  tbe  right  side  denotes  a  mor- 
bid condition.  The  coexistence  of  other  signs  incident  to  the  same 
physical  conditions  is  a  safeguard  against  the  mistake  of  eonfound- 
ing  morbid  with  natural  variations, 

The  physical  condition  of  which  exaggerated  roeal  resonance  and 
bronchophony  are  the  signs  is  increased  density  of  the  pulmonary 
Btmcture.  These  signs  occur  in  the  different  affections  which  give 
rise  to  the  broncho.v«sicular  and  the  bronchial  respiration,  and  are 
generaltyfound  in  combination  with  the  latter.  The  two  signs,  respec- 
tively, represent  different  degrees  of  Boliiiificalion.  Bronchophony 
is  tbe  sign  of  either  complete  or  considerable  solidification ;  cxag- 


>  TfaniUilon,  l;  UMkham.     Am.  ed.,  piig«e8. 


3M 


FBTSICAL   BXri.eBATI0S  OP  TIB  VBBST. 


grade*  of  broadio-vcnealar  rMptntioa.  TbCM  vooU  sign* 
ScBtioo  Bs^  be  prcwnt  vb«n  the  mprmtorj  ^lu  are  wtWhig,  mk 
•ram.  BraKbophoD  t  is  georrBllr  preaeat,  nd  is  often  Uim^ 
rked,  in  conneetioo  witb  ifae  solulificsdoa  iBcidMit  to  tbe  smat 
•tageof  p— wwoaitig.  In  that  dbeue,  tb« aiutwa  tnvbicbitii 
oiwamJ  »  ■voUj'  tJte  niddle  sad  lower  ddids  of  tlw  posteriflr  tm- 
face  of  tb«  chest  on  one  side,  the  seat  of  the  inflammabaEL,  in  tW 
adalt.  being  the  inferior  lobe,  in  ibe  larger  proporttoo  of  OMI. 
It  is  in  pneumonitis  especiallr  that  bronchophonj  is  stroog.  li* 
Toice  seeming  to  be  Ter;  near  the  ear,  and  the  pitch  notabljr  bi^wr 
than  on  the  noaffected  side.  As  respects  the  londaea  of  iiwiniim. 
bowever,  diflerent  cases  of  pnenrooBitia  present  grtat  nrktioi^ 
dependent  on  diSereoces  in  the  degree  of  solidification,  on  aiore  ot 
lees  obstruction  of  the  bronchia)  tubes,  and  olber  circvBwtaMcs 
len  obvious.  Tbe  character  of  the  voioe,  other  things  being  equal, 
exeru  an  inflaenee  on  the  intentiilT  of  the  sign.  The  etrengUi 
of  the  reeonanee  will  be  proportionate  to  the  power  of  the  voiec, 
irre^tective  of  its  pitch  or  special  qualitj.  Other  ctrcuraetaocct, 
mch  aa  the  thicknesH  of  the  moscalar  and  adipoM  layers  coTenng 
ibe  cheat,  affect,  of  course,  the  resonance  in  diwie  aa  well  as  thai 
incident  to  health.  The  reTerberaiion  and  vibration  nre  greater, 
etrtfri$  parHitit,  in  persi^ns  whose  voices  arc  graTe  or  baas;  but  tW 
force  or  extent  with  which  the  roice  pencirate«  llic  ear  is  greater 
when  (he  pitch  of  the  oral  voice  is  high.  Bronchophony  ia  not 
pres^mt  in  all  eases  of  pnenmnnitis,  and  tbe  vocal  reeonanee  aaj 
not  be  exaggerated,  so  that  absence  of  either  or  both  of  thcM  aigUi 
bj  no  means  affords  positive  evidence  >>;3insl  the  existence  of  tht 
disease.  Kach,  however,  is  present  in  different  periods  of  the  dis- 
ease in  the  great  majority  of  instances.  They  may  be  presesl 
withont   being  associated  with  the  bronchial  or  broncho-TCfltcalsr 


lOOtTATIOI 


DTBBAB1 


23& 


I 


I 


lintion,  and  in  such  innsncea  the;  &re  highly  important  with 
rence  lo  the  queetion  of  solidification. 
Next  to  pneuinonilis,  the  affection  in  which  exaggerated  vocal 
Bonance  and  bronchophony  are  most  frequent  in  occurrence,  and 
nioet  iniportsnl  as  phjaicul  si^e,  ie  phthinii).  A  tnberculoua  deposit 
giYea  rise  to  either  cxnggerntad  resonance  or  to  bronchophony,  ao- 
rdinf;  to  the  quantity  of  tubcrcl«,  the  degree  nf  solidification  which 
it  inducer,  its  exteuHion  to  the  snpcrfiueft  of  the  lung,  and  its  prox- 
imily  to  Ihc  larger  bronchial  tubes.  It  ia  sufficiently  intelligible  that 
theEe  circumstances  will  affect  the  amount  of  exaggeration,  or  the  d»- 
-gi'«e  of  bronchophony,  in  addition  lo  the  slrength  and  character  of 
the  voice  of  the  itiiliviilual,  etc.  Owing  to  the  diversity  pertaining  to 
the  physical  conditions  favorable  for  the  production  of  these  signs, 
difierent  easm  of  tuberculous  disease  differ  greatly  as  respects  their 
presence  and  their  prominence.  Even  an  exaggerated  resonance 
may  not  be  appreciable  in  some  inHtaiiccs  in  which  a  considerable 
quantity  of  tubercle  exists.  For  example,  if  a  tuberculous  mass  be 
separHte<l,  on  the  one  hand,  from  the  larger  bronchial  tubes,  and,  on 
the  other  hand,  from  the  walk  of  the  chest,  by  layers  of  healthy 
lung,  the  vocal  resonance  may  scarcely,  if  at  all,  exceed  a  nonoal 
degree  of  intensity.  Its  presence,  therefore,  as  necessary  to  the 
diagnosis,  ia  much  less  lo  be  connted  on  than  in  pneumonitis  ;  nor 
ia  ihc  intensity  with  which  it  may  be  present  to  be  considered  as 
ttidieating  the  abundance  of  the  deposit.  Bronchophony  is  much 
odencr  absent  in  phthisis  than  in  pneumonitis,  and  it  is  rery  rarely 
ao  strongly  marked  in  cases  of  the  former,  as  it  is  in  the  larger  pro- 
portion  of  the  cases  of  the  latter  disease.  Occarring  in  connection 
with  tuberculous  disease,  bronchophony  and  exaggerated  resonance 
are  almost  invariably  situated  at  the  summit  of  the  chest,  in  the 
infra-clavicular  and  scapular  regions,  oftener  the  former.  They  do 
not  extend  over  so  large  a  space  as  in  ca^s  of  pneumonitis  affecting 
either  a  lower  or  upper  lobe,  being  usually  limited  to  a  oircuin- 
MCribed  area ;  bat  ihc  history  and  symptoms,  in  conjunction  with  all 
lh«  phynical  sign»,  rarely  render  it  a  difficult  problem  lo  decide  be- 
tween pneumonitis  and  tuberculosis.  It  is  in  the  diagnosis  of 
phlbiiis,  especially,  that  the  normal  variations  in  vocal  resonance  at 
lfa«  sommit  of  the  chest  are  important  to  be  borne  in  mind.  Exag- 
gerated resonance  on  the  right  side,  contrasted  with  the  left,  is  not 
evidence  of  the  presence  of  the  deposit  of  tubercle ;  whereas  a  slight 


2S4 


PHT8I0AL    ■Xtl.DBlTIOS    Ot   TBK    CDBST. 


gentc)  vocal  rMonaD««  d«noif*  n  greater  orlcs*  amAant  of  >ali£i- 
eation,  but  an  amount  fBlling  i<l)urt  of  thnt  rcijDisite  to  prodntc 
broncbopbon;.  With  bronchopbony,  consequenilyt  la  iMMdaMJ, 
gtMiBllj,  Ibv  bronchial  r«-8piration ;  but  nn  amount  of  Mlidtficatiia 
snfieicnt  to  give  ris«  to  well-mark  i^d  broncbophon;  may  be  ^rpt^^ 
sentcd  bj  a  broDcho-micuUr  raspiration  approximating  to  tlit 
bronchial ;  in  other  words,  it  does  not  require  as  much  solidificitioo 
to  cause  bronchophony  a<  it  does  to  give  rise  to  bronchial  rc«pin- 
tioo.  Exaggerated  vocal  resonance  is  associated  with  the  diSenm 
grades  of  broncho- vesicular  respiraticMi.  Thc»e  vocal  signs  of  solidi- 
fication may  be  present  when  the  respiratory  signs  arc  wanting,  aaJ 
piee  Tvna.  Bronchophony  is  generally  prescDt,  and  is  oft«n  strongly 
marked,  in  eoniicetion  with  the  solidification  incident  to  the  sccoad 
stage  of  pneumonitis.  In  that  disease,  the  situation  in  wbich  it  it 
obeervfld  is  uBually  the  laiddlc  and  lower  thirds  of  the  poaterior  am- 
face  of  the  chest  on  one  side,  the  seat  of  the  inflammatioti,  in  At 
ndiilt,  being  the  inferior  lobe,  in  the  larger  proportion  of  case*. 
It  ia  in  pneumonitis  especially  that  bronchophony  is  strong.  Oa 
voice  seeming  to  be  very  near  the  ear,  and  the  pitch  notably  bigbtr 
than  on  the  unaffected  side.  As  n-spects  the  loudneaa  of  reaoiUBM. 
however,  diflerent  caseit  of  pneumonitis  present  groat  TariotitH^ 
dependent  on  differences  in  the  degree  of  solidification,  on  nortV 
kas  obstrurtion  of  the  bronchiiil  tubes,  and  other  circumstaocft 
Ion  obvious.  Tbo  character  of  the  voice,  other  things  being  equal, 
exerts  an  influence  on  the  intensity  of  the  sign.  The  strengtk 
of  the  resonance  will  be  proportionate  to  the  power  of  the  VQiee, 
irrc«peclire  of  its  pitch  or  special  quality.  Other  circumstaacei. 
such  OS  the  thickness  of  the  muscular  and  adipose  layers  corettog 
the  eliest,  sfT^t.  of  course,  the  resonance  in  disease  as  well  as  that 
incident  to  health.  The  reverberation  and  vibration  are  grestfr. 
etrtfrii  ftaribtia,  in  persons  whose  voices  are  grave  or  bass ;  bat  llw 
force  or  extent  with  which  the  voice  penetrates  the  ear  u  grealtr 
when  the  pitch  of  the  oral  voice  is  high.  Bronchophony  is  Mt 
present  in  all  coses  of  pneumonitiss  and  the  vocal  resonance  Mf 
not  be  exaggerated,  so  that  absence  of  either  or  both  of  tltcM  l^gB^ 
bj  no  means  affords  positive  evidence  s;;ainst  the  existence  of  lltt 
dJMase.  Kacli,  however,  is  present  in  different  periods  of  tbedif- 
ease  in  the  great  majority  of  insUnees.  They  may  be  prewni 
withoai   being  assoriated  with  the  bronchial  or  broncho-vrsicaltr 


285 


I 


piralioD,  anil  in  such  iiistsnc«a  the;  ire  higblj  iinportant  vith 
ference  lo  the  question  of  solidification. 

Kext  to  pneumonitis,  the  aflectton  in  wliicli  fxn{;gpratcil  vocal 
onance  and  broncbopbony  are  most  frequent  in  occurrence,  and 
oat  important  as  pbysioal  si^s,  is  phthisis.  A  tuberculous  deposit 
ives  rise  to  either  exaggerated  resonance  or  to  broncbopbony,  ac- 
rding  to  the  quantity  of  tubercle,  the  degree  of  soUdiScation  which 
it  inducer,  its  exten»ion  lo  the  superficea  of  the  lung,  and  its  prox- 
imity 10  the  larger  bronchial  tubes.  It  is  aufficienily  intelligible  that 
;he»e  circumfllanceo  will  affect  the  amount  of  exaggeration,  or  the  de- 
gree of  brondiophony,  in  addition  to  the  strength  and  character  of 
the  voice  of  the  individual,  etc.  Owing  to  the  diversity  pertaining  to 
the  physical  conditiono  favorable  for  the  production  of  these  signs, 
Terenl  caReit  of  tube  real  our  diaeaAe  difier  greatly  as  respects  their 
resence  and  their  prominence.  Kvon  an  exaggerated  resonance 
may  not  be  appreciable  in  some  instances  in  which  a  considerable 
qoantity  of  tubercle  exints.  Fur  example,  if  a  tuberculous  mass  be 
separale<I,  on  the  one  hand,  from  the  larger  bronchial  tubes,  and,  on 
the  other  hand,  from  the  walls  of  the  chest,  by  layers  of  healthy 
ung,  tb«  rocal  resonanoo  may  scarcely,  if  at  all,  exceed  a  normal 
t^  tDteasity.  Its  presence,  therefore,  as  nccessiiry  to  the 
ii  mtich  less  to  be  counted  on  than  in  pncnmonitis ;  nor 
ia  the  intensity  with  which  it  may  be  present  to  he  considered  m 
indicating  the  abundance  of  the  deposit.  Bronchophony  is  much 
oftrner  absent  in  phthisis  than  in  pneumonitis,  and  it  is  very  rarely 
so  strongly  marked  in  cases  of  the  former,  as  it  ia  in  the  larger  pro- 
portion of  the  cases  of  the  latter  disease.  Occurring  in  connection 
with  tuhercutoua  disease,  bronchophony  and  exaggerated  resonance 
are  almoat  invariably  situated  at  the  summit  of  the  chest,  in  the 
infra-clavicalar  and  scapular  regions,  oftener  the  former.  They  do 
not  extend  over  so  large  a  space  as  in  cases  of  pneumonitis  affecting 
either  a  lower  or  upper  lobe,  being  usually  limited  to  a  circuin- 
Mribcd  ares ;  but  Uic  history  and  symptoms,  in  conjunction  with  all 
the  physical  fiigns,  rarely  render  it  a  difficult  problem  to  decide  be- 
tween pneumonitis  and  tuberculosis.  It  is  in  the  diagnosis  of 
phthisis,  especially,  that  the  normal  variations  id  vocal  resonance  at 
the  aummit  of  the  chest  are  important  to  be  borne  in  mind.  Exag- 
gerated resonance  on  the  right  side,  contrasted  with  the  left,  is  not 
evidence  of  the  presence  of  the  deposit  of  tobercic ;  whereas  a  slight 


PDTSICIL    BXPLOKITIOK    OF   TBI    CBBBl. 

czKggeration  on  the  left  side,  in  itself,  is  iiaSeicot  gronui  for  l^ 
prcemnption  thai  the  depoflit  exists. 

Increased  density  of  the  lung,  in  consequeoM  of  conpreaaoa  \j 
the  acenmnUtioD  of  liquid  vithin  the  pleural  amCr  may  gire  rite  t> 
exaggerated  vocal  reaonance  and  bronchophooj.  Under  the  cirao- 
■taneea  the  latter  is  rareW  marked,  und  frequeotlj  both  are  absoiL 
Excepting  some  inatanoea  in  irhidi  the  Inog  is  retained  tn  ooatan 
viih  the  walls  of  the  cheat  hy  adhesion,  the  effect  of  tbe  accvnnlfr 
tion  of  liquid  is  to  remore  it  to  the  opjier  and  puatcrior  part  of  tht 
chest.  Bronchophony  or  exaggerated  resonance,  jf  either  cxiitt, 
will  then  he  heard  at  the  summit,  in  front  or  behind.  Over  tliepiu- 
tion  of  the  cheat  corresponding  4o  the  space  oceapicd  bj  the  Uqwl 
the  resonance  is  either  diminished  or  suppressed. 

Serous  inliltrntion  or  codcma  may  gtvo  rise  to  exaggerated  resa- 
nance-  Marked  bronchophony,  hoHevcr,  is  very  rarely,  if  ever,  de- 
veloped in  iliiH  affection;  »nd  both  si^s  arc  frequently  absent. 

In  the  rare  forms  of  disease  in  which  a  portion  of  the  lang  it 
solidified  by  carcinomatous  orroclanotic  deposits,  extra  vasated  Uoo^ 
gangrene,  and  also  in  cases  of  extra-pulmonic  morbid  growths,  ex- 
aggerated resonance  and  bronchophony  may  or  may  not  be  preseoL 
The  circumstances  which  should  lead  the  diagnostician  to  attrihvte 
tlie  prepuce  of  these  signs  to  aome  one  of  these  a&eotiona,  instead 
of  the  more  common  morbid  conditions  to  which  they  are  incidcot, 
arc  the  same  th&l  have  been  noticed  in  connection  with  the  anbiect 
of  bronchial  respiration,  to  which  the  reader  is  referred.  In  general 
terms,  if  exaggerated  resonance  or  bronchophony  be  circumMribed 
in  extent,  not  conEucd  to  the  summit,  but  situated  in  any  part  of  the 
chest,  and  persisting  (these  circnmetancea  excluding  the  diseawa 
prcrioiijly  referred  to),  wc  may  infer  the  existence  of  some  one  of 
the  aficctioDB  just  enumerated.  In  dotermioing  which  one  of  theae 
several  affections  exists,  we  arc  to  bo  guided  by  the  circamstancet 
associated  with  the  physical  signs;  for  example,  the  expectoradoo 
of  blood  in  pulmonary  apoplexy,  and  of  fetid  matter  in  gangreue.  ^^ 

Dilatation  of  the  bronchial  tubes  is  another  morbid  condition  i^^ 
which  exaggerated  vocal  reHonanoc  and  bronchophony  arc  euppo«ed 
to  occur.     In  this  rare  lesion,  the  dilated  tubes  are  surrounded,  to  a 
greater  or  less  exent,  with  condensed  -  or  indurated  lung,  bo  that  it 
is  difficult  to  say  what  proportion  of  the  exaggerated  resonance 
bronchophony  is  fairly  attributable  to  the  enlarged  calibre  o 


IKASK. 


237 


[tubeii.  Bronchophony  is  not  consuntl;  associated  with  the  lesion, 
hod  is  present  in  different  infltances  wiih  variable  degrees  of  inten- 
dty.  sometimes  bnng  very  strongly  marked,  when  the  dilatation  co- 
txi»td  with  considerable  induration  of  the  surrounding  luDg. 

The  m«cljaniam  of  bronchophony,  as  of  sonie  other  physical  signs, 
offers  scope  for  much  discussion.     Id  a  practical  point  oF  view  it  is 

I  not  very  important ;  nor  ia  uniformity  of  opinion  in  regard  to  it 
Deceaaary  to  agreement  in  so  much  of  the  principles  and  practice  of 
kowultatioD  a»  relate  to  the  availability  of  the  sign  in  the  diagnoeia 
of  dineaaes.  To  this  part  of  the  subject,  therefore,  I  shall  devote 
but  littlD  space,  referring  the  reader  who  may  desire  a  more  extended 
^  eontiideralion  of  it  to  works  which  professedly  treat  of  the  physical 
f  principlos  involved  in  the  production  of  auscultatory  phenomena. 
L&ennec  attributed  it  to  the  greater  conduoting  power  of  lung,  when 

»it«  density  is  increased.  According  to  this  explanation,  the  vibra* 
UoBS  of  the  vocal  chords,  and  of  the  air  within  the  larynx,  are  prop- 
agated downward  along  the  walls  of  the  bronchial  tubes,  or  the  ur 
contained  in  the  tubes,  or  through  the  medium  of  both,  and  are 
beard  in  diseases  attended  by  solidification  of  lung,  with  more  inten- 

■  tity  than  in  health,  simply  because  soHdilied  lung  is  a  better  cou- 
dactor  of  Konnd  than  nir-vcsiclcs  filled  with  air.  This  explanation 
baa  generally  been  accepted  as  satisfactory,  until  recently  it  has 

■  been  thought  thorc  arc  certain  difficulties  which  it  does  not  fully 
meet,  and  it  has  bcvn  attempted  by  Skoda  to  disprove  allogether  its 
ooiTPctncs«,  and  to  substitute  another  cxplnnution,  to  which  refer- 
ence has  been  made  in  treating  of  bronchial  respiration.  Skods 
attiibutes  bronchophony,  as  well  as  the  bronchial  respiration,  to  the 
reproduction  of  sonorons  vibrations  within  the  bronchial  tubes,  in 
accordance  with  the  musical  principle  of  consonance.  The  bronchial 
tobes,  according  to  this  author,  take  no  direct  part  in  the  mechan- 
ism ;  that  ia  to  say,  he  excludes  vibration  of  the  walls  of  the  tubes 
from  any  participation  in  the  roeonanco,  regarding  the  column  of  air 

I  contained  within  the  tubes  as  alone  concerned  in  the  production  of 
the  thoracic  sound.  In  the  normal  condition  of  the  lungs,  the  coo- 
aonating  sounds  are  slight,  owing  to  the  smaller  bronchial  lubes  being 
inembranousi,  and  tlie  want  of  firmness  in  the  surrounding  paren- 
ehyma ;  but  whenever  the  density  of  the  lung  is  increased,  provided 
the  tubes  reniaiti  pervious,  the  physical  conditions  necessary  for 
stronger  consonance  are  present ;  and  hence,  bronchophony  is  devcl- 


288 


POTSICAL    BXPLOSATtOX    OP   TBI    CHEST. 


opfid'  uniler  these  c t re nm stances.  In  support  of  this  theory,  it  b  »• 
iHimvd  bv  Skodn  tlial  bronchophonj  is  absent  wbencTer  tbe  broach 
tabes  ire  obMructe*!,  and  that  it  appear*  and  disappears  tra^ma^ 
within  a  brier  ipacc  of  time,  owing  to  tbe  aliernaie  r«nw>Tal  aal 
accumdlstion  of  mucous  secretions.  This,  to  the  extent  asaertedl^ 
Skoda,  is  at  rariance  with  common  observation.  That  obetructioo, 
e«p<'ciully  of  th<^  larger  tubes,  mav  occasion  a  suspeDsion  of  the  b|B, 
and  iiflTcct  lU  intensity,  is  probably  true;  but  the  sign  is  certanlj 
not  BO  dependent  on  the  presence  or  absenoe  of  mocous  secretioM 
in  the  sninller  broucbial  subdivisione,  as  Skoda  assumes.  This  &ci 
alone  renders  the  theory  of  consonance  inadequate,  in  itself,  teae> 
count  for  the  phcnonicno  of  bronchophony.  In  disproval  of  Laa- 
nec'a  doctrine  of  conduction,  8koda  declares,  as  the  result  of  experi- 
ments on  hepatised  lung  renK>Ted  from  the  body,  that  the  condactisj 
power  is  less  than  that  of  hesltliy  lung;  and  that,  hence,  if  exag- 
gerated r(-««nnnce  depended  on  conduction  alone,  it  should  exist  in 
henltb  rather  thim  when  tbe  pulmonary  structure  is  solidified  by  dis- 
ease. The  cxpcriment8  on  which  this  opinion  is  based  eonustin 
listening  vith  the  stethoscope  applied  over  a  portion  of  solidiM 
lung,  while  iinollier  person  speaks  tltrough  s  stclhoMope  applied  ottt 
parts  of  tbe  same  lung,  more  or  less  distant.  It  is  obvious  that  SKk 
experiments  do  not  fairly  represent  the  circumstances  under  wWh 
bronchophony  tnke^  place  in  the  living  body,  unless  it  he  grfttuiioaaly 
UKomed  (as  it  is  by  Skoda),  that  the  column  of  air  id  the  brondBil 
tubes  is  the  only  agent  concerned  in  the  mechanism.  Even  with  tlni 
assninption,  the  cases  are  hardly  parallel.  But,  as  already  remarked 
in  connection  with  bronchial  respiration,  others,  in  repeating  tbe 
same  experiments,  do  not  arrive  st  the  same  conclusion.  WaUie 
has  found  that  different  specimens  of  hepatixed  lung  do  not  conduct 
sound  equally,  a  fact  according  with  the  variations  in  the  intensity 
of  vocal  resonance  which  are  clinically  observed  in  different  euei 
of  -pneumonilis,  but  that,  in  some  instances,  the  sound  is  conducted 
with  great  intensity.  Again,ae  stated  by  VValahe,  if  a  porsm  speak 
through  a  stethoscope  introduced  into  the  trachea  of  a  subject  dead 
with  pneumonitis,  in  a  case  in  which  bronchophony  had  been  mstkcd 


<  The  tanin  (ixplanatlon  of  bruncbuphuDf  wm  oflVivd  manj  j«an  ago  hj  Or. 
S.  A.  Cut,  in  a  papn  read  to  %  modiotl  xock'^,  (Mttnat  pnbttelMd,  Kdt  HiiWt 
Msdicd  Jouniftl,  vol.  v»l.  1808. 


AVSOVLTATIOir    IN    DIBBA8E. 


239 


iring  life,  and  luiotlier  person  liittcn  to  the  chiMt,  tlicrc  is  often 
»rly  complete  nbsence  of  souml.  Here  iirc  tbc  pliy»ic«l  condi- 
DOB  for  coiim>nuDci?,  provided  the  broncbUI  tubes  are  unobstructed, 
kods  cndpiiTont  to  explain  the  non-production  of  sound  in  this  ex. 
mment  bj  assuming  that,  after  death,  the  smaller  tubes  are  always 
Jed  with  fluid;  but,  accordinf^  lo  Walshe,  cloae  examinations 
liowed  (bis  not  to  have  been  the  case  in  oome  of  the  siibjttcta  on 
rhich  the  experiment  was  made.  But  there  nre  other  and  more 
jsitive  considerations  which  render  the  theory  of  coiiKonnneu  iin* 
lable.  A  consonating  sound  always  KiiKtains  a  fixed  hnrmonic  re- 
to  the  original  sound  upon  which  ildfpend^.  The  two  sounds 
;  be  in  UDtson.  Now  it  i^  a  ninttcr  of  observation  thut  the  sound 
krd  over  the  chest,  and  ihat  heard  over  the  larynx  of  the  wiac 
itient,  are  not  always  in  harmonic  relation  to  each  other  :  in  other 
rordfl,  musically  speaking,  tht-y  are  discords.  Again,  air  contained 
within  a  certain  space  is  capable  of  being  thrown  into  consonating 
vibrations,  only  with  cerlaiD  notes  which  correspond  to,  or  are  in 
nniaon  with  the  fundamental  note  of  the  space.  But  bronchophony 
U  produced  by  spealcing  in  various  tones;  some  of  which  must  be 
at  variance  with  the  fundaracntnl  note  of  the  space  in  which  the  con- 
eoDsting  vibrations  are  imagined  to  take  place.  Finally,  a  conso- 
nating sound,  except  under  conditions  which  the  pulmonary  organs 
cannot  furnish,  is  always  very  much  more  feeble  than  the  original 
sound ;  yet,  the  thoracic  voice  is  sometimes  moro  intense  than  over 
tlie  trachea  or  larynx.  The  theory  of  consonance,  therefore,  is  at 
Tkriance  with  the  laws  of  acoustics.' 

The  doctrine  of  Laennec,  which,  as  has  just  heon  seen,  is  by  no 
raeaos  disproved,  nevertheless  fails  to  account  for  all  the  phenomena 
of  bronchophony.  Simple  conduction  is  inadequate  to  explain  the 
inten^fication  of  sound  which,  although  infrequent,  does  occssionally 
take  place  within  the  pulmonary  organs;  and  it  is  equally  inadc- 
qnat«  to  explain  the  variation  of  pitch  sometimes  observed  between 
tiie  laryngeal  and  the  thoracic  voice.  The  vocal  sounds  must  be,  in 
certain  insUnces,  at  least,  in  some  way  reinforced  within  the  bron- 
cIuaI  tubes,  and  also  receive  there  modifications  of  its  quality  and 


^^^^ 


«  nuikuT  would  uipreM  Us  ladsbte^now  for  tbo  foregoing  |ioiot«  to  tbe  nd- 
mirablR  work  of  Or.  Walih*  <oditIon  fbr  1S64) ;  to  wlilvh  sbo  he  would  refor  the 
Ttmier  destrooa  of  a  ful)«r  con»ld« ration  of  the  lubject. 


240 


PHTStCAL    BXrLOHATIOir    Ot   TBS    OIIBBT. 


tone.  CoQsonance  mttj  be  one  of  the  snbsidiarjr  sgeaeies  involnJ: 
In  addition  to  this,  nn<l  to  the  influences  which  the  soand  rewina 
io  puAsing  by  conduction  tbn>ugh  dllTerenl  media,  refiection  and  n- 
Tcrbcralion  probably  take  place,  Gonstitnling  what  to  dintiuguuM 
as  union  resonance  and  echo.  From  eomc  of  the  example*  emplojcj 
bj  Skoda  to  illustrate  bis  theory  of  consonance,  it  troald  teem  that 
nnder  tbiii  title  he  intended  to  comprehend  the  scou«>tic  prinapki 
referred  to  bjr  the  terms  just  mentioned.  With  the  foregoing  brirf 
discnacion,  which,  in  Ttew  of  the  practical  character  of  this  work,  hai 
been  perhaps  already  too  exicnded,  I  leave  the  consideration  of  lie 
mechanism  of  bronchophony,  repeating  the  remark,  that  the  subjctl 
■B  one  chiefly  of  specalatire  interest ;  for,  whether  the  theory  (f 
consonance  be  received  or  rejected,  is  a  matter  nnimportant  so  &r 
as  the  significance  and  value  of  the  sign  are  conotfrnod,  our  kn(nr)- 
edge  of  the  latter  being  based  solely  on  clinical  and  autopsieal  ob- 
servations. 

3.  ExAGosBATKD  Bborculu,  Waispek  add  Wbisperisq  Bkox- 
OHOPHOKY. — Under  the  name  normal  bnneidal  tehiaptr,  wai  de- 
seribcd,  intreating  of  Auscultation  in  Ileal  th,  s  blowing  sound  ofvan- 
able  intensity  in  different  persons,  heard  with  whispered  words  at  the 
summit  of  the  chest,  iq  front  and  behind,  and  iD  some  persons  faeaid 
feebly  over  other  portions  of  the  chest.  This  sound,  which  it,  is 
fact,  ideotical  with  a  forced  expiratory  sound,  is  more  or  Ics*  exag- 
gerated, raised  in  pitch,  aod  becomes  tubular  in  quality  in  casts  of 
solidification  of  lung,  and  it  is  developed  with  more  or  less  inUo- 
sity  in  portions  of  the  chest  in  which  it  may  be  wanting  or  bat 
faintly  appreciable  in  health.  Complete  or  considerable  solidifies- 
tioD  of  lung  generally  cauHCH  an  intcose,  tubular,  and  high-pitebed 
whispering  sound.  A  notable  degree  of  ioleosity,  tuhularii;, 
and  elevation  of  pilch,  therefore,  denote  complete  or  considerable 
sol idtfi cation,  and  the  significanoc  being  the  same  as  bronchophooy 
with  the  loud  voice,  the  sign  may  be  called  whUpering  hronehophmf. 
This  sign  may  often  be  obtained  when  the  patient  speaks  in  a  lowl 
voice,  but  it  i^  beat  obtained  with  whispered  words.  The  sign  if 
sometimes  available  when  ordinary  bronchophony  and  the  bro*- 
obia)  respiration  arc  wanting.  It  is  a  very  serviceable  sign  in  casei 
in  which  the  loud  voice  is  lost  or  impaired  by  laryngeal  disease,  and 
when  from  feebleness  it  is  difficult  for  the  patient  to  epeftk  in  a  loud 
Toicc. 


AOSCUbTATIOtr  IH   DICBA8B. 


S41 


I 


I 


A  slight  or  moderate  inoreaHc  ot  tliu  iiiU-iiMtt;  of  tlic  norma)  bron- 
lial  whisper,  wilh  a  corres|)(>ntiiiig  clevatioii  of  pitch  and  alteration 
if  quality,  dcnoteii  a  slight  or  inudcrutc  amount  of  salidification, 
toiil  this  sign  in&y  be  ckIIvi]  exaggerated  bronchial  wkitper.  Il  cor- 
Dds,  ■»  regards  it^  .-ligniGoaiicv,  with  vxiiggeratcd  vocul  reso- 
^aanve,  and  honco,  the  propriety  of  giving  to  it  u  similar  name.  This 
SigD  is  often  highly  useful  in  the  diagnoitia  of  pulmooary  tuberculosis. 
And,  wilh  reference  to  this  (iisense,  th«  points  of  disparity,  as  re- 
gards the  normal  bronchial  whisper,  between  ihu  two  sides  at  the 
Bammit  of  the  chest,  are  to  bo  borne  in  mind.  TIic  whispering  »ound 
)«  louder  on  the  right  than  on  the  left  side,  and  higher  in  pitch  on 
the  left  than  on  the  right  side.  A  whispering  sound  louder  on  the 
left  than  on  the  right  side,  is  a  morbid  sign — an  exaggerated  bronchial 
whisper,  if  the  increA»e  of  intensity  be  slight  oriiioderalo.  lint  on  the 
rigfatside,  a  greater  relative  intensity,  ifslight  or  moderate,  may  not  be 
a  morbid  sign  ;  if,  however,  tbc  pitch  of  the  sound  be  higher  on  tbe 
right  side,  it  ia  a  morbid  sign,  viz.,  an.  exaggerated  bronchial  whisper. 
These  two  signs  arc  generally  available,  and  are  highly  nseful  in 
determining  the  existeuvc  and  the  amount  of  solidiGaation  of  lung. 

3.  DiumigHBD  Mtb  SCfPfl88SBD  YocaL  ResoNANCB. — An  effect 
of  certain  morbid  conditions  is  either  diminution  or  3uppres.Bion  of 
tbt  normal  vocal  resonance.  If,  therefore,  it  be  apparent  that  the 
re«onaneo  proper  to  any  part  of  the  che»t  in  health  bo  lessened  or 
absent,  evidence  Is  thereby  afforded  of  the  existence  of  some  one  of 
tbc  morbid  conditions  which  are  known  to  produce  tliis  effect.  There 
being  no  fixed  staodard  of  normal  vocal  resonance,  its  diminution, 
n»  well  as  its  increase,  ia  dcttermined  by  a  comparison  of  tlie  two 
sides  of  the  obest.  In  the  one  case,  not  Icsa  than  in  the  otiier,  it  is 
important  to  take  cognisance  of  the  normal  disparity  ejciHting  be- 
tween the  two  sides  in  a  large  number  of  individuals,  and  of  tbe 
fact  that  the  relatively  greater  degree  of  resonance  is  naturally  on 
the  right  side.  Without  due  regard  to  tbc  latter  fact,  the  less 
amount  of  resonance  on  the  left  aide  so  frequently  found  in  health, 
might  be  attributed  to  disease  situated  in  ihut  side,  as  well  as  vice 
tiCTM.  An  abnormal  disparity  between  the  two  sides,  provided  the 
greater  resonance  on  one  side  do  not  exceed  an  amount  compatible 
wilh  health,  may  proceed  from  a  morbid  diminution  on  one  side,  or 
from  a  morbid  exaggeration  on  tbc  other  side.  In  the  one  case,  the 
disease  b  seated  in  tbe  side  in  which  the  rcsouBDce  ia  relatively  loas; 

16 


Mf 


FBTiiCAL  izri.«BATto>  or  Tas  cawsT. 


fa  tW  Mkr  CM*.  A*  lAetcd  a 

it  vimU  laMtd^M  be  difcall  to  deccrwaa,  Miler  Aob 

lovfaieb  Mile  the  iH a  !■  W 

A«  laligmAtMa  to  be  derived  firaa  ether  searae  . 

be  much  room  for  doobc  aa  thu  Mere  in  uit  iaBKeaee. 

The  morlnd  tuiwIitHMii  u>  which  iliaiiMtbeil  veeel 
eident  mn  certata  euee  of  solidiSestieB,  ohrtcaetina  af  aae  ef  ik 
brge  brofMhi,  the  preaertee  of  sbnodsnt  Uqiod  cffiMioiiT  or  of  tit,  n 
the  pleural  bsc.  Of  tbeee  serera)  cotnlirioBa,  in  the  fint,  vit^  mU- 
feelioD,  the  normal  rcemanee  is  dimitiisfa«d,  not  anifemilr,  bat  ■• 
certsin  proportion  of  cwe«  only;  thereeonancevgcnersllT  incnaael. 
It  ia  in  eonnectioD  with  this  eondinoa,  aa  bu  been  w^n,  thai  ezi^ 
gerst«<J  vocal  mooanco  and  broochophonj  occur  in  the  grew  •»■ 
jority  of  instances.  As  exceptions  to  the  ral«,  bowerer,  ao  ofipceia 
effect  is Hometimes  induced.  Caritiee  filled  with  li<)ui'l  prodnctaaij 
oeeuion  dimination  of  resonance  within  s  circumKribed  spaee  ear 
reeponding  to  the  site  of  the  excavation.  Obstmciion  of  one  of  th» 
large  bronchi  diminishes  the  resonance  in  so  far  as  the  colmaa  •( 
air  within  the  bronchial  tnbce  takes  part  in  tfao  propagation  of  vocal 
sounds,  and,  perhaps,  also,  in  conseqaence  of  the  changes  indoeed  in 
the  Inng  in  which  the  circulation  of  air  is  cut  off.  In  pleoritis,  br- 
drothornx,  and  pnennio-hydrothoras,  the  diroinntion  of  resonance  ii 
the  rale,  and  in  tbeee  affcotiona  suppreiLiion  is  often  observed.  The 
presence  of  lit{(ud  in  the  two  former  affections,  anil  of  air  togetber 
with  lif|nid  in  the  one  last  mentjonuii,  remove  the  lung  »o  far  from 
the  thoracic  walls  thnt  the  vocal  vibrations  emanating  from  the 
larvnx,  as  well  as  the  re.ipirntory  sonnda,  ful  to  reach  the  ear  of  the 
auscultntor,  or,  if  appreciated,  they  are  feeble.  Abeence  of  vocal 
resonance,  and  its  abnormal  diminution,  are  to  be  embraced  among 
the  Ktgns  by  which  the  presence  of  lirjuid.  or  of  lic|nid  and  air,  is  lo 
be  determined.  It  ix  chieSy  in  these  applications  that  the  sign  poe- 
seHscM  clinical  value. 


4.  PBCTORii-OQor — Cavkrsows  axd  Auphobic  Voice. — The  dis- 
tinctive eharactmslic  of  pectoriloquy,  as  the  name  imports,  is  the 
tranHmlHsion,  not  oiinply  of  vocal  sound,  but  speech :  the  arlionUte 
words  are  appreciated  by  the  ear  applied  to  the  chcsL  This  char 
aetcrislio  is  sutficicnc  to  diatinguiah  it  from  bronchophony,  but,  as 
will  be  preseotly  seen,  in  a  certain  proportion  of  oases,  it  may  with 


AtTBCTJtTATIOW   IN   DISEASB. 


243 


ropmty  be  conaider«d  u  a  variety  of  bronchoptionj.  The  type 
pecroriloqu;  is  to  he  found  among  tbe  pbenomens  incident  to  the 
»ice  in  healih.  Wiib  the  stethoscope  placed  over  the  trachea  or 
irjnx,  the  ear  sometimes  receives  with  distinctness  the  words  enun- 
by  tbe  person  examined.  In  most  instances  the  articulated 
Dice  is  not  perfectly  transmitted  through  the  instrument,  but  heard 
ith  more  or  leas  indistinctness.  The  nature  of  the  sign,  and  its 
liflTcrent  degree:)  of  completeness,  may  thus  easily  he  made  fnniiiiar 
^raetically  by  nimcultaling  the  trachea  and  larynx  of  different  indi- 
riduals.  This  sign  does  not  pertain  normally  to  any  portion  of  the 
but  it  may  be  presented  in  connection  with  certain  morbid 
tndiliona,  and  then  constitutes  true  pectorilo(]uy,  or  chest-talking. 
Phe  intensity  with  which  the  words  enter  the  ear  may  even  be  greater 
|tfas»  when  the  siethoBcope  is  applied  over  the  larynx  or  trachea. 

Laennec  regarded  pcotoritoqiiY  as  a  pathognomonic  sign  of  a  pul- 
tnonBry  earity.  Ho  divided  it  into  three  varieties,  viz.,  perfect,  im- 
tperfect,  and  doubtful.  In  perfect  pectoriloquy  the  transmission  of 
the  articulated  voice  is  complete :  in  the  imperfect  variety,  the  words 
arc  indistinctly  heard;  and  when  doubtful,  it  is  not  distinguishable 
from  bronchophony,  save  by  circumstances  other  than  those  pertain- 
ing to  tbe  voice.  It  is  evident  that  in  giving  to  pectoriloquy  thi« 
oonipreheiisive  scope,  Laennec  was  inSuencod  by  the  dexire  mani- 
fested in  other  instances  to  establish  for  each  particular  le»ion  a 
special  physical  sign.  Taking  his  own  description  of  doubtful  and 
incomplete  pectoriloquy,  these  varieties  are  neither  more  nor  leas 
than  bronchophony.  So  far  as  distinctive  characters  are  concerned, 
Laennec  did  not  attempt  to  draw  the  line  of  demarcation.  Accord* 
ing  to  him,  bronchophony  is,  in  fact,  pectoriloquy,  whenever,  from  its 
sitnation,  the  general  symptoms,  and  tbe  progress  of  the  dineasc,  it 
may  be  deemed  to  proceed  from  a  cavity.'  Observation  »ince  the 
time  of  Laennec  has  abundantly  disproved  the  hypotbesis  of  the 
transmission  of  speech,  even  when  most  complete,  being  always  due 
Ito  the  presence  of  a  cavity;  and,  at  the  present  time,  pectoriloquy, 
1m  it  never  so  perfect,  has  not  the  significance  which  it  po^scn^ud  in 
tbo  eatimation  of  the  illustrious  founder  of  auscultation. 
I  The  physical  condition,  irreopective  of  excavation,  to  which  pec- 
toriloquy is  sometimes  incident,  is  solidificalion  of  lung,  either  from 

■   fufaTrcatiM  on  Diomuea  of  tli*Cfa««t,  eU-.     Translatad  b;  Purtrm,  pftg«  89, 
lew  York  •dttlun.  IBSO. 


M4 


rBTSiOAi.  txrioBATioy  or  tdb  obcst. 


uflsouMtonr  or  taherculoos  depoait.  Coder  these  iJiniwilMim 
tbe  rign  it  inridcoul  to  brondiophooT.  The  othvr  signs  iuXieunt 
of  Bolidifintion  will  be  likely  to  be  Hooeiatctl  with  it,  m.,  DOUUt 
dahMM  OD  pcrcossioD,  and  the  bronebial  recpiniiioo.  In  botb  fum 
oTdisMse,  bat  more  »pedftUy  in  pnetUBonitis,  tlie  peclonloqiir  viH 
ba  dJffMsd,  i, «.,  bMrd  orer  a  eoMiderable  *pace.  In  ooiin«ctm 
with  cmde  tabcrclv,  the  sitoation  in  which  tt  is  fvnod  is  at  the  smK 
out  of  the  chest;  and  it  la  mo»t  apt  to  occar  in  pneoti)OnitJ»  aftet> 
ing  the  upper  lobe.  It  is  bj  no  means  frtyjnentljr  present  in  theiflee- 
tiens  just  named,  bat  only  in  a  «mal1  proportion  of  cases,  depemkat, 
it  is  probable,  on  a  continuoas  and  uniform  <leui>ilT  of  lang  bct*tn 
cone  of  the  larger  bronchial  divisions  nod  the  thoracic  waQ». 

OKT«nura>  pectoriloqay.  howerer,  does  oceor;    that   is  to  nj, 
the  sign  maj-  proceed  from  an  excsratioo.     Bat  it  is  perhapi  ta 
rarely  observed  in  connection  with  cavities,  as  in  cases  in  which  th« 
long  is  etdidified.     Tuberculous  excavations  nrc  sufficiently  oonunoa, 
jet  it  is  not  often  that  well-marked  peetoriloquj  is  developed  in  the 
progress  of  phthisis.     Its  occurrence  cannot  therefore  be  eoanttd 
on  as  evidence  thnt  the  iliscasc  has  advanced  to  the  stage  of  excava- 
tion.    Occurring  at  a  late  period,  when  it  is  altogether  probable, 
from  our  knowledge  of  the  pathological  history  of  phthisis,  ih 
CBvity,  or  cavities,  hare  formed,  how  are  we  to  determine  that  i 
not  CMSod  by  the  solidification  from  the  presencD  of  crude  tube 
which  (re<|acntly  exists  in  the  vicinity  of  the  excavatioosT     The 
crimination  of  broDchophootc  from  carornoas  pectoriloquy  may  be 
based  on  a  difibrence  in  character.     If  the  pectoriloquy  he  iu<adent 
ts  bronchophony,  the  distinctive  features  of  the  latter  will  be  preseat 
in  nddittoo  to  the  transmission  of  the  speech;  that  is,  the  voice  will 
be  near  the  ear  and  raised  in  pitch.     On  the  other  hand,  if  the  pc» 
toriloquy  be  cavernous  the  bronchophonic  features  are  wanting; 
the  resonance,  under  these  circumstances,  may  be  more  or  less  m- 
tenso^  the  intensity  in  some  cases  being  extremely  great,  without 
proximity  to  the  ear,  and  without  notable  raising  of  pitch.     If  the 
inleusily  of  the  resonaikcc  be  incrciiscil,  the  pectoriloquy  is  incident 
to  exaggerated  vooal  resonauee  instead  of  bronchophoinj. 
circumsiance.i  which  aid  in  the  discriminntion,  arc  the  limitation 
the  flign  to  a  circumscribed  space,  ond  the  association  with  other 
signs  indicative  of  excavation,  viz.,  tympanitic  or  amphoric  reso- 
nanee  on  pcrcuiMion,  or  the  cracked  metal  resonance,  the  caveroon     I 
respiration,  the  cavernous  whisper  and  gurgling.     CaverDOoa 


I 

I 
I 


AvaovLTATioy  in  disiase.  245 

riloqay  requires  the  conjunction  of  several  conditions.    Tlic  cuvity 

fiat  be  of  considerable  aixe.  It  must  communicntc  freely  with  the 
roDchial  tubes.  It  must  be  free,  or  nearly  so,  of  liquiil.  It  inu»t  be 
toated  near  the  walls  of  the  chest,  and  the  sign  >8  more  likely  tv 
l>e  prodnced  if  adhesion  of  the  pleural  Hiirfaccfl  linve  tnkcn  place 
over  the  part  of  the  lung  in  which  it  ia  »ittiatcd,  so  thnt,  in  addition 
to  the  thoracic  walls,  a  thin  condensed  stratnm  of  ptihniinary  etruc- 
tore  alone  inlpivenea  between  the  exterior  of  the  cavity  and  the  ear 
of  the  auscultator.  The  walla  of  the  cavity  muat  be  sufficiently 
firm  not  to  collapse  when  it  is  empty.  The  space  within  th«  excava- 
tion must  not  he  intersected  by  parenchymatous  bands.  The  infrc- 
qoency  with  which  these  several  conditions  are  united,  accounts  for 
tbe  aiMcncc  of  the  «igu,  even  when  cavities  exist,  and  for  itH  being 
transient  or  intermittent  in  e»«cs  in  vliieb  it  may  be  fioinetimu  dix- 
ooTcred. 

In  by  for  the  greater  proportion  of  the  instances  in  which  cav- 
ernouit  pectoriloquy  ocourn,  the  excavations  are  due  to  tnberenlvus  di«- 
v»»c.  It  may,  however,  be  incidental  to  the  cavities  resulting  from 
circumscribed  gangrene  and  abscess.  But,  in  addition  to  the  great 
inlnqaency  of  the  latter  affections,  the  favorable  conditions  are  less 
likely  to  be  combined  than  in  tuberculous  excavations.  In  that 
rare  le»ion  in  which  a  pulmonary  cavity  is  simulated,  or  rather  vtr- 
tunlly  exists,  vis.,  pouchlike  dilatation  of  the  bronchial  tubes,  pec- 
toriloquy may  be  marked. 

Tlie  voice  resounding  in  a  cavity  of  considerable  sice,  somctimee 
feasntiies  a  mmiical  intonation,  resembling  the  modi6cation  which  the 
vocal  sonnd  receives  on  speaking  into  an  empty  vase  or  pitcher. 
Thii  constitutes  what  is  called,  from  the  similitude  just  mentioned, 
amphoric  voice.  1'he  character  is  analogous  to  that  belonging  to  the 
rfVpiratory  sound  to  whieh  the  same  term  is  applied.  It  has  no 
special  «ignifiennee  beyond  denoting  the  existence  of  a  canity,  but 
inoiHnuch  ■.«,  when  it  is  strongly  marked,  it  probably  proceeds  from 
sn  empty  spacf,  whereas  peeloriloquy  may  he  due  to  solidification, 
it  has  a  positive  dingnostic  value  in  the  rare  instances  in  which  it  is 
beard.  It  occurs  rarely  in  pulmonary  excavations,  bat  frequently 
in  eases  of  pneunio-hydroihorax  with  a  Rstnlous  communication  be- 
tween the  bronchial  tubes  and  the  pleural  sac.  Although  a  sign  of 
much  vainc,  it  suffices  for  all  practical  purposes  to  notice  it  thus  in- 
cidentally and  briefly  in  the  present  connection. 

Pectoriloquy  doca  not  sustain  sny  constant  relation  to  the  inten- 


S46 


PBTSICAL    EXPLOBATtOS    OF    TDB    CBB8T. 


ntj  of  thoracic  resonance  and  Itie  luisoeiaU-d  thrill,  nor  w  U  ieftt- 
dent  on  the  loudness  of  the  oral  Taic«.  Tlie  trnn^mtMiun  of  «li» 
perol  vords  ia  distinguished  as  tekitprrutg  pf^ortU^vig,  which  ii 
regarded  by  Walebe  aa  highly  distinctive  of  a  carity.  Mj  o«a 
observations  lead  tne  to  a  different  conclusion.  I  huvc  rcpentf^T 
found  wcll-niArked  whispering  pectoriloquy  over  aolidiGcd  lung:  m^ 
without  having  analyzed  cases  with  respect  to  thiai  point,  I  AtaiA 
mj  that  it  is  oftener  met  with  in  such  caso«  than  the  tmnsmissian  if 
wordfl  spoken  aloud.  This  accorda  with  the  revalts  obtained  by  •» 
cnltation  of  the  roice  in  benlth,  vis,,  wbieprrcd  words  are  ofuaa 
trin)'mitt«d  over  the  tracb«a  and  larynx.*  Pectoriloqny  with  lb 
whispered,  as  well  aa  the  loud  voice,  may  be  vither  cavernous  « 
bronchophonic.  The  disoriminntion  may  readily  be  made  by  aiti» 
tioD  to  the  pitch  and  quiility  of  (he  vocal  sound.  If,  with  the  trai» 
mitted  itpecch,  the  transmitted  voice  ha  high  and  tubular,  the  pectwH- 
oqny  is  broncbophonic :  in  other  words  the  pectoriloquy  is  uaociatod 
with  whispering  bronchophony.  Ou  tho  other  band,  if  the  vocal 
sound  be  low  and  hoUow  or  blowing,  the  pectoriloqny  is  carerDoas; 
that  ia,  the  pectoriloquy  is  incident  to  the  cavernoos  whisper. 

The  nifchanism  of  pectoriloquy  claims  but  a  few  words,  ina^mnk 
as  the  phyAicnl  priiidpU-s  involved  ore  e»flcntially  identical  «ilk 
those  concerned  in  the  production  of  bronchophony.  Cooductedby 
the  air  contained  wilbin  the  bronchial  tubes  and  cavity,  aided  by  the 
bronchial  walls  and  solidified  parenchyma,  when  the  intensity  of  the 
transmitted  speech  is  con«idersble,  the  sound  is  probably  reinforced 
by  reflection  from  the  walls  of  the  excavation,  and  possibly,  also,  ts 
some  extent,  by  consonance,  according  to  the  theory  of  Skoda. 
The  amphoric  modification  of  the  vocat  resonance  is  probably  due 
to  reverberation  of  sound  within  the  cavity  giving  rise  to  a  kind  of 
echo.  Skoda  entertains  the  opinion  that  the  development  of  ibt 
amphoric  voice  does  not  require  a  free  communication  between  ik 
cavity  and  the  bronchial  Inbes,  hat  that  the  necessary  eooorouTh 
brations  may  be  excited  within  the  former,  provided  a  thin  layer  (f 
tissue  only  intervenes.     Barth  and  Koger  concur  in  thia  opinion 

5.  Cavbrsous  Whisper  —  Auphokic  Whispbr.- — Whiipeiti 
words  frequently  eaune  a  sound  over  puinionary  cavities  when  the 
speech   is  not   Iraintmiltcd.     Corresponding  with   the   cxpintor/ 


VUd  AiucuIlAtion  it  thu  Voice  in  Hnllh,  page  lU. 


A080trLTATI05   IH  DtSBASI 


247 


I 
I 

I 


aound  in  thr  cnvcmous  ronpimtion,  i(8  qtmlity  is  hollow  or  blowing, 
•»  contrasted  with  thn  tiibnlur  qunlity,  nnd  it  is  low  in  pitch.  It 
TBric8  io  int<-ni>ity  in  iliiTcTent  cilros,  being  sometimes  fvcblc  and 
•ometimct)  tolcrahlj  loud.  Tho  Kign  mny  bo  called  the  cavem- 
OHM  H'Jii'per.  TLo  sign  occuts  under  the  same  conditions  which  are 
required  for  tlic  production  of  the  cavernous  res  pi  rut  ion,  viz.:  the 
BUperficinI  sitwilion  of  the  cavity,  its  emptiness,  flsccidity  of  its 
wallE,  and  freedom  from  obstruction  of  the  bronchial  tubes  lesding 
to  it.  But  as  the  oxpirntory  effort,  when  words  arc  whispered,  is 
generally  greater  than  in  respiration,  the  cavernous  whisper  is 
Bometiines  more  arailable  than  the  cavernous  respiration.  It  is 
beard  within  ■  circumscribed  spncc,  and,  not  infrequently,  a  cavity 
being  surrounded  by  solidified  lung,  the  cavernous  whisper  is  ren- 
dered distinct  and  marked  by  its  proximity  to  whispering  bronchoph- 
oay,  or  an  exaggerated  bronchial  whisper.  I  have  often  illustra- 
ted the  cavernous  whisper  in  juxtaposition  to  the  signs  of  solidi- 
fication just  named,  the  chnracters  of  quality  and  pitch  belonging 
to  the  sign,  being,  under  these  circumstances,  brought  into  strong 
relief. 

An  amphoric  sound,  under  the  conditions  required  for  the  pro- 
duction of  amphoric  respiration,  is  sometimea  heard  with  whispered 
word«  more  distinctly  and  in  a  more  marked  degrev  tbun  with  res- 
piration. This  moy  be  distinguished  as  amphoric  whigper.  The 
amphoric  sound  from  pulmonary  cavities,  and  in  cases  of  pneumo- 
thorax, is  more  marked  with  the  whiepered  than  with  the  loud  voice, 
the  reeonsDce  of  the  latter  and  the  fremitus  tending  to  obscure  the 
music^  intonation. 

G,  ^flOptioNY. — The  modification  of  ihi^  thoracic  voice,  ihua  named, 
has  given  rise  to  much  diftcusniou  respecting  iia  pathological  signifi- 
CBtioe,  aa  well  aii  its  mechanism.  Limiting  the  nitetilion  almost  ex- 
clnsirely  to  the  former  of  these  two  aspeetit  of  the  subject,  I  ahull  not 
devote  to  it  extended  coiiifideraiion,  especially,  an  will  be  admitted 
by  all  practical  auHciillator^  at  (he  prcKcnt  time,  clinically,  the  sign 
is  among  the  least  important  of  those  furnished  by  physical  explora- 
tion. The  characters  by  which  it  is  distinguished  arc  well  defined 
and  diAtinclive.  Its  peculinrities  arc  sufficient  to  establish  its  indi- 
Ttduatity;  and,  when  well  marked,  it  is  readily  recognized.  The 
inferior  rank  which  it  holds,  results  from  the  infrequency  of  its  oo- 
cnrrcfice,  its  superfluousness  in  certain  of  the  instances  Id  which  it 


gsxdi  tW  pub  of  tkc 

to»l«il«d  «xt«M  «f 

Iif»d.tbt 

■»  br,  thi  iBga  » 

eace  of  lM|n4 


to  ID*  wMrif  I  to  utrAilcit 
•f  1m^  dht  tha  ^en^  ttik 
fct  t»  tbt  |iii»ii«,  of  iIm  liqnd.  b 
i^»Qj  broM&opiwaj,  ezerpt  tluu  tbe  fn»- 
tkm  ■nin  dittSBt  u  eoapwd  «itli  «i£mj 


broBchopfcoay.  Hm,  kowcrcr,  m  n  other  milincfB  in  «bk&  At 
fhjncal  friaciflM  tBTtdrcJ  in  the  ncehuniB  of  mgat  are  nit- 
tHBned,  tbo  qaestioa  is  one  of  epecoUtiTe  ntbfr  thfta  pnctiol 
Btenst. 

Ib  coacloBJon,  from  the  fwts  ooDtuoeal  in  the  forgoing  iccowt 
of  Kgophooj,  its  eUinu  to  be  reoogaixeJ  u  ■  veritable  iodmlHl 
mga  appear  to  me  to  be  not  Icot  valid  than  those  of  pectoriloqaj. 
lake  the  Utter  sign,  it  has  disttaetiTe  traits,  bj  which,  vbeo  «d^ 
marked,  it  is  disiingoished  without  difficultT  from  other  a^ 
MoreoTer,  BOtwithttaDding  the  opinion  of  Skoda  to  the  cofttrsrj.it 
hu  a  positive  aifatfieaaee,  iDdicating,  certainlj  in  the  vast  nuQorii; 
of  the  can«s  in  which  it  is  observed,  a  speml  pathological  coiMlitia^ 
viz.,  a  certain  amoonl  of  li4]uid  eflnsion  between  (he  picoral  soifaflM. 
XevcrtkelcH,  %»  eutcd  at  the  out«e(,  in  view  of  the  iofreqMeaejW 
its  occurrence  in  connection  with  the  pathological  condition  which  il 
represents  when  it  does  occur,  its  brief  duration,  and,  in  geoenl, 
the  sufficiency  of  other  physical  signs  denoting  pleuritic  effn8ion,iD 
elinical  value  is  comparatively  small,  and  it  might,  without  noii 
detriment  to  physical  diagnosis,  be  dropped  from  the  eatslogu  d 
signs.  It  is  to  be  classed  among  tbe  curiosities  of  physical  czplon- 
tioo,  ratbor  than  among  the  plicnomena  posaessiug  much  praetinl 
importance. 

In  connection  with  the  phenomena  incident  to  the  voice,  ma;  ht 
mentioned  a  novel  method  of  ezploralion  proposed  by  M.  Hoarmtmi, 
in  which  the  au.'u:ultator  observes  the  effect  of  his  own  voios  oa  lit 
chest  of  llic  patient.  With  the  car  placed  in  appositioa  to  tic 
chest,  but  not  prc»»cd  loo  firmly  iigniniit  it,  more  or  less  resoDUK 
and  vibrution  are  perceived,  when  wordii  are  pronounced  with  a  ImI 
voice,  and  in  a  manner  to  secure  reverberation  ihrongh  thenaul 
pMUgee.  To  this  method  M.  Hounnann  applies  the  title  aiUepimaf 
Whatever  clinical  value  attaches  to  autophonic  pheooincna,  of  comtt 


■  Fruiu  auTN,  kod  *mfn. 


AtTSCCLTATIOX    TV    DISBASB. 


249 


hsracters,  other  distinctire  traits  relate  to  the  situation  where  it  is 
aallj  heard,  ihe  extent  of  its  diflosion,  etc.  ^gophony  does  not 
ir  indifferent];  at  any  part  of  the  thorax.  It  is  found  much 
soer  than  elsewhere  at  or  near  the  inferior  angle  of  the  scapula, 
eqnently  being  limited  to  a  small  space,  and  usually  more  marked 
^t  that  situation,  when  it  is  more  or  less  diffused.  From  the  point 
St  mentioned,  when  it  is  not  thus  limited,  it  generally  extends, 
conling  to  Laennec,  and  other  observers,  to  the  interscapular 
e.  and  tn  a  zone  from  one  to  three  fingers  broad,  following  the 
le  of  the  ribii  toward  the  nipple.  This  rule  as  respects  situation  is 
fot  without  exceptions.  Fournet  slates,  as  the  resnit  of  numerous 
bbserTaiioDS,  that  it  may  exist  over  the  greater  part  of  ihc  lateral 
snd  pOBterior  portions  of  the  chest,  but  never  extending  to  the  sum- 
it.  It  baa,  however,  been  observed  in  the  infra-clavicnlar  region, 
id  also  diffused  over  nearly  the  entire  chest  on  one  side.  It  is 
[»metimes  found  to  tbift  ilJt  seat,  or  to  disappear  whi-ii  tlic  po.«ilion 
if  the  patient  is  changed.  The  explanation  of  thetie  facts  involve:*  a 
tference  to  the  physical  conditions  upon  which  the  sign  is  dependent, 
rifl  will  be  noticed  presently.  It.-«  duration  i»  variable,  but  rarely 
extending  beyond  a  brief  period.  The  average  lime  of  it«  continu- 
ance i»  eMimnie*!  from  five  to  eight  days  ;'  but  in  a  ca«c  of  chronic 
plctiritis  citi^'d  by  Lncnnec,  it  lasted  for  several  months.  In  the  prog- 
imt  of  the  same  disease,  ris.,  pleoritis,  it  may  appear,  continue  only 
for  a  short  time,  and  at  a  subsequent  stage  reappear  for  a  brief  period. 
This  has  been  repeatedly  observed,  but  is  by  no  means  an  invariable 
rule.  During  the  period  of  its  continuance  it  is  pretty  constant,  i.  «., 
heard  at  nearly  every  examination ;  but  it  is  not  equally  manifested 
rilh  viich  act  of  the  voice,  or  articulated  word.  It  is  more  intense 
some  moments  than  at  others,  and  may  be  temporarily  suspended 
an  aecuinulntion  of  mucus  in  the  bronchial  tubes,  being  repro- 

immedialcly  after  coughing  and  expectoration. 
Lavnnec  regarded  ngophony  as  conclusive  evidence  of  the  presence 
of  n  certain  quantity  of  liquid  within  the  pleural  sac.     Uc  asserts 
that   he  discovered  it  in  nearly  every  case  of  pleurisy  that  cnme 
Under  bis  notice  during  the  period  of  five  years.     Subsequent  obser- 
vations have  abundantly  confirmed  the  fact  of  its  occurrence  in  con- 
nection with  the  pathological  condition  just  mentioned,  hut  in  a  pro- 
don  of  instances  less  than  was  supposed  by  the  founder  of  au9- 


>  Barlb  and  Ruger. 


PIIT^ICAI.    EXPtOEATIOK    OF   THE    CBEST. 


cuhation.     With  the  utmost  Ten<-r&tioD  of  th«  mcmorj  of  Lofniwr, 
it  muat  be  presumed  that,  with  reference  to  Kgofiliony,  «Aia  At  em 
of  pectorilo()uy,  a  strong  ilesiiro  to  invest  each  Mgn  vtiih  aipttal 
Bignifionce,  representing  eonstantly  the  nme  anatomical  nikdiMs, 
to  some  extent  affiecleil,  uncon.«cioiuily,  ihe  accuracy  of  bin  ohHm- 
tions.     Thia  presumption  is  fttrengthvnc<i  by  his  confc«woo  at  tk 
difficulty,  fn'(]ueiitly.  of  diacrimiDiiting  Rgopbony  from  broiichc|k- 
ony ;  and,  al.io,  by  the  importniioc  which  he  attacht^s  to  pnwi^ 
the  car  very  lightly  againnl  the  aletho9cop«  iit  seeking  for  thittigL 
Thia  method  of  auscuitattng  suRiceB  ofUta  to  give  to  theToioca 
legnphonic  intonation.     At  all  erents,  it  in  oertain  that  well-markd 
le^^ophnny,  so  far  from  being  constantly  or  generally  prtaent  ii 
pleuriii.4,  is  a  rare  phvaical  sign,  and  there  are  doubtlc«9  tnany  vk 
have  had  considerable  experience  in  phyxical  exploration  withni 
ever  having  met  with  a  singlp  gnnd  example  of  it.     It  nay  be  an^ 
ciated  with  the  pre^nce  of  li4uid  of  any  kind  betwceo  the  pkoil 
surfaoea,  aenim,  pu«,  or  possibly  even   blood ;  and  it  U  thercfote  > 
sign  which  may  be  incident  to  ordinary  pleoritis,  the   bemorrliagit 
variety  of  the  di^ase,  empyema,  pneumonitis  with  li(|aid  clanoD, 
and  hydrothorax.     Even  in  the  time  of  Laenneo,  the  uniform  dvpeml- 
encc  of  tegophony  on  the  jireiti^ncr  of  liijuii!  was  iloubted  by  Mat 
obaervers,  who  profes^ivl  to  liavc  discoTcrod  it  in   cases  of  sia^ 
pneumonitis  involving  solidificntion  of  long  without  liqaid  effusm. 
Sk«dii  rfji'ots  entirely  the  sppcinl  significance  attached  to  it  by  La- 
cnnec,  and  declares  that  he  has  met  with  it  both  in  simple  pneuaoa- 
itis  and   tubercular  infiltration.      Such  instances,    if  they    exist, 
are  certainly  exceptional.     Without  denying  their  oocurrenee,  it 
may  be  suspected  that  the  presence  of  a  small  quantity  of  liqnii 
sufficient  to  oocasion  this  sign,  but  not  abundant  enongh  to  give  riN 
to  other  physical  evidences  of  effusion,  may  be  the  explaDatioa  ii 
some  cases.     The  sharp  tremulous   character  of  the  oral  voict  mj 
also  account  for  its  occanional  apparent  manifestation.'    Brooebop^ 
ony,  and  the  normal  resonnnce,  assume  fre<]uently  an  ttgopbait 
eharncter  in   the  aged  of  both  scxv^,  but  es)H'cially   in   fcBsies 
Moreover,  with   rcfcrenco  to  this  puint,  a  didtinction  is  to  be  malr 


■  Niirmal  a^phonv,  due  tn  tb«  aharac^r  ortheofsl  voice  In  thv*g«<l,*QW 
llknlii  lo  bv  pn»«iit  on  Ifutfa  tide*  uf  tlic  illicit.  Thii  will  torve  la  dutitfouk  b 
fro'io  the  morbid  lisn  which,  eicpptiiiK  '""le  rare  inMitncc*  of  hy<lnitkoru.k 
llmilid  to  cnii  uliI*.  Hut  ibp  utiuniuli-r  ofihc  uml  voiutr  will  bvappwaL  Dm*" 
over,  tb«  otbur  pbfiiul  «ignii  of  pl<:ariilc  ofl^loa  will  b«  waaUng. 


AOSCULTATIO!!    IK    DISEABC 


between  <iisiincUj  marked  legophony,  and  a  eligblly  sgophonic  char- 
acter of  the  thoracic  voice.  The  latter  mav  occnr  as  a  nonnal 
peculiarity,  or  in  connection  vilh  solidification  of  lung,  without  in- 
validating  the  significance  which  properly  helonga  to  the  former. 
Bat  whether  or  not  nell-inarked  Kgophony  be  sonietiraca  itioidvnt  to 
solidification  of  lung  alone,  thii>  fact  muAt  be  ndniitted,  vin.,  of  the 
iDstsnces  in  which  it  ia  obserred,  in  all  save  a  few  exceptional  cases, 
it  is  doe  to  liquid  eflusion.  Obsenation  also  has  auflicieniiy  estah- 
^sbed  thai,  in  general,  it  demands  for  ila  production,  a  made-rate 
pmonnt  of  liquid  efTuAion.  Laennec  atatca  tljat  he  had  diacovered  it 
in  cases  in  which  there  did  not  exist  above  three  or  four  ounces  of 
fluid  in  the  chest.  A  quantity  sufficient  to  produce  slight  com* 
pression  of  the  lung,  inlerposing  a  ihin  stratum  between  the  pul- 
aarj  Hurface  of  the  tJioracio  parietes,  appears  to  furnish  the 
iry  pliyiiical  <;«niIit.ioni^  In  the  progrt-i<»  of  plogrilis,  iho  sign, 
when  it  occurs,  ti  found  iit  an  ejirly  pt-rlod  uf  tli*- iliscAW.  Laennec 
discovered  il,  in  some  instances,  within  n  few  hours  after  the  attack, 
but  genentlly  not  strongly  marked  until  the  second  or  third  day. 
YVhcre  the  quantity  of  effusion  increases  so  as  to  produce  considcr- 
pble  cotnprejwioD  of  the  lung,  removing  it  at  a  distance  froui  the 
-greater  part  of  the  thoracic  walls,  the  sign  almost  invariably  disap- 
pears.  It  continues,  therefore,  frequently  but  a  short  lime,  perhaps 
for  a  few  hours  only,  rarely  longer  than  two  or  three  duyw.  Its  Itmi- 
^lion  to  a  particulnr  juncture  in  the  course  of  the  disease,  niid  its 
hort  duration,  uudoubteilly  arc  rvai<on»  why  it  ia  not  discovered  lu 
lany  caves  in  which  it  cxtKts.  In  some  instances  it  may  have 
Burrci  and  disappcMrcd  prior  to  patient*  coming  under  obst-rvaiion, 
kt  a  Hubi^equont  stage  of  plcuritis.  when  the  quantity  of  liquid  is 
luccd  by  absorption  to  that  involringthe  requisite  physical  coiidi- 
DD8,  il  is  sometimes  observed  a  second  time,  or  it  may  be  diMOvervd 
hnder  these  circurastances,  when  it  had  not  been  observed  pre- 
viously. Returning  regopbony  {ef/ophonie  de  retour,  oegophonia 
mtehtx),  thus  Furnishes  evidence  of  the  progress  of  the  disease  toward 
restoration.  The  dtpendence  of  the  sign  on  the  prcM-nce  of  a  cer- 
tain quantity  of  liquid,  has  been  itomonstrnted  by  its  sppciirance  in 
cases  of  empyema,  in  which  paracentesis  was  rcfrortcd  to,  the  Kgoph- 
ony,  which  had  not  existed  prior  to  the  operation  in  consequence 
of  the  large  quantity  of  liquid,  becoming  developed  after  a  porlloD 
had  escaped.  It  has  been  observed,  during  the  removal  of  the  liquid, 
to  change  its  place  as  the  quantity  lessened,  falling  lower  and  lower 


252 


PHT8ICAL    BXPLOBATIOH    OF    TUB    CB88T. 


on  the  surface  of  the  cheBt,  and  finsllr  dieappparing  after  tW«Mt 
of  the  fliiid  contents  of  ibe  chest  had  been  withdrawD.'     The  fact  i( 
f^ophon;  1*eing  commonly  foand  at  a  particular  sittution,  viL,ii 
the  lower  angle  of  the  scapula,  and  over  a  narrow  fpaee  exteodiig 
from  this  point  in  the  direction  of  the  ribs  to  the  nipple  (the  patim 
being  examined  in  a  sitting  postnrc),  haa  led  to  the  Auppositioa  An 
the  peculiar  modification  of  the  vocal  ftound  i»  produced  at  the  k>ri 
of  the  liquid ;  in  other  words,  that  the  xoiie  just  mentioned  indicsta 
the  height  on  the  chest  to  which  the  effaMoii  ri#c9.     It  '*»  not,  hw- 
ever,  us  has  been  stated,  alwa}-«  limited  lo  the  simntion  descriM; 
niid,  a*  rcmarVed  by  Fournot,  it  is  more  probable  that  the  pointf  ai 
which  Ihc  "igii  is  heard,  nrc  those  whore  the  stratum  of  l!<iaid  iat 
prcciedj  the  reciuisite  tblnnese,  the  quantity  ahove  being  too  soil, 
and  below  too  large.      This  concluvion   is  sustained  by  eviibaet 
afforded  by  the  pcn-tiH^ion  and  respiratory  sounds,  found  aboTCui 
below  the  site  of  the  Rgophony.     Dalncssof  thrsoandonprrcasiia, 
and  diminution  of  the  re^iratory  murmur,  hare  been  oWf-rr^d  to bt 
progressively  and  gradually  more  marked  in  dcEceuding  from  acer- 
tiiin  distance  above  the  limits  of  the  ^egophony;  Qainesfl  and  tbt 
ahsciioe  of  respiration  esisting  at  the  lower  part  of  the  chest,'    At 
exceptions  lo  the  gc-ncml  rule,  tegophony  is  occaaionally  well  rasrkeJ 
in  cases  in  which  the  quanlity  of  liquid  is  quite  large,  sufficientereB 
to  occasion  considerable  enlargement  of  the  chest.     In  the  rare 
instances  in  which  icgophnny  is  heard  over  the  greater  portion  of  llw 
eheot  on  one  side,  the  explanation  offered  by  Laennec  is,  that,  ewinj 
to  adhesions  of  the  pleural  surfaces,  at  numerous  disconnected  poiaU^ 
the  lung  is  prcvi.-nted  from  being  pushed  upward  before  the  accmnil- 
Inting  liiiuid,  which  consequently  is  diffused  over  the  whole  pnlw^ 
nary  surface,  except  where  the  morbid  attachments  exist,  the  stntgni 
being  uniformly  of  the  requisite  thinness.     Id  two  instances  be  foi- 
fled  the  correctness  of  this  explanation  by  the  appearances  towA 
after  death.     The  shifting  of  the  seat  of  the  segophony,  or  it*  Mp- 
pression,  when  the  position   of  the  patient  is  varied  (apoiBlM 
ob*crved  by  M.  Rcynimd,  a  contemporary  with  I^ennec),  is  explaMd 
by  the  chnngc  of  relation,  which  takes  place  between  the  lung  tm 
the  surrounding  liquid.     Assuming  thai  the  sign  requires  an  inWt^ 
vening  stratum  of  fluid  of  a  certain  depth,  it  is  nut  diOicult  to  coMnrb 
that,  having  been  discovered  at  a  particular  part  white  the  patient  a' 


'  I  Bartb  and  Roger,  op.  «t.  p.  202,  edition  of  IB61. 


*  foonat,  «fL  OL 


rSCULTATIOH    t?I    DISSASE. 


258 


tn  Iho  nittJng  posture,  ita  stluation  sliould  b«  found  (o  be  movable  as 
I  bodj  is  JDoliDcd  to  one  nidc  or  thu  otiier,  or  fur  forirnrd,  in  con- 
jaenoe  of  tlic  rHntive  disposition  of  the  ruguid  being  m  chniigod 
tb»t  ibe  locality  in  irhkh  the  ncocssary  pliy^icitt  coiidJiiona  »re 
pn>i>«i)t,  viiriPH.  It  U  bUo  intelligiMi},  thtit  ii  chiingc  of  position  by 
vhich  the  lung  displnc«B  ft  tbin  stratum  ol)  liquKl,  and  cumi-s  into 
contact  with  tbo  walls  of  tlic  chest,  as  wbi-ii  s  patient,  after  having 
been  examined  in  the  eittiog  posture,  lies  on  tbc  iil>donii-n,  ebonld 
cause  suppression  of  sgopbony.  Tlieso  phenomena  have  been  re- 
peatedly observed,  but  by  no  means  nniformty  in  tbc  cases  in  vhivh 
(cgophony  occurs,  which  acconla  iritb  the  ncll-knowR  fact,  that  it  is 
only  in  a  certain  proportion  of  cnees  that  the  level  of  tbo  effused 
fluid  is  affected  by  changes  of  the  position  of  tbe  puttcnt. 

In  the  vast  majority  of  tbo  instuncea  in  which  a^gopbony  is  ob- 
served, it  is  incident  to  simple  pleuntis.  It  is  very  rarely  found  in 
empyema,  tbe  quantity  of  liquid  being  too  large.  It  may  occur  in 
liydrotborax,  and  be  present  oti  both  etdcs  of  the  cbcst.  It  has  boon 
known,  as  an  anomalous  fact,  to  nocoDipuny  hydro-pericardium.  Id 
pncuinonitis  tbe  occurrence  of  wcU-m»rkod  wgophony  is  exceedingly 
rare ;  it  is  not,  howcrer,  very  uocommou  for  the  thoracic  roioe  to 
Maume  some  approximation  toward  legophouy.  The  sign  is,  in  fact, 
a  variety  of  bronchophony;  tremuloininess,  or  the  bleating  charac- 
ters, being  characters  snperadded  to  those  which  belong  to  bron* 
chophony.  It  is  not  uiicomnion  to  have  weak  bronchophony  witlioui 
tbo  fcgopbonic  characters,  under  tbe  conditions  which  occasionally 
give  rise  to  aegophony.  The  roioe,  howerer,  under  these  oircum- 
Itanoi^,  is  Dot  near  the  ear,  but  mora  or  less  distant. 

The  meehanitim  of  legophony  is  a  mooted  point  whtcb  it  would  b« 
anproGtable  to  discuiw,  and  I  shall  giTC  to  this  branch  of  the  subject 
but  a  few  wordii,  Lavnnoo  ntlributeil  the  trciuulousncw  of  tbc  voice 
to  tbe  agitation  of  titc  liquid  by  tbc  art  of  speaking.  It  may  be 
conceived  that  the  vocal  sound  transmitted  through  a  stratum  of  lluid 
under  ibese  circiimsIaRces,  would  acquire  a  corre»ponding  vibratory 
character.  Whvthi^r  this  csplnnation  be  correct  or  not,  none  utlier 
more  satisfactory  has  been  offeretl.  The  other  vcgophoiiio  element, 
riz.,  tbe  elevation  of  piCcl),  Laennco  accounted  for  by  supposing  tJiat 
the  broticbial  tubes,  Battened  by  the  compression  of  tbe  liquid,  are 
made  to  resemble  the  mouthpiece  of  certain  muiiicul  instruments, 
like  the  bassoon  or  hautboy,  and  tbut  tbc  modification  of  tone  was 
due  to  this  condition.    This  theory  is  generally  deemed  unsatisfoc- 


FasiiCAi  axri^KATiax  mj  rat  cassi. 


BIcnsL 


fnm  ibe  &eu  eaotuMd  n  the  roregoing  Meonu 
of  mgoftkonj,  iu  dua*  lo  be  meopuxcd  u  »  rmuble  indindal 
«gB  kppear  ta  »•  M  be  »ot  Ich  nhi  dna  tbone  of  pectonloqnj. 
Ldte  tbe  bttcr  sign,  it  ha*  £ttisctiTe  tnita,  b^  vhich.  vbra  «d^ 
■■ftrf.  it  is  Jooagwihtd  vitboat  fSenttr  fnm  olber  ci^ 
lfoi««vcr,  BOtwitWlaBfiBg  At  spiaiM  of  SIea<U  to  ifae  eoDtnrj.il 
fcaa  »  penlite  ngnienm,  JadJetlipg,  certAinlT  in  ike  vast  maJMitj 
of  tb«  cases  io  which  it  is  ohaemd,  a  tptcul  patfaologieal  eoailitioit, 
rix.,  K  certain  xmonnt  of  K<|aid  rflfiiMDii  between  tb^  [ilennil  sariaeee. 
NeTcrtbeles*,  as  stated  at  tbe  oouei,  in  riew  of  the  infrrquene;  •* 
ita  occnrrettce  id  coni>e<:UoQ  with  the  pathological  condltton  whJdi  it 
repreeenta  when  it  does  oecnr,  its  brief  daratioD,  and,  in  general, 
the  niSciencj  of  other  phrsical  signs  denoting  pleuritic  eSusion,  iti 
elitiKal  Tstne  is  coroparatirelf  small,  and  it  might,  without  macb 
detriment  to  physical  diagnosis,  be  dropped  from  the  (dialogue  sf 
signs.  It  is  to  be  classed  among  the  cariosities  of  phirsical  ezplotv 
tioo,  rather  than  among  the  phenomena  possessing  much  prnctieal 
importance. 

In  connection  with  (he  phenomena  incident  to  the  voice,  m»j  k( 
mentioned  a,  novel  method  of  exploration  propowd  by  M.  nonrmans, 
in  which  tlie  awtcullalor  observes  the  effect  of  bis  own  voice  on  dw 
chest  of  the  patient.  With  the  ear  placed  in  ippontion  te  |h( 
chest,  bat  not  presned  too  finnlj  ngsinst  it,  more  or  lees  resonsncs 
and  fibration  are  perceiTC<l,  when  words  are  pronotioced  vith  a  )eti 
TOioe,  and  in  a  manner  to  Mocnre  reverberation  through  iheasM) 
panugeH.  To  lhi»  mi>tliod  M.  Uourmimn  applies  the  title  auU'phtmia? 
Whatever  clinical  value  attaches  to  autophonic  phenomena,  of  toaist 


1  Prom  «*«•(,  and  fm4ir. 


AOiODLTATtOK   IK    DI8KABB. 


266 


clcpoti<l8  OD  certain  modificBtioriB  r«prD»enling  c«rtiiin  morliid  con- 

E lions.  It  is  ttUcg^d  timt  vhca  tlie  dcnsily  of  the  lung  in  obnor- 
■lly  incrtaitcd,  the  rcAOnanci!  iitiit  vilirtitioii  comniiiiiicwlcd  to  (lie 
orucic  wnlU  nre  proporlionally  cxaggeratetl,  and  hence  a  disparilj 
letwrcn  the  two  sides  i>f  the  cIlwI  in  this  respect  belongs  nmong 
fii«  sign?  of  KotidiGcfttion  from  pncmuonin,  crude  tubercle,  &«. 
parth  and  Roger  stitto,  as  the  muItH  of  a  scries  of  clinical  obscrvn- 
|ion»  miiilc  with  a  view  to  dcU-rminc  tbc  viiltic  of  tlii?  mrtbod,  that 
fa)  nbont  oni--hnlf  of  the  instnnccs  in  wlilcb  solidifiuaiion  cxislcd, 
nlher  from  the  presence  of  tubercle  or  inflniiiinn.tory  cxudnlion,  the 
Ikotophonic  phonomcna  were  more  marked  ;  in  the  other  half  no  ap- 
fareciabic  difference  existing  between  the  healthy  and  diseased  sides; 
led  tliiit,  in  general,  in  the  cases  io  which  a  disparity  was  apparent. 
It  was  slight  in  degree,  being  sometimes  not  appreciable  without  the 
]ose«t  coinpnrison.  In  no  instance  did  the  sound  present  any  spe- 
jlial  character  which  might  indicate  something  more  than  the  fact  of 
IcroMcd  density  of  the  lung.  The  informsiion  to  be  derived  from 
his  method,  therefore,  corresponds  to  bronchophony;  and  it  may  be 
sionally  useful  when  the  voice  of  the  patient  is  lost.  Except  in 
of  aphonia,  it  seems  hardly  deserving  of  attention;  and  under 
_  ny  circumstances,  its  valne  eon.iist,*  in  the  eonfinnntJon  which  it 
Way  afford  of  other  auscultatory  signs  far  more  reliable. 

SoKMART  OP  Facts  pRKTAiNixa  to  Vocai.  Sionp. — The  normal 
borscic  resonance  of  the  load  voice,  in  connection  with  certain 
grbid  conditions,  may  be  increased  or  diminished,  and  the  reso- 
ice  of  both  the  loud  and  whispered  voice  may  present  abnormal 
benomena  as  regards  quality,  pitch,  etc.,  of  sound.     The  various 
eviations    from  health  constitute  the    following  signs:   exagger- 
Tocal  resonance,  and  bronchophony;  exaggerated  bronchial 
rhisper,  and  whispering  bronchophony;  diminished  and  supprcMed 
boeal  resonance ;  ftectoriloquy,  including  amphoric  voice,  cavernous 
^d  amphoric  whisper,  and  Kgophony.     In  exaggerated  vociil  reso- 
nance, the  diffused,  distant  resounding  of  the  voice,  accompanied 
Bilh  more  or  less  vibration  or  thrill,  which  constitutes  tho  normal 
^ocal  re«onance,  is  increased  in  intensity,  without  any  notable  alter- 
ation in  other  respects.     Bronchophony  is  characterised  by  an  ab- 
lormal  concentration  and  elevation  of  the  pitch  of  the  vocal  sound, 
lie  voice  seeming  to  be  near  the  ear.     The  vocal  resonance  may  be 
;litly,  moderately,  considerably,  or  greatly  exaggerated.     Bron- 


256 


PBVSICAL    BXPLOSATIOK    Of    THB    CBIST. 


choplioity.  also,  inmj  be  more  or  less  marked.     If  Blightl;  or  and- 
eralely  msrk«d  it  is  called  weak,  and  if  it  hsve  conadenUt « 
great  inteniitj,  tt  is  called  elrong  bronchophony.    Strong  br«. 
chophony  may  cicecd  in  intensily  the  Bound  heard  over  the  tiwict 
or  larynx;  on  the  other  hand,  in  veak  bronchophony  the  no 
uuncc  may  be  less  intense  than  in  health.     The  pitch  of  BMud  ii 
not  alvrays  the  same  as  that  of  the  tracheal  or  laryngeal  T<we. 
The  vibration  or  thrill  which  generally  accompanies  exaggerated  rtf 
onance,  is  not  necessarily  increased  in  proportion  to  the  abnonnd 
strength  of  the  bronchophonic  voice,  and  it  may  be  dimitiisbc^ 
Exuggcrnte<l  vocal  resonance  habitoally  exisU  on  the  right,  ceft- 
trasteil  with  the  left  side  of  the  chest,  and  the  thoracic  voice  at  lb 
summit  of  the  right  side  of  the  chest,  in  front,  may  even  be  bron- 
chophonic without  denoting  disease.     Exaggerated  vocal  resonasM 
and  bronchophony,  represent  different  degrees  of  increased  deaatj 
of  long.  They  occur  in  connection  with  the  physical  conditions  which 
give  rise  to  the  broncho-vesicular  and  the  bronchial   respirttiM. 
They  a.re  generally  marked  in  the  second  stage  of  pneumonitis,  aal 
it  is  in  that  disease  especially  that  strong  bronchophony  is  obseml. 
SitUEiled  at  the  nunimil  of  the  chest  on  one  side  within  a  circus- 
scribed  uren,  making  due  allowance  fur  a  normal  dcgn.-«  of  disparity, 
they  are  vitluablc  signs  of  a  tuberculous  deposit.     Increased  deniity 
of  lung  from  coaiprcssiou,  in  cu:<cs  of  pleurisy  with  liquid  effuswn. 
may  give  rise  to  t\\c*f  signs,  sicuatcd  ovvr  a  part  of  tbc  chest  cor- 
responding to  the  BpHce  occupied  by  the  condensed  pulmonary  sUae- 
tare;  and  this  situation,  save  in  some  exceptional  instances,  will  be 
at  the  superior  part  of  the  chest.     Exaggerate*!  Tocal  rcsoiiann 
may  also,  in  connection  with  other  signs,  together  with  symptom!^ 
denote   carcinoma   of   the   lung,   melanotic   deposit,   extravsMled 
blood  or  apoplexy,  gangrene,  serous  in6Urat4on,  or  cxtra-ptdtneoie 
morbid  growths.     It  is  raro  that  well-marked  bronchophony  ei'ttu 
in  connection  with  these  severul  affections.  Dilatation  of  the  broncfcv 
accompanied  with  surrounding  solidification,  furnishes  oondiiioos  nl- 
culatcd  to  give  rise  to  strongly  lanrked  bronchophony. 

Slight  or  moderate  solidification  of  lung  increases  the  inlcnsttytf 
the  normal  bronchial  whisper,  and  may  give  rise  to  a  sound  villi 
whispered  words  in  situations  in  which  no  sound  is  appreciable  ia 
health.  The  sound  is  also  somewhat  tubular  in  quality  and  higbtcin 
pilch  than  the  normal  bronchial  whisper.  This  sign  of  sligkl  or 
moderate  solidification  of  luog  may  be  called  the  exaggerated  brM- 


adscultatioit  iir  dissabr. 


Iiini  whisper.  It  ni&y  be  pr«!ienl  wlioti  oxnggcrutod  resonance  of 
ae  loud  Toice  ami  ibe  bronelio-vosiiciilitr  rccpiralion  are  not  avail- 
ible.  It  is  a  valuable  sign  in  the  iliagnottii^  of  n  smull  or  moderate 
Bit  of  tubercle.  Complete  or  considerable  solidiGcatJon  of  lung 
enerally  gives  rise  to  notable  intennily  of  tlie  broncliiol  whisper, 
rbicli  is  aba  tubular  and  high  in  pitch.  This  sign  niity  be  called 
rbiapering  bronchophony. 

Diminution  and  suppression  of  the  normal  vocul  rcgooancc  are 
icident  to  the  rarefaction  of  the  lung  which  obtitiim  in  emphysema; 
obstruction  of  one  of  the  large  bronchi;  to  liquid  effusion,  and 
tfa«  presence  of  air  within  the  pleural  sac;  to  cnvitios  filled  with 
li<tuid;  and,  exceptionally,  to  solidiRcation  of  lung. 

Pectoriloquy  ia  ihe  transmission,  more  or  less  complete,  of  ar- 
ticulate  words  through  the  cheat  to  the  ear  of  the  unscultator.  This 
ugD  may  I>c  present,  when  various  circumstancfs  favorable  to  its 
production  concur,  in  ca-tes  of  pulmonary  cnvitios;  but  it  is  by  no 
kna  a  sign  distinctive  of  an  excavation,  u«  was  held  by  Locnnec. 
It  is  sometimes  well  mnrkeil  in  chih'a  of  s'llidiGcation  of  lung  in  the 
second  stage  of  poeuinonitin,  mid  from  crude  Iitherole.  When  duo  to 
ft  toberouions  cftvity,  it  18  uRaccouipuntcd  by  the  churactcr^  of  brouuho- 
pbony.  the  space  in  which  it  is  heard  is  circumscribed,  situated,  in  the 
rasl  majority  of  cases,  at  the  summit  of  the  chest,  and  it  may  be  asao- 
ciated  with  the  cavernous  respiration  and  ral<!8.  In  connection  with 
palmonurjr  cavities  arising  from  ab^ccst  or  circumscribed  gsngreoe 
it  is  seldom  present,  tlic  several  circumstances  necessary  for  its  pro- 
duction rarely  concurring.  It  is  not  always  heard,  even  when  luber- 
enlons  otvities  exist,  the  various  conditions  upon  which  it  dependi) 
■being  cither  permanently  wanting,  or  only  transiently  present. 
^A  cavernous  voice  sometimes  has  a  musical  tone  rc.^<mbling  the 
Bonnd  produced  by  speaking  into  an  empty  vase.  It  is  then  railed 
amphoric.  This  modification  is  noticed,  for  Ihe  sake  of  convenience 
as  incidental  to  pectoriloquy,  but  it  may  or  may  not  coexist  with 
transmission  of  speech.  It  is  a  sign  distinct  from  pectoriloquy,  and 
is  much  more  significant  of  a  cavity  than  the  latter.  The  traiiMmis- 
sioD  of  articulated  words,  or  pectoriloquy,  docs  not  sustain  any  fixed 
relation  to  the  amount  of  thoracic  resonance,  or  to  the  strength  of 
the  oral  Toice.  It  may  be  strongly  marked  when  the  voice  is  foeble 
and  even  extinguished.  Whispering  pectoriloquy  may  accumpntiy 
•olidification  of  lung,  as  well  as  an  excavation ;  in  the  former  case 
L  the  Toioe  in  high  and  tabular,  in  the  latter  case,  low  and  hallow  or 

II 


S58 


PBTSICAI.   KXri.OBATIOX    OP   TDK   CBEST. 


blowing.    An  amphoric  vocal  sound  is  more  apt  to  occur  m  ' 
bjtlrotliurax,  tlian   in   tubvrcnloDS  gicbtsUods.     It   may  fce 
marked  in  ponch-liko  tlilatatioa  of  tlio  bronchi,  s  lesion  of  rm  i 
occurrence. 

Careroous  whisper  is  a  oon-tvbalu',  hollow,  or  bloving  atmi,"^ 
low  in  pitch,  and  of  rariable  intensity,  he«rd  over  palmanarr  an- 
ties.  It  is  a  valuable  sign  for  detenniDing  the  existence  of,  aad  1 
ixing  a  tuberculous  c»vily.     An  amphoric  whisper  ia  firet|« 
ca»«»  of  pneumothorax;  if  beard  within  a  circumscribed  epace^i 
pneuDtolhorax  be  excluded,  it  ia  a  sign  of  a  tubercaloas  earity. 

^gophony  is  characterised  by  bleating  or  tremnloosnesa,  topAa 
with  a  high  pitch  of  the  thoracic  voice.  Tbe*e  characters  are  mm> 
times  ilue  (o  pecoliaritiea  of  the  oral  voice,  and  care  ta  in  iiiaiiij  tt 
SToid  attributing  them  to  morbid  conditions  under  thtfm  tiit^ 
Stance*.  Morbid  legophony  may  be  strongly  marked,  or  tbe  thondt 
voice  may  be  slightly  Kgophonic,  and  tlie  abnormal  modiScations  1*17 
have  every  shade  of  gradalioa  between  these  extremes.  It  is  nou 
apt  to  be  beard  nt  or  near  the  lower  angle  of  the  scapala.  and  if  it 
extend  from  this  point,  it  is  generally  fonnd  within  a  narrow  soar 
following  the  direction  of  the  ribs  toward  tbe  nipple.  It  may.  how- 
ever, be  beard  at  any  part  of  the  chest,  and  is  sometimes  diffused  over 
the  whole  side.  It  occurs  when  a  small  or  moderate  amomt  «f 
lii^uid  eflFusion  is  contained  within  the  pleural  sac.  It  is  tbetdoff 
incident  to  plenritis.  hydrothorax,  and  occasionally  to  empyema  said 
pnt'UiDonilis.  If  it  be  sometimes  observed  in  connection  witb  soGifr 
(icalion.  without  liquid  effusion,  as  held  by  some,  tbeae  instances  >n 
rare  exceptions  to  the  general  rule.  In  the  vast  proportion  of  tkt 
instances  in  which  it  is  observed,  it  is  incident  to  simpl«  plemitti; 
bnt  it  is  seldom  discovered  even  in  that  affeeUon,  owing  to  the  preeiw 
amount  of  liquid  requisite  for  its  production  existing  only  in  certain 
ca.<ie«s  »nd  in  these  only  for  a  brief  period.  When  difl^-oversble  il 
is  nsoally  at  an  early  period  after  the  attack,  or  late  in  the  progroi 
of  tbe  diaeasa.  Occurring  in  connfction  with  pDeumouitis,  it  hat 
been  obsored  to  disappear  frosn  tbe  lover  scapular  region  when  the 
body  ia  inclined  far  forward,  and  to  be  re^ilaced  by  ordinary  brw- 
eh<^bony.  Although  very  rarely  well  marked  in  ca.<tcs  of  pnennro* 
nitis,  il  is  not  nncommon  for  the  broochophonic  voice,  in  that  *§» 
tion,  to  present  slight  tremulou^mcM  with  elevation  of  pitch,  is 
itbrr  words  to  manifest  an  approximation  to  Kgophony.     In  csM) 

pleurilia  tbe  sign  has  been  observed  to  shift  its  aoat  in  the  prog- 


AtTSCTLTATIOK    IX    DISBASB. 


259 


of  the  diHeaiie,  rollowing  the  itiurcait«,  on  ib«  one  hand,  and 
be  diminution  on  the  other  haud,  of  the  quontitj'  of  liquid  effusion. 


PHBXOMBNA   INCIDENT  TO  THK  ACT   OF   COUOUINO. 

Tusuro  phcDOmona  poHsess  comparatively  .small  itnporliince,  inaa- 

inch  u  the  information  which  they  afford  Sh,  iD  general,  obtained 

more  (iati!*fiiciorily,  and  with  greater  facility,  Ly  auscultation  of  the 

•  rciipirntton  and  roicc.  Never  th  el  ens,  the  signs  pertaining  to  cough 
•re  hy  no  means  undcHcrving  of  attention,  and  in  some  inataitc«H 
ihcy  are  valuable  auxiliaries  in  diagnosis.  A  voluntary  act  of 
H  eoughinj;  is  often  useful  incidentally  with  reference  to  other  signs. 
^P BoinKtimc;^  when  from  nervous  agitation,  or  awkwardness,  a  patient 
breathes  unnaturally  and  fails  to  comply  with  the  directions  to  in- 

*  crease  the  intensity  of  the  respiration,  if  requested  to  cough  he  in- 
voluntarily takes  a  deep  inspiration  preparatory  to,  and  after  the 
act,  and  the  respiratory  murmur  may  then  be  well  developed,  when 
before  it  was  hardly  appreciable.     In  this  way  a  crepitant  rale  may 

I  perhaps  ho  evolved,  not  otherwise  perceptible.  By  an  act  of  oough* 
JDg,  an  obstruction  seated  in  some  of  the  broneliiul  tubca  may  be 
removed,  and  the  rcspii-atory  murmur  reproduced  in  parts  of  tho 
cbMt  in  which  it  had  been  temporarily  suspended.  The  cause  of 
the  absence  of  the  murmur  is  thus  determined.  Instances  occasion- 
ally occur  in  which  it  is  difficult  to  decide  from  tho  characters  per- 
taining to  the  sound  whether  a  rale  emanates  from  the  bronchial 
tubes  or  pleura.  In  such  a  case,  if  it  be  found  to  disappear  or 
uodergo  a  material  modification  after  coughing,  it  is  bronchial,  but 
^■if  it  remain  unaffected  it  is  likely  to  be  pleural. 
^P  The  tuiisive  saunda  Incident  to  health  have  been  briefly  described. 
Those  heard  over  the  chesit  undergo  certain  modifications  in  conse- 
quence of  intra- thoracic  diseHwe,  and  ciTtain  adventitious  sounds 
may  also  bo  produced  by  coughing.  Both  species  of  signs,  i.  e. 
modified  natural  sounds,  and  now  sounds,  are  few  in  number  com- 
pared with  those  derived  from  rw'piration  and  the  voice ;  moreover, 
each  of  the  tussive  signs  will  be  found  to  have  its  analogue  amoD^ 
■those  incident  to  respiration. 

An  the  phenomena  incident  to  the  act  of  coughing  which  are 
practically  important,  may  bo  arranged  into  two  olasaetf,  rii.,  I. 
Ironchial  Cough ;  2.  Cavernous  Cough. 


260 


PUYSICAt    EXPLOKATIOK    OF    THE    QDBST. 


1.  Bronchial  ('ocnii. — The  tussive  sound  is  Wonchial  or  tobnlar, 
wbcn,  in  pUce  »f  the  feeble,  ahorl,  diffusi^l  sound,  unacconipanied 
b,Y  much,  if  nny,  impulse  or  shock,  heard  orer  the  chest  in  health, 
till"  car  r<-ocives  a  concussion  more  or  Icsa  forcible,  logciher  with  ■ 
tubular  Round,  more  or  less  itit«nse,  prolonged,  concentrated,  high 
ill  pitch,  conveying  the  impression  of  Deiirne«ti.  Thow  charactcra 
arc  similar  to  those  which  belong  to  the  phenomenii  produced  nor- 
mallj  nilliin  the  trachea  by  the  net  of  coughing.  The  analogue  of 
the  bronchial  or  tubular  cough  is  the  bronchial  respiration,  and  the 
loud  voice  is  usually  more  or  less  bronchophooio.  The  characters 
which  have  just  been  menltoncil  arc  in  fnct  identical  with  those  which 
belong  to  the  expiratory  Kound  in  the  bronchial  respiration  and  they 
are  also  the  characters  of  whimpering  bronchophony.  They  may  bo 
strongly  marked  in  Jiomc  cascH  in  which  bronchial  respiration  is 
feeble,  and  hence  the  tussive  sign  may  bo  valuable,  not  only  as  con- 
firming, hut  as  a  »ub.-^titule  for  the  latter.  It  roprcscnts  precisely 
(he  eamu  pliyKtcal  conditions  aa  the  bronchial  respiration  and  hroD- 
diophony.  The  bronchial  cough,  therefore,  oeonre  espocinlly  in  liifl 
Mcond  stage  of  pneumonitis;  next  in  frequency  and  prominence,  ia 
connection  with  crude  tubercle;  iiUo  in  picuritis,  over  the  lung  ren- 
dered dense  by  compree«ioD,  in  apoplectic  cxtrarasalion,  txdema, 
dilatation  of  the  bronchial  tutes,  etc.  The  mechaDJem  of  ii£  pro- 
duction involves  the  same  physical  principles  as  the  bronchial  exfn* 
ratory  sound.  It  originates  within  ibe  trachea  and  bronchial  lubes; 
the  column  of  air  therein  contained  being  expelled  with  force  by  the 
violent  and  ([uick  expiration,  the  vocal  chords  at  the  same  time  ap- 
proximated, and  tlie  blowing  sound  transmitted  with  greater  intensity 
to  the  ear  of  the  auscultator  in  consequence  of  the  densslly  of  the 
intervening  pulmonary  structure  and  the  suppresaion  of  the  veiicular 
murmor. 


2.  Cavbrnous  Cot'titt. — The  cavernous  cough  cmbraocs  three 
distinct  varieties.  The  first  occurs  when  a  pulmonary  cavity  is 
empty,  i.  e.  free  from  liquid  contents.  Under  these  circumstances 
the  net  of  coughing  gives  rise  to  a  shock,  often  much  more  marked 
than  in  bronchial  cough.  The  head  of  the  anscult«tor  scema  some- 
times to  bo  raised  by  the  force  of  the  impulse.  It  is  accompanied 
by  a  blowing  sound  more  or  less  intense  and  prolonged,  lower  in 
pitch  than  the  expiratory  sound  in  bronchial  respiration,  or  the 
tubular  sound  accompanying  whiapored  words ;  and  conveying  the 


AUSOCLTATIOV    IK    DISEASE. 


S6t 


^ 


>n  of  its  being  produced  within  a  liollow  space.  Theite 
ftractersi,  oontraated  with  those  bclongiDg  to  the  brotioliial  cough, 
dUtinctive;  but  the  discrimination  involves,  in  adilitJou,  thi^  fact 
at  thry  are  foiind  within  circumscribed  limits;  mid,  inaeinuch  a* 
Imoiiiirjr  rxcavatloiHJ  are  due  lo  tuberouloiiit  di^cnsv,  in  the  vast 
■jority  of  cases  ihc^-  Arc  alnioHt  invariabljf  »ilunlcd  at  the  Bumuiit 
if  the  chest,  in  the  infra-ciavicuhir  rcgi'iii.  These  two  poiuU,  vii., 
e  limited  area  and  ibe  locality',  will  serve  to  dii^tingulsh  a  cavern- 
'bm  from  a  bronchial  blowing,  taken  tn  connection  with  the  difierenees 
ill  the  characters  of  tbi;  two  rounds.  The  pathological  significance 
of  this  variety  of  cavernous  cough  is,  of  course,  the  same  as  that  of 
cavernous  rciipiraiioii:  the  latter  Is  its  analogue.  The  one  may  be 
Well  marked,  when  the  other  is  not  distinctly  appreciable.  A  cavern- 
US  blowing  produced  by  Uic  act  of  coughing  may,  therefore,  somft> 
tiuiea  be  urailable,  wht-n  wilb  ordinary  respiration  it  Is  not  readily 
discovered.  If  boili  are  pri-scnl,  they  serve  mutually  to  confirm 
each  other.  The  mecbanlsui,  it  is  obvious,  is  the  same  in  either  in- 
stance. The  circumstance!^  which  ore  favorable  lo  the  prcsi:nce  of 
both  are  identical,  viz.,  in  nildiliou  lo  emptiness  of  the  cavity,  iti 
size,  commuDicatiou  witb  the  bronchial  tubes,  the  latter  being  unob- 

»stmctcd,  superficial  sitnation,  «tc. 
The  second  variety  is  amphoric  cough.  A  cavernous  cough  be- 
comes  amphoric  when  it  has  a  musical  tone  resembling  that  which 
cottstituicH  a  variety  of  tho  respiratory  and  vocal  sounds  lo  which 
the  same  tenn  is  applied.  Il  occurs  under  the  circumstances  which 
give  rise  to  amphoric  voice,  viz.,  in  connection  with  a  pulmonary 
cavity  of  Urge  size,  witb  rigid  walls,  or  with  pncumo-bydrotborax 
involving  perforation.  The  signiBcance  and  the  mechanism  are  in 
all  respects  the  same, 
^b  The  third  variety  is  an  adventitious  sound  produced  when  the 
earitj  is  partially  filled  witb  litiuid.  The  analogue  of  this  kind  of 
caveraoiis  cough  is  the  gurgling  rale  accompanying  respiration. 
Under  the  conditions  which  are  necessary  for  the  production  of 
gurgling,  the  liiiuid  contained  within  the  cavtly  is  more  violently 
agilalei)  by  the  uiovcmenlit  involved  in  coughing,  and  a  spla.'thing 
sound  is  frequently  produced.  This  sound,  well  marked,  is  more 
readily  ihaii  gurgling  distingiiished  from  the  bronchial  mucous  rales, 
and  if  situated  itt  the  riumioit  of  the  choxt,  within  a  circumscribed 
•rra,  it  ifl  tho  most  tiignilicnnt  of  the  physical  signs  denoting  a  tu- 
[bcrciiloas  cavity  of  conMiIcrablc  sixc.     It  will  be  likely  to  alternato 


362 


PBTSICAL    BZPLOKaTIOV    OT    THB    CSBST. 


vilh  the  dry  VKnetv  of  cavrrnons  coagh,  viih  eaTcnMu  nspiralii^ 
pouiblj  also  with  prctoriloquj,  and  to  cocxut  with  gvrgltitg:  Wl 
it  maj  be  prncnt  when  none  of  th«  csTernous  sigiK  jut  nmbmi 
are  distioctl;  marked. 


HBTALLIO  Tt?:KLn>fl. 

The  Hign  called  metallic  tinkling  has  not  been  inclndM  unoeg  At 
•usealutor;  phenomena  incident  la  rc»pirniion,.the  voic«,  or  OMgh, 
liocauflo  it  doe*  not  portitin  exclusivelj  to  either,  but  \»  oomnion  to 
bII.  It  id  an  adventitious  MuncI,  rewiDbliiig  ihe  mini  in  the  fact  cf 
its  production  within  the  ehest  being  always  due  to  diwaae,  bat  a 
will  be  seen  presently,  an  analogous  sound  13  HOmetiinps  tmmiatluA 
from  the  stomach.  As  an  isolated  sign  it  is  ooe  of  the  ver^r  few 
that  possess  a  significance  almost  pathognomonic;  and  its  disuw 
tire  characters  are  singularly  marked  and  apprc<;i»blc. 

The  title  metallic  tinkling  is  eminently  dcscriptire  of  the  chan»- 
tcmlic  sound.  Laennec  compared  it  to  the  sound  emitted  I15  "a 
cup  of  metal,  glass,  or  porcelain,  when  gently  struck  with  a  pin,  or 
into  which  a  grain  of  sand  was  dropped;"  and,  again,  to  the  "ribn- 
tion  of  a  uietatlic  wire  touched  by  the  finger."  Other  iilnstrationi 
employed  by  dtilereni  writers,  are  the  tinkling  of  a  stnall  bell ;  shak- 
ing a  pin  in  a  decanter;  dropping  em»ll  shot  into  a  brass  basin ;  the 
ebullition  of  fluid  in  a  glass  rcton  or  flask.  An  apt  comparison  by  Dr. 
Uigelow  is  to  the  "  note  of  short  brass  wire  in  certain  children's  toys." 
In  all  these  analogieit  there  is  a  common  feature,  rie.,  a  high-pitched, 
abrupt,  short,  silvery  tone.  Tliere  is  no  difficulty  in  practically  de- 
termining the  presence  of  the  sign;  and  by  a  description  alone  so 
observer  is  prepared  to  recognise  it  at  once,  the  first  time  it  is  pr^ 
Bcnted  to  hia  notioe.  The  tinkling  may  consist  of  a  single  somid, 
or,  more  commonly,  of  two.  three,  or  more  sounds,  distinct,  and  fo9- 
lowing  in  quick  but  irregular  succcsi^ion.  As  already  stated,  the 
Mgn  may  accompany  respiration,  speaking,  and  coughing.  It  b 
oftener  produced  hy  Ihe  two  latter  than  by  the  first,  and  moreespe- 
cially  attends  the  act  of  coughing.  The  act  of  deglutition  may 
also  occasion  it.  This  fact  was  first  noticed  by  Dr.  Charles  T.  lEld- 
reth,  of  Boston,'in  ISIl.     It  has  since  been  oonfinned  broiberob- 


tot  Mciikftl  InproTvavat,  fugt  ML 


AtrsCOLTATION    IX.  DISEASE. 


268 


I 


T«rs.     Beau  reported  a  case  in  which  it  wa.i  produced  by  tli6  con- 
(usioD  arising  from  the  heart's  action,  and  lliis  I  have  obiwrvcd. 
occaasion,  or  shaking  the  body  of  the  patient,  is  also  found  in  many 
to  give  rise  to  it,  and  it  is  sometimefl  observed  to  occur  in  eonse* 
nence  of  a  change  of  position,  from  the  horizontal  to  the  vcriicat. 

I^ben  it  accompanies  respiration,  it  is  more  apt  to  ^>c  produced  by 
the  iivipiratory  than  the  expiratory  act,  itltboufih  it  may  be  pre.tent 
irith  uil]icr,  or  both.     It  occurs  at  the  cl»se  of  inspiration,  the  tink- 

|:Hng  sounds  fri,HiHcnt1y  being  continued  into  the  expiration.  Some- 
eijt  when  it  is  not  heard  with  ordinary  br<'athing,  it  becomes  deveU 
oped  by  a  forced  inspiration.  It  rarely  a<'compnni4-s  each  sncces«nv« 
kct  of  respiration,  but  it  is  heard  at  irregular  intervals.  It  is  impor- 
tsDt  to  bear  in  mind  the  fact  that  it  may  be  found  in  connection  with 
the  voice  and  eoujch  when  it  docs  not  attend  the  respiration;  and 
that  it  may  be  produced  by  coughing,  when  it  is  not  obwrvcd  cither 
with  the  voice  or  respiration.  Its  situation  is  commonly  nt  the  mid- 
dl«  lhir<l  of  the  chest,  anteriorly,  posteriorly,  or  laterally.  It  is 
Mtnetimcs  confined  to  a  eircumscribcd  spaco  at  the  summit.  In  other 
instances  it  is  diffused  over  the  entire  chest  on  one  side.  In  the  prog- 
rcim  of  the  same  disease  it  may  be  found  to  shift  its  scat,  being  heard 
at  first  over  the  middle  of  the  chest,  and  afterward  at  a  higher  point. 
Its  duration  in  difierent  cases  differs.  It  may  be  transient,  or  per- 
aiet  for  a  long  time.  In  constancy  it  is  also  variable.  Sometimes 
it  appears,  ceases  for  a  time,  and  it  is  again  reproduced;  or,  it  ooroes 
and  goea  at  irregular  intervals.  The  sound  in  some  instances  ap- 
pears to  be  near  the  ear,  and  in  other  instances  more  or  less  remote. 
Finally,  in  sharpnesa  and  quality  of  tone,  as  well  as  intensity,  there 
•re  variations  which  are  clinically  unimportant.  For  the  most  part 
the  differences  ju,tt  mentioned  are  explicable  by  reference  to  varying 
circumstances  connected  with  the  physical  conditions  upon  which 
tlie  sign  is  dependent. 

In  determining  the  presence  of  the  sign,  there  is  scarcely  a  posai> 
bility  of  eoiifountling  it  with  any  other  of  the  aiLtcultatory  phc< 
tiomena.  The  only  liabilily  to  error  arises  from  the  fact  that  a  me- 
tallic tinkling  Konnd,  as  ii.lrcady  intimntod,  is  occasionally  produocd 

{Hitiiin  the  Rtomuch,  and  trani^miued.  so  as  to  bo  apparent  on  auscul- 
iting  the  inferior  portion  of  the  left  chest.  Mere  gastric  tinklinge, 
however,  arc  never  so  freciueutly  repeated  or  persisting  as  are  gen- 
erally lho«'  produced  wtlbin  the  ehe*t.  They  occur  irrespective  of 
either  respiration,  voice,  or  cough,  and  this  alone  suffices  for  the  dis- 


9M 


rnrsiCAL  cxplobatios  or  tbb  caisr. 


elimination.  Moreorer,  th«  associated  eigos  and  symptom  «3 
•Iwsjrs  show  the  tbeenM  of  tbe  iotra-tkoracic  sffecUoos  to  vlo^il 
is  incident  vhen  proflucpd  within  tbc  chcsl. 

Tlie  physical  conditions  involved  in  th«  prodaction  oT  netific 
tinkling  are  sofficientlj  established.  It  requires  the  extslencctlt 
eavilj  of  considerable  sise,  containing  a  certain  qoantily  of  Uqo^ 
tbe  remainder  of  tbe  space  being  filled  with  air  or  gas.  Skoda  nb- 
ten<l»  that  the  presence  of  liquid  is  not  essential — an  opinion  Wii 
in  a  measure  bound  to  entertain  for  the  sake  of  coQsisteucy  vithla 
peculiar  theoretical  notions  reacting  the  mechanism  by  vhicktkt 
sign  is  produced.  Obser>-ation  and  experiment  appear  to  sbowibu 
as  tlic  rule,  with,  perhaps,  some  exertions,  a  certsin  smonni  sf 
liquid  is  requiiiite.  Laeonec  supposed  commmiicatioQ  of  tbe  cavit; 
with  a  bronchial  lube  to  be  not  a  iwceSBBry  condition,  as  is  incorrectly 
Hlstctl  by  »ome  writers,  but  to  exist  in  the  cases  in  which  the  sip 
is  proxcni,  with  very  rare  exceptions.'  Sobse<)ueDt  obaerratkn 
bare  shown  that  it  is  not  indispensable,  althoiigh  much  more  fa*«> 
able  to  its  production  by  respiration,  speaking,  and  conghing;  ui, 
in  fact,  as  staled  by  Laennec,  the  instancee  in  which  the  Mgn  ucctin^ 
when  such  a  conitnanication  docs  not  exist,  are  extremely  infrequoiL 
The  essential  conditions,  viz.,  tbe  existence  of  a  ^paco  of  twnvidft- 
able  size  containing  air  and  liquid,  are  furniiibi-Kl  in  pneumo-hydro- 
thorax  ani)  pulmonary  excavations.  Metallic  tinkling  represents 
invariably  one  of  these  two  alFections,  excluiling  cases  of  simple 
pneumothorax  ss  a  form  of  disease  of  «ueh  exceeding  infrequni^ 
that  it  may  practically  be  disregarded.  It  does  not  oecnr  in  other 
forms  of  intra -thoracic  dise«se.  It  is  n  rare  incidental  sign  of  a 
pulmonary  cavity.  It  occurs  when  the  excavation  ia  large,  whit 
rigid  walla,  and  then  only  at  particular  times,  when  the  relative  pro- 
portions of  liquid  and  air  happen  to  be  favorable.  From  the  infr^i 
quency  of  its  occurrence,  and  the  sufficiency  of  other  signs  for  ^^H 
diagnosis,  it  is  clinically  of  very  little  value  in  connection  with  tw^^ 
lesion.  When  produced  within  a  pulmonary  excavation,  the  latter, 
certainly,  in  tbe  vast  majority  of  cases,  if  not  without  any  cxceptioa, 
procee^ls  from  tuberculous  disease ;  hence,  the  sound  will  be  found 
oonfincd  within  a  circumscribed  space  at  the  summit  of  tbe  cheM. 
In  a  practteid  point  of  view,  it  may  almost  be  said  that  tbe  sign  is 
pathognomonie  of  pneumo-hydrothorax.     It  is  frequently  present  in 


•  ruc  op.  cit. 

and  00. 


Am.  cd.  of  Forbo*'*  Tiandatlon,  oditlon  of  1830,  pagei 


ArSCTrLTATtOIl    II?    DIBBABB. 


^ 


of  tliai  afTection.     This  fact,  taken  in  connection  with  its  ex- 
lue  iiifmiiii^iicj'  in  phtliisis,  woiili]  almost  justify  the  practitioner 
[tredicaiing  the  diagnosis  upon  the  presence  of  this  isolated  sign, 
ipecially  if  it  be  situated  at  the  middle  third,  or  diffused  more  or 
sa  over  the  chest.     But  dependence  on  this  sign   exclusively  is 
:ever  necessary,  the  concomitant  signs,  denoting  pneumo-hydrotho- 
'Tax,  being  quite  distinctive,  as  has  appeared  from  the  phenomena 
cident  to  [>«rcu»sion  and  auscultation,  which  have  already  been 
n«idcrt'd. 

Although  the  phjifical  conditions  giving  rise  to  this  sign  are  ao 
ell  undvmtood,  unil  it:<  piithi>1ogical  significance  so  precise  and  veil 
defined,  the  mechanism  of  its  production  hns  been  the  subject  of 
!niuch  discussion  and  diversity  of  opinion.  Wc  have  hero,  however, 
•nother  exemplification  of  the  fact,  that  the  clinical  value  of  physi- 
cal signs  is  not  dependent  on  our  ability  to  adduce  all  the  physical 
principles  which  their  production  involves.  DiffLTcnl  wntcr«  may 
differ  widely  as  rftspeots  the  latter,  hut  there  is  very  little  room  for 
discrepsncy  of  opinion  concerning  the  pathological  or  anatomical 
relations  of  metallic  tinkling.  To  discuss  the  various  hypotheses . 
which  hare  b«cn  offered  in  explanation  of  the  sign,  would  require 
more  Apace  thnn  the  importance  of  the  subject,  in  a  practical  point 
of  Tiew,  mrril»,  and  I  shall  therefore  restrict  luyseii  to  a  brief  notice 
of  those  whichapp^ar  to  be  sustained  by  observation  and  experiment. 
Lacnncc  attributed  its  production,  in  certain  in^^tHnce.s  to  dnip^of  fluid 
falling  from  the  upper  part  of  the  spucc,  upon  the  Kurfiice  of  (he  liquid 
below.  He  offers  this  explnnntion  in  the  ranes  in  which  the  sound 
is  observed  to  follow  change  from  the  rceumbent  to  a  sitting  posture, 
and  implic)>  that  it  is  not  intended  to  apply  to  all  other  inittnncos. 
That  the  falling  of  drops  of  liquid  upon  a  quantity  of  liquid  within  ■ 
cavity  will  give  rise  to  a  tinkling  sound,  he  dcmonstrntcd  by  inject- 
ing, in  small  quantities  at  a  time,  a  fluid  into  the  cbcNt  of  a  pntient 
with  empyema  after  the  operation  of  paracentesis.  An  imitation  of 
the  sound  takes  place,  when  drops  of  liquid  are  made  to  fall  into  a 
vessel  one-third  full  of  water.  Another  explanation,  suggested  by 
Dr.  Spittal,  of  Kdinburgh,  in  1S30,  and  di-monsirated  by  experi- 
ments reported  by  Dr.  Jacob  Bigelow,  of  Boston,'  Dance,  Fournet, 
and  Barlti  aod  Koger,  in  France,'  is,  that  the  air,  finding  its  way 


>   Vid*  .\iniirlRan  Journnl  f-i  Mi'd.  ScJcnca,  18S9,  and  a  rec«nt  volomc  by  Dr. 
Bigrlow.  pDlillfil.  N«urc  in  Disoasu,  i-tc. 
*  Vide  Tnwtbof  bj  Barlh  and  RngvtF,  French  cdiliQD  of  18M,  and  hf  Fournet. 


256 


PHTSIOAL    BXPLORATIOX    OF    T8B    CnSST. 


chophony.  also,  mty  he  more  or  lesa  marked.  If  sltgfatlj  or  aei^ 
eratelj  marked  it  U  called  veak,  and  if  il  have  connderaUe  « 
great  intensity,  it  ia  called  strong  bronchophony.  Strong  bna- 
chophonjr  may  exceed  in  inten«ty  the  sound  heard  over  tbe  tracbca 
or  larynx;  on  the  other  hand,  in  weak  bronchophony  the  ttt^ 
nance  may  be  less  intcDse  than  in  health.  The  pitch  of  sowUii 
not  always  the  same  as  that  of  the  tracheal  or  laryngeal  voict. 
'J'he  vibration  or  thrill  which  gfiifrrally  acooinpanies  exaggerated  m* 
otiance,  is  not  nccc4«arily  incrcnaod  in  prop«r^OD  to  the  abnormal 
Htrength  of  the  lironchophonic  voice,  and  It  may  be  diminiibed. 
Exaggerated  vocal  resonance  habitually  eitists  on  the  right,  am- 
tra»tcd  with  the  left  side  of  the  chest,  and  the  thoracic  roiee  at  iKe 
summit  of  the  riglit  side  of  the  chi-sl,  in  front,  may  even  be  bn** 
chophonic  wiihoul  denoting  disease.  Exaggerated  vocal  resonance 
and  bronchophony,  represent  different  degrees  of  increased  deuitj 
of  Iitng.  Tliey  occur  in  connection  with  the  physical  conditions  iiiuA 
give  riae  to  the  broncho- vesicular  and  Oie  bronchial  respiration. 
They  »re  generally  marked  in  the  second  stage  of  pneumonitis,  and 
it  is  in  tbnl  disease  especiully  thai  strong  bronchophony  is  obaerrcd. 
Situated  at  the  summit  of  the  chest  on  one  side  within  a  ctrcii>- 
scribed  nrea,  making  due  allowance  for  s  normal  i]cgrce  of  ilisparity, 
they  are  valuable  signs  of  a  tuberculous  deposit.  Increased  dciuiiy 
of  lung  from  compression,  in  cases  of  pleurisy  with  liquid  efliisiiMi, 
may  give  rise  to  these  signs,  situated  over  a  part  of  the  chest  cor- 
responding to  the  space  occupied  by  the  condensed  pulmonary  stroo- 
ture;  and  this  situation,  save  in  some  exceptional  instances,  will  bt 
at  ihe  superior  part  of  the  chest.  Exaggerated  vocal  rcocoaDC* 
may  also,  in  connection  with  other  signs,  together  with  symplomi, 
denote  carcinoma  of  the  lung,  melanotic  deposit,  extrsvaMtci 
blood  or  apoplexy,  gangrene,  serous  infiltration,  or  extra-pulmoiuc 
morbid  growths.  It  is  rave  that  well-marked  bronchophony  exisu 
in  connection  with  these  several  afiections.  Dilatation  of  the  bronchi, 
accompanied  with  surrounding  solidification,  furnishes  conditions  cal- 
culated to  give  rise  to  strongly  marked  bronchophony. 

Slight  or  moderate  solidificatioD  of  lung  increases  the  inten^t; 
the  normal  bronchial  whisper,  and  may  give  rise  to  a  sound 
whimpered  words  in  situations  in  which  no  sound  is  appreciable  is 
health.  The  sound  is  also  somewhat  tubular  in  <|uality  and  higher  u 
pitch  than  the  normal  bronchial  whisper.  This  sign  of  slight  Of 
moderate  solidification  of  luug  may  be  called  the  exaggerated  bron. 


<c«l- 


AOSCULTATIOH    IV  DISBA8B. 


lial  whisper.  It  mar  bo  pr«s«nt  nhea  exaggerated  resonance  of 
lie  louJ  Toice  «n<l  the  broncho-vcsicalar  respiration  are  not  avnil- 
tbte.  It  b  a  valuable  sign  in  the  dingnoiie  of  a  i^mall  or  nioderala 
epoflit  of  tubercle.  Complete  or  conitidcrablc  solidiBcation  of  lung 
enerallj  give's  rise  to  nolable  intensitj  of  the  bronehinl  whisper, 
rhich  is  also  tubular  and  high  in  pitch.  Thici  sign  muy  be  called 
rhjspcring  bronchophony. 

Diittinutiun  aixl  suppression  of  the  normal  rocnl  resonance  are 
Qcident  to  the  rarefaction  of  the  lung  which  obtnins  in  emphysema; 
obsl ruction  of  one  of  the  large  bronchi;  lo  liquid  effusioD,  and 
be  presence  of  air  within   the  plcurul  tnc;  to  cavities  filled  with 
joid;  and,  cxucplioniLlW,  to  solidi&cation  of  lung. 
Pectoriloqny  is  ihe  transininxion,  more  or  less  complete,  of  ar- 
iculnte  vrord»  throngli  tlie  chc»t  to  the  ear  of  the  auscultaior.    This 
'sign  mny  be  prcjcnl,  when  various  circurostanues  favorable  to  ita 
production  concur,  in  c«ees  of  pulmonary  cavities;  but  it  Is  by  no 
means  a  sign  distinctive  of  an  excavation,  as  wss  held  by  Laennec. 
It  is  flometimea  well  marked  in  casc«  of  solidification  of  lung  io  the 
second  stage  of  pneumonitis,  «nd  from  crude  tubercle.  When  due  to 
a  toberculotis  cavity,  it  is  unaccompunicdby  the  charactcTS  of  broncho- 
phony, the  space  in  which  it  is  heard  is  circumscribed,  situated,  in  the 
vast  majority  of  cases,  at  the  summit  of  the  chcsl,  and  it  may  be  asso- 
cisted  with  the  cavernous  respiration  and  rales.    In  connection  with 
pulmonary  cavities  arising  from  abscess  or  circumscribed  gangrene 
,it  ia  seldom  present,  the  several  circumstances  necessary  for  its  pro- 
luetion  rarely  concurring.     It  is  not  always  heard,  even  when  tuber- 
cnlons  cavities  exist,  the  various  conditions  upon  which   it  depends 

» being  either  permanently  wanting,  or  only  trunsicntly  present. 
A  cavemouH  voice  sometimes  has  a  musical  tone  resembling  the 
•ound  produced  by  speaking  into  an  empty  vase.  It  is  then  called 
amphoric.  This  modification  is  noticed,  for  the  sake  of  convenience 
as  tucidentat  lo  pectoriloquy,  but  it  may  or  may  not  coexist  with 
transmission  of  speech.  It  is  a  sign  distinct  from  pectoriloquy,  and 
is  much  more  significant  of  a  cavity  than  the  latter.  The  transmis- 
•ion  of  aniculale<l  words,  or  pectoriloquy,  docs  not  sustain  any  fixed 
relation  to  the  amount  of  thoracic  resonance,  or  to  tho  strength  <rf 
the  oral  voice.  It  may  be  strongly  marked  when  the  voice  is  feeble 
and  even  extinguished.  Whispering  pectoriloquy  may  uccnmpany 
solidification  of  lung,  as  well  as  an  excavation;  in  the  former  ca«e 
the  voice  is  high  and  tubular,  in  the  latter  case,  low  and  hollow  or 

IT 


^l 


r«TiICAL   IXrtOKATlttS    O?    TMI    CBBST. 


^BSttty  «f  Ac  Utter.    TW  •ciSee.  alMi,  of  ibr 

tiMM  piyTxii :  aa  spntm  asj  a<  oac  pcned  of  dw  4iwig  cnt, 
sad  aA«rwM4  bee«M  fttwmwmijj  riweil  Tkd«  rarriBg  arena- 
Maace>  aiH  lerTc  la  tijlili  ifee  rariitiBai  ia  qoaljtj,  iutetiBtj,  w- 
aatioa,  Jwatwa,  panimaey,  etc,  w)n^  kare  been  aeea  to  mv 
iala  iW  4e«riptiBa  af  ■rtillJe  dakBag. 

MetalGe  ttakfiag  ii  bcqamtly  MMmtcd  with  anpkorio  rffpin- 
tioa,  Toiee,  aad  eoi^^  Asd  it  taay  be  toarideteJ  ae  cwealJiUj  Mai* 
Isr  ta  tbe  ikna  Mgae  latt  — atiaoed.  TWe  patbologieal  »aA  dn^ 
noetic  rdatieat  an  the  w.  Metallic  Unklia^  bgvrm-,  «iifa  fr« 
exwpliiw,  ocean  in  earitics  coataiaiDg  at  tba  eaiae  tnac  air  aaJ 
fiqaid.  It  myimittdj  pfftic  that  in  oac  of  tbe  modca  1>,t  wluch  it 
b  am>|>oicd  to  be  pniaeti,  ns.,  b;  babhlea  exploding  at  the  opw- 
tag  of  a  binloB*  FOmmnntcatwa,  tbe  prtaenec  of  liqiiid  witkia  tk 
earttj  u  not  bdiqie&HbIc;  bat  a  &»tiiloa*  eoanDimieatiaQ,  dtkcr 
vitb  «  palBtOBar7  ezesTrntioo  or  tbc  plcoral  eantj,  more  ctpecnilj 
with  the  latter,  vtrj  rarrlj  exist*  witbont  tbe  picaence  of  more  or 
Icsx  Itqoid;  Bod,  moreoTer,  id  tbe  cafe  j(»t  in»uiiced.  a  macau 
liqaid  is  retjntred  for  the  forniatioD  of  tbe  babbles  wLicb  explode  it 
tb«  point  of  eoromnnication.  Amphoric  resptralioD,  coagb,  and 
Toioe,  on  tbe  other  baod,  it  ia  supposed,  may  occur  in  ooanecDcm 
«ith  empty  cavities  withoat  broncbial  communication,  prorided  a 
thin  septum  only  iDterrene  between  the  space  and  a  large  hrobclua. 
And  when,  aa  is  generally  tbe  case,  a  conroooication  exists,  and 
liqiud  is  present  in  the  cavity,  the  latter  does  not  take  pari  in  the 
prodsction  of  amphoric  respiration,  voice,  and  coagb;  whereat, 
certainly  in  a  large  proportion  of  instances,  the  liquid  playa  an  im- 
portant part  in  (he  production  of  metallic  tinkling.  Ampbonc  re»- 
piralion,  voice,  and  cougb,  demand  only  a  space  of  considerable  uie 
filled  with  air.  Metallic  tinkling,  occasioned,  as  has  been  sees,  goi- 
erully  by  bobblofi  riaing  to  the  surface  of  a  liquid,  or  by  drops  of 
liquid  falling,  or  by  agitation  of  a  mass  of  liquid,  cannot  take  placs, 
iHVc  in  the  exceptional  mode  loentiotictl,  in  a  cavity  containing  noth- 
ing but  nir.  ThcHo  slatcnii'nts  arc  ifhowii  to  he  correct  by  facta  de- 
tailed in  connection  with  the  expeniiieuts  by  Bigelow  and  others,  to 
which  reference  bus  just  been  miidc.  Jn  subjects  dead  with  pneiirao- 
hydrotbornx,  or  patients  on  whom  had  been  practiced  the  opera- 
tion of  paracentesis,  and  with  u  n^ccnt  bladder  or  stomach  partja! 
filled  with  liijuid,  whenever  air  was  blown  through  a  tube,  introdm 


AOSCOLTATtOK    IN    DieBASB. 


269 


ito  tbe  casntj  and  carried  above  the  lerel  of  the  liquid,  ft  sound 
ftDftlogous  to  the  amphoric  respiration  was   heard  on  applying  the 

u  to  the  chest,  or  to  the  distended  memhrane;  and  nev<;r  theme- 
Jie  tinkling,  excepting  saliva  vas  carried  into  the  tubt,  producing 
bubbles  at  its  extremity. 

• 

SuMHAKT. — Metallic  tinkling  requires,  aa  a  rule,  a  cavity  of  oon- 
siderable  sixe  containing  air  and  a  certain  quantity  of  liquid.  In 
the  vast  proportion  of  cases  the  cavity  in  which  it  occurs  communi- 
^cfttes  with  the  bronchial  tithes.  It  is  occasionally  produced  within 
H^tuberculoUB  excavations,  hut  occurs  in  a  large  proportion  of  ensea  of 
^Kpoeumo-hydrothorax.  It  is  almost  pathognomonic  of  the  latter  af- 
^^fcction,  and  is  found  frequently  to  coexist  or  alternate  with  ampho- 
ric respiration,  voice,  and  cough. 


I 


ABKOHJIAL  TRANSUIHSION   OF  THE   SOUNDS   0?  TBE   HEART. 

In  auscultating  the  chest  in  health,  the  sounds  of  the  heart  may 
be  beard  in  all  directions,  at  a  di-<tance  more  or  less  remote  from 
the  prffioordial  region,  the  extent  of  their  dilTn-sion  and  iheir  in- 
tensity differing  coneidoruhly  in  different  persons.  Provided  tlic 
intra- thoracic  organs  arc  free  from  disease,  it  may  be  assumed  that 
tbe  loudness  of  the  li curt- sounds  is  proportion rttc  to  the  proximity 
to  the  heart;  and  they  will  ho  found  to  diminish  gradually,  as  the 
ear  is  removed  from  the  pnecordia,  until,  at  Icngih,  they  cense  to 
be  appraeiablo.  If,  therefore,  they  arc  discovered  to  be  more  in- 
tense at  a  certain  distance,  than  at  any  intermediate  point,  it  showg 
that  a  morbid  condition  exists,  in  consequence  of  which  they  are 
abnormally  transmitted.  For  example,  if  the  sounds  are  heard  with 
greater  dislinctnc^'<  and  loudness  just  below  the  left  clavicle,  than  at 
any  point  between  this  situation  «nd  the  prwcordia,  it  fDllows  that 
there  18  an  abnormal  transmission  to  the  part  designated.  .Agttin, 
if  the  sounds  have  greater  intensity  in  the  right  than  the  left  infra- 
clavicular region,  the  former  being  farther  removed  from  tlieir  source, 
it  is  due  to  a  morbid  condition.  Abnormal  transmission  of  the  sounds 
of  the  heart  may  thus  become  a  sign  of  disease.  It  is  chiefly  with 
reference  to  the  diagnosis  of  tuberculous  disease,  tliat  the  sign  pos- 
«H(*  olinical  value.     In  that  connection  it  is  worthy  of  attention. 


270 


PHVSICAL    BXPLOBATIOir    0?    TOS    CBEST. 


The  dnixNtii  of  tulcrelc  rcndcn  ihc  portioo  of  lung  iffeoted  a  l» 
tvr  comluctur  of  thu  eounils  cninaoling  from  tlie  heart.  AmiW 
reiuton  why  tbc  hciirt-sounds  nrfl  louder  oror  b  deposit,  in  cerua 
CAMS,  is  the  dimiDution  ur  )iuppre«sioD  of  the  resicular  reepinur; 
murmtir  in  the  purt  affected.  A  tubcrcnlomt  deposit  at  the  ap«x  <■[ 
the  left  lung  msj  occ*m<mi  nn  abnormal  transinissioti  to  beloviW 
left  clavicle,  rendering  the  eoands  more  intense  there  than  u  u; 
point  between  this  situation  and  the  pnecordia,  and  eren  mono* 
tense  than  in  the  Utter  region.  Again,  a  tuberculotis  deposit  at 
the  apex  of  the  right  lung,  may  caate  the  eoands  to  be  beard  nitk 
distinctness  in  the  right  iDfra-clavicaUr  or  scapular  regions,  «hai 
they  are  inappreciable  in  the  corresponding  regions  od  the  left  ait; 
or  they  may  be  decidedly  more  intense  at  the  summit  of  tbe  right, 
than  of  the  left  «dc  of  the  chest.  The  latter  is  not  icfreqaeotlj 
obscrTed  in  cases  of  tuberculous  disease.  Tbe  sign,  ander  iheic 
drciinslances,  famishes  ■strong  presamptive  evidence  in  iieelC  of 
the  existence  of  phthisis ;  and  it  is  entitled  to  considerable  wei^ 
in  combination  with  the  various  other  signs  nbich  concur  to  eslablitli 
the  diagnosis  of  that  affection.  To  constitute  this  a  sign  of  inbo- 
caloei&r  bonevor,  a  condition  is  to  be  observed  upon  which  ve  ban 
seen  tu  <lepcnd  the  significance  of  various  other  sigtu,  viz.,  it  muH 
be  limited  to  a  circumscribed  area  at  the  summit  of  the  cfae«t. 

In  cpiDpariog  the  heart-souods  in  the  right  and  the  left  infn- 
clavicular  region,  normal  points  of  disparity  arc  to  be  borne  in  mind. 
The  first  sound  of  tbe  heart  is  somewhat  louder  on  the  left  thu  on 
the  right  side  in  health ;  and  the  second  sound  of  the  heart  is  loodef 
on  the  right  than  on  tbe  left  side.  This  statement  is  based  on  i 
large  number  of  examinations  of  healthy  persons. 

In  consolidation  from  pneumonitis,  and  in  cases  of  liquid  effu^ioa 
viihin  the  pleural  sac,  the  sounds  of  the  heart  are  unduly  audible 
In  connection  with  these  affections,  the  abnormal  transmission  e» 
tends  over  a  much  larger  space  llian  in  the  cases  of  tuberculosis  in 
vbich  the  sign  occurs.  In  the  diagnosis  of  these  affections  its  valoe 
is  insignificant,  other  signs  being  abundant  and  poKiiivc. 

Observed  within  a  more  limited  «p«cci,  but  not  confine*)  to  the 
superior  portion  of  the  chest,  this  sign  may  coexist  with  otiiers  o( 
much  greater  reltubility,  denoting  solidification  from  cxtiavswteJ 
blood,  carcinoma,  etc. 

Ad  abnormal  diminution,  as  well  as  increase  of  tbe  transmitted 


ADSOULTATIOK    lit    DIBBASB. 


271 


^souodR,  may  con«titHt«  a  physical  sign  of  disease.  Empbyseinft 
sens  the  conductinf;  power  of  the  l<in^,  and  as  one  of  the  results  of 
lis  mffoctioD,  the  sounds  may  be  found  lo  hiiw  grt-ater  iiiieiisity  at  a 
ertain  distance  from  the  pnccordia,  than  at  miotber  situation  less 
emote.     Dr.  Wnlahc  states  that  in  n  Ciise  of  intense  emphysemu  of 
tie  left  lung  in  whicli  the  discnse  was  limited,  and  especially  marked 
'the  posterior  aspect  of  the  clieitt,  be  found  the  heart-sounds  con* 
yderably  more  diFlinct  posteriorly  on  the  right  ihnn  on  the  left  stdo, 
liere  being  no  evidence  of  indunilion  of  the  right  lung  to  intensify 
\us  sounds  on  that  side.     The  disparity  here  was  attributed  to  an 
Abnormal  diminution  of  the  trnnsuii^isioii  of  the  i>oun<l3  to  the  pos- 
erior  surface  of  the  left  side  of  the  cheat,  the  right  side  remaining 
in  a  normal  condition  in  this  respect.     Without  knowledge  of  tlio 
fact  that  the  transmission   may  thus  be  abnoriimlly  diminished,  a 
_BonDal  intensity  may  be  misitaken  for  a  morbid  sign, 
y    Abnormal  feebleness  of  the  sounds  of  the  heart  in  the  prsccordial 
irgion  is  an  effect  of  emphysema  nffecting  the  left  lung.     The  en- 
largement of  the  lung  from  the  ovcr-distension  of  the  cells  causes 
.    it  to  extend  over  the  whole  of  the  surface  of  the  heart,  instead  of 
■the  latter  organ  being  in  contact  with  the  walls  of  the  chest  within 
B  certain  space.     Under  those  circumstances  it  is  easy  to  perceive 
tlint  the  sounds  of  the  heart  must  be  transmitted  to  the  ear  applied 
KtYcr  the  priecordia  with  less  intensity  than  in  a  normal  condition. 
Abnormal  diminution  of  the  sounds  of  the  heart  in  the  priccordia,  in 
connection  with   undue  intensity  of  the  percussion -resonance,  and 
•bsoncc  of  the  heart's  impulse,  denotes  that  a  thick  layer  of  lung 
intervenes  between  the  organ  and  the  thoracic  parieti's. 

kThc  cardine  sounds  may  not  only  be  transmitted  with  undue  in- 
tensity to  different  portions  of  the  chest,  but  they  may  emanate 
from  other  situstions  than  the  privconlia,  in  consequence  of  dis- 
_  placement  of  the  heart.  This  will  be  found  to  enter  into  the  history 
■  of  pleuritis  with  large  liquid  effusion,  and  of  pneumo-hydrothorax. 
Finally,  n  bellows  arterinl  sound  is  sometimes  heard  within  a  cir- 
cumscribed space  at  the  summit  of  the  chest  on  one  side,  not  trana- 
mittt«d  from  the  heart,  but  limited  to  the  subclavian  artery,  proba- 
bly produced  by  pressure  upon  the  artery  of  the  apex  of  the  lung 
consolidated  by  tuberculous  deposit.  Dr.  Stokes  was  the  first  to 
call  attention  to  the  occasional  occurrence  of  this,  as  «  physioil  sign 
of  phthisis.  He  thinks  that  sympathetic  irritation  of  the  artery  is 
eofficient  to  occasion  it  without  pressure,  basing  this  opinion  ou  its 


raviiCAL  ixrLosATioi  or  tbx  chbkt. 

ig  akaafoi  it  !•  a^nde  ftftrr  copM 
■  Ifce  ■■WUviMB  or  azOUrr  rrgiai' 
mMMV«r  MX  he  the  cxylaiMUaa,  tlM  oceMJoaal  »ecnrren«i  of  u 
>n<M'Hl  Mfw,  JB  w>— ectio«  vitk  k  taberealou  dtpeot  »f  the 
apci  of  l^  fmg,  1^  MMttd  bang  vsatn^  in  Uw  brmefaial  artcij  d 
lh«  MRw  lifle,  in  the  heart,  aoru,  sad  carotid,  and  in  the  oppocitt 
MF>rla*Un,  i«  s  fact  of  some  iniponaiiee.  But  a  fact  to  be  bant 
ID  mitid  i>  that  a  lubelaTian  nnrmBr  exials  in  tomt  bcalthv  persou, 
MpMJall;  in  mail!*.' 


HieTotT. 

Allhou]{)i  nUtfiion  to  lislcDing  in  order  to  diecoTcr  abnonul 
Koanda  within  tbo  chest  idbj  be  found  in  tho  works  of  varioos  writen 
iivnn  nil  niicieiit  n»  tbofr  of  Ilippocnitvi^  jct  to  ho  little  extent  vit 
llila  mothod  of  invpstigntion  prcvioui^Ij  employed,  and  so  lOMgnif- 
(Mill  lind  been  its  results,  that  the  hoti'or  of  the  discovery  jtistlj  t)^ 
lonfc*  to  Mn6  Thi^phile  Iliracintlie  Laennec,  a  native  of  Lower 
Ilriltniijr,  born  in  17^1.  The  dtscorcry  wati  made  bj  Laennec, 
while  ROting  as  chief  ptiTsician  to  lite  Hospital  Neckcr,  in  Pari*,  in 
1810.  It  WM  communicuieil  to  ibe  French  Academy  of  SeiencM  ■ 
a  memoir  rend  in  1818,  and  during  the  following  year  was  pnUilM 
tbo  great  work  entitled,  "  Df  t AtucHltation  MtdiaU,  «u  Tr^i  A 
^iagnMtie  Un  Maladwt  det  PoumoHt  et  du  OmtTj  f»ndi  frimt^ait- 
mrmt  nr  »  nokiviim  neym  d'fxf'larnion,"  In  the  introdsctioti  to 
this  wvirk,  IdcnuK  anuuunc«4  llie  discorer;,  and  rclatea  the  eircm- 
•lattov  which  led  to  it  in  the  following  word*:  "In  1$16,  I  «■•««• 
*ullt>d  br  a  Tonug  wotnan  laborng  uiuler  geoeral  ajnptoiBt  of  dir 
r«»vil  hiMfi.  and  in  vhcsc  caM  perewnioD  and  the  appUcatu*  4l 
the  hand  «i»v  of  little  avail  on  aecoant  of  the  gnat  dtgnw  af  bfr 
MM-  Tin  other  a«thod  jut  ■— tioawd  hcof  nwiwrt  imiami' 
Uthy^aC*uKlau«ftW  pMiMt,  I  hippwiil  to  raedbMS 
nM(Ja  aad  well^Jkowa  (act  ib  moMSSa,  aad  fiaciad,  at  At  mm 
«bBK  Aat  tt  Bifkl  W  tancd  w  aoB*  wm  m  At  |hmm*  naHB- 
n*  IhM  I  alMvia  » tWHvwatad  i«fr«MM  «r««A  vha  M- 
njKii  dtn«^  Mttua  aubl  ha£«t — at  wtwwtl— rtWairMArfa 
|aBM«M«iMi«fapMt««f  w««LaB^fl;iaf  Mwcvw  AtMfcft. 


.»rfc*. 


til 


AOSCrLTATIOH    IN    DI6BASE. 


273 


I 


[Immrdialely,  on    tliia  suggestion,  I  rolled  a  qniro  of  paper  into  n 
jkind  of  cjlmd«r,  and  applied  one  end  of  it  to  the  region  of  the 
lliesrt  xnd  the  other  to  tay  i?ar,  and  was  not  a  little  surprised  and 
IplMKcd  l«  find  th»t  I  could  thereby  perceive  the  action  of  the  heart 
fin  a  manner  much  more  clear  and  dii;tinct  than  I  had  ever  been  able 
to  do  by  the  immediate  application  of  the  ear.     From  this  moment 
I  ima^ned  that  the  circumstance  might  furnish  means  for  enabling 
i  ns  to  ascertain  the  character,  not  only  of  the  action  of  the  heart, 
but  of  every  species  of  sound  produced  by  the  motion  of  11II  the 
,  thoracic  nscera,  and,  consequently,  for  the  exploration  of  the  res- 
piration, the  voice,  the  rale,  or  rhcmckii*,  and  perhaps  even  the  fluc- 
tuation of  fluid  efl'used  in  the  pleura  or  pericardium.     With  this  con- 
'  riction  I  forthwith  commenced,  at  the  Hospital  decker,  a  scries  of 
obserratinos  which  have  oonlinued  to  the  present  time.     The  con- 
•equcnco  is,  that  I  have  been  enabled  to  discorer  a  set  of  new  signs 
of  dUc«M  of  the  chest,  for  the  most  part  certain,  simple,  and  prom- 
inent, and  calculated,  pcrliiipH,  to  render  the  diagnosis  of  the  dis- 
e«seK  of  the  lungs,  heart,  and  pleura,  ns  decided  and  ciroum<<tan- 
tiil  ■«  the  indications  furnished  to  the  anrgcon  by  the  introduction 
of  the  finger  or  sound,  in  the  complnintn  wherein  these  are  used."' 

It  is  a  curious  fact,  that  the  suggestion  which  led  to  the  dii<covery 
was  an  error  in  physics.  The  sound,  in  the  illustration  cited  in  the 
foregoing  paragraph,  is  not  augmented,  but  merely  conducted  better 
than  through  the  atmosphere:  and  it  is  now  well  established  that 
intrn-lhoracic  sounds  are  heard  with  the  ear  applied  directly  to  the 
chest,  as  well  as,  if  not  better,  than  through  the  intervening  medium^ 
or  stethoscope,  to  which  Laennec  attached  so  much  importance  ii»  to 
name  the  new  method  mediate  auscultation. 

In  the  remarkable  work,  the  title  of  which  has  been  given,  the 
various  phenomena  revealed  by  auscwttation  arc  named,  described, 
classified,  explained,  and  their  relations  to  morbid  conditions  deler- 
mined  with  a  degree  of  completeness  and  accuracy,  constiltiting  it 
an  imperishable  monument  of  the  industry  and  genius  of  the  author. 
To  such  an  extent  was  the  science  of  auscultation  perfected  in  the 
hands  of  its  founder,  that  a  considerable  portion  remains  to  the  pres- 
ent moment  unchanged,  notwithstanding  the  labors  of  a  host  of 
obserrem.  who  have  striven  to  enlarge  the  boundaries  of  its  applica- 
tion to  ihc  diagnosis  of  diseases.    KnrDly,  if  ever,  has  there  been  an 


Torbu'i  trantlatlon. 
18 


274 


FBTfllCAL    BXPtOBATIOS    OF    TBI    CBBST. 


JBrtanfi  «f  ■  diMowrj  »f  e^aal  Mipqrl»BCB  ia  windi  ao  litllf  wii 
Ifft  bj  tiM  dbcoTcnr  to  W  pwfnf  »d  ky  oAwi.  Uoreovrr.  u  m 
exMption  lo  ti«  j^nMrml  mle,  tttc  ^imtiSeaboa  was  accorded  to  Lt- 
•■BK  of  witannag  tfae  •ekaovkdgBwot  of  the  T>lti«  of  his  <&»' 
totcTj.  ind  haadoplSoa  bj  the  Boat  iatelligefitof  his  conumponnn. 
XevertbelcM,  Uk  labon  of  tboee  who  k«Te  devoted  attention  to  the 
calliraliVii  of  this dppartmeDl  of  medical  erience,  eince  the  AiMcoven 
hy  Lsennec,  hare  bjr  no  nea&a  been  withoal  ds^TuI  reealts.  Soeh 
errors  have  been  corrected,  aosmltatory  pheDomeoA  bare  beta 
studied  in  new  aspects,  imporiant  facts  bare  beeu  added,  and,  b 
short,  the  pbjaical  da^BMS  of  thoracic  affection  has  been  rendered 
more  easy  and  precise  by  coDiribattons  to  our  knowledge  from  nri* 
0U9  persons  already  mentioned  in  the  foregoing  pages  in  eonneetioo 
with  the  particular  >«r*icea  with  whidi  tlietr  names  are  idetitifird. 

Laennec  died,  in  1826,  of  tubercnlooa  diiewe  of  the  lung«,  id  the 
fort^-fiftb  year  of  his  age. 


CHAPTER   IV. 


IKSPKCTION. 


> 


Fbt^ICal  oxplorittioR,  h}'  nii'unH  or  inspection,  con»i#lit  in  nn  ocu- 
lar esatniDSlion  of  itio  cluitt,  in  ori]cr  to  diiK^orcr  <IovintioD8  from 
STinmctrir.  or  Bny  Blinoniiiii  njipcnniiictrii,  tw  regards  v'lxv  ami  form, 
and  also  altrmtions  of  Llic  natural  moveintnis  incident  to  rcvpirn- 
tion.  Imporlniit  plijnieal  signs  are  d(.'termini-<l  bv  lliii*  mi;tliod.  In 
the  relaliT?  value  of  <lic  phcnomimn  wlilvli  it  furni9bi-i>,  it  rank»  next 
to  auecultalion  nnd  pcrcuMtjon.  In  t)ic  practice  of  pliv^ical  oxplora- 
tioD,  this  method  should  goncrallj'  be  first  cuiployid,  braau^e  iij<  rc- 
SoltA  are  to  be  taken  into  account  in  CHliinatiug  the  importance  vhich 
belongs  to  somo  of  the  phenomena  obtained  by  the  inetbodit  nhicfa 
have  been  alreadv  considered. 

Vr'bvncver  a  careful  iiiiipcGtion  is  necessary,  it  is  most  convenient 
and  MltHfactory  to  survey  the  chest  dlv-ested  of  all  clothing.  ThU 
naj  be  dune  with  propriety  if  the  patient  be  of  the  male  sex ;  but  a 
due  regard  to  delicacy  reijuire^  that  the  entire  clicst  of  the  female 
shall  n»t  be  iincorered.  To  secure  the  adTantagea  of  a  complete 
examination  without  offence  to  modesty,  different  section*!  may  be 
inspecie"!  separately.  Tlic  lower  portion  of  the  cheat  anteriorly, 
including  the  maiDinw,  may  be  covered,  while  the  upper  part  is  ex- 
posed ;  and  afterward  the  uppi-r  part,  with  jhe  mammie,  covered, 
vhile  the  lower  portion  is  denuded. 

This  will  «ufIico  for  ail  tht-  piirpofes  of  exploration,  without  insist- 
iog  on  an  exhibition  of  the  mammary  region.  The  examination  may 
be  made  while  the  patient  in  recumbent,  fitting,  or  stnnding.  When 
etrcuRiAtancei*  render  il  praeiirable  and  proper,  the  las  I- mentioned 
po«ition  or  the  wcond  is  preferable  to  the  first.  Sitting  or  standing, 
the  patient  should  be  placed  opposite  a  good  light,  and  requested 
not  to  incline  the  body  in  cither  ilirccttun  ;  the  attitude  should  be 
perfectly  easy,  the  muscles  relaxed,  the  upper  extremities  hanging 
loosely  by  the  side,  while  the  practitioner  first  surveys  the  chctt  at 
a  suitable  distance  directly  in  front,  and  afterwards  on  each  side, 


H      a  ovt4iavii 


FBTSIClt    IXFLOkATIOS    Or    TBI  CBBST. 

obuhdng  a  view  in  profile.     The  anterior  ud  pwtorMr  sv&cci  rf 
ike  dtot  are  to  b«  uupeeted,  olMcrring  the  niB«  precMdiowL   IW  ■ 

txuamztifm  of  the  posterior  torfM*,  ecpecullj,  u  acet  eoinai. 
eotljr  made  wbeo  the  paiietit  ttaadiL  If  the  reenmbcDt  fttdtid*  b 
neccsurj,  on  aceonnt  of  the  fe«f>1enc*«  of  the  patient,  w  atkt 
caows,  care  b  to  be  ohMrted  that  the  body  rests  on  mn  even  pbob 
Inattention  to  this  point  nuj  affect  materially  the  result*  of  th»  o- 
ami  nation. 

In  the  aiie,  configuration,  etc.,  of  the  ehest,  eonsiclenble  dlAr- 
eneea  are  obaerred  in  difft- rent  peraons  free  from  tfaoracw  diacait. 
It  U  irapoaaible  to  Sx  upon  s  nonnal  atandard  which  shall  arm  att 
criterion  bj  which  to  estimate  either  the  existence  or  the  degncti 
abnormal  dDvialions.  The  phjaical  signs  furnished  bj  tnspectiim, 
aa  a  rule,  are  dctermtaed  bj  observing  a  want  of  correspondcMt 
between  ibo  two  sides.  Taking  advantage  of  the  fact  that,  for  lie 
most  part,  intra-thoracic  dUcascs  involving  physical  changes  an 
either  confined  to  one  side,  or  affect  one  fide  more  than  the  olhtt, 
mil)  Murgming  that  in  a  normal  condition  the  two  sides  arc  symncV 
ricul  (whi^h,  with  certain  esceptions,  obscTTstion  chows  to  be  corrMl]^ 
a  mnrked  disparity  in  the  visible  appearances  is  fairly  prcsamrd  H 
he  the  effect  of  diaease.  Moreover,  observation  teaches  that  dtsesHi 
tend  to  province  difTcrcnt  cffectsi  upon  the  site,  form,  and  raoreiaeitt 
of  the  chent,  and  that  diffrn-rit  affections,  individually,  are  chara^ 
teriied  by  their  own  special  nilcrations.  U«?nce,  the  source  of  tbt 
Bigoificaocc  of  the  tatter  as  physical  signs.  Their  value,  as  iodiaf 
of  ci-rtiiin  phyi^ical  conditions,  rests  on  the  constancy  of  thetr  coo- 
neciioTi  with  tbc«e  conditions. 

Most  of  the  facts  which  would  fsll  under  the  head  of  mtptOmi 
m  /tealth  liftV(>  already  been  stated  in  the  iiitroduelion  to  this  work. 
It  is  important  to  take  cogniiiancf  of  certain  variations  from  the  rale 
of  symmetry  of  the  two  «Je«.  occnrring  very  freqoently  not  onlj 
in  beiihh,  but  without  spinal  curvature,  or  any  other  deformity.  In 
some  persons  the  size  of  the  right  side  at  the  middle  and  lower  po^ 
tions  is  obviously  somewhat  ((reotcr  thitii  that  of  the  lefV.  GeDcrslIy* 
however,  to  determine  the  disparity  whichexistsin  this  region,  men- 
surntion  is  requisite.  The  direction  of  the  ribs  on  the  right  siile  il 
a  little  less  oblique  than  on  the  left  .-(ide.  M.  Woillez'  found,  of  197 
subjects  in  good  health,  and  without  spinal  curvature,  that  in  47 


OpLdt. 


IVSPSCTIOX. 


277 


» 


only  «n8  the  tyntvantrj  in  all  rciipeots  absolutely  perfect.  A  fi<h 
jcotion  of  ihf  left  stifle  in  front,  either  at,  or  above,  or  b«)ov  the 
nipple,  cxistcJ  in  the  proportion  of  26  per  cent.  An  anterior  pr<v- 
jccliou  on  th«  right  aide  existed  only  in  tno  instances.  Ueuce,  if  a 
pTdji-ctiou  be  observed  oQ  the  right  side,  the  probabilities  of  its  being 
pathological  arc  tnoch  greater  than  if  it  be  on  the  left  side.  On  the 
other  hand,  a  posterior  projection  on  the  right  aide  is  verj'  frequently 
obstn'rcd,  existing  in  20  per  cwnt.  of  the  subjects  ejiamined  hy  M. 
Woillez,  while  it  is  very  rvely  noticed  on  the  left  side.  Variations, 
doe  lo  slight  spinal  curvaturo,  are  exceedingly  Gommon.  The  ma- 
jority of  persons,  especially  laborers  and  mechanics,  are  not  alto* 
gether  exempt  from  disturbance  of  symmetry  due  to  this  cause. 
The  inclination  is  commonly  to  the  right,  causing  depression  of  the 
shoulder,  and  approximation  of  the  ribs  on  that  side,  ^^light  our^ 
vaturc  of  the  spine  in  aiito  very  common  with  females.  Want  of 
harmony  between  the  two  sides,  not  sufficiently  marked  to  be  ob- 
served vithottt  careful  examinntion,  may  occasion  an  appreciable  dis- 
parity as  respects  pcrvuMion,  and,  hence,  the  importance  of  first 
comparin;;  closely  by  inspection  wherever  it  is  important  to  instilnti; 
a  ctosc  cotnparisou  by  tncaQB  of  thiit  method  of  exploration.  It  is 
especially  with  reference  to  the  diagnosis  in  certain  ea»cs  of  tuber- 
calous  disease,  that  slight  deviations  from  symmetry,  dependent  on 
spinal  currature,  or  other  causes,  irrespective  of  existing  disease, 
are  to  be  taken  into  account.  Alterations  of  stic  and  configuration, 
when  well  marked,  will,  of  course,  not  require  for  their  discovery  a 
do6e  inspection.  In  snch  instances,  the  questions  to  be  determined 
are,  whether  they  arc  due  to  deformity,  congenital  or  acquired,  or 
injury  of  the  thoracic  walls ;  to  iDtra-thoracic  affections  of  an  ante- 
rior date,  more  or  less  remote,  which  hare  left  permanent  effects  on 
the  conformation  of  the  chest,  or  to  present  disease.  The  nature  of 
the  alterations,  and  the  attendant  eircnm stances,  generally  render  it 
easy  to  decide  in  which  of  tlicse  oaiegoriefl  abnormal  appearances 
properly  belong. 

The  morbid  appearances  determined  by  inspection,  which  relate  lo 
present  or  pre-existing  intra -thoracic  disease,  may  be  divided  into 
those  pertaining,  fint,  to  alterations  of  siae  and  form,  and  ttvxmd, 
to  the  respiratory  movemenla. 


1.  Morbid  Aphkaraxcrb  Pbrtaixins  to  thb  Sizk  akd  Form 
OF  TUB  CuEST.— The  more  important  of  these  may  be  clasaified 


278 


PHTSIOAL    KXPLORATK 


CHBST. 


unilcr  tiro  bonds,  rix.,  «iitargenient  an'l  conlraotion ;  ench  ulmitting 
or  0iib<lirieiion  into  grneral  nnA  partiul.  The  enlargement  or  can- 
tritotion  IB  gvncntl  wlien  llir  <liincii»iona  of  oitlicr  t)ic  wholi-  or  am 
dido  of  tlic  cheat  is  tovresMd  or  (limiaished.  Partial  enlArgemoiit 
or  coMtraclion  in  when  there  is  «tlher  a  projoclion  or  depreBsioo  of  k 
limiled  {lortion  of  the  cheat  on  one  or  both  sides. 

Gonerul  enlargement  of  the  ohest  occurs,  Jst,  in  consequcnc*  of 
augmented  volume  of  the  jiulmonary  organs,  or  2d,  from  the  soni- 
muUtion  of  liquiil,  or  air,  or  both,  within  the  pleural  sac.  The  es- 
Urgcment  from  either  of  tliese  causes,  produces  changes  in  the  re- 
Intions  of  the  component  parts  of  the  cheat  analogona  to  those 
incident  to  a  deep  inspiration.  The  .itemum  and  clavicles  are 
cirvitted;  the  upper  ribs  converge;  the  lower  ribs  are  more  widely 
B^pnrutcd;  and  the  abdominal  space  below  the  xiphoid  cartilage, 
and  between  the  false  and  floating  ribs,  is  widened.  It  is  generalljr 
practicable  to  determine  by  the  appearances  pertaining  to  the  en- 
largemttnt,  on  which  of  the  two  anatomical  conditions  just  mentioned 
it  is  dependent,  that  is,  whether  it  be  owing  to  the  augmented  Tolum« 
of  the  lung,  or  to  the  presence  of  lt<|uid  or  air  between  the  pleural 
surfaces. 

The  lungs  are  rendered  abnormally  voluminous  by  the  retontiua 
of  an  undue  qunntity  of  air  within  Uie  pulmonary  cells,  con»lituliDg 
emphysema.  If  the  lungs  arc  highly  emphysematous,  the  chvet 
remains  expanded  as  it  is  by  a  deep  inspiration.  The  cnlnrgement, 
however,  is  most  marked  at  tlie  superior  and  middle  porlionn  of  the 
chest  1  the  revenw  of  this,  as  will  be  seen  prcsontly,  obtains  when 
the  enlargement  is  due  to  liquid  in  the  cavity  of  the  pleura.  Tb« 
reasons  for  the  fact  just  titntcd  are,  first,  emphysema  affects  most 
the  upper  lobes ;  and,  second,  the  action  of  the  diaphragm  inciiieot 
to  the  labored  respiration  oecae^ioned  by  the  disease,  offers  an  ob* 
stacle  to  the  enlargement  of  the  inferior  portion  of  the  chest.  Tbe 
latter,  indeed,  may  appear  to  be  contracted,  from  tli«  greater  rela- 
tive dilatation  of  the  superior  and  middle  portions.  In  this  rc«pect 
the  enlargement  from  emphysema  differs  from  that  due  to  liquid  lo 
the  pleural  sac,  the  expansion  in  the  latter  being  more  regular. 
Moreover,  the  enlargement  from  emphysema  is  never  so  great  as 
that  not  iofreijuently  observed  from  pleural  effusion.  EmphyMCQa 
affecting  both  lungs,  the  two  sides  of  the  chest  are,  of  coarse,  «ii> 
larged.  And  if  both  lungs  are  equally  enlarged,  it  is  difficalt  to 
determine  to  what  extent  the  dimensions  arc  inoreaaed,  not  having 


IKBPECTIOH. 


279 


r 


i«  Advantngr  of  a  compumon  of  Ibc  two  sides  witli  rt-Hp«et  to  thii 

■int.     It  is,  hoirovfr,  very  rnrcly  tlic  ciisc  that  ciiiphyjicinn  does 

ot  Bflect  one  Itmj;  to  a  gruiiter  extent  tlinn  the  otUcr;  uiii)  obsorvai- 

aons  sliovr  tbat  tliv  left  lung  is  more  prone  to  a  greater  relative 

Diotinl  of  »tij;mcntntioD  than  tbe  nglit.     Dilntiition  of  tlio  elietit 

oni  cinptiytteuiu  is  oftcner  limited  than  general,  ho  tliat  llie  analom- 

.1  condition  constituting  tliitt  affection  will  pretientlj  bo  cited  as 

CSU8C  of  [Mrtiftl  enlargement.     General,  but  usually  unequal  en- 

iargoment  of  tbe  cbcst,  occurs  in  some  caK«s  of  bronchitis,  probably 

ing  to  dilatation  of  tbc  air-colls,  in  fact  to  a  temporary  empbyHcm- 

stous  condition.      This  obtains  especially  in   bronchitis  affecting 

tbe  sranlicr  broncbinl  tubes  (capillary  bronchitis);  and  it  b as  been 

ibservcd,  in  a  marked  degree,  in  tbc  bronchitis  complicating  typhoid 

iver.'     Supplementarily,  the  dimensions  of  the  chest  on  one  side 

come  increased,  when,  from  any  cause,  the  functions  of  the  lung 

ID  tbe  other  side  are  interrupted.     Thus,  a  manifest  enlargement  of 

tbe  healthy  side  occurs  in  chronic  pleuritis,  owing  to  the  respiratory 

movements,  and  consequent  inBation  of  the  lung  on  that  side,  being 

increased  to  compensate  for  the  partial  or  complete  suspension  of 

faffiuatoisis  in  the  diseased  side.     Increased  voluntary  respiratory 

efforts  aystviDBtically  continued,  effect  a  considerable  iiugmentatioa 

of  tJic  volume  of  tbe  lungs,  as  shown  by  the  enlargement  of  tbe 

chest  which  follows  tbe  use  of  the  tubes  of  late  years  in  vogae  for 

that  purpose.     Gymnastic,  or  other  muscular  exercise,  inrolring  «n 

unusual  actirity  of  reapiralion,  also  produce  the  same  result. 

la  pneaiDonitis  affecting  an  entire  lung,  tbe  chest  on  tbe  affected 

ids  may  be  visibly  enlarged.     Generally,  however,  in  cases  of  (his 

tbe  inSammation  being  limited  to  a  single  lobe,  the  enlarge- 

mnt,  if  it  bo  sufficient  to  be  apparent,  is  confined  to  a  portion  of 

the  cbcBt.     The  augmented  volume  of  the  lung  incident  to  this 

affection,  is  due  not  necessarily  to  pleural  effusion,  but  to  tbe  deposit 

,of  solid  matter  within  the  air-cells,  in   consequence  of  which  the 

Tolame  of  tbe  lung  is  sensibly  augmented. 

It  is  in  cases  in  wbicb  a  large  quantity  of  liquid,  or  air,  or  both, 
•re  contained  in  the  pleural  sac,  that  general  enlargement  of  one 
Bide  of  the  chest  occurs  most  frequently,  and  is  most  marked.  Uni- 
versal and  not  infrequently  great  dilatation  on  one  side,  is  an  im- 
portant physical  sign  in  chronic  pleuritis  with  abundant  effusion, 


>  TTuM  de  Diftgnoitie  Midical,  par  le  Dr.  RacIc,  1864. 


PBTflCAI.    IXPLOKJITIOV    Ot    THB    CttEST. 


mi)<l  in  pDtB»o4jdrolfconz.  Tht  mlaxgemmut  ia  tbcM  ■feeiim 
u  alukj-j  eoDlnMl  to  one  ade.  An  mccnBvfaUMNi  of  li^sU,  or  m, 
m  both  pl«arftl  caviiiMi,  MficieBl  to  dilu«  tbe  two  tfdes,  «o«U  k 
iooonpstible  witk  UTe,  nuce  it  woaM  mr«)Te  diiDiiiatioo  «C  di 
ToluB*  of  tbe  Initga  to  ka  extent  to  reader  tbea  oeu*!;  or  ^mi 
■mIm*.  Tbe  eaUrgement  is  more  r^nbr  tius  ia  eieae  of  caf^ 
•cno,  bfrt  it  i*  laost  itunifc»t  At  the  lover  part  of  the  cbest,  ta  dii 
rc«pcet  presenting  a  contrast  with  the  eniargement  from  i  iii|ihjiiiM 
The  ooDConiiUBt  sigat,  howeTer,  especiall;  in  simple  pleoritis,  reader 
the  dttaimination  aaScieBtly  easy.  In  rmph^Brnta,  tbe  percnma- 
rawnanee  is  nerer  loat,  bat  ia  generally-  aboormalljr  dear,  wiib  a 
i{valitj  more  or  In*  approxtmating  to  the  tynpanitie.  lu  plearitii, 
with  abundant  liquid  cffaaion,  there  is  flatness  on  pemtwion.  b 
pneDmo-bjdrothorax,  the  dii^e^l^ncp,  as  regards  tbe  agia  tam^ti 
b;  percoMion,  is  Ie«8  striking.  The  chat  is  HtgUjr  reaooaal  ni 
tympanitic  above  the  level  of  the  liquid,  fiatoeea  existing  below  that 
point:  bat  with  the  aid  of  the  aascnltator^  ^giu,  in  connection  wi'A 
tbe  symptoms  and  history,  the  differential  diagnosis  doc»  not  tav<dTie 
much  difficoltj.  Tbe  expansion  of  the  thoracic  walls,  if  it  be  cao- 
aiderable,  br  the  direct  pressure  of  liquid  w  air,  ooeasioiu  otbtr 
ohangas  than  those  incident  to  simple  entargeoient,  whidi  hafe 
been  mentioned.  The  direction  of  tbe  lower  ribs  undergoes  t 
change.  They  are  less  obliqne.  Tbe  intercaital  dcpresaions  an 
eflbeed,  and  the  integument  between  the  ribs  may  even  become  pro- 
tuberant. It  has  been  asserted  that  tbe  effect  on  the  interoovlal 
•paces  ia  ebaiact eristic  of  enlargement  from  the  pFcwnne  of  liqniJ 
or  gsa,  in  distinction  from  that  due  to  the  augmeDtwl  rolame  of  tht 
lung.'  The  intercostal  depresMons,  howerer,  niny  be  cSaced  in  casei 
of  emphysema.  The  error  of  supposing  utherwiee  has  pefhspi 
ariKTR  from  observations  having  been  coiiEued  to  the  lower  part  of 
tbe  cbcst,  where  the  depressions  are  moet  eonspicooiis  in  health. 
Liquid  effusion  oblitcrntc^  the  depresMons  in  this  situation,  tbedif- 
teneion  being,  as  has  bvcn  seen,  greatest  nt  the  lower  part  of  the 
chest ;  but  emphysema,  affecting  most  the  superior  portion  of  tlu 
lang,  tbe  depressions  at  the  low^  part  may  eootinue,  and,  if  the 
respiration  be  labored,  may  even  be  greater  with  the  inspiratory  set 
than  in  health,  iiotwithstaoding  the  general  enlargement  of  the  ebnt. 
It  is,  however,  undoubtedly  true,  that,  at  the  superior  portioo  of 


*  Df.StolcM. 


IKSPBCTIOy. 


381 


be  cbest,  the  intercostal  deprcasiontt,  in  perxons  in  whom  thej  ktc 
lortDxIl^  risible  in  these  .lituatioiis,  may  bo  diminiiihcil  or  loitt  in 
a&eqaence  of  the  pressure  of  emphjsemalouH  lung. 
Partial  enlargement  is  inciilent  to  moat  of  the  nnatomtcal  condi- 
tions already   mentioned,    viz.,  to   emphyitema,  pleuritic   efftieionf 
I     jttioumo-hydrothonix,  iind  piivunioiiili*,  and  lo  other  uffcctions  not 
^Bldeqaite  lo  give  Hhc  to  dilAtntion  of  the  whole  of  ou«  or  both  sides 
Bof  the  cho»t.     The  cnliirgcnu-nt  from  eniphyscmn  in  oftcner  partial 
^thnn  general.     It  oceastouH  undue  promiuerice  over  n  portion  of  the 
cii^^t  eorrcHponding  to  the  ecnt  of  the  nffeclion,  aiiil  proportionate 
in  ntnount  to  the  o.xlcnt  of  the  atfectton,  with  diminution  or  oblitera- 
^lion  of  the  intcroostKl  dcprensious.     Affecting  the  Koperior  portion 
^■Df  the  lung  gcnemlly,  if  not  alwajH,  on  both  BidcH,  but  greater  on 
^buaiilc  than  on  the  uther,  a  ehnniclcriHtii:  appcarnnce  is  an  abnor- 
^RmI  bulging  above  and  below  the  ciavicle.     Tht-se  uppuaritnccs,  more 
marked  on  one  side  than  on  the  other,  disconneoled  from  other  »igns, 
might  lead  the  obacrrer  to  attribute  the  rclntive  deprowion  of  the 
anpra  and  in  frit-clavicular  regions  on  one  side  to  dii^ea«i'  of  the  Gub> 
JBcent  long.     The  evidence  derived  from  pcrcii«i«n  and  ausculia- 
tion  Hullice  to  correct  this  error.     The  phyaical  evidences  of  the  mor- 
bid conditions  inducing  abnormal  depression  will  be  wanting,  while  the 
concomitant  Mgii  of  emphyi^ems,  viz.,  vusieulo-tynipanitio  reeonance 
sod  feeble  respirntiun,  arc  fonnd  on  the  side  on  which  the  greater 
prominence  exists.     Over  the  mnmmnrj  region  the  emphysematous 
lung  canses  greater  relative  fulness,  especially  neur  the  sternum, 
with  diminished  obliquity  of  the  ribs,  the  intercostal  spaces  being 
concealed  by  the  pectoral  nrnscle  nnd  the  mnmmarj  gland ;  and  if 
the  affection  exist  on  both  sides,  the  chest  presents  an  unnatural 
rounded  or  globular  appearance,  which  is  highly  characteristic. 

In  pleuritts  with  effusion  the  lower  portion  of  the  thorax  yields  to 
the  distension  from  the  fluid  gravitating  lo  the  bottom  of  the  pleural 
ssc,  before  the  superior  part  of  the  chc«t  becomes  obviously  cn> 
Urged  from  the  accuinolation  of  the  liquid.  Unless  the  quantity 
of  effusion  be  large,  the  dilatation  is  partial,  and  situated  inferiorly, 
in  this  retrpect  contrasting  with  enlargement  from  emphysema  in  the 
majority  of  ca.ses  of  the  latter  affection.  The  contrast  as  respects 
the  signs  derived  from  percussion  and  auscultation,  however,  gener- 
ally serve  to  distinguish  these  affections  from  each  other  as  broadly 
as  possible. 

Id  piieumo-bydrothorax  the  quantity  of  liquid  at  tlie  bottom  of 


28S 


FHTStCAL    BZPLOBATIOX    OP    TBI    CHIST. 


th«  chest  nuT  be  ituSictcnt  to  occsuon  ntAaifcU  cnlsrgna«ot  aha 
no  obrious  ditparitj  exists  above. 

Pneumonitis  affecting  *  Mnglr  lobe  soraetioiM  gires  me  to  an  i^ 
preciablj  iDcrea8<'d  TulncKs  of  the  part  of  tbc  chMt  sitaated  OTcrtbc 
solidified  long,  but  the  cnlurgcment  i«  apparent  in  onlja  BnaD  piv- 
portion  of  in»UiDccs. 

Variona  conditions  additional  tn  tbo«c  maj  produce  partial  a- 
Isi^ment,  tbo  mom  important  of  which  are  as  follows: 

(1.)  Circumscribed  plcuritis,  a  collection  of  liquid  suOieient  low- 
casion  bulf^ing,  bi-ing  oonfinod  within  a  limited  area  by  adhesioni «{ 
the  surrounding  pleural  surfaces.  Caf«8  of  tbia  description  an 
sometimes  observed,  but  they  are  rare.  I  have  met  with  an  insunct 
of  a  large  collection  of  purulent  fluid  conflned  to  a  Epacc  fire  orni 
inches  in  wiitth  extending  around  the  entire  scmicircnrnfcrenM  d 
ibc  lower  pnrt  of  the  chest,  firm  adhesions  preventing  an  aaceot  tt 
the  liquid  above  this  space.'  (2.)  Enlargement  of  the  spleen.  Marked 
projection  uf  the  lower  portion  of  the  left  side  is  sometimes  duett 
this  unutDintcitl  condition,  which  occurs  especially  in  protracted  or 
frequently  renewed  nttncks  of  intermittent  fcrer.  (3.)  Distension 
of  the  stomnch  witli  gas-,  if  considerable,  occasions  temporarily  u 
abnormal  protrusion  of  the  lower  left  ribs.  (4.)  Eolargeatent  of 
the  liver,  from  tumors,  abscess,  fnlty  deposit,  etc.  In  this  case,  of 
oourM,  tlic  pnrtinl  enlnrgeiuent  of  the  chest  will  be  situated  on  the 
right  Bide.  (5.)  Liquiil  effu:>ion  within  the  pericardium,  and  enlarge- 
ment of  the  hcnrt.  The  priecordial  portion  of  the  chest  may  be 
rendered  abnunnally  prominent  by  these  affections.  It  is  a  eonoss 
fact  thiit  u  projection  in  this  situation  in  health  was  found  by  H. 
Woillet  to  exist  in  a  larger  mtio  of  instances  than  by  Bouillattd  in 
ctiscM  of  liypertropliy  of  the  heart.  It  is  probable  that  the  dcriatioa 
from  symmetry  in  thi»  situation,  which  is  found  in  the  proportion  of 
about  ono-founh  of  healthy  persons,  has  beon  often  incorrectly  a^ 
tributed  to  the  hypertrophy  of  the  hcnrt  in  the  instances  in  whitk 
it  has  been  observed  in  connection  with  that  affection.  (G.)  Anew- 
ismal  und  other  intra-thorucic  tumors.  (7.)  According  to  Dr.  Chun- 
bors,  deposit  of  tubercle  miiy  occasion  bulging  at  the  summit  of  the 
chest  above  and  below  thu  clavicle.  This,  however,  has  not  been 
noticed  by  others,  and  the  correctness  of  the  observation  ceeiiU  con- 
firmation. 


'  Emi;  on  Chraiiu  Pleurisy,  by  autlMr. 


IJrSPBCTIOS. 


288 


^ 


VariatioDs  in  si««  nniii  form,  the  reTerse  of  those  just  considered, 
may,  also,  aa  has  been  Mated,  be  general  or  ptirtinl.  When  contrac- 
tJOQ  h  genenil,  t.  e.,  affiecting  the  nrhole  of  one  side  or  both  sides,  the 
reUlions  of  the  component  pans  of  the  chest  are  analogon^  to 
tUoae  incident  to  a  forced  expiration.  The  upper  ribs  are  more 
widely  sepantled,  while  the  lower  are  approxiiuatcd  to  each  other, 
and  the  space  below  the  xiphoid  and  between  the  lower  costal  carti- 
lages is  diminiahed. 

Geoeral  contraction  of  one  side  is  presented  in  a  striking  degrc« 
after  recoTery  from  chronic  pleuritis.  The  chest  is  diminished  in  all 
its  diameters,  and  so  appears  in  whatever  direction  it  be  examined. 
The  lung,  after  remaining  collapsed  and  compressed  for  weeks  and 
months,  does  not  readily  expand,  after  the  liquid  is  absorbed,  to  its 
former  volume.  Moreover,  the  false  membranes  formed  upon  its 
surface,  and  the  union  of  the  pleural  surtaces,  olfer  a  mechanical 
ob«iacle  to  its  complete  expansion.  The  atmospheric  pressure, 
therefore,  forces  the  thoracic  walls  to  accommodate  themseln.'^  to 
the  diminished  bulk  of  the  pulmonary  organ.  The  reduced  dimen* 
siuns,  compared  with  the  other  side  (the  latter  becoming  increased  in 
size),  are  Hiillieiently  obvious  od  inspection,  but  the  altered  relations 
of  difTcrenl  part*,  component  and  accessory,  pertaining  to  the  chest, 
we  aW  con«picncius.  The  shoulder  is  depressed.  The  inferior  angle 
f  the  scapula  falls  bclaw  the  level  of  that  on  the  unafiected  eide, 
and  projects  from  the  chest.  The  width  of  the  lower  interscapular 
space  ia  notably  diminished.  The  ribs  are  approximated.  The  nip* 
pte  on  the  affected  side  is  lowered.  More  or  less  spinal  curvature 
takea  place,  the  lateral  inclination  being  toward  the  alTectcd  side. 
All  these  appearances  give  a  characteristic  aspect,  by  which  the  fact 
that  picuritis,  with  ooptous  effusion  and  enlargenient  of  the  dicst,  has 
exbted,  is  evident  at  a  glance. 

Abaormal  diminution  of  the  Toliime  of  the  lang  from  any  cause, 
provided  the  pleural  cavity  docs  not  contain  fi(|ni<l  fffiision  or  air,  is 
of  nece^ily  accompanied  by  a  contraction  of  the  cheet  exactly  pro- 
portioned to  the  extent  to  which  the  pulmonary  organ  is  reduced  in 
balk.  Collapse,  from  obalruction  of  a  large  bronchus,  involve*  an 
amount  of  general  contraction  corresponding  to  the  diminiskcd  vol- 
ome  of  the  lung.  Condensation  from  inSammatory  exudation  within 
the  air-vesicles,  remaining  after  the  removal  of  this  exudation,  leads 
to  some  reduction  of  bulk,  and  hence  contraction  is  sometimes  ob- 
served to  follow  the  resolution  of  simple  pnoumonitil,  and  is  general 


S84 


FflTSIOAL    IZrLOBlTIQS    OF    TBB    CHEST. 


if  Ibe  inflammation  und  sotidificxtkm  affected  ibe  entire  long,  lb 
coDtnetioD  under  thc*e  clrcnmflUDoea  U  r&reljr  msrked,  xnitu 
fondant  liquid  (fusion  has  coexisted.  Sli^t  general  eootractiok 
has  also  been  obwrred  to  acooinpanT  atropkj  of  the  pttfaaaui; 
pairnchyina  in  oonnection  with  dilated  bronchial  tabes.  Eztaaan 
tubcrculonB  disease  indDce:^  a  ehrinking  of  the  longs,  and  earn- 
cpooding  diminution  of  the  sixe  of  the  cbeet ;  and  this  effect  fotkm 
long  confinement  to  the  bed  with  an/  diseue.' 

The  morbid  conditions  which,  ofiener  than  any  other,  give  riaeta 
partial  contraction  of  the  chest,  are  incident  to  tubercDloits  dbeaaa 
Abnormal  depression  above  and  below  the  clavicle,  and  more  or  lot 
flattening  at  the  summit,  are  occasionally-  observed  in  phthias,  sU 
in  some  instances  are  among  the  strilcing  pb,raical  evidences  of  ibi 
dtwue.  These  appearances  mav  be  presented  early  in  the  diseaie^ 
shoiftng  iliat  the  apex  of  the  lung  becomes  in  some  instance*  rednecd 
in  volume  in  consequence  of  tbe  presence  of  crude  tuberculoiu  mat- 
ter; but  thcj  are  found  more  frequently  and  in  a  more  mnrkcd  ils 
grce  nfler  softening  and  ezcaration  have  taken  pUcc.  In  conncctiM 
with  the  changes  b;  which  cavities  are  fonoed,  their  rationale  ii 
«u(&cienily  plain,  since  there  occurs  an  actnal  Io«s  of  putmoasi^ 
subftance  to  a  greater  or  less  oxlenl.  It  is  needless  to  add.  that 
to  constitute  a  physical  sign  of  disease,  the  contraction  nnvt  be 
manifested  on  one  side  of  the  chest  by  a  comparison  with  the  wthct 
■tide. 

Other  conditions  inducing  partial  conirnctioo,  le«$  frequent,  ntd 
clinically  less  important,  are  the  absorptioD  of  liquid  effusion  re- 
tained by  pU^uritic  ud)ii^!«ions  within  a  circumscribed  space;  remoni 
of  the  cxudation-uiuttvr  deposited  in  pneumonitis  when  the  latter  is 
confined  to  a  single  lobe ;  and  limited  collapse  or  atrophy. 

3.  Morbid  App£arakce»  pbrtaikixg  to  tus  REStnaaTOtT 
MovKMRNTS. — Tho  respiratory  movements  in  health  have  been  eoe- 
sidcred  in  the  introduction  to  this  work,  inulusivc  of  certain  modifi- 
estions  incident  to  sex,  age,  etc.,  and  also  variations,  irrespective  of 
disease,  presented  in  different  individuals,  all  of  which  are  impor> 
lant  by  way  of  preparing  the  observer  to  estimate  correctly  morbid 
appearances.  Incidentally,  in  connection  with  the  physiological 
facts  relating  to  this  subject,  allnsion  has  already  been  made  to  the 


'   VUi  Silnoni  Hcdicul  Aantom;-,  Fucicalo*  1. 


IKepBCTIOK. 


285 


I 


tore  prominent  of  thow  abcrratione  of  the  respiratory  moTements 
j-which  constitute  phj-BJcal  signs  of  diBease. 

AbDormal  frequency  of  th«  respirations  may  be  ascertained  by 
inspection.  By  observing  tbe  visible  motions  of  the  cheiit  or  abdo- 
lD«n.  the  inspirations  are  ennmerated,  and  the  number  in  a  given 
Utae  determined.  For  this  end,  it  is  not  necessary  thai  the  chest  be 
ezpo«ed.  Diminished  frequency  of  tbe  respirations  implies  a  morbid 
condition  seated  in  the  nerrons  system,  the  respiratory  function 
being  affected  secondarily,  or  syinfitoinaiic«IIy.  Increased  fre- 
qacncy  is  incident  to  various  afTectionii  compromiiiing  the  function 
of  biematosis,  suob  as  plciiritis,  pneumonitis,  pbthiiiij),  and  in  a 
lotable  de^ce  to  capillary  broucliitis.  The  luiitiber  may  be  in- 
creased from  the  bealtliy  average,  ranging  bctvocn  14  and  20  per 
minute,  to  40,  50,  and  even  (iO.  Abnormal  frequency  of  the  reapi- 
rations  does  not  iiecesnarily  denote  diecanc  of  the  pulmonary  organs. 
!lt  is  incident  to  disorders  Rifecting  tbe  circulation,  and  to  hyeK-iia. 
In  tracing  i(  to  its  source,  a  point  of  #omo  utility  i^  tbe  ratio  which 
should  exiiit  between  the  respirations  and  the  pnlHC.  A»  a  rule,  four 
bent!*  of  the  henrt  take  place  tn  health  during  the  time  occupied  by 
each  respiration.  This  ratio  is  usually  prei>erved  in  diseases  not 
inTotving  the  heart  or  lungs.  A  pulmonary  affection  may  be  pre- 
samed  to  exist  whenever  an  increase  in  the  number  of  respirations 
is  unattended  by  a  oorresponding  increase  in  the  frequency  of  the 
pulse.  This  may  be  stated  as  a  maxim  which  will  generally  hold 
good;  but,  of  courne,  the  vxiNtenco  of  pulmonary  disi-a-se  ik  to  be 
determined  in  all  case^  by  evidence  more  direct  ami  positive. 

The  rhythm  of  tbe  ri-spiTntwry  niovcmcnls  to  affected  differently 
in  connection  wilh  different  morbid  conditions.  The  inspiratory 
movement  is  somewhat  shortenei),  as  a  rule,  whenever  dyspnosa 
exists,  the  want  of  fre^li  supplies  of  air  instinctively  canning  the 
act  to  be  hurried.  Shortened  inspiration  is  specially  marked  in 
emphysema  for  another  reason,  vis.,  the  cbest  ia  already  dilated, 
and  the  extent  of  its  capability  of  expansion  proportionally  le»- 
■ened ;  henee  it  is  more  quickly  performi;d.  This  occurs  in  cases 
■n  vbiclipain  is  produced  by  a  full  or  deep  inspiration,  an  in  pleuritis, 
tntercoHiai  neuralgia  or  pleurodynia.  The  patient  instinctively 
represses  the  inspiratory  movements,  and  thus,  as  far  as  posaiblc, 
consistently  with  the  introduction  of  sufficient  air  for  hicmatosis, 
shortens  the  duration  of  inspiration.  An  abrupt  arrest  of  inspira- 
tion, with  manifestations  of  acute  pain,  is  a  sign  highly  distinctive 


280 


PBYSICAI.    KXPLOKATIOX    OF   TBB    CHBST. 


BD'I  io  pnomno-hydro thorax.  Th?  cnlnrgpiDi-iit  in  tbcM  Affcclion! 
ia  always  confined  to  out  side.  An  accutnuUtioQ  of  liquid,  or  air, 
in  both  pleural  cavities,  suflicieut  to  dilate  ibo  two  siilcs,  woolil  bt 
incompatible  with  life,  since  it  would  involve  diraintition  nf  tbt 
Tolume  of  the  luogs  to  an  extent  to  reader  them  oe«rtj  or  qaite 
uaeless.  The  eolargement  is  more  regnUr  than  in  caaw  of  coifibT- 
sema,  but  it  is  most  manifest  at  the  lower  pait  of  the  chest,  in  tUi 
respect  presenting  a  contrast  with  the  enlargement  from  emphjMvi. 
The  concomitant  signs,  however,  especially  in  simpio  plettritis,  reoibt 
the  discrimination  sufficiently  easy.  In  emphysema,  the  percussicn- 
resonance  ia  never  lost,  but  is  generally  abnormally  clear,  wiili  a 
iguslity  more  or  lees  approximating  to  the  tympanitic.  In  plewitk 
with  abundant  Iii]uid  effusion,  there  is  flatness  on  percu&Kion.  h 
pneomo-hydrothorax,  the  difference,  as  regards  the  signs  fumish«f 
by  piTCu.'iKion,  is  lets  striking.  The  chi:^*!  is  hij^hlj  resonant  ami 
tympanitic  above  the  1«vcl  of  tliv  liquid,  flatness  existing  below  thai 
point;  but  with  the  aid  of  the  nuscidtatory  signs,  in  connection  wiik 
tlie  Hymplnms  and  history,  the  dilTercntiul  diagnosis  doc«  not  inrolTc 
much  difficulty.  The  expansion  of  the  thoracic  walls,  if  it  be  cob- 
siilerable,  by  the  dirt-ct  pre*.«ure  of  liquid  or  air,  occasion*  other 
changes  than  those  incident  to  eimplc  enlargement,  which  hxn 
betu  mentioned.  The  direction  of  the  lower  ribs  nndergoea  a 
change.  Tlicy  are  less  obliqup.  The  intercostal  dcprc«sioiu  an 
eflfitcod,  and  the  inlcgumenl  between  the  ribs  may  even  become  pn^ 
tubcraiit.  It  has  been  asserted  that  the  cfTcct  on  the  int«rcan>l 
spacen  is  characteristic  of  cnkri^omcnt  from  the  procure  of  liquid 
or  gas,  in  distinction  from  that  duo  to  the  augmented  volume  of  the 
lung.'  The  inu-rcostal  depressions,  howerer,  may  be  effaced  in  cases 
of  emphysema.  Thu  error  of  supposing  otherwise  has  perhaps 
arisen  from  observations  having  been  confined  to  the  lower  part  of 
the  chest,  where  the  depressions  are  most  conspicuous  in  health. 
Liquid  effusion  obliterates  the  depressions  in  this  situaUni,  the  dis- 
tension being,  as  has  been  seen,  greatest  at  the  lower  part  of  the 
chest;  but  emphysema,  affecting  most  the  superior  portion  of  the 
lung,  the  depressions  at  the  lower  part  may  continue,  and,  if  Ibe 
respiration  be  labored,  may  even  be  greater  with  the  inspiratory  act 
than  in  health,  notwilliNtanding  the  genernl  enlargement  of  the  chest. 
It  ia,  however,  undoubtedly  true,  that,  at  the  superior  portion  of 


>  Dr.  Stokat. 


IS8PKCTI0X. 


S8I 


(     tbi 


I 


!thc  chest,  ibc  intercostal  itcpressions,  in  persons  in  wlioni  thfj  &re 
.-nonnaHjr  risible  in  theso  Biluations,  may  be  dioiinisbetl  or  lost  in 
con«<-quenci!  of  the  pressure  of  empb^sematous  lung. 

Pu-tinl  enlargement  is  incident  to  most  of  the  anatomlcnl  condi- 
'tions  already  mentioned,  viz.,  to  empbysema,  pleurilic  effusion, 
poeumO'bTdro thorax,  and  pneumonitis,  and  to  otber  sfieclions  not 
sde<{uatc  to  give  rise  to  dilatation  of  the  whole  of  one  or  both  sidoa 
of  the  chi-at.  The  enlargement  from  emphysema  is  oftener  partial 
than  genera).     It  occasions  undue  prominence  over  a  portion  of  ibc 

iCat  corresponding  to  the  seat  of  the  affection,  and  proportionate 
in  amount  (o  the  extent  of  the  affcclion,  with  diminution  or  oblil<-nt< 
tion  of  the  intercostal  depressions.  Affecling  the  superior  portion 
of  the  lung  gcnorallir,  if  not  ntirays,  on  botli  )iid««,  but  greater  on 
one  side  than  on  the  other,  a  chnracteri-itic  appearance  is  iin  abnor- 
mal bulging  above  and  below  the  clavicle.  These  appearaiiceii,  more 
marked  on  one  side  than  on  the  other,  disconnected  from  other  vigns, 
might  lead  the  observer  to  attribute  the  relative  depre.'^ion  of  the 
supra  and  infra-clavicnlar  regions  on  one  side  to  disease  of  tbo  )<ub- 
jacent  lung.  The  evidence  derived  from  percussion  and  auKulta- 
lion  suffice  to  correct  this  error.  The  physical  evidences  of  the  mor- 
bid c<iud>tionj<  inducing  ahiiornial  depression  will  he  wnnttng,  while  the 
eoucomitani  sigii  of  emphysema,  viz.,  vesiculo-tyuipanitic  resonance 
Knd  feeble  respiration,  are  found  on  the  side  on  which  the  greater 
pnminencv  e:iist».  Over  the  mammary  region  the  emphyscmutong 
lung  causes  greater  relative  fulness,  especially  near  the  stornnm, 
with  diminished  obliquity  of  the  rib«i,  the  intercostnl  spaces  being 
concealed  by  the  pectoral  muscle  and  the  miimmary  gland;  and  if 
the  affection  exist  on  bolb  sides,  the  chest  presents  an  unnatural 
rounded  or  globular  appearance,  which  is  highly  characteristic. 

In  plcuritis  with  effusion  the  lower  portion  of  the  thorax  yichls  to 
the  distension  from  the  fluid  gravitating  to  the  bottom  of  the  pleural 
8*c,  before  the  superior  part  of  the  chc^t  becomes  obviously  en- 
larged from  the  accumulation  of  the  liquid.  Unless  the  quantity 
of  effusion  be  large,  the  dilatation  is  partial,  and  ?ituntc<l  inferiorly, 
ID  this  respect  contrasting  with  enlargement  from  emphysema  in  the 
majority  of  cases  of  ihe  latter  affection.  The  contrast  as  respects 
the  Mgns  derived  from  percussion  and  anseullation,  however,  gener- 
ally aerve  to  distinguish  these  affections  from  each  other  as  broadly 
■8  (Mssible. 

In  pneumo-bydrothorax  the  quantity  of  liquid  at  the  bottom  of 


282 


PUTSICAL    SXPLOBATIOS    OF   TBS   CBBST. 


thfl  che9t  Dutj  be  sufficient  to  occa^on  tDanifest  eoI»rgemeni  vba 
no  obriou)!  ilijpariljr  exists  above. 

Pnvurooniti»  afTccting  a  ttingle  lobe  sonicticnes  gives  rt*e  to  an  i^ 
preciabl;  iDCrcMCtl  fulDess  of  thepartof  the  chest sitoatetl  oreriibi 
solidified  lung,  but  the  enlargement  is  apparent  in  onlj  a  nsall  pro- 
portion of  instances. 

Varioim  conditions  additional  to  these  tnty  produce  partial  a- 
lai^gement,  the  more  important  of  which  are  as  follom: 

(1.)  CircnniBcribcd  pleiiritiii,  a  collection  of  )t<juid  snSicieiit  to  ofr 
CMton  bulging,  being  confinH  wilhin  a  litnitcd  are«  b^  Adhe«KiMif 
tbe  surrounding  pleural  surfaces.     Cases  of  this  description  an 
sometimes  observed,  but  tliey  are  rare.     I  have  met  with  an  iostasM 
of  A  large  collection  of  purulent  lluid  oonftncd  to  a  8pac«  five  or  rz 
incbcK  in  widrh  extending  around  the  entire  semieircumferenoe  «i 
tbc  lower  part  »f  tbc  cbcst,  firm  adlic»ion8  preventing  an  atecnt  af 
the  liquid  above  llii«8pnec.'  (2.)  Enlargcmentof  the  spleen.    Matid 
projecliun  of  tbe  lower  portion  of  the  left  aide  i»  sometiines  duett 
this  anatomical  condition,  which  occurs  especially  io  protracted  or 
fre(}uentl;  renewed  attacks  of  intermitlenl  fever.     (3.)  DiatcDani 
of  tbe  stomach  with  gas,  if  considerable,  occasions  temporarilj  an 
abnormal  protrusion  of  the  lower  I(-ft  ribs.     (4.)  Enlargcntcal  of 
the  liver,  from  tumors,  abscess,  fatty  deposit,  etc.     In  thi«  cbm,  of 
eouTse,  tbe  partial  enlargement  of  tbe  chest  will  be  sitmitcd  on  the 
right  side.    (•'>.)  Liquid  effusion  within  the  pcricnrdium,  tind  enlarge- 
ment of  the  heart.     The  pra>cordial  portion  of  the  chest  ma;  U 
rendered  abnormallv  prominent  by  thcitc  affections.     It  if  a  curiooi 
fact  Ihiit  a  projection  in   this  situation  in  facultb  was  found  by  H. 
Woillee  to  exist  in  a  larger  ratio  of  instances  than  by  BouiUandlB 
cased  of  hypertrophy  of  the  heart.    It  is  probable  that  the  doviatioa 
from  symmetry  in  this  situation,  which  in  found  in  the  proportion  of 
about  one-fourth  of  healthy  persons,  has  been  often  incorrectly  at- 
tributed to  the  hypertrophy  of  the  heart  in  tbe  inalaDces  in  whiA 
it  ban  been  observed  in  connection  witli  that  affection.     (6.)  Anecr- 
i«inal  and  other  intra- thoracic  tumors.   (7.)  .\ccording  to  Dr.  Cliun- 
bers,  deposit  of  tubercle  may  occasion  bulging  at  tbe  summit  of  the 
chest  above  and  below  the  clavicle.     This,  however,  has  not  bteo 
noticed  by  others,  and  the  correctness  of  the  observation  needs  cod* 
Srmation. 


*  £iMgr  on  Chronic  Pleuriiy,  Iq  auilim. 


IKSPECTIOK. 


288 


I 


I 


Varifttions  in  site  and  forni,  the  reverse  of  those  just  considcrvd, 
maj-,  nlM,  a«  hue  btitn  Mntod,  be  general  or  partial.  When  contrM- 
lioD  is  geacral,  f.  c,  nflectitig  the  whole  of  one  side  or  both  sides,  the 
r«lationH  of  the  compoiienl  parl»  of  the  chest  are  anslogous  to 
those  incident  to  a  forced  expiration.  The  upper  ribs  are  iDore 
widely  ecparfttcd,  while  ihc  lower  are  approximated  to  each  other, 
and  the  spsev  below  the  xiphoid  and  between  the  lower  costal  carU- 
lagcs  18  ilimiiiifhcd. 

General  contraction  of  one  (ide  is  presented  in  a  striking  degree 
after  recorery  from  clirouic  pleiiritty.  The  cheat  is  diminished  in  oil 
it«  iliumetcr^  and  so  appeurtt  in  whatever  direction  it  be  exainineil. 
The  long,  after  remaining  collapsed  and  comprii>S4td  for  weeks  and 
months,  doc«  net  readily  expand,  nftoi'  tlu^  liquid  i.«  ahitorhed,  to  ita 
former  volume.  Moreover,  the  false  membranes  formed  upon  ita 
Furfiice,  and  the  union  of  the  pk-uriil  surfaees,  offer  a  mccbanieal 
obstncle  to  its  complete  vxpniiHion.  The  atiDORpheric  pre»«ure, 
therefore,  forces  the  thorncic  walls  to  accommodntc  themselves  to 
the  diminished  hulk  of  the  pnhtioiiary  organ.  The  reduced  dimen- 
sions, compared  with  the  other  nidc- (the  latter  becoming  increased  in 
WZ9),  are  sufficiently  obvious  on  inspection,  but  the  altered  relations 
of  different  parts,  component  and  accessory,  pertaining  to  the  cheat, 
are  also  conspicuous.  The  shoulder  is  depressed.  The  inferior  angle 
of  the  scapula  falls  below  the  level  of  that  on  the  unaffected  side, 
and  projects  from  the  ehest.  Tbc  width  of  the  lower  interscapular 
Space  is  notably  diminished.  The  ribs  arc  approximated.  The  nip- 
ple on  the  affected  side  is  lowered.  More  or  les*  spinal  curvature 
takes  place,  the  lateral  inelinatton  being  toward  the  affected  side. 
All  these  appearances  give  a  characteristic  aspect,  by  which  the  fact 
that  plcuritis,  with  copious  effusion  and  onlargcmvnt  of  the  chest,  has 
existed,  is  evident  at  a  glance. 

Abnormal  diminution  of  the  volunio  of  tbc  lung  from  any  cause, 
provided  the  pleural  cavity  does  not  contain  liquid  effusion  or  air,  is 
of  necessity  arcompanicd  by  a  contraction  of  the  chest  exactly  pro- 
portioned to  the  extent  to  which  the  pulmonary  organ  is  reduced  in 
bulk.  Collapse,  from  obstruction  of  a  Urge  bronchus,  involves  an 
amount  of  general  contraction  corresponding  to  the  diminished  vol- 
ume of  the  lung.  Condensation  from  inflammatory  exudation  within 
the  air-vesicles,  remaining  after  tlie  removal  of  this  exudation,  leads 
to  some  reduction  of  bulk,  and  hence  contraction  is  sometimes  ob- 
served to  follow  the  resolution  of  simple  pneumonitis,  and  is  general 


^ 


284 


PHYSICAL    BSPLORATIOK    OF   THB    CSEST. 


if  the  ii)flnmmiiliQii  and  golidilioiition  aSecu^d  ibe  entire  Ino^  Tdt 
oontniclioo  amlcr  lIifM  uirctiinsMncca  is  nrcly  marked,  vsitm 
abundnot  liijuld  i-fru.4iaii  Iibk  oocxtflliHl.  Slight  general  contracbia 
has  aUo  been  obmirvod  to  nccompjinj  atrophy  of  tht  pahnohaij 
psrciichyina  in  connecUon  wilh  dilated  bronchial  tubes.  Eitcnsit 
tubcrvuloufl  discaae  inductfii  a  shrinking  of  the  lungs,  and  com- 
Hpomliiig  diminution  of  the  size  of  the  chettl;  and  this  effect  fbUm 
long  onnRnoment  to  the  bed  with  anv  disease.' 

Thi;  morbid  conditions  which,  aften^r  than  any  other,  girt  raetn 
partial  contraction  of  the  chest,  are  incident  to  tuberculona  diMMc. 
Abnormal  depression  above  and  below  the  clavicle,  and  more  w  Its 
flattening  nt  the  sammit,  are  occasionallv  observed  in  phthisia,  tai 
in  some  instances  are  among  the  striking  physical  eridcoec*  of  that 
dicCMC.  These  appearances  may  be  presented  carljr  in  the  diiicut; 
Bhowing  thai  the  apex  of  the  Inng  becomes  in  some  iii»tanc«9  redaed 
in  volume  in  consequence  of  Ibe  prcMncc  of  crude  tab«rca]oiu  art- 
tor ;  but  they  are  found  more  fropiently  and  in  a  more  marked  d»- 
grcH!  after  softening  and  excavation  hare  taken  place.  In  conorcttM 
with  the  changes  by  which  cavities  are  formed,  their  rationale  il 
vufliviently  plain,  since  there  occurs  an  actual  ]of*  of  pulaouiy 
MubKtnnce  to  a  greater  or  less  extent.  It  is  needless  to  add,  iku 
to  eonstilute  a  physical  sign  of  disease,  the  contmction  miust  tt 
manifested  on  one  side  of  the  chesi  by  »  oompari^on  with  the  otkiT 
side. 

Other  conditions  inducing  partial  contraction,  less  frequent,  ni 
clinically  le^  injportnnt,  nro  the  ubaorption  of  liquid  effosioB  n- 
tainrd  by  picnrilic  adhesions  within  a  circumscribed  space;  renonl 
of  the  cxudutiun-mattor  deposited  in  pneumonitis  when  the  latter  il 
confinod  to  a  tiinglc  lobe;  and  limited  collapse  or  atrophy. 


2.  Morbid  Appearances  pkrtaimno  to  tuk  Res^piutobt 
Movements. — The  respiratory  muvcmcnU  in  health  hare  been  tw 
sidered  in  the  introduction  to  this  work,  inclusive  of  certain  niod3> 
cations  incident  to  ncx,  age,  etc.,  and  also  variations,  irrespectJTB  rf 
disease,  presented  in  different  individuaU,  all  of  which  axe  inpof* 
tuiit  by  way  of  preparing  the  observer  to  estimate  correctly  aoM 
appearances.  Incidentally,  in  connection  with  the  physiologial 
facts  relating  to  this  subject,  allusion  has  already  been  made  l«  ik 


>  Vide  SilMDO'i  Mcdiesl  Aiwloiay,  Faicicniut  1, 


IN8PBCTI0S. 


285 


nkiore  prominent  of  ihosw  aberrations  of  the  respiratory  movements 
lirbich  constitute  phyeical  signs  of  disease. 

I      Abnormal  frequency  of  the  rospirations  may  he  ascertsioei]  by 
linspection.    By  observing  the  visible  motions  of  the  chest  or  abdo- 
iinen,  the  inspirations  are  ennmerated,  and  the  number  in  a  given 
Ltime  determined.    For  this  end,  it  ia  not  necessary  that  the  chest  be 
Ivxposed.    Diminished  frequency  of  the  respirations  implies  a  morbid 
leondition  seated   in  the  nervous  system,  the  respiratory  function 
lT»*ing   affected   secondarily,   or   symptomatica lly.      Increased  fre- 
Iqaency  is  incident  to  various  alTections  compromising  the  function 
of  ha^matosis,  snch  as  pleuritis,   pneumonitis,   phthisis,  and  in  a 
I  notable  degree  to  capillary  bronchitis.     The  number  may  be  in- 
I  creased  from  the  healthy  average,  ranging  between  14  and  20  per 
minute,  to  40,  50,  and  even  60.     Abnormal  frequency  of  the  respi- 
rslions  does  not  necessarily  denote  diflense  of  the  pulmonary  organs, 
tit  is  incident  to  di^iordors  ttfTecting  the  circulation,  anil  to  hysteria. 
In  tracing  it  to  ila  Hourcc,  a  point  of  some  utility  is  the  ratio  which 
[  should  cxi.tt  belwecn  the  respirations  and  the  pnUe.    As  a  rule,  four 
[beats  of  the  heart  Wkc  place  in  health  during  the  time  occupied  by 
[each  respiration.     This  ratio  is  usually  preMrrvcd  in  diwMCS  not 
[involving  the  heart  or  lungs.     A  pulmonary  affection  may  be  pre- 
reametl  to  exist  whenever  an  increase  in  the  number  of  respirations 
I  b  unattended  by  a  corresponding  increase  in  the  frequency  of  the 
f  poise.     Thia  may  he  stated  as  a  maxim  which  will  generally  hold 
I  good ;  but,  of  course,  the  existence  of  pulmonary  disease  is  to  be 
I  determined  in  all  cases  by  evidence  more  direct  and  positive. 
I     The  rhythm  of  the  respiratory  movements  is  affected  differently 
I  in  connection  with  different  morbid   conditions.     The  inspiratory 
t  movement   in  Roniewhut   shortened,  as  a  rule,  whenever   dyspnuea 
exists,  the  want  of  fresh  snpplies  of  air  instinctively  causing  the 
act  to  be  hurried.     Shortened  inspiration  is  especially  marked  in 
emphysema  for  another  reason,  rix.,  the  chest  is  already  diluted, 
and  the  extent  of  its  capability  of  expansion   proportionally  les- 
sened ;  hence  it  is  more  quickly  performed.     This  occurs  in  cases 
in  which  pain  is  produced  by  a  full  or  deep  inspiration,  as  in  pleuritis^ 
intercostal   neuralgia  or   pleurodynia.     The   patient   instinctively 
represses  the  inspiratory  movements,  and  thus,  as  far  as  possible, 
consistently  with  the  introduction  of  siillicient  air   for  hivinatosis, 
shortens  the  duration  of  inspiration.     An  abrupt  arrest  of  inspiriv- 
tion,  with  manifestations  of  acute  pain,  is  a  sign  highly  distinctive 


286 


PnTStCAI.   EXPLOBATION    OP   TBB   OBBST. 


of  the  sfiiectionA  just  named.     Tlie  inspiration  h  also  ahoruacd  t^ 
an  otislruction  in  ttie  larynx  arrealiiig  the  current  of  air  l>t^ 
the  a«l  b  completed.     This  occurs  in  cedemit  glottidis,  in  croup.ui 
ID  spaam  of  tlie  glottis.     On  the  other  hau'l,  tlie  cxpirati»n  ■»  pn- 
longed  in  emphysema,  owing  lo  the  iiupnirod  contractilitv  of  i)« 
long;    in   broucliiliis    attended   with    obstraction   of    th«    simDs 
broncliiHl  lube:<;  nnd  in  vpntim  of  the  bronchial  maseulnr  &bre».0M- 
ttitotiog  aitthiiiu.     The  prolongation  is  great  vhen  the  three  nottnl 
conditions  ju»t   meniionod    are  combined.     Under   tlie«e   cinim- 
tlancu»,  the  difGcally  in  the  performance  of  expiration  is  e«peciallt 
manifent  at  ilic  close  of  the  act.     The  air  ia  expelled  from  the  Imgs 
Tith  a  slovriie^n  which  tnerenses  until  the  act   is  completed.    Ot 
strnction  seated  in  the  lar^x,  throat,  nasal  passages,  or  bronchi, 
is  also  attended  by  prolonged  expiration.     In  all  tbew   mstation 
the  alovnees  with  which  the  air  is  expelled  is  uniform  throngh  iht 
expiratory  act,  in  this  respect  differing  from  the  instance*  in  «iii^ 
the  obstriiotion  arises  from  want  of  contractiiitj,  or  from  obatni^ 
tion  seated  in  the  smaller  bronchial  tubes.     Sibson's  ihlcrTslwni 
show  this  to  be  a  point  of  distinction.' 

To  determine  with  considerable  aoeuraoy  the  relatire  dm 
the  inspiration  and  expiration,  the  following  plan  u  usually  ai 
beating  lime  rapidly  and   rcgiilnrlj  with   the  finger,  ajid  cooBtiif 
the  number  of  brnts  iluring  each  net. 

An  obstruction  within  the  larynx,  trachea,  throat,  or  nasal  pM- 
sage«,  prorenting  the  free  ingress  of  air  into  the  pnlinonary  organic 
occasions  certain  peculiar  mollifications  of  the  thoracic  moTemeaa 
with  the  act  of  inspiration.     The  vacuum   produi^d   by  the  aetiaa 
of  the  inspiratory  muscles  not  being  filled  by  an  nde<|uaie  admimMs 
of  air,  the  preesure  of  the  external  ntmosphere  causes  depreasioe  at 
certain  points  where  the  resistance  is  least.     These  points  are  abon 
and  below  the  elitviv1ct>,  the  lower  piirt  of  the  sternum,  and  anief^ 
laterally  over  the  lowermost  of  the  ribs  attoched  to  the  slemniD. 
Thifi  vfTcet,  reversing  the  hcsllliy  movements  of  the  che»t  with  in- 
spiration, will  be  marked  and  extensive  in  proportion  to  the  degree 
of  obstruction.     If  the  obstacle  to  the  entrance  of  air  be  slight,  the 
lower  portion  of  the  sternum  only  falls  backward.     The  colUpang 
movement  extends  over  the  itidcs  in  proportion  to  the  difficulty  at- 
tending the  ingress  of  air ;  and,  in  extreme  caws,  the  entire  thoracic 

■  On  ibi)  MuvuiDUnU  of  Botpiratioa  In  Diwow. 


lertrntitM 

-J 


UrSPROTIOH. 


287 


I 


Its  am  contracted,  exoeptinf;  tLc  ribs  to  which  the  iliaphra^  is 

ittftcbed.      Owing  to  thi>  acticni  nf  the  (linphmpm,  the  latter  are  still 

oveJ   outwardly.'     An  fxtiepiioii  to  ilic  cITuct  on  the  chest  just 

ted,  occum  when,  from  old  ag^,  the  costal  cartilngcts  hnvo  become 

id  and   unyielding.     Undor   lhi^.'<e  cireuinHiiinccs,  the   thoracic 

alia,  reu(i!tting  the  pro««urc  of  the  Htnioyphcrc,  expand,  and  the 

ibdoinen  retrncls  with  inspiration.     The  effect  of  obiitniction  on  the 

oracic  niovcincnt*  is  espcriiillj  mnrkcd  in  children,  owing  to  the 

eater  Hcsihility  of  the  thoracic  walls  in  early  life.     Continued 

ibfllrnction  in  tins  way  leads  to  pcrinuDcnt  contraction  and  deformity 

or  the  chest. 

In  treating  of  the  respiratory  movcineiit?!  in  health,  it  has  been 
en  that  they  may  be  divide<I  into  different  lypen,  viz.,  ahilominaX, 
imAeotial;  the  In  Iter  being  further  divliihle  iiitu  the  Jw/'crior  and 
the  inffrior  eottal  typn.  The  combinution  of  these  sevcnil  types, 
and  their  relative  predominance,  respectively,  in  other  words,  dif- 
ferent modes  of  breathing,  constitute,  as  already  stated,  important 
physical  evidence  of  disease.  In  breathing  rolantarily  forced,  or 
in  laborious  respiration  from  any  morbid  cause,  all  three  types,  viz., 
abdominal,  inferior  costal,  and  superior  costal,  are  cxeoiplified;  but 
capecially  the  two  latter  become  prominent,  compiircd  wiih  the 
ibituKl  tranquil  breathing  in  the  male,  the  latter  involving  chicGy, 
and  sometimes  almost  exclusively,  the  abdominal  type.  In  cases  of 
^riioniti^  in  which  the  play  of  the  diaphragm  occasions  acutfl 
pain,  the  respiratory  movements  are  in  a  great  measure  restricted 
to  the  thoracic  walls ;  the  breathing  is  costal.  The  same  effect  14 
produced  hy  mechanical  obstruction  to  the  descent  of  the  diaphragm 
from  hydro- peritoneum,  picgnaney,  tympanitis,  or  abdominal  tu- 
mors. On  the  other  hand,  in  cases  of  pleuritis,  intercostal  neu* 
ralgia,  or  pleurodynia,  in  which  the  thoracic  movements  occasion 
Mate  pain,  these  movements  being  instinctively  restrained,  the  ab- 
dominal are  proportionately  increased,  and  the  breathing  is  sitid  to 
b«  abdominal  or  dinphrngmatic.  In  a  case  of  double  pleuritis,  which 
e>me  under  my  observation,  in  which  the  clii'^t  on  both  sides  was 
half  filler)  with  liquid  elTusion,  the  lungs  tirmly  adherent  above  the 
level  of  the  fluid,  the  type  of  breathing  waa  almost  exoli)»ively 
superior  costal.  The  respiratory  movements  at  the  summit  of  the 
che»t  were  remarkable.     It  !«  a  repetition  to  state  that  the  superior 


PBTSICAL    EXFLOBATIOJI    OP   TBB    CDBST. 

c<o«ta1  tTpe  of  br^allting.  Ed  bcalth.  is  eicmplified  mneb  men  in  At 
female  than  in  the  malp.  In  psnilf  «is  sficcting  the  co»ta]  Dn»d« 
tb«  abdominal  tjpe  of  respiratioD  brccmcs  strongly  marked. 

DisparitT  between  the  two  sidos  of  the  chc*l,  aa  rr^pecta  the  nt- 
piratorv  morements.  coostitnie?,  in  totne  in!tancc«.  important  dii|^ 
Dostic  endence  of  di»a««.     In  the  dtlaution  of  ibe  chest  do  m» 
aide  from  larjE;e  liqaid  efftuton.  the  movements  on    thxt  aide  an 
notablj  dimiDUhcd,  uid  maj  be  almost  n(dl.  whilst,  on  the  oppoiila 
side  they  are  sapplementarilv  increased.     A  amil&r  disparity,  bM 
nerer  to  the  same  extent,  exists  in  some  cases  of  empbyseaiL  ta 
which  the  affection  if  more  marted  on  one  side.      The  same  ooDtraft 
exists  in   pneumo-h^rdrothorax.     In  simple  pneumonitis,  affectii^ 
either  the  upper  or  lower  lobes,  the  respiratory  movements,  m  s 
certain  proportion  of  cases,  are  obnousty  restrained ;  and  this  ii  M 
be  ol>«erve<l  afii-r  ucute  pain  has  ceiiHetl,  or  in  cases  in  which  thu 
sjmplom  ia  not  present.     This  was  denied  by  Laoonec ;  but  a  ean> 
ful  comparison  of  the  two  sides,  in  a  aeries  of  cases,  mast  conmee 
any  one  of  the  correctness  of  the  statement.*     A  local  disparity  u 
the  sammit  of  the  chest  is  sometimes  a  highly  significant  ago  of 
tuberculous  dJMase.    The  superior  eoKtal  movements,  owing  to  pU*" 
rittc  adhesions,  or  other  rauses,  in  some  iostanceK  are  notably  ItM 
on  Iho  »idc  in  whiph  a  tuberculous  deposit  exists,  than  on  the  opp«- 
rile  side.     This  will  be  more  manifest  if  the  respiration  be  labored, 
00  as  to  call  into  action  the  superior  costal  type  of  breathing.    It 
nay  be  obfious  if  the  respiration  be  forced,  when  tt  it  Dot  appareal 
with  tranqnil  breathing.     It  will  be  more  marked  in  females  than  in 
malcft.   owing  to  the  superior  costal  type  being  more   promiiKat 
in  them  than  in  males,  irrespective  of  disease.     An  iospectioii  «f 
the  chest,  with   reference  to  a  careful  comparison  of  the  relslin 
mobility  of  the  two  sides  at  the  sammit,  is  a  point  not  to  be  omittol 
in  an  exploration  for  eridence  for  or  against  the  existence  of  lahcr- 
cnloas  disease.     Tlie  diagnoatic  value  of  this  sign  of  course  defoA 
on  the  assumption  of  equality  in  the  movements  of  the  swnBil  tt 
the  chest  in  health.     As  the  rule,  provided  the  two  sides  besyv- 
metrical  in  conformation,  this  may  be  assumed;  bat  in  making  (!• 
aminHtions  of  persona  presumed  to  be  free  from  disease,  I  hare,  is 
«.  few  instances,  ob»ervcd  a  slight  disparity  in  that  sitaation,  asvtO 


■  Lk^nniK,  It  U  l«  !>•  r«ni«rk«<l,  paM  vcrj  liltl«  att««ti»n  ta  Ui«  pbjtii*!  ■$« 
derived  frixn  inipcctioa.  IiidM>d,ba  declared  that  iha  ochIm  <iaiaFialka  «f  fc 
eh«M  with  r«fWTcn<«  to  the  rttflrUorj  bdotciiimiu  i*  of  very  little  niJIlt;. 


IXSPBCTIOM. 


28» 


It  tbe  lovor  pnrt  of  tliv  chest.     Id  vwvi  of  tliMo  occasmttal  ex- 
foeptions  to  tltc  general  rule,  a  dii^parity  in  mobility,  as  an  Uolat«d 
rign,  ahoald  be  distriutei);  bnt,  asoociati'd  with  other  signs,  it  ia 
titled  lo  considerable  weight.     Finally,  a  marked  disparity  in  the 
rements  of  the  two  sides  obtains  in  cases  of  spinal  hemiplegia. 
The  scapuUe,  in  health,  in  forced  respirations,  are  more  or  Icsa 
raised  with  the  act  of  inspiration;  and  diminished  or  arrested  elova- 
tion -movement  of  the  scapula  on  one  side  is  a  morbid  sign  of  some 
ralue.     This  tiign  i.t  observed  in  cases  of  pleuritie  with  effusion,  of 
I  pneomo-hydrtilhoraic,  in  some  cases  of  pneumonitis,  and  when  one 
ia  oontractud  as  a  »vt{ufi  of  pleuriua.     It  is  also  observed  in 
De  cases  of  tuberculosis,  and  it  is  chieHy  with  reference  to  the 
'  ftfTedton  last  nam«i)  that  the  sign  is  of  value ;  it  belongs  in  the  col- 
lection of  signs  which  arc  cotnbinvd  in  making  the  diagnosis  of  this 
.  affection. 


Sdmmaht. 

Tl)c  phenomena  determined  by  inspection  embrace  morbid  appear- 
ances pertaining  (1),  to  the  size  and  form  of  the  chest;  and  (2),  to 
the  respiratory  movements.  The  morbid  appearances  pertaining  Ut 
site  and  form  are  resolvable,  for  the  most  part,  into  enlargement 
and  contraction,  both  of  wliich  may  be  general,  i.  r.  extending  over 
the  chest  at  least  on  one  side;  or  partial,  i.  «.  limited  to  a  portion 
of  the  chest  ou  one  or  both  sides. 

General  enlargement  involves  either  augmented  volume  of  (he  long 
OD  one  or  both  sides,  or  the  prcseoee  of  liquid  or  air  in  one  of  the 
pleural  cavities.  To  the  former  of  these  annlnmiciil  conditions  is  due 
the  enlargement  in  cases  of  cmpliyseniii,  which  affects  both  sides  of 
the  chest.  Enlargement  of  the  chest  from  emphysema  is  moat  marked 
at  the  superior  and  middle  portions  of  the  chcKt  anteriorly;  and  the 
fturface  rarely  presents  a  uniform,  regular  dilatation.  A  more  fre- 
qncnt  anatomical  condition  giving  rise  to  general  enlargement  is 
the  aecnmulatioD  of  liquid  in  the  pleural  sac  in  cases  of  chronic 
picuritis.  General  enlargement  from  this  cause  is  necessarily  con- 
finctl  to  one  side.     The  dilatation   from  tho  pressure  of  liquid   ifl 

■  more  uniform,  and  the  surface  of  tho  chest  presents  a  more  regular 
appearance.  The  intercostal  depressions  are  effaced,  in  chronic 
plcaritis,  where  they  are  normally  most  conspicuous,  viz.,  anteriorly 

■  and  laterally  at  the  lower  part  of  the  chest.     In  this  situation  llicy 
I  are  rmrely,  if  ever,  effaced  by  the  pressure  of  an  emphysematous 

L        


T9TftCAt. 


iftATi*s  ar  Tss  cmist. 


>«f  A«i 


GcM0«l  esbrgcnot 
ks  eetin  -t^^ 

to  CT»pllJTI», 

It  »  abe  iiriJaa 
of  tbe  ^itm; 
t  «f  tW  Gtct  ;  pcHcuAu, 
'«f  Ai  kMrt;  ■iiiMiwil  cad  mW 


rftfc* 


•r  Ik* 


,nsi^ldesrt«,th«< 


frMi  coOmpM  of  »  Me 
Gig  to  it;  it  miettmpr 
tbI—ii  wcett dins  p<»8— ' 
b  sqr  alM  coexist  with  dihul 
abora  »ad  Mow  the  cUvid* 
bnsg  iacfdcst  to  the  earty 
rcfrcfaent  mad  more  nwrkcd  ia 
It  foHovB  tbe  renoTml  of  fivvxti 


I.    ftetad 

■AWtaoMsor 
■taf*  a  MBC  UMtMw%  Ut  it  i* 
••  idTSBced  period  of  Uw  ttt»u 
cfiaioo,  attend*  limited  adhpsf,  uid  the  redaction  in  the  Tolanc  of 

Increase  fre^aeaey  flf  the  rfir»tiiiai  n  incident  to  sffectJou 
c«mpromiBiag  the  laaetiea  nf  beaatMiii  aad  i>  therefore  obsemd 
in  plearitis,  poeanooitia,  phttuss,  and  c«pemllj'  in  cftpillar;  hnn- 
chittB.  Ocearriag  oftener  tbut  in  (be  rm6o  of  one  to  four  beats  of 
tbe  heart,  palawnsry  disease  of  some  kind  is  gcaerallj  indicated. 
Tbe  inspiration  is  shortened,  as  »  general  mle.  in  djepnoes.  It  mij 
beairesied,  before  the  act  tsoompleted,  bjanobstmctionofthcFiml- 
pipe,  and  is  rolmitarit;  arrested,  to  eooseqaence  of  pain,  in  plenriti* 
and  intercostal  neuralgia.  It  is  abort  id  etnpbTsema,  owing  to  lh< 
permanent  expansion  of  tbe  cbest.  The  expiration  is  prolonged  in 
enphyMfea,  owing  to  tbe  diroinisbed  elasticity  of  tbe  long,  and  in 
cases  of  obstmction  in  tbe  air-passages.  If,  owing  to  obetroetioQ 
in  any  part  of  the  air-passages,  tbe  air-cells  are  not  filled  propor- 
tionably  to  tbe  enlargement  of  tbe  cbeet,  tbe  act  of  inspiration 
causes  depression  of  the  thoracic  walls  at  certain  points,  ris.,  abon 
and  below  the  clavicles,  and  laterally  and  anteriorly  at  tbe  loirer 
part  of  tlie  chest.  This  is  more  marked  in  children  than  adaiis, 
and  is  one  of  llic  cauaea  of  defonnily  of  the  chest.    The  respiratioD 


4 


IK8PECTI0H. 


291 


i  sbnonnalW  tfaoracic  or  costal,  whpn  the  plaj  of  the  diaphragm  is 
Dlamaril;  restrained  in  consequence  of  the  paio  which  it  occasiona 
I  peritonitis,  and  when  its  descent  is  prevented  mechanically  in  tym- 
litGS  and  asciteH,  by  tumors,  and  in  pregnancy.   Abdominal  or  dia- 
BgiBatie  respiration  ia  marked  when  the  thoracic  movement«  occa- 
;  differing  in  pleuritla  or  intercostal  neuralgia,  and  in  paralysis  of 
lie  cosul  muscles.    In  health,  the  type  of  respiration  in  the  male  is 
rcbiefly  abdominal;  but  whenever  tlie  breathing  iit  labored,  the  info- 
[rior  and  costal  types  are  also  manifested.     When  the  chest  on  one 
Bide  is  greatly  dilated  in  chronic  pleuritis,  the  side  affected  is  nearly 
lininiorable,  the  movements  on  the  unaffected  side  being  supplement- 
rily  increased.     The  same  disparity,  but  in  a  less  degree,  may  be 
Eexhibiled  in  cases  of  emphysema  in  which  the  affection  is  mor« 
larked  on  one  side.     It  is  observed  in  pneumo-bydrotborax.     A 
lisparity  in  the  respiratory  movements  of  the  summit  of  the  chest  is 
ometimes  a  valuable  sign  of  tuberculona  disease.    In  cases  of  spinal 
hemiplegia,  the  movements  of  the  chest  on  the  paralyzed  side  of  the 
body  are  diminished,  and  those  on  the  oppo.4ite  side  increased.     Di- 
minution or  arrest  of  the  elevation-movement  of  the  scapula  on  one 
side  occurs  in   pleuntis,  pneilmn-bydrotborax,  pneumonitis,  when 
tbe  chest  is  contracted  after  plcuritis,  and  in  some  cases  of  tuber- 
culosis.    Its  value  as  a  morbid  sign  is  chiefly  in  tbe  diagnosis  of 
itaberculous  disease. 


HlBTORT. 

Inspection  was  doubtless  resorted  to,  in  the  investigation  of  dJs- 

B,  from  the  earliest  date  in  the  history  of  medicine ;   but  the 

■potse  given  to  the  subject  of  the  physical  exploration  of  the  chest 

llty  tbe  discovery  and  researches  of  Laennec  led  practitioners  to  em* 

Iploj,  to  a  much  gn'ater  extent  than  previously,  and  with  vastly  more 

advantage,  thia  method  of  exiinii nation.     The  value  of  rciiults  ob< 

tained  by  inspection  is  very  greatly  enhanced  by  their  asaooiation 

■»ith  the  phenomena  fiirni!<heii  by  other  methods,  more  especially  by 

peroossion  and  auscultation. 


Aimirmt 
in  aaewtf 

WttWttn  Offt" 

cawtndH 

K&I* onnccted  <nlk  A*  naB^BMt.  AeoapwisMBf 
I  if  Ibt  ta*  ailBtM*^  ^Biii^nth  dw  cue,  aq 
hAi«»*yWhirriBHi  ft  >««uii,  maw  finMliiiiii  are  mn 
cuvUIt  obOTciwl,  Meb  w  pbog  tfcc  ulnaitinaf  tW  . 

i  to  Miks  Bvitsr  pnant*  ^  •oe  (id*  tia*  <■ 
tfc*  oikw,  tW  iMiihi  «9  b>  EkrW  ta  W  fafiMm* ;  n4  in  vicv  «f 
iHt  fiiUitj.  pwCnl  nhagoMBCi  «r  amttmedam  la  oac  lide  in 
r  iifwfMfnTy  ayywirtrf  fcy  flBfmw  with  the  i 


HSNSURATIOK. 


2d3 


difference  between  the  two  sides  in  any  of  the  diameters,  ^ufficiont 

Ito  become  an  important  physical  sign,  is  apparent  on  careful  ex- 
oiiiiiiton  Krnl  comparison  by  inspection.  It  is  chiefly  in  noting 
tt»  for  tiniilytioal  invcstij^ation,  tliat  an  exactnesB  of  measurement 
by  thix  or  «lht*r  modes,  which  can  be  expressed  numericftlly,  is  do- 
uriiblc.  For  examinations  with  a  view  simply  to  diagnosis,  it  is 
lot  rc*)iii^it« ;  anil  this  being  the  case,  the  objections  to  the  use  of 

l«n  inKlriimcnt,  cumbrous  and  somewhat  formidable  in  appearance, 

Lluvc  justly  precluded  itn  inlrodiiction  into  private  practice.     I'hc 
iriations  in  size  obtained  by  this  mode  of  measuremenl  are  those 
already  noliocd  under  the  bead  of  Inspection,  viz.,  on  the  one  band, 
■largcmcnt,  general  and  piirtial,  due  to  emphysema,  pleuritic  effu* 

Itton,  etc.;  and,  on  the  other  hand,  contraction,  incldeut  to  recovery 

{from  pleiirili.4,  tiiberoulo»i!<,  etc. 

Another  application  of  mensuration  consists  i»  measuring  di«- 
tancei   on   the  surface  of   the  <:be.tt,  between  certain   promincDt 

I  anatomical  points.  For  example,  the  nipples,  in  a  che«t  perfectly 
symraeirioal,  of  an  adult  male,  arc  situated  on  the  fourth  rib,  or 
iuteriipaee,  eiiuidislant  from  the  centre  of  the  Bternum.     Ealnrgo- 

'  meat  of  one  side  in  connection  willi  morbid  conditions  which  b»TO 
been  already  mcolioned,  rcmorcx  the  nipple  on  the  afiVcted  side  to 
II  greater  distuncu  from  the  mesial  Udc,  at  the  Hamo  time  raiding  it 
abore  the  lerel  of  the  other.  Contraction  of  the  chest,  on  the 
other  hand,  diminishes  the  distance,  and  depresses  it  below  its 
natural  situation.  The  extent  of  these  changes  may  be  accurately 
measured.  The  distance  from  the  posterior  margin  of  the  scapula 
to  the  spinal  column  is  increased  when  the  chest  is  dilated,  and  di- 
minished when  the  chesi  is  contracted.  In  the  first  instance,  the 
inferior  angle  of  the  scapula  is  observed  to  be  elevated  above  the 
level  of  Lliut  on  ibe  unaffected  side;  and,  in  the  second  instance  to 
be  lowered.  These  deviations  from  symmetry  incident  to  disease, 
may  be  accumtety  ascertained  by  comparative  measurements.  The 
extent  to  which  the  ribs  arc  sep-iratuil  or  approximated  by  different 
morbid  conditions  may  alxo  be  meiutured.  Xu  recording  cases,  it  \$ 
well  to  express  the  amount  of  dispurity  between  llic  two  sides,  u 
reepects  the  points  just  mentioned,  in  figures ;  but  so  far  as  con- 
cerofl  the  bearing  of  the  facts  on  diaguuKis,  such  precision  is  tupcr- 
fiuoua.     The  facts,  as  estimated  by  the  eye,  arc  sufficiently  exact. 

Another  mode  of  practising  mensumtiou,  eonsistH  in  measuring 
the  horitotttal  circumference  of  the  chest,  and  compariug  the  two 


2M 


pnreiciL  explokatios  of  tbb  cbbst. 


Inita  in  tliis  respect.     Thb  maj  be  dooe  vithtmt  difEcnltT.  It  ststt 
of  a  eonmoa  Upe  or  cord,  with  the  aid  at  an  snistanl,  if  th«  puieu 
be  able  to  be  raised  to  a  sitting  posture.     The  cord  or  tap«  te  paael 
aroB&d  the  chest  just  below  the  acapnia,  ooe  cttd  being  anwni^ 
fixed  to  tilo  meaial  line  over  the  aterasa   in  fVoot.     After  ha^ 
ercnl;  adjiuied  with  eqaal  pressure  on  both  ndea,  taking  pniatt 
MC  that  thr  direction  is  as  cirenlar  as  posaible,  mi  nannnDt  rnaAk 
the  point  at  which  it  crossea  the  sptnoos  prooeas  of  the  Tnttlm 
with  ink,  or  hj  inserting  a  pin.     The  point  meeting  the  cxtnvR; 
fixed  at  the  centre  of  the  st^mum  is  also  marked.     The  data  fir 
determining  the  circumference  of  the  whole  chent,  and  that  of  ttA 
eide  arc  in  thin  way  obtained;  and  Mnce,  practically,  the  i^tef  li- 
ject  is  nsaally  to  compare  the  two  sides,  it  snfSces  to  doable  the  e«H 
or  tape  from  the  point  at  which  it  croaked  the  »pinc,  and  acceftaiB 
how  much  one  portion  exceeds  the  other  in  length.      In  place  of  a 
common  cord  or  tnp«  (which  answen  every  purpose  if  other  mmat 
are  not  at  hand)  a  gruiiuuted  measure,  such  a«  tailors  oee,  vuj 
employed.     The  Mmi-circmnrcreiice  ni  cnch  ai4le  is  sometimes 
eared  separately ;  but  a  difficulty  in  the  way  of  accuracy  arises  froi 
the  liability  of  the  cheat  not  being  equally  expanded  while  the  net- 
earcmcnts  of  the  two  sides  arc  taken  in  succcsition.     This  diSenltf 
may  in  a  great  tncasorc  be  obviated  by  requesting  the  patient  u 
take  a  deep  iriApiration  as  each  »idc  is  measured,  and  to  hold  the 
breath  unlil  tlje  measurement  is  inadt*.     The  best  plan,  boweTer.is 
l9  we  two  graduated  tapes  joined  together,  the  scale  of  inches  ai 
fraction  of  inches  commencing  on  each  tape  at  the  line  of  junction. 
One  great   advantage  of  the  latter  plan  is,  it  may  be  applied 
while  the  patient  is  recumbent.     The  point  of  junction  boing  Gx«d 
over  the  spine,  and    the  two  tapes   brought  forwnnl,  the  circns- 
fercnco  of  each  side  is  shown  by  a  glance  at  the  centre  of  the 
sternum.      Comparison  of  the  semicircular  measurements  of  the 
two  sides  enables  the  vxnmincr  to  form  an  idea  of  the  extent  ts 
which  the  dimensions  of  ouc  side  arc  cither  increased  or  diminttlMd 
by  disease;  but  the  actual  ditlcrcnco  of  size,  it  is  to  be  borne  in 
mind,  does  not  represent  exactly  the  amount  of  a  morbid  incretie 
or  diminution,  since,  a&a  general  rule,  the  two  sides  are  uormallj 
une<[aal.     In  the  majority  of  persons  the  right  semi-oircumfereites 
cxccwd«  the  left,  the  mean  disparity  being  about  half  an  Joch.    Is 
a  small  proportion  of  Individuals  the  two  sides  arc  C(|nal,  and  in  a 
few  instances  tJie  left  senii-cireumfcrcncc  exceeds  the  right.     Th* 


MBKKITItAIIOir. 


295 


I 


kttfr  is  found  to  occur  ortener  among  luft-hnndvd  periODf.  Oving 
thcfv  Dftturul  differences  tlio  fact  of  n  disparity,  as  shown  by 
i mensuration,  if  H  be  but  tmuU  or  moderate,  does  not  neoesearUy 
'denote  disease.  To  become  a  morbid  sign  it  is  to  be  taken  in 
connection  with  other  signs,  unless  the  dispariiy  exceed  the  range 
of  normal  variationa;  and  if  this  be  the  case,  comparison  of  the 
two  sides  bj  inspection  sufliden  to  eatabliHh  th£  existence  of  morbid 
Iftrgemeiit  or  contraction.  Mensuration  under  these  circum- 
ices  only  aflsiHta  in  forming  a  closer  estimate  of  the  extent 
of  tlic  deviation  from  the  normnl  dimensions,  a  point  not  without 
interest,  but  not  ei«ciiti«1  lo  diagnosis.  Moreover,  mcnsurement  of 
tbe  horizontal  circumference  of  the  chest  affords  evidence  only  of 
■general,  not  of  partiitl  enlnrgement  or  contrnction  of  one  side. 
Partial  projection  or  depression  may  exist  without  a  corresponding 
increase  or  diminution  of  the  scuii ■circumference  of  the  side  affected, 
sod  under  theic  circumHtnnces  the  latter  must  he  determined  by  in- 
spection, or  by  the  cnllipors.  The  advantage  of  circular  measure- 
ment does  not  relate  to  the  determination  of  the  existence  of  a 
morbid  disparity  in  size  between  the  two  sides,  so  much  as  to  another 
object,  vix.,  to  ascertain  the  variations  in  the  amount  of  morbid  in- 
erase  at  different  periods  in  the  same  ca§e.  This  object  has  refer- 
ence mainly  to  a  single  disea§e,  viz.,  chronic  pleuriiis,  including 
empyema.  Mensuralion  employed  daily,  or  at  intervals  more  or 
less  brief,  during  the  continuance  of  this  disease,  the  result  being 
noted,  affords  exact  information  respecting  the  progress  in  the  accu- 
mulation or  removal  of  the  liquid  effusion.  Tbe  practitioner,  in 
other  words,  is  able  to  determine  with  precision  whether  the  ({uantiry 
of  effusion  be  increasing  or  lessening,  or  stationary.  Information 
on  these  poinLi  may  also  be  derived  from  inspection,  but  not  to 
promptly  and  leas  accurately.  The  positive  or  negative  effects  of 
different  therapcuticnl  measures  are  demonstrated  in  this  way  by 
the  ^Tidencc  afforded  by  mensuration,  and  in  this  point  of  view 
meMoremcnls  repeated  more  or  less  frequently  are  of  not  a  little 
utility  in  regulating  the  treatment.  These  remarks  with  reference 
to  pleuritis,  are  measurably  applicable  to  pneumo-hydrothornx,  and 
to  some  extent  to  emphysema.  The  progress  in  the  slow  expaDsion 
of  the  che.-'t  after  the  contraction  which  immciiiately  follows  the 
removal  of  liquid  effusion,  may  also  be  determined,  from  time  lo 
time,  by  measurements,  with  greater  precision  than  by  means  of 
ocular  examinations. 


296 


PHTSICAL    BXPLORATIOK    OF    TBS    CRBST. 


The  foregoing  remarks  bare  rer^riMicc  to  *  compsrwoa  of  ik  m 
sides  of  Uiv  ctiest,  bj  means  of  which,  a^  has  been  stated,  naAH 
alt«ralioiu  in  sixo  arc  nsoally  d^^tenoined.     Aboorina]  dcriatieuii 
this  re«peeL  u  io  other  points,  are  not  aacertained   bj-  referente  to 
any  fixed  criterion  or  average,  but  the  chest  on  one  side  is  tskas 
as  the  healthy  standard  peculiar  to  the  iodividital.     The  Tariniou 
in  the  site  of  the  chest  are  so  great  within  the  limits  of  bealtb,  dm 
meao  dimensions  obtained  by  a  »cri<vt  of  mc««Drcmcnt8  ar«  of  fitilt 
value  in  estimatiag  the  changes  due  to  diseaae.     The  horiiotiia]  cs- 
camference  of  the  whole  cheat,  i.  t.  of  both  sides,  maj  nbge.  ac- 
cording to  Wabhe,  between  twenty-seven  and  forty-foor  inchti; 
the  mean,  in  the  adalt  male,  being  about  thirty>thrcc  inches.     yUA 
GOch  an  oxteDsive  range  between  the  exlrccnes  of  health,  it  is «( 
little  raloe  to  take  into  consideration  the  united  dirocDnons  of  tW 
two  aides  in  determining  the  existence  or  the  nature  of  disease;  tW 
disparity  between  the  sides  is  the  point  to  be  considered.     The  re- 
Marches  by  M.  Woillex,  however,  hare  led  to  some  interesting  re- 
cults  as  respects  the  changes  in  the  general  capacity  of  the  tborai 
which  are  to  be  observed  during  the  career  of  acute  disease*,  ^cst 
results,  expressed  as  concisely  as  possible,  are  as  follows:' 

Examined  by  mensuration  at  diiferent  stages  of  tlio  course  of  dif- 
ferent acute  aiTections,  accompanied  by  well-marked  febrile  raoT» 
nient,  the  size  of  the  chest  is  found  to  present  almost  constantlj^H 
series  of  changes.  The  changes  may  be  arranged  in  three  peri*^^ 
which  follow  in  regular  encceission,  vis.,  Erst,  progressive  enlarge- 
ment.  next,  a  stationary  period,  and  lastly,  a  gradual  return  to  the 
normal  dimensions.  These  three  penoda  are  of  variable  duration, 
corresponding  to  the  varying  course  and  character  of  different  affee- 
ttons.  The  alterations  in  capacity  arc  nccompnoiod  by  propor 
tionulc  modifications  of  the  elasticity  of  the  thoracic  walls.  Tb* 
elasticity  diminishes  as  the  enlargement  increases,  and  again,  gradu- 
ally returns  to  the  normal  degree  a«  the  chest  rcsomes  its  natural 
size.  The  extent  of  enlargement  varies  from  thre«-fiftlu  of  an  inck 
to  a  little  over  three  inches,  the  mean  increase  being  about  otw  aad 
a  half  inches.  In  the  exanthematous  fevers,  the  enlargement  it 
shorter  in  duration  than  in  other  acute  affections ;  and  in  variola 
especially,  a  return  to  the  normal  size  takes  place  prior  to  the  cob- 
pleto  development  of  the  eruption.     Particular  causes,  affecting  the 


*  Tttili  de  DtngaiMlic  IKdivKl,  par  Bacl«. 


HSNSDRATIOH. 


297 


uUr  eonrw  of  nn;  acute  airri;lion,  idbj  disturb  the  rpguUntj^  of 
le  siirecssion  of  the  several  periods  imo  wliich  tlio  alteratloDS  of 
lOracic  cnpactty  nrv  Jividoil.  Tlic  eiilnrgcmt'nt  of  the  cheat,  and 
i«  diininiHhe<l  clusticity,  arc  nttributcd  by  M.  Woillez,  to  pulmonarjr 
ngci^lioD  accoinpiinving  tbc  development  and  career  of  acute  af- 
ection«.  Thcso  changes  in  the  sixe  of  the  chest,  revealed  b;  meu- 
.ration,  be  regards  as  evideuco  that  pulmonary  congestion  is  ao 
important  element  of  all  acute  diseases.  iMcnsuration  enables  the 
praeiiiionor  to  observe  the  extent  and  progress  of  ibis  element.  In 
degree,  the  enlargement  sostains  no  constant  relation  to  the  fre> 
n«Qoy  of  the  pulse;  and  it  is  affected  neither  hj  bloodletting,  nor 
gtstrO'intcstinal  evacuations,  nor  by  any  course  of  alimentution. 
The  prcftenoc  of  gas  in  the  sloiuaeh,  in  vunnble  quantity,  is  a  cause 
of  variation  in  the  i\xe  of  lite  chest,  not  to  bo  overlooked.  Pro- 
'Meire  emaciation  i»  tinother  enuac  of  diintnisLied  siao  by  meosa- 
itioD,  vhicb  i»  to  be  distinguished  from  the  effect  of  the  reduced 
Tolume  of  the  pulmonary  organs.  Occasionally,  irregular  oscilla- 
tions in  the  amount  of  pulmonary  congestion  appear  to  occur,  giving 
ris«  to  variations  in  the  thoracic  capacity.  But,  as  a  rule,  increaa- 
ing  enlargement  of  the  capacity  of  the  chest  denotes  a  progreesiv« 
development  of  the  disease,  a  stationary  condition  of  enlargement 
indiatte^  k  peisiating  acuteness,  and  a  decrease  in  the  dimensions 
of  the  chest  often  precedes  the  symptoms  and  other  signs  which 
afford  evidence  of  commencing  resolution  of  the  malady.  These 
conclusions,  purporting  to  have  been  deduced  from  a  series  of  meas- 
oremcnts  in  a  variety  of  acute  affections,  aro  striking,  and  not 
unimportant.     Of  their  correctness,  I  am  unable  to  speak  from 

rpenwunl  obscrvaliuus. 
S.  Mensuration  with  rrfsbbhoi  to  Abnohmal  AtTBRATiosa 
19  TBB  BXTBXT  OF  Kn.-^PiKATOST  MovEucxTs. — Measurement  of 
tb«  extent  of  motion,  at  different  portions  of  the  chest,  involved  in 
the  respiratory  acbt,  is  made  by  instruments  which  have  been  already 
dncribed.  By  means  of  the  "chest-measurer,"  invented  by  l)r. 
Sibson,  movements  in  a  ditimetricjil  direction  may  hv  determined 
with  great  accuracy.  A  great  number  of  examinations,  with  tho 
aid  of  this  instrument,  enabled  Dr.  Sibson  to  arrive  at  interesting 
and  important  results  respecting  tito  actual  and  relative  extent  of 
the  motion  of  different  parts  of  the  chest  in  health,  vrith  the  pecu- 
liarilies  incident  to  sex,  age,  etc. ;  and,  also,  the  effects  of  different 


I 


298 


PHTBICAL    BXPLORATIOK    0?    TBB    CSCST. 


fonns  of  disease,  in  moilirying  the  nortnnJ  respiratorr  iDo»ptr",'i 
The  naore  important  of  the  facta  deduced  by  Ur.  Sibaon  h*^^  ':  ■: 
already  referred  to  in  the  introduction  to  this  work,  and  under  tli 
head  of  Inspection,  in  the  preceding  chapter.  Dr.  SihMn'l  ia- 
gcnious  instroinent,  howuver,  only  measures  the  forward  mavtmtta 
of  the  che»t.  It  does  not  show  the  actual  amoant  of  expaiWTC  so- 
lion.  For  this  end,  the  "  stetbomclcr"  of  Dr.  Qusin  iii  prefcnbk. 
Moreover,  the  luttt-incntioncd  inMrument  it  lc«H  cumbrous,  and  a 
applied  with  much  greater  facility.  The  valae  of  both  ehiid; 
relntv8  to  scientific  rexcarches,  in  which  it  i«  convenient  to  cxpm* 
the  rcvults  of  ohservations  with  numerical  exactness.  For  ordiasij 
clinical  objiMils,  thi«  is  not  necessary.  It  suffices  to  determine  tW 
existence  of  certain  abnormal  modifications,  without  ssc^rtai&iag, 
with  Brilhmctieal  precision,  the  extent  of  the  deviations  from  heattk 
This  information  is  furnished  by  inspection.  Mensuration,  vili 
reference  to  the  respiratory  movements,  is  even  less  eeseotial,  aad 
less  resorted  to.  than  with  reference  to  deviations  in  size.  Ocolir 
examination,  comparing  carefully  the  two  sides  of  the  chest,  ettthla 
the  observer  to  distinguish,  without  difficulty,  an  amount  of  abnorstl 
alteration  in  the  respiratory  movements,  sufficient  to  constitutes 
physical  sign  of  disease.  When  it  is  desired  to  confirm  the  evideMc 
which  the  eye  discovers  by  resorting  to  measurement.  Or.  Qaain*i 
fitetbometer  is  convenient.  To  measure  partial  movements,  tins  or 
some  analogous  instrument  is  reiioired.  Itut  to  ascertain  the  amouai 
of  expansive  movement  of  both  sides,  or  of  the  two  sides,  separately, 
in  order  to  institute  a  comparison  between  the  two,  it  is  sufficiently 
accurate  for  practical  purpoaes  to  take  the  circular  dimensions  wiik 
the  graduatc<l  tape,  first  during  a  full  inspiration,  and  next  after  % 
forced  expiration.  According  to  Hutchinson,  the  average  range  tf 
motion,  as  thus  osctirtaincil,  in  persons  of  middle  stature  and  wei^it, 
is  about  three  inches,  seldom  umouoliug  to  four  inches.  If  the  cir- 
cumference of  the  two  sides,  when  fully  dilated,  and  subsequently 
when  contrucUKl,  be  obtained,  the  simple  rule  of  enhtraclion  gives 
the  range  and  expansibility  nt  the  part  of  the  cbest  where  the  cir- 
cular measurement  was  mndc.  The  expaneibility  of  each  side  bemg 
in  the  same  way  ascertained,  n  comparison  of  the  two  sides,  »»  n- 
epects  the  amount,  of  course  gives  the  extent  td  which  the  tDOve- 
ments  on  one  side  are  abnormally  diminished,  or  on  the  other  side 
increased,  or,  ap;nin,  what  is  oftcuer  the  case,  diminished  on  one 
side,  and,  at  the  same  time,  increased  on  the  other  side.     The  effect 


UBNSURATIOV. 


290 


>f  disease  on  the  ri-spirslorjr  movcrncats  is  most  »trikiiig1j  oitetnpli- 

led  in  cases  of  chronic  pteuritis  with  large  effusion.     As  Mated  1>; 

IHValsbc,  the  di0V>rcnce  between  the  fullest  expiration  nud  the  fullest 

in^iration  on  the  side  affected,  maj  not  eiceed  one-sixtconth  of  an 

itcb,  while  the  other  eide,  in  consequence  of  its  movements  being 

isupplement&rilj  increased,  may  show  a  dlBerencc  of  two  and  a  balf 

iches, — an  extent  as  great  as  the  movements  of  both  sides  onited, 

'in  health. 

The  Tarioiia  forms  of  disease  which  occasion  notable  modifications 
BvT  the  respiratory  movements,  have  already  claimed  consideration  in 
B  connect  ion  with  the  subject  of  inspection.  To  consider  them  in 
Hconncction  with  menMir»tion,  would  involve  a  repetition  of  the  facta 

■  contained  in  Cliapter  IV,  to  which  the  reader  is  referred. 

H      Mensuration  miiy  be  extended  to  embrace  the  measurement  of  the 

■  capacity  of  the  chest,  as  regards  the  ([iiantity  of  air  which  it  is 
y  capable  of  receiving  with  inspiration,  and  expelling  by  the  act  of 

expiration.  An  instrument,  called  the  tpirovieter,  invented  by  Dr. 
Hutchinson,  is  designed  for  this  purpose.  This  instrument  has  been 
already  noticed  in  connection  with  mensuration  of  the  chest  is  health; 
and  in  that  connection,  ila  application  to  the  study  of  disease  was 
incidentally  oon&idercil.  In  view  of  the  extensive  range  of  capacity 
within  the  limits  of  health,  and  also  of  the  fact,  that  the  ijuantity 
of  air  which  can  be  voluntarily  expelled  from  the  lungs  is  subject 
to  considerable  variations  from  causes  irrespective  of  the  condition 
of  the  pulmonary  organs — causes  affecting   muscular  power — the 

■  utility  of  the  spirometer  in  the  diagnosis  of  disease  ia  very  limited. 
The  information  which  it  is  capable  of  affording  is,  for  the  most  part, 
n^alive ;  that  is,  if  the  vitul  capticily,  adopting  tlie  expression  usmd 
by  Hutchinson,  be  great,  it  is  presumptive  evidence  that  intra- 
thoracic  dit^ense  do(»  not  extitti  but  found  below  the  average,  it  is 

I  by  DO  means  proof  of  the  existence  of  pulnioniiry  diseoae.  ErcQ 
when  tlic  existence  of  disease  is  positively  indicated  by  this  mode  of 
mensuration,  it  furnishes  no  indications  of  the  nature  or  scut  of  tlie 
morbid  condition.  If  the  vital  capacity  of  an  individual  in  health 
have  been  ascertained,  whether  it  be  great  or  small,  so  long  as  it 
continues  undiminished,  it  may  be  rationally  inferred  that  the  lungs 

»  remain  free  from  disease.  With  reference  to  such  a  comparison,  it 
is  desirable  that  persons  should  test  the  power  of  expiration  in 
health,  and  note  the  result.  Repi>al<-d  trials  with  the  iipiromcter, 
siflo,  during  the  course  of  disease,  will  afford  some  evidence  as  to 


800  PBTSICAL    BXrLOKATIOH    Or    TBB    CH18T.  1 

tbe  extent  of  its  progre** ;  bat  tliu  eridcnce  cutoot  be  much  kIM  1 
apoo,  owing  lo  lk«  iuBuenoe  of  cireanslanoM  otbcr  than  pnlnumaij 
leiions. 

Th«  ipirt>in«ter  «inplojr«d  b;  Dr.  HuLckinran  is  so  caaibnw  u 
instruueDt  as  to  be  only  available  in  bo9])ital  or  office  practice.  Mr. 
Coxeter,  surgical  tnstrnment  maker,  in  l^ondon,  hms  inrented  a  tdw 
ttitute,  which  is  rery  convenient  and  portable.  It  consists  of  a  bt^ 
made  of  India-rubber  cloth,  of  snfficient  site  to  hold  the  niimi 
amount  of  air  that  a  person  with  the  largest  rital  capacitj  can  etycl 
from  the  lungs,  with  two  apertares,  to  one  of  whicb  is  fitted  a  gtav 
Dionth-pipoe,  while  the  other  communicates  with  a  cjrtiadrical  lit| 
holding,  when  full;  distended,  lift;  cubic  inches  of  sir.  The  haa 
b  the  meter,  auil  by  a  scale  murkcd  on  its  exterior,  anj  qsantin 
less  all  the  amount  it  will  contain  mny  be  messored.  The  orik«s 
of  the  large  bag  or  rcs^roir  are  regulated  by  stopcock* ;  aad  hj 
an  orifice  at  the  extremity  of  the  meter,  abo  regul«t«d  by  a  ettp- 
cock,  its  contents  may  be  expelled.  The  patieot  brcnthing  int«tht 
rescrToir  witli  as  prolonged  an  expiration  as  poesible,  the  air  it  re- 
tained by  closing  the  stopcocks.  It  is  then  measured,  by  refilliag 
the  meter  until  all  tbo  contenia  of  tlte  rvscrToir  are  expelled.  Tbc 
whole  apparatus  cun  be  folded  compactly,  and  placed  in  a  Icathora 
case  not  too  balky  to  carry  in  the  pocket. 

StIHM&BT. 

The  objects  of  mensuration  are  to  determine,  first,  alterklioMis 
the  si«e  of  the  chest,  which  may  be  partial  or  general ;  and,  seeoo^ 
alterations  in  the  extent  of  respiratory  morements.  Partial  «• 
largement  or  depression  is  measured  by  means  of  callipers  ;  general 
enlargemeDt  or  contruction  is  OcU-rmined  by  comparing  the  hori- 
sootal  semi-circamference  of  the  two  sides,  which  is  aaoerlained  by 
the  employment  of  a  graduated  inelastic  tape,  and  by  tDeasniing 
distances  between  certain  anatomieal  points,  such  as  the  dtMsnee  cf 
the  nipple  from  the  mesial  line,  and  the  space  between  the  posterior 
margin  of  the  scapula  and  the  spinal  column.  In  scientific  re- 
searches involving  observation-t  recorded  for  annlytieal  inrestigatioii, 
it  is  convenient  and  important  to  employ  the  inHtruments  just  nteti- 
tioued,  expressing  resulL-<  in  figures;  but,  in  general,  alterations ii 
site  may  be  ascertained  sufficiently  for  diagno^i^,  by  inspection. 
Oliaically,  tbc  advantage  of  mensuration  with  reference  to  compari- 


HBVSURATIOII. 


301 


>n  of  the  dimensions  of  the  two  eictes,  relates  to  Tariatioos  taking 
ji1ic«  at  diflcront  periods  in  tbe  same  case,  these  variations  somc- 
imes  being  important  to  be  considered  in  connection  wiih  thera- 
putical  agencies ;  and,  thus  restricted,  plenritis  with  effusion  is  the 
Imffeciion  in  which  this  method  of  exploration  is  particularly  usofni. 
According  to  tbe  rescarchea  of  M.  Woilicz,  mensuration  practised 
uly  daring  tbe  career  of  acute  diseases,  shows,  first,  a  progreesivo 
lenlargeinent  of  the  whole  thorax  during  the  development  of  the  dis- 
Lesae ;  second,  a  stationary  condition  of  enlargement  while  the  acute 
symptoms  continue ;  and,  third,  a  gradual  return  to  the  normal  sise 
rhile  resolution  of  tbe  disease  is  going  on.     This  scries  of  altera- 
tions is  accounted  for  by  M.  Woitlei:  on  the  hypothesis  of  pulmonary 
Qgestion  existing  as  an  important  element  of  all  acute  affections. 
Aberrations  of  tbe  renpiralory  movements  are  determined  by  the 
[cbest-measurer,  and  by  tbe  Atctbometer.     Tbe  first  measures  the  ex- 
Itent  of  motion,  at  any  part  of  tbe  chest,  in   tbe  direction  of  ita 
[diameter;  the  latter  mcatturi'^  tbe  amount  of  expansive  movement. 
fTheae  instruments,  altliouj»h  extremely  serviceable  in  certain  scien- 
'  ti6c  rccearcbc*.  are  not  necdpd  in  determining  the  cxistcnci:'  or  non- 
existence of  abnormal  movcmcnta,  inasmuch  a»  comparison  of  tbe 
two  sidea  with  the  eye  suffices  for  that  purpose.    To  institute  a  com- 
parison between  the  two  sides  as  respects  the  relative  extent  of  gen- 
f  eral  expansibility,  tbe  difference  may  be  taken  between  the  horixontal 
circumference  after  a  deep  inspiration,  and  that  after  a  forced  expi- 
ration :  this  mode  of  determining  the  extent  of  general  motion  does 
not  secure  complete  accuracy,  but  it  is  sufficiently  exact  for  ordinary 
praclical  purposes. 

The  spirometer  invented  by  Dr.  Hutchinson  is  designed  to  deter- 
mine the  "  vital  viipacily  "  of  tbe  lungs,  by  ascertaining  tbe  qiian- 
■  tity  of  air  which  can  be  expelled  hy  a  single  prolonged  i-xpiration. 
The  rcsulw  of  thi«  method  of  men  juration  are,  however,  in  a  great 
mcunre,  dependent  on  circiimjitanccs  affecting  muscular  power,  ir- 
respective of  tbe  condition  of  the  pulmonary  organs ;  and  the  de- 
gree of  the  vital  capacity  of  different  individual*  is  found  to  differ 
widely  in  health.  It  is  rarely,  therefore,  that  pomtive  information 
'  respecting  the  existence  of  pulmonary  diHcasc  in  to  bo  obtained  from 
this  Boorce,  in  cases  in  which  symptoms  and  other  signs  fail  to  indi- 
cate tbe  fact.  In  a  negative  point  of  view,  however,  the  spirometer 
may  sometimes  he  useful.  If  the  degree  of  vital  capacity  be  found 
to  eqnal  or  exceed  the  average,  it  warrants  the  presumption  that 


S02  FHTSICAL    BZPLOBATIOK    OF   THB    OHKST. 

disease  does  BOt  exist ;  or,  if  the  amount  of  vital  capacity  proper  to 
an  individual  in  Kealth  be  known,  and  it  be  found  that  this  amonnt 
is  not  diminisbed,  it  may  be  fairly  presumed  that  the  pnlmonary 
organs  are  sound. 

HiSTOBT. 

The  remarks  made  under  this  head,  in  connection  with  the  subject 
of  Inspection,  Chapter  IV,  are  equally  applicable  to  Mensuration. 


CHAPTER    ri. 


PALPATION. 


ExAMiKATlo:4  bj  pnlpnlioH  coiinrnts  in  Himpl;  nppljring  the  palmar 
urfacc  of  the  bund  or  the  Gngc-rs  to  the  exterior  of  the  cht^st.  Xliia 
.  on«  of  the  least  itnpartont  of  the  methods  of  pbj'sical  exploration, 
but  in  some  cases  of  disease  It  furnishes  signs  of  considerable  im- 
[tortance.  In  general,  the  evidence  of  disease  which  it  affords  10 
luxiliary  to,  or  confirmatory  of,  information,  more  positive  and  com- 
plete, derived  from  other  methods.  The  phenomena  appreciable  by 
le  application  of  the  hand  to  the  chest  are  of  different  kinds,  I 
ihsll  proceed  at  once  to  notice  those  which  are  important  to  be 
l»u-n«  in  mind  with  reference  to  the  diagnosis  of  intra-thoracic 
aeases. 

By  means  of  the  touch,  the  existence  of  teDderncss  on  pressure, 

it«  degree,  siluation,  and  extent,  are  aHcertained.     Manual  oxami* 

Fitation  aasistii  in  dettirniining  whether  it  be  seated  in  the  integument, 

[or  within  the  thorax.     If  it  be  owing  to  RennitiveTiCKH  of  the  surface, 

it  will  be  supcrGcial ;  mere  contact  of  the  fingers  will  excite  pain, 

rhicb  iet  not  proportionately  increased  if  firm  presiture  be  made.    If 

FntitrH-thoracic,  the  band  lightly  applied  will  be  supported,  and  the 

Buffering  will  be  according  to   the  force  employed.     In  short,  the 

rwlett  by  which  a  neuropathic  temlerncjia  is  dintinguisbed  from  that 

due  to  infi;immation  arc  available  here,  as  in  other  ffituntions. 

The  elasticity  of  the  thoracic  walls  is  ascertained  by  manual  ex- 
amination. Information  on  this  point,  it  is  true,  may  be  obtained, 
incidentally,  in  practising  percussion  :  but  in  order  that  the  attention 
shall  not  be  divided  between  two  objects,  it  ia  useful  to  make  pres- 
soro  with  express  reference  to  the  sense  of  resistance.  The  eUeti- 
eity  of  the  walls  of  the  chest  is  diminished  in  proportion  as  the 
pulmonary  substance  is  rendered  non-elastic  by  solidification  ;  and, 
»l«o,  in  a  notable  degree,  when  a  considerable  quantity  of  liquid  i« 
contained  within  the  pleural  sac.  In  oonnection  with  other  signs, 
this  possesses  considerable  importance. 


804 


PIITSICAL   BXPLOEATIOK    OF    TDB    CHBftt. 


By  paflBing  the  hand  over  the  thoracic  surface,  we  sre  tiiti  • 
jadging  of  th«  uatare  and  extent  of  changes  in  form  and  nu  be- 
dent  to  diftease.     Incqndilies,  due  to  depressions  or  proJKli  - 
mmelimes  h«lt«r  appreciiiti'il  hx  the  touch  ihiin  hr  in»pcctioii.   lij 
the  loach,  it  is  ascertniiied  whcllier  enlnrgoincDt  arises  from  aa»- 
bid  condition  exterior  to  the  walla  of  the  obcjit,  for  example,  «dnu. 
or  abscess,  or  whether  it  he  intra- thoracic.     If  the  latter,  ihc  Man- 
tioiiK  coniRiunicalcd  to  the  liand  sometime*  alTord  important  iefor- 
nation  as  to  the  character  of  the  disease.  A  circumvcribrd  enliijc- 
nient,  produced  by  an  nneurismal  tnmor,  may  be  accompanied  by  t 
pulsation,  which,  in  connection  with  other  eigne,  serves  to  ostaUiA 
the  diagnosiit.     It  is  important,  however,  to  remark,  that  a  circa*- 
scribed  puUating  tumor  may  be  caused  by  a  collection  of  pus  W 
nrath  the  skin,  communicating  with  an  accamulation   withiit  tlw 
chest  by  means  of  a  perforation  through  the  thoracic  walls.    In  ib 
case,  the  pulsation  is  due  to  the  cardiac  impulse  propagated  thnn^ 
the  mass  of  li<)uid.     Throbbing,  diffused  over  a  considerable  exteot 
of  surface,  has  alsio  been  repeatedly  observed  in  case*  of  enpyeoa 
without  perforation  of  the  thoracic  walls,  the  pua  being  retained  m- 
tirely  within  the  pleural  cavity.     These  instances  have  given  riaelo 
a  variety  of   the  affection  called  "  piilstating  empyema."'     rader 
these  circumstances,  the  heart's  impulse,  communicated  to  the  pu»> 
Icni  collccliou,  is  sufficient  to  eaufic  an  appreciable  movement  of  the 
walix  of  the  chest.     The  same  phenomenon  has  been  obfervrd  hj 
Dr.  Graves  in  a  case  of  pneumonitis,  and  by  Dr.  Stokes,  in  ooa- 
nection  with  a  large  cercbriform  tumor  springing  from  the  poitcnor 
mediaHtinum,  and  displacing  the  upper  lobe  of  the  left  long.'    In 
the  latter  instances,  it  is  doubtful  whether  the  pulsation  was  the 
transmitted  cardiac  impulse,  or  whether  it  was  doe  to  arterial  thrs^ 
bing  of  the  parts  within  the  chest.      The  last  is  the  explanatiM 
adopted  by  Dr.  Stokes.     These  different  morbid  conditions  andrr 
which  an  ubnormnl  pulsation,  circumscribed  or  diffused,  is  discovered 
by  palpation,  are  to  be  discriminated  by  calling  to  our  aid,  in  addi- 
tion to  syniptoiiis,  the  aai4«cialed  signs  determined  by  the  eerenl 
methods  of  exploration. 

Fluctuation  is  ocessionftlly  distinctly  felt  in  cases  of  chronic  pl»«- 
ritis,  or  empyema,  in  the  distended  intercostal  spaces.     I  have  inei 


•  VuU  WaUba  on  Diteato*  of  ths  binp,  *tc. 

>  Hiokas  «a  tha  Cbatti  woond  Amvieaa  cditioa,  liM,  fj«g»  VO- 


P41FATI0K. 


rith  instance  in  which  it  was  well  miirk«i]  over  «  large  excavation 

pntienu   «tr«iTK']y  cmacifttcil.      The  voDctisxion   produced   by 

i<)ui<l  within  a  superficial  cavity  thrown  with  force  ngniiist  the  tho- 

eic  walU  "by  the  act  of  coughing  is  Honielimefl  very  plainly  per^ 

cptible  to  the  tonch,  as  well  as  to  the  eye. 

The  divergence  and  convergence  of  the  ribu,  whether  persisting  or 

loidcDt  to  the  renpiratory  movcmentit,  are  appreciated  by  palpation 

better  than  by  inspection.    Placing  a  fingi-r  in  the  intercostal  spaces, 

ley  con  be  accurately  compared  with  respect  to  their  relative  width 

in   the  two  side«,  and  the  manner  in  which   they  are  affected  by 

Bpiration.     In  this  way  it  may  be  ascertained  that  when  one  aide 

of  the  chest  is  enlarged,  either  by  increased  volume  of  lung  or  by 

plenral  effusion,  the  lower  intercoat&l  fipaces  are  widened,  and  those 

between  the  upper  ribs  narrowed.     The  ribs,  under  these  oiroum- 

IBtanees,  on  the  aff'ected  side,  will  be  found  to  remain  comparatively 
Btotionless  during  the  movements  of  respiration,  while,  on  the  oppo- 
tite  side,  those  situated  at  the  lower  portion  of  tie  chest  manifestly 
become  more  widely  separated  by  the  inspiratory  act.  Obliteration 
of  the  hollows  between  the  ribs,  from  the  pressure  of  a  liquid,  is 
more  distinctly  felt  than  seen.  The  smooth,  even  surface  which 
charaelerizes  the  affected  side  in  cases  of  chronic  plenritis,  or  ein- 
_  pyema,  with  notable  dilatation  of  this  side,  is  appreciated  by  the 
y  touch  better  than  by  the  eye.  In  the  same  manner,  tactile  exam- 
ioation  serves  to  distinguish  the  comparatively  unequal  enlargement 

»dne  to  emphysema. 
With  the  hand  applied  on  the  chest,  the  extent  of  motion  at  that 
part  with  inepiratton  ia  apparent.  A  comparison  of  the  two  sides 
at  different  points  may  in  this  way  be  made  with  respect  to  the 
relative  amount  of  expansibility,  the  evidence  obtained  by  ocular 
■  examination  being  thus  confirmed  or  modiGed.  In  exploring  the 
female  cheat,  if  sensitiveness  on  the  score  of  delicacy  preclude  a 
Batisfactory  examination  by  inspection,  palpation  may  be  employed 
as  an  altcmativo. 

The  respirations  may  be  conveniently  enumerated  by  means  of 
palpation.  In  one  respect  this  method  has  an  advantage  over  in- 
spection, v'a.f  the  moroments  being  felt,  the  eyes  are  left  unoccupied 
except  to  note  the  time  during  which  the  respirations  are  counted. 
In  the  female,  the  hand  may  be  applied,  for  this  object,  in  the  infra- 
claiicalar  region ;  in  the  malC]  the  upper  part  of  tlie  abdomen  is  to 
b«  preferred. 

20 


PHTelCAL    SXPLOBATlOn    Of    TBE    OHIST. 


Tbe  ntoktioQ  of  the  spex-unpnlse  of  the  besrt  is  aottiaa  «  J 
importSBt   poiut    lo    tbe   diagnosis  of  die«ae«s    affecting  ike  fi-  I 
mooary  organs.     In  large  pleoritic  effaeJoos,  and  in  some  cum  4  I 
eniphyf«ina,  tLe  heart  is  removet!  from  ils  DOrmsl  sitntion.    Ttim  1 
these  circumstancet^  the  impulse  maj  be  felt,  «S  well  MS  seen,  U  i  I 
point  more  or  lens  distant  from  tbttl  whor«  it  ia  to  be  ftooghl  ht  it 
health.     A  collv«tiou  of  llijuid  in  the  right  pleural  aac  posbea  ik 
heart  in  a  lin«  somovbat  diagonal,  upward  and  oatirard,  to  tbe  fafi 
of  it«  nonnaJ  sitttation.    If  the  liquid  be  contained  in  the  left  plennl 
caritjr,  and  sufiicicntly  copiuuit,  the  organ  is  carried  apvard  and  bfr 
erally  to  the  right,  and  majr  be  found  to  pulsate  between  the  Itt 
and  seventh  ribs  to  tbe  right  of  the  stentun.     Tbe  absorpiioD  tf 
Large  liquid  effusion  in  either  side  also  tends  to  displace  the  bean, 
through  the  inSuence  of  atmospherical  pressure  or  suction.    Hm 
effect,  but  to  a  less  extent,  has  been  obserred  in  other  affectiobR  in- 
tended with  diminution  of  the  bulk  of  the  long,  vis.,  after  absorptia 
of  iDHammatory  exudation,  collapse,  or  atrophy,  and  in  caMS  of 
tuberculosis  involving  considerable  destruction  of  tbe  palmoaaij 
subelance.   Absence  of  tbe  heart's  impulse,  owing  to  the  organ  bdag 
pushed  backward  &om  tbe  thoracic  walls  by  tbe  increased  voluihe 
of  the  overlapping  lung,  is  one  of  the  signs  of  emphysema ;  and  in 
some  instances  of  tbia  afi'ection  the  heart  is  depressed,  so  that  )U 
impulse  U  transferred  to  tbe  cpiga.ttrium. 

Finully,  vibratory  moliona  of  the  nails  of  the  chest,  aooompanj' 
ing  the  act  of  tipcaking,  and,  under  certain  circumstances,  respira- 
tion, constitute  physical  signs  possessing  in  some  cases  consideraya 
importance.  If  the  palmar  surface  of  the  band  be  lightly  applied 
over  tbe  healthy  chest  in  certain  situations,  the  vibraiiona  of  the 
TOcal  obord»,  propnj;atvd  along  the  bronchial  tubes,  and  commimi- 
cated  to  the  thor.icic  purietctt,  giro  ri»«  to  a  thrilling  sensation, 
called  tlie  vtieal  vihrafUn  or /remihu.  This  is  strongly  marked  if 
the  lingers  are  plucod  upon  the  larynx  or  trachea.  It  is  mort  «r 
less  apparent  in  the  infra-clitvicular  region;  in  an  inferior  degree  in 
the  mammary  and  the  infra-mamnuiry  region ;  ceasing  below  the  line 
of  hepatic  dulness ;  slight,  if  appreciable,  behind  over  tbe  scapnle ; 
generally  felt,  and  sometimes  well  marked,  in  the  inter-  and  infia^ 
scapular  and  axillary  regions.  The  normal  vucal  fremitus,  like  the 
TOcal  resonance,  the  respiratory  mnrmur,  and  the  sound  en  percas- 
uon,  is  found  to  present  great  variations  in  degree  in  different  iadi* 
Tidaala  entirely  free  from  pulmonary  disease.  In  some  persons  it 
is  strongly  marked;  in  others  it  is  moderate,  and  in  others  slight; 


PALPATIO})'. 


SOT 


I 


id  somelinies  it  is  DOirhero  appreciable.  Other  things  equal,  it  ig 
Stronger  in  proportioa  as  the  chest  is  thinly  oovcred  witli  fiit  and 
lie.  The  character  of  the  voice,  also.  materiatlyaireGtsiliiiiitea- 
In  general,  the  fremitus  is  notably  stronger  in  pera^ns  whose 

licesftre  powerful  and  low  in  pitch.    It  is  therefore  oflenerpriwcnt, 

id  iii  more  apt  to  be  intentie,  in  ailiilt  male.*,  than  in  fvmitleH  and  chil- 
dren.whosc  voices  are  feebler  and  more  acute.  lb  is  appreciated  bj 
the  esr  applied  to  the  ohest,  even  better  than  with  the  hand,  and,  in 
eonnedion  with  the  subject  of  vocal  reaonance,  it  baa  alrvsily  been 
ineidentslly  noticed.  As  already  remarked  in  that  connection,  the 
Tocal  fremitus  doe^  not  sustain  any  fixed  relation  to  vocal  reso- 
nance. The  latter  may  be  intense  while  the  former  is  slight,  and 
viee  wrsa.  This  statement  applies  equally  to  health  and  disease. 
A  loud  shrill  roice  is  most  favorable  for  intenaity  of  vocal  resonance, 
vheliior  nonnal  or  morbid;  on  the  contrary,  a:t  just  stated,  baes 
lofies  are  mo«t  likely  to  give  rise  to  »  strong  fremitus.  The  in- 
tensity of  the  fremitus,  in  health  or  di«ea«e,  is  affected  by  position. 
In  the  great  majority  of  instancui*,  it  is  more  strongly  marked  if 
the  patient  be  recumbent,  than  in  the  sitting  postnre. 

With  respect  to  the  normal  vocal  frnnitus,  it  Is  important  to  bear 
in  mind  that  uniformity  of  the  two  sides  of  the  chest  is  the  excep- 
tion rather  than  the  rule.  In  the  larger  proportion  of  individuals 
it  is  more  marked  on  the  right  than  on  the  left  side.  This  is  true, 
not  only  of  the  summit  of  the  chest,  but  at  the  lateral-posterior 
portion  inferiorly.  This  natural  disparity  must  he  taken  into  ao- 
ooont  in  estimating  the  effects  produced  by  disease. 

The  Toeal  fremitus  may  be  increased,  diminished,  or  suppressed, 
by  morbid  conditions.  In  a  positive  oml  negative  point  of  view, 
therefore,  the  voice,  by  means  of  palpation,  furnishes  physic*! 
evidence  of  disease.  An  increase  of  the  vocal  fremitus  occurs  in 
solidification  of  lung,  especially  from  inSammatory  exudation  and 
tobercnlous  deposit;  less  frequently  anil  in  a  less  degree,  in  con- 
nection with  oedema,  extravasation  of  blood,  or  carcinoma.  Bear- 
ing in  mind  the  disparity  between  the  two  sides  just  stated,  a 
relatively  greater  amount  of  fremitus  on  the  right  than  on  the  left 
tide,  affords  equivocal  evidence  of  the  existence  of  disease-  If, 
however,  a  greater  amount  be  found  on  the  left  side,  it  is  highly 
significant  of  a  morbid  condition.  Seated  at  the  summit  of  the  chest, 
ID  conjunction  with  symptoms  denoting  a  chronic  pulmonary  aflcction, 
it  points  to  a  tuberculous  deposit.  In  the  second  and  the  resolving 
of  pDeumoniUH,  fremitus  is  sometimes  increased  and  somctiuM 


PBTSICAL    BXPLOBATIOX    OF    TAB    CRBfiT. 


diminished.     When  notablir  diminished,  in  most  cmc»  the  dioun- 
tioR  is  doe  to  the  pre«cnc«  of  liquid. 

The  normal  vocal  fremittu  u  diminished  or  sopprefMd,  u  '.l- 
rule,  wheneror  the  lung  is  removed  from  the  thoracic  walls  h;  ut 
sccumaUlion  of  liquid  or  gas  vrithin  the  pleural  cavitj.  Gtnnallj, 
in  cases  of  pleuritis  vlth  effueion,  of  hydrothorax,  and  of  pncGms- 
hydrothorai,  fremitas  on  the  affected  side  is  ah»cnt,  or.  if  ['tnent, 
relatively  feeble.  This  negative  sign  is  of  more  valac  if  it  be  fouad 
OD  the  right  side,  the  rule  in  this  instance  being  tfae  rererse  of  thst 
applicable  to  increased  fremitus.  The  reason  for  tho  role  is  obriiMS. 
Were  we  to  attempt  to  arrive  at  a  diagnosis  bv  exclusive  reliaoce 
m  tlie  Tocal  fremitus,  it  would  be  necessary  to  enjoin  cautioi)  not  to 
regard  the  normal  fremitas  remaining  on  the  left  side,  in  cases  in 
which  it  is  diminished  or  suppressed  by  disease  on  the  right  8ide,u 
proceeding  from  a  morbid  conditioti  of  the  left  lung.  The  tiabili^ 
to  tills  error  will  always  be  obviated  by  attention  to  associated  apt. 

In  some  cases  of  pleuritis,  the  vocal  fremitus  is  increased  at  de 
summit  of  the  chest,  over  the  lung  condensed  by  oompreAsioB,  wUt 
it  is  feeble  or  null  below  the  level  of  the  liquid. 

As  already  remarked,  the  normal  vocal  fremitus  on  the  right  lidt 
censer  below  the  line  of  hepatic  flalncKs.  In  ca»cs  of  enlargetBCOt 
of  the  lirer,  in  which  it  encroaches  on  the  thoracic  space,  sbaence  sC 
fremitus  constitutes  one  of  the  signs  aasisling  in  determining  the 
fact  that  the  flatness  on  percussion,  extending  a  greater  or  Int 
distance  above  the  normal  limits,  is  not  due  to  consolidated  lung. 
The  sign  is  important  in  tliis  connection,  because  when  the  lower 
lobs  of  the  right  lung  i«  soliditie<l,  |>ercu«»ion  may  gire  flatu^^ 
equally  over  the  liver  and  the  solidified  lung.  ^^M 

Certain  motions  of  the  chest,  perceptible  on  manual  examination, 
arc   occasionally   incident    to   the    respiratory    moretnenls.    The 
bronchial  rales,  both  dry  and  moist,  t.  e.,  the  mucous,  sonorous;  and 
sibilant,  and  the  gurgling  incident  to  cavities,  sometimes  cauaea 
vibratory  thrill,  appreciable  on  application  of  the  hand.     This  it 
called  the  rhonchal  /remitiu.     In  some  of  the  instances  in  which 
pleural  friction -sound  is  present,  the  rubbing  of  the  roughened 
faces  is  distinctly  apparent  on  palpation.     This  never  occurs 
when  a  friction-sound  is,  at  the  same  time,  strongly  marked  on 
anscultation.     It  is  observed  at  a  late  stage  in  pleurisy,  after  ab- 
sorption of  liquid  has  brought  the  pleural  surfaces  into  contact,  the 
period  of  the  disease  when  the  friction- sound  is  ofWnest  observed, 
and  is  most  apt  to  be  loud  and  rough. 


LJcha    J 


J 


809 


I 


Summary. 

Palpntion  furnisliea  informalion  re»poctiiig  llie  ilogrei',  situation, 
.■aA  cxtont  of  soreness  of  iJie  clutsl ;  lh«  ilt-gruv  of  vlasticit;  of  the 

oncicwalU;  tliv  cb«nf;L't>  in  form  nnd  size;  incqunlitics  of  the 
isurfacc:  ihc  condition  of  tliv  intercostal  spuccs,  and  the  amount  of 
convergence  or  divergence  of  the  ribs  in  renipiration. 

In  some  inHtnncoK.  hy  determining  the  existence  of  fluctuation,  it 
esubliehcs  the  prosenue  of  liquid  in  the  plcum,  or  in  a  superficial  piil- 
nODsrj  excavation.  It  ma;  be  employed  in  eiitiinnting  the  cxteot 
of  motion  with  the  respiratory  act»,  nnd  in  ti  comparison  of  the  two 
sides  of  the  chest,  in  difTcrcnt  situations,  in  this  respect.  It  affords 
a  convenient  mode  of  enumerating  the  respirations.  It  is  useful  in 
,  determining  whether  the  heart  rcmnins  in  its  normal  position,  or  haa 
been  dislocated  in  connection  with  disease  affecting  the  pulmonary 
organs. 

The  total fremitui,  felt  when  the  tanJ  is  applied  to  the  healthy 
chest,  \s  increased,  diminiahcd,  or  suppressed,  in  connection  with  dif. 
ferent  forms  of  disease.  It  is  frequently  increased  in  cases  of  solidi> 
fioation,  especially  from  inflammatory  exudation,  and  from  tubercle. 
An  iocrcivsed  amount  of  fremitus,  situated  on  the  left  side,  accord- 
ing to  the  part  of  the  chii^t  at  which  it  i.^  observed,  iit  a  signiGoant 
sign  of  cither  phthisis  or  pneumonitis.  Diminii<hcd  or  siipprei*$cd 
fremitus  ie  incident  to  discaees  in  which  the  lungs  arc  removed  from 
contact  with  the  thoracic  wulU,  viz.,  pleuritis  with  effiisiuu,  and 
pneu  mo-hydro  thorax.  It  coexists  with  flatness  on  pcrcusition  over 
the  spaceoccupied  by  an  enlarged  liver.  DimiDished  and  suppressed 
fremitus  are  much  more  valuable  as  physical  nigiis  when  they  occur 
on  the  right  side,  in  consequence  of  the  normal  fremitus  being  gen- 
erally more  marked  on  that  side. 

A  fremitus  sometimes  accompanies  the  bronchial  rales,  and  gur- 
gling; and  a  rubbing  sensation  is  ocoisionally  felt  in  conjunction 
with  a  loud  and  rough  friction-sound,  occurring  in  pleuriti*,  generally 
after  the  removal  of  the  liquid  effusion. 

History. 

The  genera!  remarks  under  this  head,  made  with  reference  to  In- 
spection, Chapter  IV,  are  nl.'«o  applicable  to  palpation.  The  absence 
of  the  normal  vocal  fremitus,  as  u  sign  of  pleuritic  effusion,  was  first 
pointed  oat  by  M.  Reynaud. 


CHAPTER   VII. 


Bl'CCCSSIOK. 


Sin>DKl(  sgitBtioo  of  the  bodj,  aoiet  c«rtain  ctrcnmstajiceA  of  £>• 
esse,  oeeraou  *  Bplvhing  noise  «bieb  b  quite  pathogDoaowe.  Td 
prodncc  it,  the  pnctitioaer,  apptjriog  his  ear  to  the  cheat,  grssf*  tk 
shoatdcr  of  the  patient,  and  moJta  abruptly,  bnt  not  TioIeDtlft  tk 
tmnk  backward  and  foncard,  or  lalt-nilly.  This  poethod  of  ezaott- 
nation  is  callc<)  Suceusnon,  A  splashing  noise  is  the  odIjt  phrrieal 
sign  det-elopcil  hy  this  method  ;  and,  as  just  stated,  it  has  a  tpcciil 
signification,  reprcsenling,  in  the  vast  isajoritj  of  the  eaM«  in  wtici 
it  oocurs,  »  particalar  form  of  disease,  rit.,  plenritis  with  perfcn- 
lion,  or  the  affection  coinmonly  callrd  {meoDto-h^drothorax. 

The  terra  splasbiDg  is  descriptive  of  the  dtsracter  of  the  noise.  It 
maj  be  imitated  bj  .^baking  a  bottle,  partiail;  filled  with  water,  the 
remainder  of  the  space  being  occupied  with  air.  The  conditions  r^ 
quieite  for  the  production  of  the  sign  are  a  carit;  of  large  diiDca- 
sions,  partially  filled  with  liqoid,  and  partially  with  air  or  gas.  Thme 
conditions  ohtsin  in  pneunio- hydro! borax.  In  that  affection,  air,  or 
gs«,  and  liqoid,  arc  contained  vrithin  the  pleural  csritj.  It  iorolres, 
in  the  great  majority  of  cases,  perforation  of  the  long,  bm  this  is  not 
eesential  to  the  production  of  the  sign.  Air  and  gas  within  the  plennl 
sac,  vilbout  commanication  with  the  bronchial  tubes,  and  withoot 
perforation  of  the  thoracic  walls,  sufiicc  for  its  manifestation.  The 
sign  would  be  entirely  pathognomonic,  except  that  it  is  sometimrs 
observed  in  cases  of  a  very  large  tuberculous  excavation.  It  is  ob- 
vious that  a  cavity  of  great  sise  may,  at  times,  fiimish  the  nccesaiy 
physical  conditions,  vis.,  sufficiency  of  space  containing  liquid  and 
air.  With  tbts  exception  (and  the  exceptional  instances  are  ex- 
tremely  infrequent),  the  sign  belongs  exclusively  to  pneumo-bjdro- 
thorax. 

The  intensity  of  the  splashing  noise,  and  the  facility  with  wlueh 
it  is  produced,  vary  considerably  in  different  cases.     It  may  not  be 


eiTOCUBSIOV. 


811 


I 


I 


I 


.ppnrcnt  avc  when  the  ear  is  either  in  contact  with,  or  in  close 
roximity  to,  the  chest ;  but  in  some  instances,  it  is  sufficiently  loud 
be  heard  at  a  distance.  I  have  known  it  to  be  bo  int^niie  as  to 
'be  andible  throughout  a  large  lecture-room.  It  i»  produced,  not 
alone  hy  succussion  practised  for  that  purpose,  but  by  any  sudden, 
quick  motions  sufficient  to  occasion  agitation  of  tlii^  liquid.  Uence, 
it  not  infrequently  arrests  the  attention  of  iht-  pMicnt.  Dr.  Stokes 
relates  a  case  in  which  a  patient,  iilfeclcd  with  pncumo-hydrothorax, 
was  able  to  take  horseback  exercise,  but  whencrer  he  rode  in  a  gal- 
lop, or  h»rd  trot,  he  was  annoycil  by  the  splashing  within  the  chest. 
An  analogous  case  has  fallen  under  my  ob»crvolion.  The  patient,  a 
female,  lived  for  sevL^ral  months  after  the  occurrence  of  perforation 
in  connection  with  ttiberculoxis,  followed  by  pncumo-hydrothorax, 
and  retained  sufficient  strength  to  walk  about,  and  to  ride  in  the 
open  air.  Sudden  change  of  potntion,  rising  up,  Hitting  down,  etc., 
produced  a  splasfiing  noise,  very  apparent  to  herself;  and  in  riding 
in  a  carriage,  orery  jolt  was  attended  with  the  eaiuc  effect. 

The  sign  is  not  unifoiinly  present  in  cases  of  pneumo-hydrothorax. 
Its  absence  in  a  certain  proportion  of  instances  depends  on  the  too 
large  proportion  of  liquid  to  the  quantity  of  air  or  gas,  or  on  the 
too  great  consistency  of  the  liquid,  or  on  both  combined.  The 
thinner  the  liquid,  the  more  readily  is  the  splashing  produced.  The 
qoality  of  the  noise,  as  well  as  its  intensity,  raries.  It  frequently 
has  a  high-pitched  amphoric  tone,  and  it  may  he  commingled  with 
well-marked  metallic  tinkling. 

A  noise  resembling  somewhat  thoracic  splashing  originates  within 
the  stomach  when  this  organ  contains  a  certain  quantity  of  liquid, 
and  i»  at  the  same  time  diatended  with  gas.  The  associated  symp- 
toms  and  signs  will  always  obviate  the  liability  to  doubt  arising  from 
this  resomblnnco.  Aside  from  the  evid.>nce  afforded  by  .succuHsion, 
the  diagnostic  criteria  of  pncnmo-hydrolhorax  are  unequivocal,  so 
that  the  former  might,  without  mueh  inconvenience,  be  ditqiensed 
with.  The  dingnositi  of  jihthbis,  also,  at  the  stage  of  the  disease 
when  it  would  he  possible  for  succussion  to  be  available,  is  suQi* 
civntly  clear  without  reporting  to  this  method  of  examiuatioa. 


Generally  in  cases  of  pneumo-hydrothorax,  and  occasionally  in 
cases  of  phthisis  with  a  very  large  excavation,  suocnasion  causes  a 


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_,._^ 

4 

PART    11. 

DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS. 


TART  II. 

»IAGNOSIS  OF  DISEASES  AFFECTING  THE  RESIJIBATOBY 

ORGANS. 


PREUMINAHT  REMARKS, 

Thr  diagnosis  of  disciiM-s  afTcctiog  the  organs  of  respiration  in- 
Ivolves  the  practical  application  of  the  principles  which  it  h»s  been 
the  object,  in  the  preceding  pages,  to  elucidate.     In  the  investiga- 
tion of  diseases,  however,  at  the;  bedside,  the  attention  ie  hy  no  means 
|b>  be  directed  solely  to  signs.     Invaluable  as  they  are,  their  im- 
artance  is  greatly  enhiiuced  by  association  with  symptoms  and  the 
knowledge  of  pathological  laws.     The  results  of  physical  explora> 
Ition  alone  frequently  lenve  room  for  doubt,  and  liability  to  error, 
lirben  a  ilne  appreciation  of  vital  phenomena  and  of  facts  embraced 
■  in  the  natural  history  of  diseases  iosiu-es  accuracy  and  positivenetig, 
lAn  orerneening  confidence  in  the  former  is  to  be  deprecated  as  well 
IS  exclasire  reliance  on  the  latter.     And  since  the  practical  dis* 
crimination  of  intra-thoracic  affections  is  always  to  be  based  on  the 
combined  evidence  afforded  hy  these  three  sources  of  information, 
in  treating  of  the  subject  it  is  desirable  that  the  attention  shall  not  be 
limited  to  one  source  to  the  exclusion  of  the  others.     In  taking  up, 
[  tberefurc,  in  the  eucceeding  pages,  the  diagnosis  of  individual  dis- 
eases, I  shall  not  disconnect  phy.^ical   signs  from  symptoms  and 
pathological  laws.     After  premti^tng  a  few  considerations,  the  signs 
belonging  to  each  disease  will  be  considered ;  and  under  the  bead  of 
Diagnoii*  I  shttll  ad<luce  symptoms  and  pathological  laws  which  are 
to  be  a&Eociated  with  the  phenomena  furnished  hy  [ihysical  cxplora* 
tioQ  in  the  diHcrimioation  of  the  disease-     The  diseases  affecting  Uie 
respiratory  organs,  may  be  di-tlribuled  according  to  their  proximate 
anatomical  relattoua  into  the  following  groups:  1.  Thoite  affecting 
the  bronchial  tubes ;  2.  Those  more  imnii'diately  connected  with  the 
air-«e11s  and  pulmonary  parenchyma ;  S.  Those  seated  in  the  pleura. 
I  shall  take  np  the  particular  diseases   embraced  in  these  three 
groups,  in  the  order  just  enumerated.    Diseases  affecting  the  trachtft 
and  larynx  will  form  a  fourth  group. 


CHAPTER    L 

INFtAMMATION  OF  THE  BBOKCHIAL  lirCOUS  XESfBlun- 
ORIMNARY  ACUTK  BRONCHlTlit-tAPILLABY  hBt>NCHrn5- 
PSErDO.MKMBKAKOl-8  BRU>-CHlTIS-CUROXlC  BBOSCHITIS- 
SECONIIABT  BRONCOiriS. 


BBONCnms,  or  inflxminntion  of  the  mucoas  membranf  lintng  ik 
brODchiai  tube*,  odiniu  of  being  divided,  nosolofncmllT,  into  tn 
fonns,  the  dixtiiiction  li«ing  liawd  on  difference  in  e^tu  In  mt 
form,  the  iuflammmtion  is  oonRncd  to  the  larger  rnbdiTisions  of  tki 
bronchi ;  in  the  other  form,  it  i«  cither  restricted  to  the  ntbrato 
branchoi,  or,  more  commonlv,  nflccte  them  and  the  larger  snV 
diviitioDK  alno.  In  the  great  mnjoritj  of  cuic*  the  di»cAse  ■>  p^^^ 
ftentcd  in  the  first  form,  end,  conscqnrntl;,  this  iD»y  be  diHtingnisbtd 
M  onlmary  bronehith.  The  Hecond  form  isgcncnill;  cnlled  eapiB*ry 
bro»chtti».  ThiH  name  implies  that  the  inflammation  is  seated  in  tW 
capillary  bronchial  tubes,  which  is  not  the  fact;  the  smaller  nai- 
fications  are  affected,  but  not  the  terminal  twigs  of  the  brondiial 
tree,  or  bronchioles,  which  are,  properly  speaking,  the  ca|Ml)«y 
tubes.  This  form  offers  striking  peculiaritiee  as  regards  symptoat, 
phyucat  signs,  and  pathological  laws. 

Another  division,  based  on  the  duration  and  degree  of  tfa«  inflsn- 
nation,  is  into  aeute  and  chronic  bronchitis. 

The  inUammation  may  be  dereloped  in  the  bronchial  tubea  ai  \ 
primitive,  idiopathic  affection,  and  it  may  coexist  with  other  di»- 
e4i«ea  seated  either  in  the  pulmonary  organs,  or  elsewhere.  Im- 
portant points  of  difference  pertain  to  this  distinction. 

The  affection  may  be  general,  in  other  words,  invading  the  bnnt- 
chial  lubes  to  a  greater  or  less  extent  on  both  sides ;  and  it  may  be 
partial  or  circumscribed,  in  the  Utter  case  occnrring  almoM  i»- 
variably  aa  a  complication  of  some  other  antecedent  pulmonary 
disease. 

Farther  divisions  were  formerly  made,  based  on  the  predocni- 
nance  of  certain  symptoms,  for  example,  the  qoantity  and  quality 
of  the  liijiiid  products  expelled  from  the  bronchial  tube*.  By  writers 
of  the  present  day,  these  differences,  although  constituting  important 


ACUTE    BBO^CHITFB. 


m 


nodiGcfttions  of  Uio  dUexse,  are  deemed    inctuffioienl  gronnda  far 

■voUiplving  noBological  dirtinvtionn.     The  occurrence  of  n  H»-called 

[lUsttc  or  fibrinous  csudnlion  on  tbo  mucous  surface,  however,  i»  k 

tp«ealiarity  sufficiently  striking  sod  importnnt  to  serve  &8  the  knsia 

jof  a  distinct  variety. 

In  treating  of  broncliitis  with  reference  to  its  diagnOEtin,  I  (OibH 
insider  nnder  separate  heads  the  following  divi:>iori8 : 

1.  Acute  broncbitia.  Under  this  head  I  include  caws  in  which 
'the  di-M^ase,  in  addition  to  its  aeuteness,  ig  idiopathic,  and  limited  to 
[the  larger  subdirisions  ;  in  other  words,  ordinary  and  primary  acute 

broncbilis. 

2.  Capillary  ttrAnohitia. 
8.  Pseado-memhranous  or  plastic  bronchitis. 

4.  Chronic  bronchitis. 

5.  Secondary  bronchitis. 


AcvTE  Bbouchitis. 


Tbe  circomttances  pertaining  to  the  anatomical  characters  of  acute 
bronchitb,  which  stand  in  immediate  cauBative  relation  to  the  devel- 
opment of  the  characteristic  physical  signs  are,  unequal  diminution 

I  of  the  calibre  of  tbe  affected  tubes,  from  swelling  or  thickening  of 
the  membrane,  and,  more  especially,  from  the  presence  of  tenacious 
mucus ;  tbe  presence  or  absence  of  liquid  in  the  tubes ;  the  quantity 
when  present ;  the  facility  with  which  it  is  moved  from  place  to  place, 

[  and  permeated  by  air ;  the  size  of  the  tubes,  among  those  of  large 
or  medium  dimensions,  in  which  the  disease  and  its  products  are 
chiefly  situated ;  obstruction,  temporary  or  persiBting,  of  some  of 
the  tabc«,  diminishing  or  cutting  off  the  supply  of  air  to  the  vesielea 
lo  a  greater  or  less  client,  and  collapse  of  pulmonary  lobules  pro- 
portionate to  the  number  and  size  of  obstructed  tubes. 

I  Phytical  iStV^ns.— Percussion,  in  general,  furnishes  no  positive  signs 
in  bronchitis,  but  negatively  the  information  which  it  affords  is  of 
greater  practical  importance  than  any  of  the  positive  signs  pertain- 
ing to  the  disease.  Unaffected  resonance  on  percussion  is  a  fund»- 
mental  point  in  the  diagnosis.  As  a  rule,  it  holds  good  that  the 
resonance  continues  resicular  and  undiminished.  The  eitoeplions  to 
this  nile  are  infrequent.  Moderate  dulness,  situated  at  the  posterior 
and  inferior  part  of  the  chest,  is  sometimes  observed  as  a  result  of 


8S4 


DIStASBS    OF    THB    RBSriRATOBT    0R0A5fl. 


the  ftccamulntion  witliin  the  bronclttal  tubes  of  the  prodncu  of  it 
fiimmalion,  lownrtl  llio  clot>«  of  ike  diHease,  in  fsial  cuea  eWi' 
t«rix«cl  bv  an  abtiiidiiit  secretion  of  )hew  prodiicu.  ColUpic 
portions  of  tbc  lung  froni  obstruetion  of  ceruin  of  the  tub**  lo; 
also  give  ri«c  to  dulnc«s.  Thi^e  excrptioiiii  do  but  little  toward  u 
Talidating  the  role.  In  the  viutl  inkjoritj  of  the  insitaDce*  in  «hi;i 
the  rcsonaD(!c  on  percussion  i«  diminiabetl,  the  bronchial  alTwtioB  u 
a  complication  of  some  other  palmounrj  dii<e«M.  The  exi»t*ac«  tl 
bronchitis  hnring  been  deKrniiiucd  by  KTinptoniii,  la«it,  and  pobtin 
signs,  the  fact  of  the  percu^ioii •Hound  reniuining  unaffected  term 
to  eitabliflb  its  idiopatiiic  charscler. 

With  an  nnimportant  exception,  auscultation  fumieltM  all  ibe 
poHitive  physical  signs  of  bronchitis.  Tlicse  consist  of  the  dry  sal 
moist  bronchial  rales.  During  the  early  part  of  the  disease,  so  loag 
as  the  matter  of  the  expectoration  is  slight  and  adhesive,  the  rmla 
are  dry,  generally  sonorous,  but  somelimcs  approximating  to  d* 
sibilanL  The  moist  or  mucous  rales  follov,  when  the  liquid  eno- 
laiucd  in  the  bronchial  tubes  becomes  more  abundant  ami  li.'ss  rifeid. 
Both  description  of  rales  may  he  afterward  commingled  in  rariei 
proportion*.  The  rorieties  of  the  dry  and  moist  rales,  Ttth  tkn 
distinctive  fluctuations  as  respects  intcnsilT,  persistency,  etc.,  haw 
been  already  fully  described,  and  it  is  unnecessary  to  reproduce  d^ 
tails  relative  to  these  points.  It  will  suffice  to  mention  the  follov- 
ing  practical  considerations:  The  dry  rain  alone  do  not  eoD>tit«u 
adeijuate  proof  of  the  existence  of  bronchitis,  for  contraction  of  the 
broncliiaJ  tubes  from  spasm,  without  inflammation  of  the  moeoM 
membrane,  suffices  for  their  prodacti<H).  Nor  do  bubbling  ralea,  U 
themselves,  invariably  denote  the  disease,  for  they  may  procee<I  fron 
cither  blood  or  pus,  as  well  as  serum  and  mucus,  wiitiiu  the  tnbo, 
without  involving  bronchial  inflammation.  If,  however,  the  r*» 
classes  of  sounds  occur  in  succession,  or  if  they  are  commingled,  the 
diagnostic  eridenco  of  bronchitis  is  complete,  but  whether  priuury 
or  secondary  is  to  be  determined  by  other  signs. 

The  occurrence  of  moist  rales  succeeding  the  dry  is,  in  geoctal, 
to  bo  considered  evidence  of  the  progress  of  inflammation  toward 
resolution. 

The  combination  of  dry  rales  of  different  grades  aa  respects  pitek 
in  other  words,  the  grave  tones  of  the  sonorous  rale  accompanying 
expiration,  united  with  sounds  approaching  in  scuicncas  the  sibilant 
rale,  the  latter  heard  especially  with  inspiration,  render  it  probable 


ACtJTB    BBOSCniTrS. 


825 


^ 


I 


tltiit  lIiD  bronchinl  inSnininntinn  extends  over  ft  con«i<lcrnble  krcft, 
«OibraciDg  tlt«  stnii)l«r  brondiinl  nub  divisions.  Tliis  conclusion  is 
t-lto  vmrimleil  bjr  the  conibi  tint  ion  of  the  course  ami  fine  varieties 
«r  llie  mviRt  or  bnbbling  mlcK.  Another  iuiliciition  of  the  extent  of 
ibe  bronchial  tree  iffectH.  is  uffdnU'd  bj  the  liiffusion  of  the  rales 
OTer  the  chettt.  If  the  infbiininnlion  be  confined  to  the  larger  tubes, 
the  ruled  will  be  found  to  orip;inate  within  ft  section  corresponding 
to  the  middle  third  in  front  and  behind;  tf  they  emanate  from  the 
npper  and  loirer  thirds,  the  fact  shows  that  the  inflammation  ex- 
leods  beyond  the  larger  tubes. 

Absence  of  the  rales  ia  by  no  means  proof  that  bronchitis  does 
sot  exist.  Both  the  dry  and  moist  bronchial  ralea  are  evanescent 
Mid  variable.  They  may  be  absent  at  one  examination  and  present 
at  the  nenl ;  or  they  may  disappear  and  reappear  during  the  same 
examinstion.  The  difl'erent  varieties  may  be  presented  in  succes- 
sion, allernation.  and  in  varied  combinations.  These  diversities 
h»rc  been  already  described.  But  repeated  explorations,  in  some 
eases  of  bronchitis,  fail  to  discover  any  of  the  positive  auscultatory 
signs.  The  physical  conditions  necessary  for  the  production  of  the 
rales  may  not  exist,  or  be  present  irregularly,  and  for  brief  periods, 
sod  thus  they  escape  observation. 

The  loudness  of  the  rales  and  their  constancy  are  not  commensu- 
Tftte  with  the  intensity  or  extent  of  the  bronchial  inflammation.  The 
physieal  conditions  reijuisite  for  the  production  of  the  dry  and  moist 
Tales,  may  be  present  in  a  more  marked  degree  in  certain  cases  of 
mild  bronchitis,  than  in  other  cases  in  which  the  disease  is  severe. 
A  little  reflection  in  connei^tion  with  the  mechanism  of  the  produc- 
tion of  these  rales,  will  render  tie  fact  just  staled  intelligible. 

Finally,  a  highly  important  practical  consideration  is,  the  rales 
incident  to  idiopathic  bronchitis  are  heard  on  both  sides  of  the 
chi'M.  The  law  of  symmetry  pertaining  ti>  this  disease  i»  often 
useful  in  the  diagnosis,  and  hence,  the  value  of  the  physiciU  signs 
of  the  cxiAtenec  of  the  bronchial  inflammution  on  the  two  sides. 

The  vehicular  murmur  i«  frequently  obscured,  or  even  drowned 
by  the  bronchial  ralea.  At  the  eommcnccinent  of  the  disease,  before 
the  dry  rales  arc  developed,  the  murmur  may  bu  abnormally  loud, 
the  expiration  being  somewhat  prolonged,  as  in  exaggerated  respU 
ratton.  The  increased  intensity  may  persist,  if  the  characters  of 
tbe  Tesicalar  respiration  are  not  masked  by  the  prescnov  of  the 
rales.     Exaggeration  of  the  respiratory  murmur  is  observed  es- 


82i8        MSEAsse  or  the  sBsrikAtoKr  oboavs. 

pedally  Bt  tbc  soperior  portioD  of  tbe  ebctt.  I&  soiae  cmo  rf 
tironcliitia  ibe  iDunnar  u  beard  Uiroogkont  the  coaiinubn  sf  da 
diflCaM,  ■ppsmitlj'  not  matcnall;  altrred  w  respects  its  iMcaa^ 
This  is  true  of  ccrtsin  esses  in  which  the  inftsmoation  is  BM  iittRi, 
confined  to  the  Isrger  tabes,  uoscoompsiued  by  mDch  svd&sg  rf 
the  nienibrstte,  snd  the  secretion  of  toueiu  slight.  The  vtsaa 
marmur  is  diniiiiifthed  oftener  than  exaggerated  during  the  prefm 
of  broDchitie,  and  not  infrei|aentlj  it  is  sappre««Cil  psrtiallj  m 
generally  orer  tbe  chest.  Partial  sopprcssion  may  be  cwued  bj  pli|- 
ging  of  certain  of  the  larger  bronchial  tabes  with  tvnacioiB  iot. 
the  passage  of  sir  being  interrupted  sufficicntlj  to  abolish  BOtnl 
Id  thui  wsy  bronchial  rales,  ss  well  as  the  resicnlar  mannitr,  be;<aid 
the  seat  of  the  obstruction,  may  be  armtcd.  Sitosted  in  the  fo- 
msry  or  secondary  dirisions  of  the  bronchi,  tbe  intemption  to  the 
pMsage  of  air  may  cause  snpprpssion  over  a  concidemble  portioM  cf 
the  chest;  indeed,  ihe  quantity  and  force  of  the  cnrrent  of  air  reeeirrd 
by  inspiratioD  taay  be  diraiDisbed  by  the  adherence  of  the  teoaciiwi 
prodocts  of  inflammation  to  the  surface  of  tbe  larger  tubes  of  both 
lunga,  so  as  to  abolish  tmiTersally  respiratory  sound,  and  yet  tht 
obstmctioD  oot  be  great  enough  to  occasion  dyspucpa.  That  partial 
suppression  is  frequf  nlly  due  to  this  cause,  is  shown  by  tbe  veHeoht 
murmur  being  suddenly  developed  after  an  act  of  coughing,  in  s 
portion  of  tbe  cbent  where  just  preceding  this  act  it  had  nut  been 
appreciable— a  fact  sometimes  observed  in  auscultating  patieali 
affected  with  tbia  disease.  This  suggests  a  procedure  which  shoaU 
be  resorted  to,  in  order  to  dctermioe  whether  the  diroiautioD  or  np- 
presnion  proceed!  from  tbe  presence  of  li<)uid  products,  nz.,  reqiMSf- 
ing  tlie  patieut  to  make  a  roluntary  effort  of  coughiog,  and  soscol- 
tating  immediately  afterward.  If  the  respiratory  sound,  with  or 
without  rales,  rcsppcsr,  or  become  more  intena*  in  a  situsbon 
where,  prior  to  th«  act  of  coughing,  it  was  either  absent  or  f«eM«^ 
the  result  shows  that  the  diminution  or  suppression  proceeded  from 
a  movable  cause  of  obstruction.  Tbe  result  may  follow  an  act  of 
coughing  without  expectoration,  the  collection  of  mucns  being  de- 
tached and  thrown  forward  into  tubes  of  larger  size,  to  be  subas- 
quemly  expectorated.  The  tumefaction  and  thickening  of  the  rnn- 
cous  membrane  may  be  sufficient  to  diminish,  sad  even  abolish,  the 
Tesicular  murmur,  in  cases  in  which  the  inSsmmstion  extends  to  tbe 
•mailer  bronobial  tube*.     Marked  diminution  or  suppresstoa  of  re- 


l6VtB  BHOKCniTIB. 


327 


itoTj  sound  gcncrnllj  over  the  chest,  unilcr  t1iG«c  eircunistnnc<^, 

endecce  of  tfav  extent  of  tfao  broncliiul  infliimmntion. 

As  regards  thu  otlivr  methods  of  cxplorstion,  in^ipcction  and  pul- 

|>ition  enable  ns  to  nscortnin  vhethor  the  rc»ptratorj  movemonts  nro 

rbidly  froquent,  or  abnortnally  tnodified.     In  the  form  of  bron- 

under  present  consideration,  the  frequency  of  the  respirations 

;  rarely  more  than  moderately  increased,  and  usually  they  are  not 

abored  nor  attended  by  dyspnoea.    The  superior  and  inferior  costal 

types  of  breathing  are  frequently  somewhat  more  developed  than  in 

bealth.     Od  applying  the  band  to  the  chest  a  ribration  or  fremitos 

may  in  some  instances  be  felt,  which  is  incident  to  the  bronchial 

Iralea,  and  called  the  rhoncbal  fremitus.     This  is  of  little  practical 
uaportance,  inasmuch  aa  it  affords  no  information  in  addition  to  that 
oblaioed  more  satisfactorily  by  auaoullalion. 
Dioffnota.—'The  diagnosis  of  acute  bronchitis,  with  the  aid  of 
physical  exploration,  is  generally  unattended  with  difficulty.     Prior 
to  the  discovery  of  auseuItBtiou,  it  was  confesfedly  inipraclicable,  in 
toany   instance*,   to   diseriininitte  between    in6aniniatory  affections 
H«eftt«d  iu  the  mucous,  8crou<,  and  parenchymatous  ilructures.     The 
<     •ppiication  of  physical  eigns,  having  rendered  this  discrimination 
««)y  and  poeitive  in  the  great  majority  of  cases,  has  thereby  con- 
■  tributed  to  the  more  succeaaful  study  of  the  semeiological  history 
Hof  these  different  affections;  so  that,  at  the  present  time,  the  diag- 
V  noetic  importance  of  symptoms  and  pathological  laws  is  much  better 
understood  than  previously.    Yet,  even  now,  cases  not  infrequently 

(present  themselves  of  which  the  diagnosis  would  be  difficult  and  un> 
certain  without  the  aid  of  physical  exploration.  Cases  of  pneumo- 
nitis and  pleuritis  are  occasionally  wanting  in  their  most  distinctive 
symptomatic  phenomena ;  and,  on  the  other  hand,  cases  of  bron- 
chitis are  sometimes  equally  deBcient  in  its  peculiar  featurea.  The 
differential  diagnosis,  under  these  circumstances,  must  rest  mainly  on 

I  the  evidence  obtained  by  physical  exploration,  \torcover,  physical 
exploration  enables  the  physician  to  discriminate  with  greater  prompt- 
neea,  ease,  and  confidence,  as  well  as  with  much  less  liability  to  error, 
than  if  he  relied  excluitivuly  on  the  symptoms.  So  far  a^t  the  r^ 
falls  of  exploration  are  concerned,  the  dittcrimi nation  of  idiopathic 

•  bronchitis  from  pneumonitis  and  pleurify  involves,  first,  undimin- 
isbed  resonance  on  percussion  on  both  sides.  In  pneumonitis  and 
pleuritis,  as  will  be  seen  hereafter,  dulness  or  flatness  occurs  on  one 


8S8 


SISIA8BS   or   TttE    BBSrUATOBT    OBOASi. 


•Id«  Mon  After  the  InruiAn.  Tn  brAn^hitU,  th«  Kir-TceidM  Rsii 
ing  filled  with  >ir,  the  percuaMaa>HODn<]  n-txin»  it«  nomMl  tnUMiM^ ' 
whereas,  in  pneumonitu  the  preseow  vf  M>tii)  matter  vit&in  the  *m- 
ele«,and  in  pleuritu  the  preaenoc  of  liijuid  in  tlir  plpnrklcantj.fi- 
niDUh  or  abolish  the  reKonaoec.  Second :  the  broacbial  rales,  aba 
bat  not  inrariabl;  present,  to  »  greater  or  less  extent,  in  broBcU^ 
exist  on  both  RiilcN  or  ihv  chext.  Bronchitis  mar  complkste  h«A 
pneatDonitit  and  pleuntU,  but  the  two  latter  affcctiona  being coaSmI 
to  ono  Hdc  in  the  vast  majority  of  instances,  the  bronchiaJ  reitt  m 
natiifetlei]  onl):  on  the  affected  side.  On  the  other  band,  ilii^ 
pathie  or  primary  broncliitis  is  a  synimetrical  diGease,  and  the  bn»- 
chiitl  rales,  when  present,  ere  generally  heard  on  both  aides.  It  ■ 
in  this  wiiy  that  the  law  of  symmetry  ha-*  an  important  bearugoB 
tlic  diagnoAia.  Third:  in  uncomplicaU-d  bronchitis  certain  datiifr 
tire  signs  present  in  cases  of  pneumotiitiit  and  plearitie  are  ahseet 
This  point,  like  the'firat,  is  essentially  negative,  bat  its  beariag  « 
the  diagnosis  ia  quite  positive.  In  ptcurili.i,  auscnltatory  anil  othtr 
•ignit  of  liquid  in  the  pleural  sac,  are  readily  appreciable  In  poeo- 
moDitis,  the  eridcnoe,  other  than  that  furnished  by  pcrcoMioo.  of 
wUd if! cation  of  lung,  together  with  thecharacterixiic  rale  (the  crtfn- 
taot),  are  generally  available.  Ucnce,  absence  of  the  physical  ph» 
nomena  which  characterito  these  two  affections  warrants  tbeir  ex- 
clusion. 

Bronchitia  in  young  children,  and  wmetimeB  in  adults,  as  will  be 
•ccn  hereafter,  may  lead  to  collap&e  of  pulmonary  lobales  to  a  greater 
or  led  extent.  Eridence  of  this,  derived  from  physical  exploratioa, 
is  not  always  easily  obtained.  Sytoploms  are  more  to  be  relied  upcn 
than  signs ;  and  the  diagnostic  eymptoms  ar«  those  which  show  the 
rcapiralory  function  to  be  compromised  to  a  greater  extent  than  is 
usaal  in  cascM  of  uncomplicated  bronchitis,  vii.,  frequency  of  the 
respirations,  dilatation  of  the  atte  nasi,  lividity  of  the  proUbia^  etc 
If,  in  connection  with  the  local  symptoms  of  ordinary  bronchitis, 
Ike  respirations  be  but  little  accelerated,  the  ala»  nasi  not  dilateil,  the 
blood  properly  oxygenated,  and  the  physical  Ngns  of  pneumonitis 
not  discorerable,  the  aSeotion  may  be  considered  to  be  sintply  broi>> 
chial  inflammation ;  but  if,  in  connection  with  the  same  loeal  ayn^ 
toma,  (he  respirations  are  hurried,  the  aUe  nasi  dilating,  the  blood 
imperfectly  oxygenated,  the  characteristic  ngns  of  poeBraoaitia  baiag 
absent,  collapse  of  lobules,  especially  in  yoaBgchthlrea,is  lo  bens- 
peeted.  But  this  topic  will  be  considered  more  folly  in  oCMectMM  wit 


ACXFTB    BR0ITCHITI6. 


829 


he  dia^osis  of  broncbhia  with  collapse  of  lobnlos.    In  tbe  remarks 

ast  lanAe  it  ia  assumed  that  the  bronchitis  is  of  the  ordinary  form ; 

other  words,  tJiat  the  iiillammation  docts  notcxlend  to  (he  minute 

rbiymchtal  branflhea.     General  capillary  bronchitis  compromises  the 

spiratory  ftinction  to  «  ^roaler  extent  th^n   ordinary  bronchitia 

rith  collapse  of  lobules;  and,  honw,  ^reat  frei^iieney  of  the  rfinpi- 

[ntion»,  ililataiion  of  the  alte,  and  lividiiy,  may  indicate  the  former, 

instead  of  ibe  latter  afn-ution.     Thr  differential  diKgn(wi#  of  thc»0 

•ffeeU0D»,  however,  will  present  itself  for  cou^idoration  hercflftur. 

The  liability  of  confounding  tuberculosis  of  the  lungs  with 
'  lironchitiH.  relates  rather  to  the  chronic  than  tbo  ncatc  form  of  the 
flatter  affection.  In  eome  cases  of  acute  phthisis,  the  abrupt  invii- 
Ision  and  rapid  progress  of  the  disease,  may  lead  the  physician,  at 
first,  to  suppose  that  he  has  to  deal  simply  with  acute  bronchiti*. 
'  TTith  due  investigation  this  error  should  b»  avoided.  The  fact  of 
icutc  bronchitis  being  preceded,  in  a  large  proportion  of  instances, 
by  inflammation  of  the  nir-passnges  above  the  tmchcti,  has  a  bearing 
on  this  discrimination.  In  tuberculosis,  the  synjploms  from  the 
first  are  pulmonary.  Tho  coincidence  of  acute  bronchitis  and  the 
derclopment  of  tuberculous  disease  occurs  in  only  a  small  proportion 
of  cases.  Hence,  if  an  acute  pulmonary  affection  have  been  nahered 
in  by  oorrKa,  gradually  advancing  downward  to  the  pulmonary 
organs,  the  presumption  is  in  favor  of  its  being  simple  bronchitis. 
Other  points  of  difference  are  entitled  to  more  weight  than  that 
just  Slated.  Aeulc  tuberculosis  is  frequently  iiccoinpanicd  by 
faemorrliagc.  This  does  not  occur  in  bronchitis,  exclusive  of  the 
bloody  streaks  with  which  the  sputa  are  occasionally  marked.  The 
pain  in  bronchitis  is  .■inbstcrnat,  and  is  dull,  obluse,  or  burning  in 
its  character.  Tuberculosis  is  sometimes  accompanied  by  sharp, 
lancinating  pains  sitiiNtcd  at  the  summit  of  Ihe  cheat,  frequently  be- 
nesth  the  scapula.  The  pulse  in  acute  phthisis  is  accelerated  out 
of  proportion  to  ihe  local  pulmonary  symptoms.  The  reverse  is 
true  of  acute  bronchitis.  The  respirations  arc  much  more  frecjuont 
in  acnte  phthisis  than  in  ordinary  bronchitis;  the  loss  of  strength 
is  notably  greater,  and  the  i-maciation  more  rapid.  But  the  physi- 
cal signs  establish  conclusively  the  differential  diagnosis.  In  the 
majority  of  cases  of  tuberculosis,  percussion  reveals  a  disparity 
between  the  two  sides,  and  this  may  be  associated  with  more  or 
less  of  the  auscultatory  signs  of  solidification.  The  question,  in 
CMOS  of  acute  phthisis,  whether  the  disease  bo  simply  bronchitis, 


BIBBACIS  or   IBB    BBSPIBATOBT    OBOABE. 


irogttsiertW 


ftiiti  afier  the  iBTsaioa,  lor  ti  di 
erideaee  of  in  ckvMttf « 


itni»fei,  a  ■d£twa  lo  tku  sfarded  bj  pbjMcal  rxplMitii. 


.  Mt 


Ae«te  <r fair  Woacfcitii  ooewrii^  in  a  penon  affected  viA  t» 
I  rifc  to  cakamfliBeat  of  tbe  respiration  and  iji^ 
apartiin  to  iW  extent  and  intenaiiy  of  the  broncU 
Witboat  koovled|EeortWeoezi*teoeeofeiDphnaBa, 
th>»y»ptaaa»wHleadloUie  toipieicBOf  attaeote  sflwtiaii  odw 
tfcaa  ordtaajj  kwwhitU,  for  ezaaiple,  pa«amonitia  or  ploritu. 
IW  luttorj  aad  phjrical  sgu  anUft  tbe  phj«!cian  readily  la  b- 
tecwM  the  eofrisiing  fa^ea  vUd  lanMs  the  attack  of  broacUv 
vkh  sack  iBvaal  sjaptavi ;  bat  to  point  oat  tbe  means  of  arming 
at  tUi  eoBclHMB,  «nU  betoantkipatatbaAagnons  of  emphnMi, 
to  wUd  a  £stiBct  dbiptor  wiD  be  derotcd. 

Broa^tis.  onatoooatad  with  other  fmimimny  diseaae,  occ«n  ai 
a  pathok^ieil  eleMcat  of  eertain  ^oeral  alTectioDS,  more  especaOj 
fcren.  It  foms  an  imporUnt  cleaMot  of  rubeola ;  and,  pram 
ia  a  greater  or  leas  degree  freqneattj  in  ^pfans  and  tjphoU 
fevers,  it  aisT  coastititte  a  prtMsincM  featare  of  these  afftetitati 
There  is  a  liabilit;,  ander  tke^  circaaitaaeee,  to  coander  tbe  it- 
tase  exclasireljr  bronchitis.  In  rsbeola,  the  bronchial  yriaptMH 
preceding  Tor  sereral  da^  the  appearaoee  of  the  emptton,  lUl 
«n«r  doe«  not  iioplr  want  of  care  or  skill  on  the  pan  of  the  dia^ 
BMtietan.  The  chief  distingnishiBg  points  are  the  degree  and  ptr- 
sisteocy  of  the  corrxa,  the  irriutioB  or  infiamiaation  exteofng 
along  the  lachrTiaal  paawges  to  tbe  coajaaciira.  and  the  dispropor 
tton  between  tbe  local  evidetKes  of  broadiilis  and  the  general  sf  ap- 
tonu:,  such  as  febrile  morement,  pain  in  head  and  loins,  loss  of  ap- 
petite, etc.  These  pointy  hoaCTer,  are  not  infreqnentlr  anaratl- 
able ;  and,  in  fact,  in  a  certain  proportion  of  easea,  it  is  difficult,  if 
not  impossible,  to  predict  that  the  afeetion  will  prore  to  be  mote 
thaa  bronchitis.  In  continued  fever  the  difficnltj  is  l»ss,  and, 
indeed,  with  doe  attention  and  knowledge,  it  shoald  rarely  exist. 
Except  in  occasional  instatices,  continaed  ferer  b  not  tubered 
in  bT  marked  STmpioms  of  a  bronchial  affeciion ;  theae  symptotu 
become  developed  after  the  ferer  is  established.  Tbe  disease  hts 
a  prodromic  period,  in  which  usually  other  phenomena  are  more 
prominent  than  those  pertaining  to  the  pulmonary  oi^ans.  Limit- 
ing  attontion  to  typhoid  fever — the  form  of  continned  ferer  graeralty 
observed  in  this  country,  and  ihe  form  in  which  the  brooebial  elcMMBt 


CAPILLARY    BnONCQITIS. 


381 


nncner  TEiirlccd — llie  duntioti  of  llic  Atnge  of  invaaion  and  the 
'etiaracleriAlic  iivinplDiii<t  frequently  present  in  this  »lnge  aufEoe  for 
tbi'  diiigiioHi;).     Afterward,  in  addition  to  tho  character!!  then  present 
lotiiig  ths  dlMHse,  vix.,  tlx-  nbdoiiiinal  iijmptoinH,  epifttiixts,  erup- 
ts, etc.,  the  pulmonary  afTeclion,  compared  with  th«  febrile  move< 
ent,  the  prostration,  anorexia,  etc.,  ia  ■li.'^propurtionately  mild. 
lie  rales  observed  are  the  ttonoroua  and  sibilant,  more  enpeoiallj 
lie  latter;  and  t\iK»tt  continue,  rarely  nierging  into,  or  becoming 
ambincd  wiili,  the  itiiiotis  ra1i-H.     Tho  fnciliiv  with  which  the  dis- 
riminalion  iti  made,  in  the  va.«t  majority  of  cases,  renders  it  super- 
Inouit  to  dwell  longer  on  tbc  dctuila  of  tlio  diflercatial  diagnosis. 


[BU3IUART  OF  TUE   PUYlilCAL  filGNS   IHtLtiKGIKQ  TO  ACUTE  OltDlNiRt 

BRONCUITIlt. 

Percnssion-resonance  undiminisheil  on  both  sides  of  the  chest.    In 
[the  early  stage,  before  liquid  secretion  takes  place,  the  dry  ralea, 
leepecialiy  the  sonorous,  present  in  a  certain  proportion  of  cases. 
After  iteeretion,  the  moist  ralea  frequently  coinmingleil  with  the  dry. 
The  rales  heard  on  both  sides.     The   respiratory  murmur  at  the 
npper  portion  of  the  chest  in  front  sometimes  exaggerated  in  the 
early  stage;  subsequently  liable  to  be  diminished  or  suppressed 
I  oTer  a  part  or  the  whole  of  the  chest ;  Bometimcs  reproduced  sud- 
denly after  an  act  of  coughing,  in  n  part  of  the  chest  in  which  its 
lopprcesion  had  shortly  before  been  ascertained,  and  in  wild  oasea 
I  jHVServing  its  normal  intensity  and  ehnraotera.    A  rhonohal  freuilua 
occasionally  present. 


I 


CapIILART   BUOKCQITIS. 

Bronchitis  is  distinguished  as  capillary  when  the  inflnmmation  in- 
Tades  the  minute  bronchial  branches.  Inflammation  of  the  larger 
tnbes  generally,  but  not  uniformly,  coexists.  The  capillary  tubes 
or  bronchioles,  in  other  words,  the  terminal  subdivisions,  are  not 
implicated.  Capillary  bronchitis  was  formerly  described  by  medical 
writers  under  the  nnmes,  peripneumonia  notlia,  and  Kiiffocittive 
catarrh.  Its  true  chnraot^-r  and  sent  have  been  but  recently  under- 
stood.  It  is  with  great  propriety  considered  as  a  distinct  form  of 
bronchitia,  differing  from  the  ordiuary  form  in  important  particulars 


882 


ttlSBASBS   OF   TUB    BBBPIRATOKT    OROAKS. 


pertaining  to  symptomg,  lavs,  mud  signs,  as  well  *»  to  ftnatanicd 
charavti^re. 

The  anatomical  conditions,  on  which  the  physical  signit  an  iniM- 
dialcly  dependent,  are,  irregular  contrBcti»D  of  the  calibre  of  lb 
minute  lobes,  the  presence  of  liqui<l  within  tlie  tobes,  and  obUtat 
ttOD  to  the  passage  of  air  to  and  from  the  rcsioles.  The  latlcr  vm- 
dition,  t.  r.,  the  obstruction,  is  that  to  which  the  most  'tiTthtrlW 
and  important  sjmptome  stand  in  immediate  relation. 

Phynral  Siffni  and  IHitffnottt.-^a  CBpiltarv.  as  to  or£iiajy 
bronchitis,  the  air  withio  the  pulmonary  vehicles  rctnaintBg  ■- 
diminished,  imd,  indeed,  increased  in  quantitj  (excepting  the  rcdw- 
tioD  due  to  the  collapse  of  lobules,  which  takes  place,  to  a  greater 
or  less  extent,  in  a  certain  proportioa  of  cases),  the  pcrcuMioD-ras*- 
nance  is  unimpaired,  aod  may  be  exaggerated  or  Tesicalo-tjmpaiiitie, 
especiall;  at  the  superior  and  anterior  portion  of  the  chest.  0»- 
diminished  resonance  on  percussion,  on  the  two  sidca,  althoogh  ncga- 
tire,  is  a  fundamental  point  in  the  diagnosis.  Dulness  dcooiM 
either  that  the  affection  is  complicated  with  pncumooitis,  or  that  ■ 
certain  amount  of  collapse  has  taken  place. 

AuRcullation  fiiniiiihvf,  ai  the  early  part  of  the  disease,  and  to  a 
greater  or  Ic^  extent  during  its  career,  the  dry  bronchial  raW 
Both  the  !(oni>roii«  and  sibilant  are  incident  to  this  varietv  of  bron- 
ohitis,  but  the  latter  is  characterislic  of  exten^on  to  the  minnle 
tnbea.  The  sibilnnt  rale  h  sometimes  in  a  marked  d^ree  aciitc  or 
whittling  in  it:^  chnnicler.  The  sonorous  rales  may  be  loud  and  mu*i- 
cal,  a«  in  ca.^cs  of  iivthnia,  being  appreciable  bjr  the  patient  himstir 
and  bj  others.  Both  varieties  are  generally  diSiised  over  the  whole 
chest.  The  presence  of  the  rales  tends  todrown  the  vcscular  mur- 
mur, but  the  latlcr  is  rendered  feeble,  and  may  be  abolished  by  th* 
ob«truction  within  the  tubes,  and  Uie  over-distension  of  the  ceQl- 
Tbc  moist  or  mucous  rales  incident  to  ordinary  bronchitis  mayltt 
present,  more  or  less,  depending  on  the  inflammation  of  the  largtr 
tabes,  which  usually  coexists,  giving  rise  to  tbe  eecretion  of  mucoc 
In  theae  lubes  ;  but  a  moist  rale  eharacterislic  of  an  affection  of  the 
minutf  lubes  is  the  gub-i-rfpilant.  This  rale,  in  il.t  sensible  charao- 
tcrs,  as  well  as  in  its  source,  holds  an  inlermediate  place  betweei 
the  mucous,  on  the  one  hand,  and  tbe  crepitant,  on  the  other  hand. 
It  is  a  bubblin;;  rale,  convf'yiiig  to  tbe  ear  the  impre#»ion  of  the 
presence  of  liquid.     TIic  bubbles  seem  to  be  extremely  small,  u^ 


04PltLAKT    BHOKCHITIS. 


Hi 


1 


I 


•omewbal  unequal  in  ^izc.  The  s>oun<I  is  finer  than  that  of  tho  finest 
RincoiiK  nlvs.  It  ma;  aCGompanj  cither  infl{)iriition  or  expitalion, 
or  b«lh  rMpiralory  acW.  Contrasted  with  the  aub-urcpiiant,  the 
errpilaot  nic  i»  ^till  finn-;  it  is  dr^,  i.  «.,  not  conrejrinf;  the  idea 
of  huhhteit,  and  <\ot»  not  belong  in  the  cate^or?  of  the  bubbling 
raW;  the  crepitations  are  equal,  and  it  in  limited  to  the  initpiralory 
act.  Theae  several  (Mints  of  distinction  enable  the  anscultator  to 
diocriminale  between  the  two  in  the  niajority  of  instances,  by  the 
een&ible  characters  alone.'  The  law  of  synimelrj?  her«,  ae  in  the 
ordinary  form  of  bronchitis,  has  so  important  bearing  on  the  diag- 
nusts.  Id  conformity  with  this  law,  the  sub-crepitant  rale  ia  found 
on  both  aides  of  the  chest.  This  is  a  point  distinguishing  it  from 
the  crepitant  rale  which,  in  the  vast  majority  of  cases,'  is  limited  to 
one  side. 

Tlic  siib-orepitant  rale  in  capillary  bronchitis  is  hpard  especially 
over  the  lower  third  of  ihe  chc-.tt  posteriorly.  IVe^enl  in  Ibis  situo* 
tion,  diffused  over  a  con»idcruhlc  »pace,  on  both  side»,  and  the  per- 
cn»«i>n-reM>nance  nnimpnireil,  thi:<  conibinutiou  of  signv  in  connec- 
tion with  the  symptoms  of  thcili»ea«c. rcndors  the diaguoHiN  po.iitivc. 
Th«  sub-crepitant  rale,  under  these  circumBlnuces,  becomvg  patbog- 
nomonic.  Aside  from  its  connection  with  capillary  broncbiti»,  this 
rale  occurs  in  ccdema  of  the  lungs,  in  hsemoptyaia,  in  cases  of 
phthisis,  and  in  pneumonitis.  But  the  associated  signs  and  .iym|k 
touts  in  all  cases  render  it  sufficiently  easy  to  dislinguish  between 
Ibcae  several  affections  and  idiopathic  capillary  bronchitia.  (Edema 
is  a  secondary  affection,  and  gives  rise  to  dulncss  on  percussion.  In 
luemoptysis,  the  bloody  expectoration  indicates  the  source  of  the 
iigo,  and  hemorrhage  (excepting  the  bloody  streaks  which  the  spula 
occasionally  present],  does  not  belong  among  the  events  liable  to 
occur  in  ibis,  more  than  the  ordinary.form  of  bronchitis.  In  phthisia, 
the  sob-crepitant  rale  is  an  occasional  sign  limited  to  a  circumscribed 
space  at  the  summit  of  the  chest,  and  associated  with  more  or  leas 
of  .ihc  other  signs,  as  well  as  with  the  symptoms,  denoting  tubercu* 
loais.  In  pneumonitis  it  occurs  at  a  late  stage  of  the  disease,  after 
the  diagnosis  has  been  delermined,  but  the  connection  is  easily  es* 
tablisfaed  by  the  ooncorailant  physioal  signa,  vis.,  bronchial  rcapira* 

>  In  •  fkM  of  r>|>illitrT  hroni-hiti*  complloslcd  With  lobar  pnoutnonilit  fa  th* 
■dult,  the  twl>.<-rvpil<Dt  ralo  accoinpKuiud  both  mpiratorj  Mti.and  tbu  crvpitaal 
wu  dUtiaclly  ajifircciabk  at  ths  end  of  intpiratioii. 


884 


DI6SASKS    DP    TBB    RBSPIBATOBT    OBOASt. 


tion,  bronchophony,  dulne^s  on  p«rc<isaion,  etc.,  tliese  ngu  \ra^ 
in  the  majority  of  cases,  liinite<l  to  one  aide  of  the  che»t. 

If  th«  practitioner  were  to  he  guided  exclusively  by  the  ijnpbiM, 
he  might  be  at  a  loss  in  some  ini)titnc«s  to  decide  between  llw  rb»- 
ence  of  capillary  bronchitis,  and  either  acute  pncumonitia,  or  plcniu. 
occurring  in  the  adult,  albeit  the  distinguishing  fealum  in  ibt(» 
mer,  as  contrasted  with  the  two  latter  affections,  are  of  a  uribi| 
character.     Acute  pneumonitis  and  pleuritta  are  generally  cfawie- 
terised   by  sharp,  lancinaling  pains,  which  do  not   ent^r  inta  ^ 
symplARiatic  history  of  capillary   bronchitis.       The   latter,  tn  tW 
great  majority  of  instances,  supervenes  on  ordinary  bronchitis.  Tfc 
former  are  preceded  by  an  inflammatory  affection  of  the  broMhtd 
mucous  membrane  in  only  a  small  proportion  of  ca»e«.     Theytn 
fn'(]uently  ushernd  in  by  a  chill,  which  is  not  obi^rred  to  accoopny 
the  onset  of  capillary  bronchitis.     The  suffering  from   ortbopKca, 
the  cyanotic  hae  of  the  lips  and  surface,  the  great  freqaencr  of  the 
putse,  the  frequency  of  the  respiratory  acts,  the  rapid  progresa  {n- 
quently  to  a  fatal  issue,  di-itinguish  sercre  cases  uf  cspillarT  itm- 
chilis,  these  symptoms  not  being  present  to  the  some  extent,  satt 
in  exceptional  cases,  of  pneumonitis  and  pleuritic.       But  with  iW 
ail)  of  physical  exploration  the  discrimination  is  made  with  so  little 
ililficulty  that  it  18  not  necesrarv  to  dwell  on  the  subject.     Beck 
pncnmonitiii  and  plcuritis  t>pecdily  present  certain  positive  sig&it  N 
constantly  present  and  &0  easily  appreciated,  that  their  ab!>enee  wmr- 
rants  the  exclu»on  of  these  affections.     These  signs  arc  incident  M 
solidification  of  the  lung  in  pneumonitis,  and  the  presence  of  lii|aid 
elTasIon  in  pleuritis.      In  the  vast  majority  of  instances  thcyait 
confined  to  one  side  in  both  affections.     On  the  other  hand,  the  sub. 
crepitant  rale,  and  the  dry  rales  belonging  to  capillary  bronchitis, 
are  diffused  nnirersally  over  the  chest. 

An  instance  has  fallen  under  my  observation  of  phthisis  in  which 
the  tuberculous  deposit  was  so  sbundsat  and  rapid  as  to  induce 
great  difficulty  of  respiration,  accompanied  with  very  rapid  palte, 
lividity  of  prolabia  and  face,  and  ending  fatally  by  asphyxia  withia 
a  fortnight.  Bat  in  this  case  tuemoptysis  occurred,  and  the  phyn- 
cal  signs  denoted  plainly  tuberculous  consolidation,  most  marked 
at  the  summit  of  the  chest.  In  such  an  instance,  an  error  of 
diagnosis  could  only  befall  one  who  depended  entirely  on  symp- 
toms. 

Other  diseases  for  which  there  is  a  liability  of  capillary  broachhi* 


CAPILLARY    BBOXCHITlg, 


S39 


I 


g  mistaVeii,  and  W<«  i'^»a,  are,  firtt,  certain  affections  of  the 
ryos,  inducing  the  phenomena  of  spncca;  and,  tfcovil,  certain 
nionary  affections  in  addition  to  those  already  mentioned,  vis., 
asthma,  ordinary  broncliilis  in  connection  with  cmphjsctiin,  ordinary 
bronchitis  with  collapBC  of  pulmonary  lobules,  and  the  variety  of 
mchilU  to  be  next  noticed,  called  plastic  or  pgeudo-mcmbrnnous. 
The  laryngeal  affections  referred  to,  are,  a^dcma  glouldis,  spasm 
>f  the  glottis,  acute  laryngitis  in  the  adult,  and  in  children  diphtbe- 
idc  laryngitis  or  true  croup.     In  cedema  glottidis,  the  scat  of  the 
ibstruction  ia  indicated  by  the  sadden  arrest  of  the  inspiration,  the 
xpiration  remaining  free:  the  reverse  obtains  in  capillary  bron- 
iti«.     Ordinary  bronchitis  precedes  and  aeconipanieii  it  only  as  a 
lincidrncc,  not  as  a  Ihw.     Auscultation,  if  there  be  no  pulmonary 
implication,  discovers  only  diminution  or  abolition  of  the  vesicular 
i-nunnHr;  not  the  rales  incident  to  capillary  bronchitis.     Moreover, 
with  the  finger  carried  to  the  top  of  the  larynx,  the  existence  of  the 
dcma  may  be  demonstratively  settled  by  the  touch. 
Spasm  of   the  glottis,  rare  in   the  adult,  but  not  uncommon  in 
tftrly  life,  is  a  paroxysmal  affection,  the  respiration  in  the  intervals 
leing  eith<'r  free  or  but  slightly  embarrassed.     It  is  chanicterixcd 
.  fre(|uently  by  a  sonorous,  crowing  im<piralton,    distinctive   of  its 
flftryngeal  origin.     It  is  unaccompanied  by  the  froiiueney  of  the 
pulse  which  belongs  lo  capillary  bronchitis.     The  difficulty  of  res- 
piration incident  to  iho  latter,  although  increased  at  times,  is  persist- 
ing.    The  positive  signs  of  inflammalion  of  the  minute  bronchial 
tnbe.4  are  wanting. 

aryngitis  always  presents  distinctive  characters  referable  to  the 
',  in  addition  to  other  points  of  difference.  The  voice  is  hoarse, 
asky,  or  extinguished,  while  its  quality  remains  unaffected  in  capil- 
lary bronchitis.  Moreover,  in  croup  the  sonorous,  tubular  breathing 
Bnd  cough  are  diagnostic  The  respiratory  nets  are  slow,  labored, 
but  BOt  increased  in  frequency,  whereas  in  capillary  bronchitis  they 
are  extremely  fretjuent.  The  absence  of  the  auscultatory  signs  of 
capillary  bronchitis  in  both  these  affections,  as  in  the  foregoing  in* 
Biances,  renders  the  diagnosis  positive. 

A  paroxysm  of  asthma  Is  chnructcriiod  by  symptODU  not  unlike 
thoi!e  presented  in  capillary  bronchitis.  The  orthopnou  and  ap- 
pcarnnccs  denoting  defective  bromatosis  are  siTiiilar  in  the  two  affec- 
tions. The  situation  of  the  obstruction  Is  the  same,  viss.,  in  the 
small  bronchial  branches;  and  the  physical  signs,  exclusive  of  the 


DISUSES    OF    TUK    BBSPIBATORT    OROiSS. 


vlio<nM   and  rabcrepiUDt  rales,  are  identical  in  dtaneto'.    TW 
MQOTOiU  anJ  sibiUtit  rales  are  much  more  marked  in  asllnaa.    U 
this  affection  the  padiologicai  element  is  spasm,  and  the  afftctiimii 
parosysmal,  alihougli  the  paroxrsms  may  hare  considerable  imv 
tion.     The  liability  of  the  patient  to  attacks  or  asthma  is  k&««^ 
lince  in  th«  great  majority  of  inMances  ihcj  oectir  in  porsons  aW 
Br«  habituated  to  them.     Generally,  the  previoofl  historr  and  phrs- 
eal  signs  denote  the  ezbtence  of  emphysema.     The  puUe  ftin>id>» 
a  grand  point  of  difference.     In  asthma,  the  pnlf>«  may  rcmaiB  ^ 
affected  in  freqiiencv,  and  never  is  accelerated  to  the  degree  gt 
served  in  capillarv  broncbitb. 

AcDle  bronchia)  inflammation,  extending  beyond  the  larger,  ba 
not  to  the  minute  branches,  occnrring  in  a  person  affected  with  em- 
physema, induces  a  train  of  symptoms  resembling  closely  tbow  at 
Uk  capillary  form  of  bronchitis.  The  suffering  and  labor  with  r*- 
piration  and  the  impaired  oxygenation  of  the  blood  in»y  be  rquaRf 
marked,  but  the  prognosis  i*  far  le»#  grare.  The  existeDce  of  em- 
physema is  readily  dt-tcriuined  by  present  signs  titkcn  in  connoctjoa 
with  the  previous  history.  The  sonorous  and  sibilant  rales  will  W 
likely  to  be  prevent  in  connection  with  the  mucous  rale«,  but  not 
the  subcrepitant.  The  cocxbtence  of  the  emphyGcma  renders  the 
sympioma  perinioing  to  the  respiration  and  hteniaiosJs  mocb  lest 
ominous  than  if  thii  complication  did  not  exist.  The  pulse,  which, 
under  these  circumstances,  is  n  better  index  of  immediate  dan^ 
than  the  symptoms  just  referred  to,  is  less  frequent  than  in  capillary 
bronchitis. 

Mild  capillary  bronchttin  occurring  in  an  emphysematous  subject, 
gifce  rise  to  dyspnea  oat  of  proportion  to  the  actual  amoant  of  ob- 
Btruction.  Moreover,  as  snch  Eubjects  are  generally  liable  to  asthn*, 
spasm  of  the  muscular  fibres  of  the  bronchial  tubes  is  a  more  prooii- 
nent  element  than  in  esses  in  which  the  capillary  bronchitis  is  oa- 
eomplicated,ani)  hence  the  difltculty  of  breathing  is  in  a  more  marked 
degree  paroxysmal.  Under  these  circumstances  the  pulse  denotes 
less  intensity  of  inflammation  and  danger  than  might  be  inferred 
from  the  pulmonary  symptoms  alone.  These  facts,  however,  have 
relation  to  the  prognosis,  and  the  importance  of  active  therapeutical 
interference,  rather  than  to  the  disguoiis. 

Finally,  capilliiry  bronchitis  presents  symptoms  and  signs  be- 
longing alike  to  the  f<inn  of  hn)ricbial  itiHammation  called  plastic 
or  pHeudo-mcmbrauouH,  irhioh  wilt  presently  be  noticed  under  a  dis- 


PSKtFDO-HBMBRAlCOV!)    BRO^ZCRITIS. 


387 


■net  bead.  Remarks  on  tlie  diagnostic  pointe  diatinguishing  theae 
TectioBB  from  each  other,  will  be  more  Appropriate  in  connection 
ith  the  Istter. 


lOMMiRT  OF  TlIB  PHYSICAL  8ISN8   BKLONOISQ  10  ACIITE  CAPILLABT 

BRONCHITIS. 

Percnssion -resonance  on  both  xidtrtt  not  diniiiiic>h<^,  but  often  ex- 

^kggerated;  floiiorou«  and  !<ibiliinl  rnlc^  difTiificd  over  tliv  oliet*!,  the 

Uikt  more  prominent  and  abundnnl  tliaii  in  unliiiary  bronchitis; 

the  «uh*crcpitant  nile  on  both  fiih-n,  and  obiicrved  fspcciallj^  at  the 

sfcrior  posterior  portion  of  the  chfnl ;  ooartic  and  fniv  mucous  ralea 

itcrmingli^l  to  a  groHt-r  or  less  extent. 


P8bci)0-Mbmbbasou8  or  Plastic  Bronchitis. 

This  variety  of  bronchitis  is  characterized  by  the  exudation  of 
lymph  on  the  mucous  anrface  of  the  smaller  bronchinl  tubes,  form- 
ing what  is  termer]  false  membrane,  identical  with  the  deposit  which 
takes  place  vithin  the  larynx  and  trachea  in  croup.  The  falae 
membrane,  in  i:ti«c»  of  croup,  soinetiiiice  extends  downward  into  the 

f  bronchial  saiKli virion s.  These  cases  arc  not  embraced  under  the 
)n-r8ent  head.  The  deposit  in  pln»tic  or  pseitdo-mcinbranous  bron- 
ohitis  oommcDCcH  in  the  minute  branches,  and  extends  upwards  to* 
irards  tile  trachea.  A  fibrinous  eiudation  in  some  of  the  tubes  is 
occmionally  observed  as  a  contingent  auutomical  clement  of  capi]> 
Blitry  bronchitis;  but  it  is  the  basis  of  a  distinct  form  of  bronchial 
inflammation,  when  it  constitutes  the  m'i«t  distinctive  and  important 
feature  of  the  disease.  Pathologically,  it  drnotcs  »  pi^culittr  modi- 
fication, irithout  necessarily  grent  inU'nsity,  of  the  inflammatory 
■  prooen. 
The  eipcctoration  of  false  membrnnc  is  prcce<led  by  cough  more 
or  less  riolent,  generally  accompanied  by  dyspnoea.  These  charac- 
teristic sputa  arc  cxpfctorated  at  intorviiln  varying  greatly  in  dif- 
ferent cases;  days,  weeks,  inonlliis  and  sometimes  even  years  int«r- 
Tening.  Ande  from  this  pccwliar  feature,  the  symptoms  may  be 
those  of  an  acute  or  subacute  bronchial  inflammation.  I>y»pntea 
and  the  evidences  of  defective  hiematosis  may  be  absent,  or  prwent 
in  a  degree  proportionate^  to  the  amount  of  obstruction  and  the  num- 
ber of  the  bronchial  nuuificutions  affected.  The  danger  and  the  rapid 

22 


SS8 


DtSIASIt   or   TBI   tlRrikATOUT    0B0A5S. 


emreer  of  tli«  duMw  depend  on  tht  nrcnmstsnees  ja>t  mentitsA 
Th»  expectoration  of  fmlec  membraov  rasj  br  fpltored  by  vM 

more  or  leM  eoinplet«.     Collapse  of  palmooar;  loboW  ntaj  tfeem, 
sddiog  to  the  grsritj  of  the  Bjtnptome,  sad  the  danger.     ('•»»• 
vhicfa  the  exadation  taket  place  exteasirdjr  tbroaghont  ihelna^ 
present  all  tbe  dietreaeiag  and  alarming  sjrmptoms  inctdcDt  to  atnm 
eapillarjr  bronchitis,  and  under  these  circumstances  the  diaeaaeisij 
prore  rapidly  fatal.     In  other  instarieea,  a  Btnall  nnmber  onlt  «f  tk 
bronchial  ramifications  being  affected,  the  BTtnptoms  are  c«inpii» 
tivelj  mild,  and  not  indicative  of  danger.     Under  the  Utter  at- 
cnmalaneea,  the  affection  mav  continue  indefinitely,  or  recnr  fnn 
time  to  time,  or,  after  the  expectoration  of  the  membraoifom  fo* 
dticta,  terminate  in  complete  recovery. 

This  form  of  bronchilig  i»  cxG4'eiling1j  rare.  It  occare  in  nuW 
oflcner  than  in  females.  It  it  not  limited  to  any  period  of  life,  hi) 
it  is  most  fre<(iieiii  beiween  the  ages  of  twenty  and  fifty.  Persooi 
debilitated,  or  who  have  previoutity  had  some  pulmonary  aSect>oa.m 
more  liable  to  the  disease  than  those  in  robust  health.  HiMDoptTM 
IB  an  event  not  belonging  to  this  more  than  to  other  forms  of  bn»> 
ebilis,  irrespective  of  the  bloody  points  or  streaks  which  tl»e  ^raH 
OOCBMonally  prctent. 

Tbe  afleclioii  may  he  acute  or  chronic.  It  mny  be  partial,  i  f-. 
affecting  a  certain  number  of  the  hrouchial  tubes  only;  or  gtmini, 
extending  over  the  greater  portion  of  the  tubes.  It  obeya  the  hv 
of  symmetry,  like  the  other  varieties  of  bronchitis,  wbeo  it  it  idw- 
pathio.  If  the  exudation  take  place  extensively,  or  if  it  Mcvii 
conneclioB  with  other  pulmonary  affections,  a  fatal  reeolt  msykt 
expected.  Of  the  cases,  however,  in  which  false  tnenbraMi  a 
more  or  leas  abundance  is  expectorated,  a  Urge  proportioa  md  » 
recorery.' 

nj/tkml  Siffiu  amJ  Pia^rtMu, — The  physieal  opis  in  pbitie  m 
pfttdo-membranous  bronchitis  do  MtC  difer  maierially  fnm  tkm 
ueidtBt  to  the  varieiies  of  the  diinte  fverioofly  cuaaidaad.  Kt- 
•hmv«  of  certain  incidental  Borbtd  eoaditiias,  via., 
ywl  aawUtioa  vf  bi|wd  fnimeU  within  the  aJr^taho, 
etteits  •  reeoaaaet  mdiainiafctJ  «■  the  two  tides,     Tkt  ■■ 


■  r>r  tto  MMlM  4f  aa  iMlpfo  af  IWM-iight  «« 
p««w  I7  Dr.  Ptana;.  •*  Lm4m  Mad.  timm, 
M>.  ef  XmL  Somw.  A^d.  ISA 


Dm.  teu. 


PSSUDO-MEUBRAirOCS    BROKCHITIS. 


SS9 


and  eibilnnt  rales  vill  be  likely  to  be  hvnrd,  on  nuscultalioo, 

fare  or  l^-ss  diffused  over  both  slilw  of  llic cliest.     The  moist  or  bub- 

ng  rales  are  developed  in  the  jvogrvHS  of  tlic  disease,  as  in  tbe 

lier  forms  of  broiicbiliei.    Supprcfftion  of  iliu  niletf  and  of  all  respi- 

Morv  sound  over  jiortioiiii  of  tbe  clioitt  h  liable  to  occur  either  from 

itruetittn  of  the  liibex  \iy  the  cxudnlion.  In  which  case  it  may 

'  tempwrar;,  and  variable  in  ftiluation  aud  extent,  or  from  collapse, 

llie  latter  case  being  more  persisting  both  iu  »t-at  and  duration. 

!  ogb-crepitant  nilc  inaj  be  discovered,  but  it  is  limited  to  cvrtuin 

srtioiM  of  tbe  chent.     A  tlia^osiic  point  pertains  to  the  facl  la«t 

lUd.     The  presence  of  the  8ub-cr«pittuit  rale  distinguishes  this 

I  ordinary  bronchiti:*,  and  the  limited  extent  of  surface  over  which 

le  rale  i»  heard   distinguishes  ihe  affection  from  capillary  brt>n- 

litis;  in  the  latter  variety,  the  subcrepitant  rale  is  diffused  over 

He  chest.     Bnrtti  and  Cazenux.  separalt'Iy,  have  reported  each  a 

tingle  case  in  which  o  peculiar  valvuLir  or  Slipping  sound  (yxtfi't  bruit 

te  aoupape),  was  heard  on  auscultation,  attributable  to  tbe  vibration 

lof  partially  delnched  portions   of  membranous  exudution.     It  is 

[doubtful  whether  the  sonnd  be  sutSciently  distinctive  to  represent 

lie  preseoce  of  this  peculiar  product  nithio  the  tubeti.    Were  it  a 

diagnostic   »ign,  the  f:ict  of  iu  being  only  ocoKionally  observed 

BvooM  render  it  praclicnlly  of  little  value. 
The  diagno«i#  of  plastic  or  pscu  do- mem  bra  nous  bronchitis,  as  dis- 
ttngui»hed  from  other  varieties  of  intlanmintiou  of  the  bronchial 
mucous  membmue,  must  be  based  almost  exclusively  on  tlie  charac- 
teristic expcetoralion.  Prior  to  false  membrane  being  expelled,  the 
^mptoms  and  sign:!i  are  not  sufficiently  distinctive  for  the  practi- 
tioner to  decide  tlint  this  particular  form  of  bronchitis  exiMls.  If 
membrRiiiform  patches  are  discovered  in  tbe  matter  of  expectora- 
tion, their  appearance  may  at  once  denote  their  soarce,  and,  cousiv 
qnently,  the  locality  of  the  inflammation,  as  well  as  its  peculiar 
character.  Solid  or  cylindrical  casta  not  only  show  their  bronchial 
origin,  but  indicate  tbe  size,  and,  in  some  measure,  the  extent  of  the 
tabes  involved.     But  if  the  false  membrane  expcctorntcd  consist 

»  simply  of  fragmentary  pieces  or  *hreds,  the  fact  of  the  exudation 
leiog  bronchial  is  settled  by  the  quality  of  the  voice  remaining  on- 
aSectod,  and  the  absence  of  other  evidences  of  laryngeal  disease. 
The  circuroslances  just  meniioned  suffice  for  the  differential  diag- 
nosis between  croup  and  plastic  or  pseudo-membranous  bronchitis. 
Tbe  period  of  life  at  which  this  affection  is  most  apt  to  occur  has 


340  DI8BASBS    or    THE    RSSPISATOKT    OKOASS. 

S0Bi«  importaiiGe  in  a  diagnostic  point  of  riew.  In  this  respMit 
differa  from  capillar;  bronchilis,  a«  well  as  from  cronp.  Tbe  !>tt* 
are  eminently  infaDlile  diseases,  whereas  the  afTection  under  cwat 
«ntton  is  oftenest  obaerred  in  persons  between  the  ages  of  mn^ 
and  6fly. 

It  should  be  added,  that  the  occurreoce  of  ibe  charaetenitirtr 
pecloration  is  not  invariable.  The  disease  na;  run  on  rapMlU  loi 
fatal  termination  befor«  sufficient  time  has  elapsed  for  ikr  [iininai 
upon  which  the  exfoliation  of  the  exudation  depends  to  be  en- 
pleted. 

The  discrimination  of  thi«t  form  of  bronchitis  from  affpcttons,  diW 
than  bronchitu,  which  con)promi.«v  rcvpiraiion  anil  the  fanctisnaf 
lueotatosis,  inTolree  the  same  diagnostic  points  alrcaJj  noticed  ii 
treating  of  ordinarj  and  capillary  bronchitis. 

eOMUART  OF  TOE  PBTSlCiL  S1QII8  BBlOKODtO  TO  PLASTIC  OB  FSEtB»- 
MKliBRAtiOtlS  BROKCBITIS. 

In  addition  to  the  physical  phenomena,  poeitire  and  A^the. 
incidont  to  other  varieties  of  bronchitis,  a  pecnliar  ralrular  or  bp- 
ping  sound  {hruit  d*  toupape)  has  been  obserred.  The  sub-crejiibM 
rale,  if  present,  less  diffused  tlian  in  moBt  cases  of  cupiUaQ'  bron- 
chitis. 

Chronic  BROKcnms. 

Bronchitis,  existing  primarily  us  an  acute  aSection,  may  be  pro- 
longed and  assume  the  chronic  form,  but  occaHionally  the  inflaoma- 
tion  is  subacute  from  the  commencement.  Contrasted  with  ike 
acute  rariety  of  the  disease,  chronic  bronchitis  offers  some  impxirtui 
points  of  difference,  not  only  in  its  symptoms,  effects,  and  paibido- 
gical  relations,  but  asregardi!  the  affections  from  which,  clinically, it 
is  to  be  distinguished.     It  therefore  merits  separate  coaaidcratioo- 

Phywical  Sigrn. — So  long  as  chronic  bronchitis  remains  OBAonqii- 
catcd  with  any  other  pulmomiry  affection,  or  with  lesions  affecting 
the  size  of  the  tubcH  or  cells,  which  are  apt  to  supervene,  tbe  die«l, 
as  a  rule,  yields  the  normal  vesicular  resonance  on  percussion.  Tbt 
only  exception  to  this  rule  is,  occasionally  the  occurrence  of  vliglii 
or  moderate  dulness  from  excessire  accumulation  of  the  liqnid  pro- 
ducts of  inBammatiott  within   tbe  bronchial  tnbes.     Exclosire  of 


CDBOKIC    BHONCHITIB. 


841 


ais  exception,  n  markci]  divpority  botwecD  the  two  itidofl  as  rei^pects 
ananoe.  assuming  the  chest  to  be  well  formed  and  symmetrical, 
■tioK>s  tliitt  tlic  bronchitis  is  eomplicntvd  citlicr  with  some  affection 
Vllkfa  increases  tlic  density  of  tlie  lung,  such  as  collapse,  pneumo- 
B,  tuberculosis,  or,  on  the  other  band,  with  rarefaction  from  cm- 
phjspma.  Complications  exist  in  chronic,  oftencr  than  in  acute 
kronchitis;  and  hence,  equality  of  the  percussion-resonance  on  the 
ro  sides  is  found  in  connection  with  the  symptoma  of  the  former, 

commonly  than  in  the  latter  affection. 
The  bronchial  raleR,  moist  and  dry,  are  heard  in  different  easca 
nth  erery  diversity  as  respects  character,  intensity,  combiiiation, 
id  relative  predominance  of  the  different  varieties.     The  bubbling 
lies  are  abundant  and  dlfTitsed  in   proportion  to  the  quantity  of 
Uquid  within  the  tubes,  its  thinness  admitting  the  passage  of  air, 
lAnd  the  extent  of  its  diffusion.     They  are  loud  and  coarac  whcu 
produced  in  the  larger  tubes;  finer  and  less  intense  in  the  smaller 
Itnuiobcs.      These   ralct*    predominate   in   cusea   characterized   by 
>piovs  expectoration.    The  vibrating   raica  are  especially  prom- 
lent  in  cases  in  which  the  matter  of  expectoration   is  sriiiill   in 
loaolitT  and  Tisetd,  adherinj;  tcnacioosly  tu  the  walU  of  the  tubes, 
idU  not  readily  travorseil  by   air.     Id  cases  charaeterized  by  tlie 
formation  of  sinnll,  solid,  mtimus  pellets,  a  clicking  valvular  sound 
liras  described  by  Lacnnec  as  occnsionally  present,  and  attributed  by 
fbim  to  their  being  moved  within  the  tubes  to  and  fro  by  the  eunont 
of  air.    As  the  inttninmntion  in  generally  limite<l  to  the  larger  lubes, 
the  sonorous  is  oftcner  heard   thiin  the  sibilatit  rale ;  and,  as  in 
the  majority  of  cases  the  expectoration  i.t  mure  or  lesB  cupiou.*,  the 
mucous  are  more  common  in  chronic  bronchitis  than  the  dry  rales. 
Both  the  dry  and  moist  rales  may  be  commingled  in  various  propor- 
tions, and  the  different  varieties  of  each  species  may  be  heard  si- 
mnhaneoufily  at  different  points  on  the  chest.     The  numerous  diver* 
sifies  which  theseralesmay  present  are  not  only  illustrated  in  a  series 
of  cases,  but  sometimes  at  different  periods  in  the  progress  of  the 
•ame  ease.     On  the  other  hand,  in  a  certain  proportion  of  cases  of 
chronic  bronchitis,  the  bronchial  rales,  so  far  from  being  prominent, 
■re  nearly  wanting.     They  may  be  only  present  occasionally,  and 
repeated  explorations  may  fail  to  discover  any  of  them.     These  are 
ca«e«  ill  which  the  quantity   of  liquid  products  is  small,  and  their 
aoval  by  expectoration  ia  speedily  effected.     Sometimes  in  cases 
af  this  dcswriptioo  rales  may  be  di«i;overed  if  pains  be  taken  to  aus- 


842 


DiaBASBSOF    TUB    IlBSPIllATOBT    0R0AN8. 


cnltitto  Mrly  in  the  morning,  Iwforc  tfao  msUer  which  has  aceoinii- 
luteil  during  sleep  i*  rcniovcd  ;  wUercu,  nfwrward,  during  tlie  day, 
tlic  tubes  being  kept  clear  by  repented  Mte  of  coughing,  the  chest 
is  Tree  from  %ivtsnt\%\ou»  sounds.  The  presence  or  absence  of  the 
rnli-s,  «nd  in  a  great  incnsure  their  diversities,  thus  depend  on  eon* 
tingent  circamstances  which  ore  irrespective  of  the  severitj  of  lb* 
disease.  While  the  presence  of  the  rales,  in  connection  with  tha 
BjiDptoms,  is  eridence  of  the  existence  of  bronchitis,  the  conrcrM 
does  not  hold  true  ;  that  is,  bronchitis  maj  exist  without  an^-  of  the 
rales  being  discoverable.  The  rales  may  bo  suspended  lemporarilj- 
in  a  portion  of  the  chest  by  ob^tmction  of  one  or  more  of  the  bron- 
chial subdiviaionR,  and  suddenly  reproduced  after  an  act  of  cough- 
ing by  which  the  obatroction  is  removed. 

The  vesicular  murmur,  when  nol  obscured,  or  drowned  by  the  rales, 
is  variable  as  re»peot«  intensity,  but  generallr  more  or  less  dimin- 
ished, and  in  aome  inatanoes  ftcarcely,  if  at  all,  appreciable.  Occa- 
sionally a  respiratory  sound  is  heard  rcscnibling  an  cxaggerat«d 
Teeicular  murmur,  but  hari^hcr,  as  well  as  louder,  than  ifae  normal 
respiration.  This  modification  is  not  peculiar  to  chronic  bronchitis, 
but  has  already  be»n  noticed  in  connection  with  the  acute  form 
of  the  disease.  As  remarked  by  Walsbe,  it  U  probably  not  of  ve- 
sicular but  of  bronchial  origin.  It  is,  in  fact,  an  approximation  to  a 
rale.  Lnennec  probably  had  reference  to  this  modification,  in  stat- 
ing that  in  some  cases  of  cbrontc  bronohilis  the  Yesioular  mDrmiir 
becomes  piierile,^-<i  statement  not  confirmed  by  subseijueni  obser- 
rattons.  And  it  is  probably  this  modification  which  Dr.  Bowdilch 
terms  a  mu^oHs  rcs/nVrtd'on.*  A  rational  explanation  la,  the  swell- 
ing of  the  mucous  membrane,  or  the  preacnoc  of  a  little  mueu»  ocea^ 
sions  an  audible  bronchial  sMund,  but  does  not  fumtsh  the  physical 
conditions  for  a  fully  developed  dry  or  moist  rale. 

The  vocal  resonance  and  fremitus  in  chronic  bronchitis,  a^  n  rule, 
remain  unaffected.  The  exceptions  to  thi.<«  rule  are  certainly  ex- 
tremely infrequent.  Exclusive  of  the  vibration  pereoptible  to  the 
toueb,  which  sometimes  accompanies  loud  rales,  it  may  be  donblcd  if 
•xoeptions  ever  occur,  provided  the  bronchitis  be  uncomplicated. 
The  relatively  greater  degroc  of  re«onancc  and  fremitus  on  the  right 
side  in  health,  which  in  some  persons  is  marked,  may  have  given  rise 
to  apparent  exceptions  to  this  rule. 


I  Tho  Toung  SwthowopiM,  page  S8, 


>d  •dItlOB. 


CHEOKIC    BAONCUITIS. 


343 


THagnofi*. — Tbo  diagntwis  of  chronic  kroncbitis,  eo  far  as  con' 
,  oems  tlic  determination  of  the  fact  of  its  c-vietence,  is  attocded  prac- 
tll;  viih  little  difficulty.  The  poiote  which  call  for  attentive  and 
skilful  inTcstigaiion  relate  to  the  prcm-ncc  or  absence  of  complica- 
tioDH  and  resulting  Icsionti.  Is  the  bronchitis  uncomplicated  ?  or  is 
it  associated  wilh  dilated  bronchial  tubes,  cmplij-scma,  pneumonitis, 
chronic  pleurilis,  or  tuberculosis  ?  These  questions  are  not  answered 
80  eaailjr  as  the  simple  inquiry  vbcther  chronic  bronchitis  be  or  be 
not  present.  In  general  terms,  the  coexistence  of  other  morbid 
eooditions  than  tboee  pertaining  to  the  mucous  membrane  is  to  be 
determined  by  the  presence  or  absence  of  the  signs  and  symptoms 
which  belong  to  them  respectively.  The  signs  and  syinptomn  dis- 
tinctive of  other  affections  will,  of  course,  be  embraced  in  the  oon- 
nderation  of  these  nfToctionH,  individually,  hereafter,  and  it  would 
involve  a  netidleas  repetition  to  inlroduce  them  in  this  connection. 
or  the  several  affections  mentioned,  the  question  of  the  coexistcnoe 
of  tubi-rculo^is  with  the  symptoms  of  chronic  bronchitis  is  oftenest 
preMnled  in  practict^ ;  and  there  are  few  problems  in  diagnosis  more 
iniportant  than  the  discrimination  of  the  latter  uncombined,  from 
its  combination  with  the  former.  Is  this  simply  a  case  of  chronic 
bronchitis,  or  is  thero  wuperadded  a  deposit  of  tubercle  ?  is  a  ques- 
tion not  infrequently  arising  in  medical  practice,  which  is  of  mo- 
meutous  import  to  the  patient,  and  which,  fur  many  reasons,  it  ia 
extremely  desirable  for  the  practitioner  tu  he  able  to  answer  defini- 
tively. Prior  to  the  introduction  of  physicul  exploration,  this  ques- 
tion often  presented  insuperable  difficulty.  Cases  of  chronic  broa- 
chitia  were  considered  cases  of  phthisis,  and  vice  vena;  and  it  waa 
impoaaible  to  avoid  these  errors.  They  arc  now  necessarily  incident 
to  the  practice  of  those  who  ignore  physical  diagnosis.  In  view  of 
the  importance  of  this  discrimination,  some  of  the  points  which  it 
tnvolvcK  may  he  here  mentioned,  but  the  subject  could  not  he  fully 
ooDtidcrcd  without  anticipating  what  will  come  under  the  head  of 
the  diagnosis  of  tuberculnAis.  The  discrimination  is  to  be  busftd 
mainly  on  the  presence  or  absence  of  more  or  less  of  the  positive 
indications  of  tubercle;  but  there  arc  certain  considerations  per- 
taining to  the  symptoms,  signa,  and  laws  of  chronic  bronchitis, 
which  have  a  bearing  on  the  question,  and  in  caHcs  in  which  the 
poeitire  evidence  of  tubercle  is  doubtful,  they  are  entitled  to  con- 
aiderable  weight  in  the  diagnosis.  To  these  considerations  attention 
will  be  at  present  limited. 


M4 


DI8BA8B6    OP    THE    &BSP1KAT0BT    OBOASS. 


Chronic  bronchitis  occnrring  at  the  period  of  life  when  the  tnbK- 
caloos  deposit  generally  take«  pUce,  encccede,  in  the  najoriiT  tt 
eases,  the  acute  form  of  the  disease ;  tubercnlona  is  ttsbered  b  bj 
soul<>  bronchitis  in  but  a  small  proportion  of  cases.     HeBee,iki 
doubtful  case,  if  acate  bronchitis  have  existed  at  tbe  comnteoecMM, 
the  chancer  arc  in  fat'orof  it»  not  being  phthisis.    Pain  is  geixfnllj 
absent  in  chronic  broncliitiit,  aiid,  if  present,  is  slight,  dull,  and  >A- 
fltoroal ;  acuUt    Btitch   puirnt   arc  very  fiomnion   in    the  eourw  tf 
phthisis,  due  to  the  circiimAcribed  plcuritis  which  Blnio»t  invsntlil; 
accompanies  tubercle,  and  they  arc  rcfcrrod  to  tbe  Hammit  of  tht 
chest  on  one  side,  or  frequently  to  bcncutb  the  scapula.    The  ratptrv- 
tions  arc  habitually  more  or  less  acd'lcrated  in  phthlxis ;  this  obtuM 
rarely  in  cTironic  bronchitis,  and  if  acceleration  occurs  it  is  generally 
in  paroxysms.  The  pulse  is  often  notably  accelerated  id  pbthins,  ud 
but  rarely  in  chronic  bronchitis.  Febrile  paroxysms,  occurring  gcMr* 
ally  in  the  progress  of  tuberctdosiK,  do  not  belong  to  the  history  «f 
chronic  bronchitis.     IIsemoptysiH  Is  an  event  of  Tcry  frequent  oo- 
cnrronce  In  phthisis,  and,  excepting  the  occasional  bloody  streab 
vhich  the  sputa  present,  it  is  never  incident  to  more  lironchitis.   The 
ch  am  c  ten  Stic  sputa  of  tuberculosis,  viz.,  solid,  nnmmalar  ussmi^ 
striated,  parti-colored,  with  ragged  edges,  are  not  observed  io  Wo*- 
cfaitis.     The  microscope  rereals  in  the  sputa  of  phthisical  pstieDU^ 
frequently,  fibres  exfoliated  from  the  pulmonary  airacture ;  thtft 
do  not  enter  into  the  composition  of  the  sputa  furnished  by  titt 
bronchial  mucous  membrane.     The  loss  of  weight  in  phthisis  is  gei- 
erally  considerable  and  progressive;  it  is  less  marked  in  chrotHH 
bronchitis.  ^1 

Tbe  bronchial  rales  arc  incident  to  phthisis,  ns  well  as  to  obroak 
bronehiti.i ;  but  in  the  hitter  atfoution  they  ore  moat  apt  to  be  hrard, 
or  are  more  abundiint,  nt  the  inrerior  aud  poelorior  part  of  the  cliMt 
on  both  nides;  whereas,  in  the  former  affection  they  are  heard  ai 
the  superior  part  of  the  chest  in  front,  an-l  frequently  either  limited 
to,  or  more  pronounced,  on  oue  tiidc.  The  preceding  points  are 
quite  distinctive;  but,  in  addition,  in  tuberculosis  there  are  presrat 
moro  or  less  of  the  positive  signs  of  that  disease,  rendering  tbe 
evidence  complete.  These  will  be  enumerated  hereafter  in  treating 
of  the  diaguoais  of  tuberculous  disease. 


SBCO^fDAKT    1IH0XCU1TI8. 


345 


BDMMART    OP  TOE   PHTSICAL  StOKS    BBLOXOIKO    TO  OaROMIO 
BBORClItTIS. 

C1«u-ness  of  the  TOHonnnce  on  percussion.    The  dry  and  moUt 

bronchial  ralos,  rariouslj  intermingled,  frequently  but  not  invari- 

tftbly  prcseDt,  henrd  e»])ccially  ov«r  thp  bttso  of  the  lungs  on  both 

A  harsh  respiratory  sound  occasionally  present.   The  vesicular 

rmnrmur  and  rales  sometime*  temporarily  suppressed,  and  reproduced 

LudtleDly  by  an  act  of  coughing,  aa  in  cases  of  ucutv  bronchitis. 


Bbcondary  Brokchitis. 

SroncIiiti»,  either  acute  or  auhncute,  occurs  an  an  intrinsic  element 
ccrluin  fevers,  vi<.,  typhuM  and  typhoi'l,  especially  the  Itilter,  and 
rubeola.     It  may  occur  as  a  contingent  eleiuenl  in  other  varieties 
of    essential    fovors.      It    becomes    developed    under    circumstances 
which  lead  the  pathologist  to  consider  it  one  of  the  forms  of  the 
^]ocal  expression  of  certain  constitutional  affections  other  than  fever. 
Hit  ts  regarded  in  this  light  when  it  coexists  with  gout,  rheumatism, 
H^philis,  scrofula,  Brigbt's  disease,  etc.     In  all  these  instances  tbfl 
HbroRchitiit  is  secondary  to  some  general  disease.     It  is  liable,  also, 
H  to  b«  proiliiced  as  a  complication  of  difierent  pulmonary  diseases. 
HThus  it  is  apt  to  accompany  tuberculosis  and  pneumonitis,  in  these 
diseases  differing  from  the  idiopathic  form  in  being  frequently  limited 
to  one  Aide,  and  even  more  circumscribed;  in  other  words,  being 
tmilateral,  not  bilateral.     In  diflcascs  of  the  heart  it  is  often  devel- 
oped a*  a  secondary  affcofion.     Qneittioiii*  relating  to  the  origin  of 
H  the  alTeciion  irben  thus  Hccondiirily  produced,  and  other  points  of 
H  pathological  interest,  do  not  fall   within  the  scope  of  this  work. 
H  CoDsidervd  In  a  diagno.-)i.io  point  of  view,  the  varieties  of  secondary, 
B  M   dtHtinjraiidieil  from   idioputhie   bronchitis,  present  peouliaritiea 
I  which  arc  important.     Some  of  thette  have  been  already  incident* 
ally  noticed.     Others  will  be  conveniently  roFerred  to  in  treating 
of  the  di»eaitei>  which  remain  to  be  considered.     It  d»ea  not,  there- 
fore, «<'eui  adviiiiiblo  to  bestow  upon  the  diagnoalei  of  bronchitis  oo- 
carring  Hecondnrily  special  consideration  under  a  separate  head. 


344 


DIRKASRS    OP    TBS    BESPIRJlTORT    OKQAHf. 


Chronic  bronchitis  occurring  Kt  the  period  of  lifo  when  the  hib«r- 
caloua  deposit  (jenerally  tstes  place,  Buccwids,  in  ihc  mmjftritT  rf 
esses,  the  acute  form  or  the  discaw ;  toWrculosia  is  nsh^red  is  by 
■cute  bronchitis  in  but  a  small  proportion  of  cases.  IleDoe,  in  > 
doublful  case,  if  scute  bronchitis  hare  existed  at  (he  commenoeiDnt, 
the  ch»nc«K  arc  in  faror  of  its  not  being  phthisia.  Pain  is  genenllj 
alwcnt  in  chronic  hronchttifl,  and,  if  present,  is  slight,  dull,  and  sob- 
itornal ;  neuter  stilch  pninit  are  Tcry  common  in  tlie  course  of 
phthisis,  due  to  the  ctrcumticribed  pleuritis  which  almost  inrariahly 
aGcumpnnics  tubercle,  imd  they  are  referred  to  the  sumaiil  of  the 
chest  on  one  side,  or  frequently  to  beneath  the  scapula.  The  reapii*. 
tions  arc  habilunlly  more  or  less  nccelcntted  in  phthisis  ;  this  obtains 
rarely  in  chronic  bronchitis,  iinil  if  seccleratiou  occurs  it  ia  generally 
in  paroxysms.  The  pulse  is  often  notably  sccvlcrated  in  phthisis,  and 
hat  rarely  in  chronic  bronchitis.  Febrile  paroxysnu,  occurring  gener- 
ally in  the  progress  of  tuberculoitis,  do  not  belong  to  the  faialory  of 
chronic  bronchitis.  Ilnjraoptysis  is  un  event  of  very  frci[ncnt  oc- 
currence in  phthisis,  nn<l,  excepting  the  uccnsional  bloody  struakt 
which  the  sputn  present,  it  is  never  incident  to  mere  bronchitis.  Tb* 
characteristic  sputa  of  tuberculosis,  viz.,  solid,  nummular  mssMS, 
striated,  parti-colored,  with  raggc<l  edges,  are  not  obtterred  in  broa- 
ohitis.  The  microscope  reveals  in  the  sputa  of  phthisical  patients, 
frequently,  fibres  exfoliated  from  the  pulmonary  structure ;  these 
do  not  enter  into  the  composition  of  the  spuu  furnished  by  the 
bronchial  mncous  membrane.  The  loss  of  weight  in  phthisis  is  gen- 
erally considerable  and  progressive;  it  is  lees  marked  in  chronic 
bronchitis. 

The  bronchial  rales  are  incident  to  phthisis,  as  well  aa  to  chroiue 
bronchitis ;  but  in  the  Utter  aJfection  (buy  are  mo4t  apt  to  be  heard, 
or  are  more  abundant,  iit  the  inferior  and  posterior  pan  of  the  chest 
OD  both  sides ;  wlierea»,  i»  the  former  affieotion  they  are  heard  at 
the  superior  part  of  the  che»t  in  front,  and  frequently  either  limited 
to,  or  more  pronounced,  on  one  aide.  The  preceding  points  are 
qoite  distinctive;  but,  in  addition,  in  tuberculosis  there  are  present 
more  or  les^  of  the  positive  signs  of  that  dis«aso,  rendering  the 
evidence  complete.  These  will  be  enumerated  hereafter  in  treating 
of  the  diagnosis  of  tuberculous  disciuc. 


BCIIMABT  OF  THH  PHYSICAL  SroNS    BELONOINO   TO  CHEONIC 

DBoncumB. 

Clearness  of  the  resonance  on  percussion.     The  dry  and  moist 

broncliial  rales,  variously  intermingled,  frcquentlj  but  not  invari- 

■  ably  present,  heard  especially  over  the  base  of  the  lun^a  on  both 

sides.   A  harsh  respiratory  sound  occasionally  present.    The  vesicular 

marmnr  and  rales  sometimes  temporarily  suppressed,  and  reproduced 

H     Bronc 


Skcondart  Brokchitis. 


I 


I 

I 

I 


Sronchitis,  either  acute  or  subncutc,  occurs  ils  nn  intrinsic  clvment 
m  ccrtniD  fevers,  vii.,  typhus  nnd  typhoiJ.  especially  the  latter,  and 
rubeola.  It  may  occur  as  a  conlingent  clement  in  other  varieties 
of  essential  fevers.  It  becomes  developed  under  circumstances 
which  lead  the  pathologist  to  consider  it  one  of  the  forms  of  the 
local  cxprest-ion  of  certain  constitutional  affections  other  than  fever. 
It  is  regarded  in  this  light  when  it  coexists  with  gout,  rheumatism, 
syphilis,  scrofula,  Brighl'a  disease,  etc.  In  all  these  inslnnces  the 
bronchitis  iit  secondary  to  some  general  dinease.  It  is  liable,  aliio, 
to  be  produced  tta  a  complication  of  different  pulmonary  diseases. 
Thua  it  is  apt  to  accompany  tuherculosis  and  pneumonitis,  in  these 
diseases  differing  from  the  idiopathic  form  in  being  fretguenily  limited 
to  one  side,  and  even  more  circum.^cribetl ;  in  other  words,  b^ing 
aniUteru),  not  biliiteral.  In  dint-nse.*  of  the  heart  it  is  often  devel- 
oped ■«  a  secondary  affection.  Qnei<tions  relating  to  the  origin  of 
the  afTection  when  thus  »econdarily  produced,  and  other  points  of 
pathological  interest,  do  not  fall  within  the  foopc  of  this  work. 
Considered  in  a  dingnoJttic  point  of  view,  the  varieties  of  secondary, 
u  di^itiiigiiishcd  from  idiopathic  bronchiti*,  prewnt  peculiarities 
irbich  arc  ioiportnot.  Some  of  these  have  been  already  incident- 
«lly  noticed.  Others  will  be  conveniently  referred  to  in  treating 
of  iJtc  diseases  which  remain  to  be  con»idfre<l.  It  does  not,  ihcre- 
forc,  seem  advisable  to  bestow  upon  the  diagnosis  of  bronchitis  oo- 
curring  secoDilarily  special  consideration  under  n  separate  head. 


PTER' 

DILATATION  AND  CONTRACTION  OF  THE  BRONCHIAL  TDBB 

—PEBTDSS  IS- ASTHMA. 

TtiB  affcottonR  named  in  the  caption  of  this  chapK^r  are  thow 
which,  ID  addition  to  bronchitia  and  pulmonarj  catarrh,  have  their 
seat  or  special  manifestations  in  the  bronchial  tubes.  The  two  first, 
rix.,  dilatation  and  contraction,  arc  le«ioD»  affcetiog  the  calibre  «f 
the  tubes.  Pertu»Mti  or  hoopingcongli  i»  an  iiifiuitile  disorder,  the 
priniary  and  prominent  locul  sjfuiptoma  of  which  pertAio  to  the  pal' 
monnr^  air-pasMnges.  Asthma  is  ehamctvrised  hy  phcaomena  dfr- 
pcndent  on  Hpwin  of  the  bronchial  mosclcs. 


DtLATATIOK    OF   TUB    BRONCHIAL   TOBBS.' 


Dilatation  of  the  bronchial  tubes  was  searcvlj  kuowa  to  pathol^ 
gists  prior  to  the  researches  of  Lacnnco.  The  iuference  naturally 
drawn  fruiii  this  fact  relative  to  the  rare  occurrence  of  the  lesioDis 
not  altogether  correct.  Tlie  inattention  paid  to  the  condiuou  of  the 
bronchinl  tubcn  in  uutopsicjil  examinations  led  to  the  existeace  of 
dilitlMtiun  being  often  overlooked,  and  somcttmea  ooufounded  with 
tuberculous  excavations.  The  same  remark  will  apply  ia  a  greM 
siOASuro  to  cxaininntionB  Biiicv  the  time  of  Lacnuec;  so  that  at  ths 
present  moment  it  is  not  easy  to  determine  verjr  accnratcly  llie 
degree  of  ite  frG(|uoncf.  Grisolle  estimates  that  in  a  very  active 
hospital  service  an  average  of  one  or  two  cases  will  be  likely  to  be 
met  with  annually.  Geuerully,  if  not  uniformly,  associated  with 
bronchitis,  it  probably,  in  most  instances,  involves  the  latter  affec- 
tion in  its  production.  The  mode  in  which  it  is  produced  is  an  in- 
teresting poiDt  of  piithological  inquiry  admitting  of  extended  dis- 
cussion. But  it  would  be  a  digression  from  the  range  of  practical 
topics  to  which  this  work  is  limited,  to  indulge  in  more  than  a  brief 


>  Called  BjvncMteliaU. 


I 


DILATATION    07    THK    BROKOHIAL   TOBBA. 


S47 


puving  »llusioD  to  it.  La^nnec  Kltribut^d  llio  diUtntton  chicfljr  to 
niochwtical  disteoHion  from  the  accumulation  of  inucutt.  Tliis  cx- 
pl&iuttion  ia  now  deemed  inadequate,  and  the  accumuliition  is  re- 
garded as  rather  the  effeet  than  the  cause  of  the  dtlatulion.  A 
morbid  condition  of  the  walla  of  the  tubes,  impairing  their  eln.iticiij, 
and  rendering  them  \eta  resisting  to  a  dilating  force,  ia,  probnhly,  m 
first  pointed  out  by  Dr.  Stokes,  s  prerequisite,  the  result  usunllj'  of 
prolonged  inflaramation.  Hence,  the  lesion  ia  one  of  the  sequels  of 
chronic  bronchitis.  With  regard  to  the  cAuses  more  immediately 
engaged,  they  are  doubtless  not  in  all  caaea  the  aame.  Extraordi* 
nary  effort*  of  the  reapiratory  organs,  aa  in  the  violent  parosvsma 
of  coughing  which  occur  in  pertussis,  may  prove  the  efficient  cause 
in  some  instances.  Obstruction  of  a  bronchus  by  the  pressure  of 
an  enlarged  bronchial  gland,  or  other  cnuses  prerenting  the  exit  of 
air  and  mucus,  may  occasion  suHicient  distension  behind  the  ob- 
struction to  lead  to  permanent  enlargement.  But  in  the  great 
majority  of  cases,  there  ia  reason  to  believe  the  dilatation  depends 
on  a  prior  morbid  condition  of  the  pulmonary  parenchyma.  Dr. 
Corrigsn'  has  described  an  affection  involving  this  lesion,  consisting 
in  a  morbid  production,  around  the  tubes,  of  fibro-cellular  texture, 
leading  to  atrophy  and  obliteration  of  the  puimonary  cell.*,  and,  in 
aarnn  inalancos,  even  conlraclian  of  th«  entire  lung.  Under  these 
eircQinslunces,  ncRordiiig  to  his  views,  two  actire  forcoa  are  com- 
bined in  producing  bronchial  ditatition.  One  is  the  preaauru  of  (he 
atmosphere  from  within  the  tubes  in  an  outward  direotioii,  to  fill  the 
vacuum  caused  by  the  diminution  of  the  bulk  of  the  surronmling 
parenchyma.  The  other  is  the  traction  exerted  on  the  brunchiul 
walls  in  consequeneo  of  the  adventitious  fibro-eelliilnr  production 
becoming  attuuhed  to  the  longitadinal  fibres  of  the  tubes,  so  that 
dilatation  in  thin  way  results  from  the  shrinking  of  the  Hurruunding 
ti»«uc.  The  morbid  condition  suppoiiiHl  to  induce  the  lesion  in  the 
manner  just  mentioned,  Dr.  Corrigan  calls  cirrhoait  of  the  lung, 
from  its  pathohiglcnl  analogy  to  the  affection  of  the  liver  known 
by  that  name.  The  contraction  of  portions  of  lung  incident  to  the 
tuberculous  depot^it,  and  still  more  to  the  cicatrization  of  cavities, 
may  induce  dilatation  of  the  bronchial  tubes,  the  walls  expanding 
to  compcnaalo  for  the  vacant  space.  More  frequently,  however, 
tbia  result  follows  obliteration  of  more  or  less  of  the  pulmonary 


■  Dublin  Medical  Jourao],  Hay,  1S3S. 


S48 


DiaitASSS    OF    THB    RBPPIRATOBT    OttOAXi. 


eclU  rroin  pneumonitis,  and  the  compressino  to  vhich  they  an  toV 
jfct  in  ciwea  at  pK-urisy.     When  the  pnrietes  of  the  obeat  <§•  Ml 
rcaililj  cotUpHe  to  fill  the  vpncu  )cft  by  the  atii«orption  of  th«  iuiv 
vcsiculnr  <Icpo«>il  Iq  pii['uiii(iiiiii«i,  or  of  the  liquid  eiriMioa  in  plcmitii, 
the  bronchial  tiihc»,  prvvinu.ily  wcakt^tivd  hy  the  proocw  of  iiifla»> 
nUion,  jteld  to  the  pri-.Hj>iirc  of  the   initpirvd  air.     Under  ibeH 
«jrciiiiisuiiioi-tt  wliiit  will  be  pn^.^eiitly  noticed  aa  llie  Dniforiu  or  cy- 
]intlrie»l  variety  of  dilntatiori  oCcuri',  alTcrting  in  some  inntancei  tbt 
tiibea  of  an  entire  lobe  or  Inng.     Finally,  according  to  Hope  mod 
Roliitani'liy,  collapse  of  portions  of  lung  from  obstruction  of  tlic 
lesser  bronchial  twit;«  in  Home  cascM  of  bronebilift,  when  the  col- 
lapsed portions  arc  situated  ai  eonsiderable  depth  in  thr  lung,  and 
near  a  larger  bronchial   tube,  may  give  rise  to  dilatation,  on   the 
principle  nhich  plays  llie  most  important  part  in  the  prudnvtioti  (if 
the  leaion  in  connection  with  most  of  the  affections  to  which  it  it 
oonsecutive,  vi:t.,  expansion  from  the  pressure  of  the  inspired  air  to 
fill  a  vneuum.' 

With  rff<.!rencc  to  physical  exploration,  dilatation  of  tbe  bronchia] 
tubes  i*  a  lesion  of  Intereiit  and  importance,  from  ita  giving  n«e  to 
signs  whTch  are  liable  to  Iviid  to  errors  of  diagnosis. 

Following  LacnnM,  subsotjuent  writers  have  described  three  va- 
netiei^  of  dilatation.  One  variety  cunsistd  in  a  spherical,  sacculated, 
or  poiioh-Iikv  ililalatiun,  vccurriug  usually  in  the  third  or  fourth 
subdiviHLouH,  forming,  in  cRect,  a  cavity  which  may  attain  the  tiiie 
of  a  aalnut,  and  according  to  Kokitun^ky,  a  hen's  egg.  A  M^cotid 
variety,  which  is  essentially  similar,  consists  in  a  series  of  globular 
dilatations  along  the  course  of  a  tube,  the  calibre  of  tbe  iniennediata 
portions  retaining  the  normal  sixo.  Tbe  tube  presents  an  appear- 
ance compnred  by  Elliotson  to  a  string  of  beads.  In  the  third  nr- 
riety,  a  cylindrical  and  nearly  uniform  enlargement  of  a  tube,  with 
more  or  less  of  its  branches,  takes  place.  The  Wt  species  of  dil»- 
tation  Bometimes  extends  over  a  whole  series  of  bronchial  subdivi* 
BJons,  the  enlargement  gradually  increasing  toward  their  extremi- 
ties, ending  abruptly  in  cul-de-sacs,  the  appearance  when  laid  0|)eD 
being  not  unlike  that  of  the  finger  of  a  glove.  Occasionally  itie 
several  forms  of  dilatation  arc  combined  in  the  »ame  lung. 

'  Thi!  ri^ndcr  ilftlmu)'  (it  *  fiilli-r  •■x|>»>liti>ii  i>r  tht  mnchanUro  of  tbn  produo- 
tion  nf  IlriB  Ip9i')ii  uia)-  coniult  with  ndvontngc  tlir  work>  on  Pathutugical  Anit- 
omy  l>r  Ubho,  Aid.  cd.,  [lagu  2^1,  el  t<q. ;  Jonoi  and  Sievdiing,  Am.  od.,  f»ft 
889;  Hiid  K'tkiuiiBhy,  Sy<L  «d.,  vul.  iv,  jisgo  6. 


DILATATIOK    OF    TBB   BBOKCHIAL    TOBBB. 


349 


Bronobial  dilatation,  aseociHtod  with  obliteration  of  the  eelln, 
•nd  conlraotion  of  tlie  pulmonary  psrencbjma,  is  attcndeil  with  n 
corr^fponiJing  amDunt  of  diminution  of  the  sixe  of  tin;  tlicst,  and 
■with  diaplacement  of  the  movable  viscera.  In  all  siifh  initfnnceR, 
probably,  the  diminished  bulk  erf  tfar  lung  sod  coiuii'ciuvnt  collapse 
of  the  thoracic  parietes  precede  the  dilatation. 

The  Mrronnding  pulmonary  parenchyma  is  more  or  leas  con- 
denned.  This  is  necessarily,  to  some  extent,  a  rotiilt  of  tin;  pri«surc 
of  the  expanded  portion  of  tin;  tube ;  bat  according  to  Corrigan,  in 
a  certain  proportion  of  cnsf»  it  i*  increased  by  the  prodnciion  of 
Boiid  material  which  preceded  tlic  dilatation.  The  dilated  tubes 
contain  puriform  li<)uid  in  grrster  or  te»s  <iiiantity. 

Cases  have  been  ob»crvcd  in  which  several  globnlar  dilatation.* 
existed  near  tbc  apex  of  the  liin;;,  cum  muni  eating  by  interviMiing 
bronchial  tubes,  so  a»  to  resemble  eluscly  n  united  group  of  excavti- 
tions  similar  to  tbo«c  not  infre'^ucntly  met  with  in  eubjeet*  dead 
with  tuberculous  dlBcase.  Under  these  circumttances  the  leiion,  on 
s  superficial  examination,  might  readily  be  considered  to  have  pro- 
ceeded from  phthisis.  In  the  other  forms,  bronchial  dilittation  wns 
formerly,  as  already  remarked,'  confounded  with  phthisical  CHVities. 
On  the  other  hand,  in  the  opinion  of  a  distinguiHlied  pathologist, 
many  of  the  instonees  of  the  so-called  cirrhoeis  of  the  lung,  are,  Id 
&ct,  cases  of  tuberculous  cavities.' 

The  anatomical  conditions  sustaining  proximate  relations  to  the 
pbysical  signs  in  cases  of  dilatation,  are  the  degree  and  extent  of 
the  enlargement,  and  the  particular  form  which  it  assumes ;  the  sixe 
of  the  bronchial  tubett  connected  directly  with  the  dilated  portion, 
or  portions ;  the  presence  or  absence  of  mucus,  and  its  abundance 
when  present;  the  diminished  bulk  of  the  lung,  and  the  consequent 
OODtractioD  of  the  thoracic  waUs. 

Phytical  Sign». — Dulnoss  on  percussion  generally  attends  dilata- 
tion of  the  bronchial  tubes.  The  dulneaii  is  mainly  due  to  the  con- 
densation and  contraction  of  the  parenchyma,  which  accompany  the 
dilatation,  and  it  is  marked  and  diffased  in  proportion  to  the  degree 


>  Tb«  tMt  or  CRTltlM  rnrmni]  hy  brnncMiil  dlUUtlcn,  tn  Joubtftil  eiue*,  ii  \\it 
pTMvncH  or  Uie  clmrnclvn  of  tliv  mucuu<  mrmbruie  in  tho  tiuun  linitix  Iho 
cavitio,  a*  dnlfrmincii  by  microacofiicikl  cxHininnllon. 

'  Prof.  J.  Huglica  Bviiiii-tL  Treatinu  on  llio  i'alliology  and  Tr«atmcnt  of 
Pulmonarjr  TttborculoiU. 


850 


DteBA8B8    OF   THB    RRSP1RAT0RT    OBSARS. 


Rud  <.';ilont  of  the  aliiiormal  di'Tisiiy  wliicli  tlic  Inng  ■cqoin'^.  Th* 
dulnc^tt  iniiy  be  souii-wlint  incn-asctl  at  timi-s  bj  nn  KccuTnaUtion  of 
aiticuH  witbiD  the  enlnrgcd  tubes.  To  the  foregoing  mie  there  ue 
pxcpption».  Ii)crC9»edInt«D3iitr  orpi;rini!i.iton-rOMin*n««uocc«iUoa* 
ally  olMrrvvd,  ootwithsUnding  Ok  pulmonnry  jMnM>ebym»  iturroun^ 
ing  the  enlnrgcd  tabes  is  more  or  lesH  coii<Ieus«d  and  contract<d. 
This  ari.iea  from  the  air  within  the  tubes  tx^Jiig  sufficicDt  to  ata- 
bslancu  thi;  abnormal  density  of  the  luiig-  Tbe  rvMonaoce  nnilcr  thcM 
circumsuncM  becomea  cither  pnri-Iy  tympnniltc,  or  ve«iculo-tyra- 
pnuitic.  The  vcvicular  quality,  in  other  words,  iti  inipairrd  or  Imt, 
and  the  pitch  »  alwayD  raised.  Tbe  rc«i>Dancc  may  even  lusnme  an 
amphoric  charaolcr.  Increaitcil  intensity  of  resonance  is  of  course 
only  pre»(-[it  «r)ien  the  bronchial  tubes  are  freo  from  morbid  pro- 
ducts; nod  as  their  condition  in  this  rciipect  raricfl  at  different 
times,  pcreiuvion  irill  elicit  only  at  certain  periods  an  increased 
resonance  nhioh  will  be  found  to  alternate  irilh  dalnes^,  the  latter 
being  prcHcnt  when  the  tnbes  are  more  or  les*  filldi  wiib  mucus. 

Tiic  physical  conditions  are  favorable  for  the  pnxluetion  of  bron* 
chial  respiration  when  the  tubes  are  nnobslructed,  prorided  the 
diUtntioii  he  of  the  oyliodrical  variety.  The  enlarged  calibre  of 
tbe  tubcK  and  the  pulmonary  condensation  combine  to  render  ibe 
res]>iratory  sound  non-vcsieulsr  and  tubular.  The  bronchial  char^ 
actcrs  are  strongly  marked  and  the  sound  intense,  caierit  paribmt, 
in  proportion  to  the  enlargement  and  increased  density.  The  diffu- 
sion of  the  bronchial  respiration  will  correspond  with  the  space  over 
which  the  dilatation  extends. 

The  presence  of  mucus  within  thu  dilated  Inbes  in  greater  or  less 
abundance  gives  rise  to  moist  bronchial  or  babbling  rales,  oocntring 
at  irregular  periods,  and  varinhle  in  loudness,  as  in  wmple  bronehilii. 
A  degree  of  coarseness  approaching  to  gurgling  will  bo  likely  to 
chnractcriic  these  mucous  rulem  if  the  calibre  of  the  tube*  be  con- 
siderably enlarged. 

The  vocal  resonance  is  generally  exaggerated,  and  bronchophony 
may  he.  strongly  marked.  Vocal  fremituit  is  inereatx-d  sometimes  in 
a  notable  d^ree.  An  abnormal  transmission  of  the  heart-sounds 
may  also  be  observed. 

The  affection  in  some  instance*  leads  to  chuiges  apparent  on 
inspection.  The  condensation  and  contraction  of  tbe  pulmonary 
parenchyma  may  be  sufficient  to  cause  depression  of  the  chest  over 
tbe  site  of  the  lesion,  rarely,  howcrcr,  so  great  as  obtaina  Id  aonu 


DTtATATTOV   OP    TUB    BHOITCniAI.    TUBES. 


S$l 


I 


cssM  of  adTancpd  tuberctilonH  dis^as^.  In  the  forni  of  the  disease 
(Ir^cribcd  by  Corrigan,  the  diminished  bulk  of  the  lung  lends  to  an 
obvious  controclion  of  one  side  of  the  chest. 

In  the  Mcculnled  or  cytitie  variety  of  dilatation,  provided  the  en- 
largcmont  be  conitiilerablc,  there  may  be  present  the  physicai  signs 
of  «  cavity,  viz.,  ordinary  cavernous  or  amphoric  respiration,  gurg- 
ling, and  in  BOroe  cases  pectoriloquy.  Even  metallic  tinkling  was 
observe))  in  a  cn«e  reported  by  Dr.  Barlow,  of  London,' 

Diagnotit. — The  diognosis  of  dilatation  of  the  bronchial  tubes  is 
attended  with  great  difficulty,  owing  to  the  physical  signs  being  simi- 
lar to,  and  indeed  identical  with,  those  incident  to  other  fonoit  of  dis- 
ease. Tho  liability  to  error  arieing  from  the  fact  ju»t  stated  renders 
it  important  to  bear  in  mind  the  diagnostic  points  by  which  this 
le«!on  is  to  be  di«criminated  from  affections  involring  analogons 
phyftical  conditions,  but  differing  widely  in  pathological  features. 

Bronchial  respiration,  increatied  vocal  resonance,  broncliophony, 
and  exaggerated  fremitus,  are  signs  which  accompany  the  consolida- 
tion of  Iting  incident  to  pneumonitis,  and  tuberculosis.  With  acute 
pneumonitis,  dilatation  of  the  tubes  can  hardly  be  confounded,  ex- 
cept the  attention  be  directed  exclQHively  to  the  physical  signs.  The 
one  is  an  acute,  and  the  other  a  chronic  affection.  .4a  respects 
acute  symptoms,  a  resemblance  exists  only  when  acute  bronchitis 
mporvenea  on  bronchial  dilatation.  Under  these  circumstances  the 
pulmonary  symptoms  will  be  tlioee  belonging  to  bronchitis,  the  dis- 
tinctive features  of  pneumonitis,  viz.,  lancinating  pains  and  the 
rusty  or  bloody  expectoration,  being  absent.  The  characteristic  aus- 
cultatory sign  of  pneumonitis,  vis,,  the  crepitant  rale,  is  abscBt. 
Were  the  mistake  to  occur  of  attributing  the  combined  phenomeos 
of  bronchial  dilatation  and  acute  bronchitis  to  pnenmonitis,  the 
progress  of  the  disease  would  in  a  «hort  time  lead  to  a  correction  of 
the  error,  for  the  physical  signs  which  were  incorrectly  supposed  to 
denote  inflummntory  solidification  are  found  to  remain,  and  perhaps 
become  more  marked  after  the  locnt  and  general  symptoms  of  acute 
inflammation  have  disappeared.  In  pneumonitis,  on  the  contrary, 
tbese  signs  cease  to  be  observed,  or  at  least  nre  notably  Wticned, 
shortly  after  the  symptoms  denote  the  resolving  stage  of  the  inflam- 
mation. From  chronic  pneumonitis  the  discrimination  is  less  ea^y. 
Bat  clironie  pneumonitis  is  an  affection  bo  rare  that,  practically,  the 


OftjH  Hnpital  KeporU,  )M7. 


853 


DIStAStS  or  TIB  KBSMKATOBT  OBOAVS. 


fact  of  it»  oee«noo*l  oceamnM  m»j  slnoet  be  disregM^ad.  Wte 
it  occnDt.  it  is  gtnenll;  preceded  by  lh«  scate  fbnD  of  tfc*  fetaw. 
If,  in  a  (ioubtfnl  nM!,  the  pre-exi«lcn««  of  acute  pneomonititbe  daHy 
dctermiriiNl,  llits  coiuititute«  u>  important  dugnoMic  point,  litre- 
ov«r,  chronic  pneumonitis  U  accoaipaoied  bj  geneni  ■ympi— ■  i»- 
dtoative  of  a  graver  maladv  than  simplj  bronchial  ditatatioo.  At 
sitnation  of  tbe  pnlmonarj  affection,  aa  indicated  by  the  pkjnaal 
•ig»«,  it  a  point  of  importance.  PneiuiKiniti«,  in  tbe  grat  nmjmitj 
of  caxM,  attacks  tbe  inferior  lobe ;  bronchial  dilatation,  ta  omM  b- 
ttajiocs,  it  Mated  in  tbe  upper  lobe. 

The  diSeuliy  of  diagnosis  relates  especially  to  tbe  diKriotDBtioa 
of  bronchial  dilatation  from  tuUtrculoua  dincaM.  Each  of  the  no 
forms  of  dilatation,  rix^  tbe  saccuUted  and  cyltndrie*),  fomitbef 
sign*  which  belong  eqoally  to  different  stages  of  phthisis.  Bronchial 
rovptriiiion,  bronchophony,  increiiHed  vocal  fremitna,  which  atteuil 
cylindrical  ililntation,  denote,  niider  certain  circnoistances,  ibc  pre^ 
cncc  of  crude  tubercle.  CaverDOus.  or  amphoric  ncptratioD  aad 
gurgling  are  tbe  signs  of  an  excavation  in  the  vast  majority  of  omM 
taberculfluii  in  its  origin.  The  discrimination  is  to  be  bawd,  not  OS 
inlrinoic  differences  in  the  pbysioal  phenomena,  but  on  circutastuioM 
inciilcnul  thereto,  and  on  the  synptomn.  Kfitnoiiing  from  amative 
facts,  we  may  arrivo  at  the  conclusion  that  the  phenomena  are  doe 
to  bronchial  dilatation,  hccauMC  tbe  absence  of  coexiMing  evideoee 
of  tuberculous  disease  rcndcrv  it  probable  that  the  latter  disease 
may  be  excluded. 

The  differential  dingnosiK  involves  different  points,  whether  the 
dilatation  be  cylindrical  or  saccidated,  but  (he  physical  Aigiis  being 
different  in  these  two  varieties,  they  claim  »cpsrut«  consider  rat  ion. 

Uilalatiun  of  the  cylindrical  variety  may  presvnt,  as  jast  stated, 
s  group  of  physical  signs  which,  in  coniii.-ctiou  with  coagb  and 
expectoration,  appi-ar  to  indicate  a  tuberculous  deposit.  What 
are  tb«  circumstances  showing  these  signs  and  symptoms  to  be  due, 
not  to  tubcrcnloiut  disease,  but  to  dilatation  of  the  tubes  ?  The  sit- 
uation of  tlie  pliyiiictkl  signs,  vis.,  the  bronchial  respiration  and  bron- 
chophony, i«  au  important  point.  A  deposit  of  tubercle  takes  plae«, 
in  tbe  va«t  mnjority  of  coses,  first  nt  or  near  tlie  ap^-x  of  (ho  long. 
The  physical  signs  of  tuberculous  consoliilat  ium  nr<.-  therefore  found 
at  the  summit  of  the  chest,  especially  marked  in  th«  scapular  aod 
infra-clavicular  regions.  The  phenomena  due  to  bronchial  dilata- 
tion} on  thfl  other  band,  ore  oftener  manifestod  over  the  middlo  por* 


MIATATION  or   Tns   BROKCIIIAL  TCBIS. 


3S8 


tion  of  the  cliest  tlinD  at  the  samniit.  Tnlten  in  contieeUon  with 
other  circumstitQces,  this  i«  n  strvn^  iliagnoHtio  iwiot ;  but  it  is  to  be 
borne  io  mind  tlint  the  rule  with  rcKptn^  lo  the  sitiuitiuu  of  the  tu- 
Iterculous  deposit  la  not  without  exceptions,  00  that  lliiei  point,  by 
itaelf,  is  by  no  iDeans  sufficient  for  the  di»giiofli«. 

More  or  lees  dulness  on  percuesion,  as  has  been  seen,  attends  Ma- 
tation,  dependent  on  the  degree  and  extent  of  the  coexisting  condcri- 
•atiwi.  The  bronchial  respiration  and  bronchophony  arc  due,  ia 
part,  to  the  greater  density  of  the  pulmonary  tissue,  and  in  part 
to  the  enlarged  cahbre  of  the  lubes.  In  tuberculous  disease,  thew 
phenomena  proceed  exclusively  from  the  consolidation,  and,  other 
things  being  equal,  they  are  muikcd  in  proportion  to  the  inereaaedi 
density  of  lung.  Hence,  in  tuberculous  dir^easo,  bronchial  respiro-f 
tion  and  bronchophony  are  not  observed  in  u  notable  degree  without 
physical  evidence  of  a  constdernble  amount  of  consolidation  being  at. 
the  »ninv  time  afforded  by  pcrciit^sion.  In  dilatation,  on  the  ooH" 
tnry,  the  enlargement  of  the  calibre  of  the  bronchial  tubes  may  be 
consideiable,  and  the  condensiition  comparatively  moderate  or  slight. 
Under  these  circumstances,  the  bronchial  respiration  and  broncho- 
phony may  b^  strongly  marked,  while  the  percUNsion-resonance  ia 
but  little  impaired.  A  striking  disproportion,  then,  between  these 
auscultatory  phenomena  and  the  evidence  furnished  by  percussion 
of  pulmonary  solidificalion,  authorizes,  to  say  the  leust,  a  preBuni[>> 
tion  in  fuvor  of  dilatation. 

The  point  to  which  mo»t  importance  ia  to  be  attached  is  the  ah* 
sence  of  the  rational  evidence  of  phthisis  derived  from  the  history 
and  symptoms.  In  cases  of  dilatation,  cough  and  expt^ctorntion  gen- 
erally hare  existed  for  a  long  period.  If  iheuffeoiionbe  tubcrciulou 
certain  eveiitn  and  results  are  to  be  expected,  which,  if  the  afiectioaJ 
be  diltilntion,  the  case  will  not  be  likely  lo  present.  Among  these 
evenia  and  results,  ihc  most  prominent  are  progri^-ssive  and  marked 
emaciation,  Iohh  of  muscular  strength,  pallor  of  the  countenance, 
hscinoptysis,  lancinating  pains  in  the  chest,  diarrhoea,  marked  ao- 
ooleratiun  of  the  pul»e.  hectic  paroxysm^*,  night  pereipiralions  and 
chronic  laryngitis.  If  all  these  be  absent,  thi.i  fact  fsvors  the  sup* 
pOAition  of  dilatation  being  the  pathological  change  giving  rise  to  the 
physical  phenomena  which,  associated  with  more  or  less  of  the  symp- 
tomatic CTcnts  just  enumerated,  would  denote  unetjuivooally  the  ex- 
istence  of  tuberculous  disease.  Occasionally,  however,  it  happens  in 
cases  of  phthisis,  that  nearly  all  these  rational  indications  are  want- 

38 


S54 


DISBA8E8    OP    THB    RKSPIRATOKY    OBOAN£. 


ing.     Hence,  it  is  not  safe  to  decide  positively  from  their  sbscnc» 
thnt  tuticrouIoMis  may  be  cxc1i)d<-d. 

From  tliis  eonKiderAtion  o(  the  difTerenlial  diagno«is  it  vill  be 
justly  infcrreil  that  it  is  extremely  diflicuU  to  dGterminc  that  cer- 
tftin  physical  signs  are  due  to  cyHndncal  dilatation  of  the  brondual 
tabee,  and  not  to  tuberculous  golidiBcmioD.  In  fact,  the  diKrini- 
DatioD  can  rarely  be  made  with  great  poaitivences.  This  would  be 
a  serious  impediment  in  the  way  of  determining  the  existence  of 
phthi:<ijt,  were  enaen  of  dilatation  of  fri>quent  occurrence.  Fort>- 
nately  for  diiif;no)(iH,  alltioogh  unrontmately  for  human  life,  the  latter 
lesion  is  «»  rurc  nit  the  former  nffcction  w  common.  And  for  this 
reason,  were  the  practiitoiier  to  ilisrcgani  the  fact  that  cawj<  of  di- 
latation nrc  occasionally  met  with,  and  not  atlrmpt  to  make  th« 
discriminatinn  in  practice,  the  cliaiieea  of  a  false  diagnOisi!<  arc  small. 

Dilatation  of  the  sacciihiied  or  cystic  variety,  tiving  rise  to  carer- 
ootis  sipiR,  viz.,  cftvemoiia  respiration,  cireumacrihed  mucous  rates 
or  giirgltng,  and  in  some  instances  pectoriloquy,,  have  Occasioiully 
led  those  mo»t  oxperienced  and  skilled  in  physical  exploration  into 
the  errnr  of  inferring  ihe  existence  of  a  tuberculous  excurniioR. 

Tlie  iiiCuation  of  the  cavity  is  an  important  point,  fgr  rea!<oiM 
already  staled. 

TuborculouH  excavations  are  generally  surrounded  with  coitsidera- 
bte  solidiScHtion  from  the  prejience  of  tubercle.  Hence,  the  cavernous 
signs  furnished  by  auscultation  usually  coexist  with  marked  dulness 
on  percussion.  This  is  less  uniformly  true  of  cavities  formed  by 
dilatation  of  the  bronchial  tubes.  The  presence  of  cavernous  signs, 
therefore,  with  but  slight  dulness  surrounding  the  site  of  the  cavity, 
favors  the  hypothesis  of  dilatation.  The  signs  of  cavities  from  tlila- 
■tation  may  be  unattended  by  any  appreciable  dulneea  on  percus- 
sion.  This  was  true  of  a  case  of  bronchial  dilatation,  simnluiing 
phthisis,  reported  by  Louis.'  In  view  of  the  law  of  phthisic  by 
which  the  deposit  almost  uniformly  takes  place,  first  at.  or  near,  the 
apex  of  the  lung,  if  the  percussion- resonance  above  the  site  of  a 
cavity  be  found  to  be  undiminished  and  vesicular,  this,  although  by 
no  means  positive  proof  against  the  existence  of  iDberculoeis,  since 
the  law  just  stated  is  not  invariable,  concurs  with  other  circum- 
stances to  render  the  supposition  of  dilatation  probable. 

Another  point  pertaining  to  the  physical  signa  is  applicable   to 


<  R«cliarch«»  iiur  I*  Pblbl«t«. 


DILATATTOir    OF    TRE    nBOKCBIAL    TUBB8. 


S55 


Imt))  Tariclic9  of  dilntition,  but  to  the  prcBent  variety  more  particii- 
I«rty.  The  dJIutntion  is  gononilly,  or  «t  least  frcqiicntly,  limited 
to  OD«  lung.  A  tuberculous  deposit  tiilccs  pinci.-  Iir»t  in  <mr  lung, 
snd  in  the  great  innjority  of  cnw»,  shorily  Hfterward  in  ihr  ollicp 
lung.  In  CMCS  of  plitliinis,  therefore,  advanced  to  the  stage  of  ex- 
cavation, there  mny  be  expected  to  be  present  on  both  aides  of  the 
che«t  phyxind  i<ij;iis  of  tnburculoua  disease.     Now,  if,  with  the  evi- 

Bdencec  of  n  cavity  on  one  side,  the  other  side  yield  no  signs  of  dis- 
ewc,  lhi«  fact  fnvors  the  excliiMion  of  tuberculous  disease. 

If  H  CUM.'  have  hci'ii  under  obHtrvatlou  for  a  coiiKideruble  period, 

Btbc  cxixtencc  of  tubereuloKig  is  evinced  by  the  physical  signs  of  ex- 
cavation becoming  dcveloptd  where  previously  thi'  signs  had  demited 
■olidiGcation.  This  succession  of  physical  phenomena  does  not  bo- 
long,  certaitdy  to  the  same  extent,  to  the  history  of  dUalution.  And 
th  some  qunliticntion  nnd  occasional  exceptions,  the  general  rule 
!  down  by  Slckes  on  this  subject,  probiibly  holds  good,  viz. ;  "  In 
phtliiaia,  we  have  firat  diilnesis  and  then  cavity;  while  iu  dilated 

I  tabes,  we  have  first  cavity,  and  then  dniness." 
The  persistency  of  the  cavernous  signs  without  material  altera- 
tiou  for  weoks,  months,  and  even  years,  is  another  point,  pertaining 
to  pliysieal  exploration,  which  has  considerable  diagnostic  weight. 
A  stationary  condition,  after  the  stage  of  e.Tcavation  in  phthisis  is 
reached,  belongs  to  the  history  of  some  cases,  but  only  as  an  excep- 
tion to  the  rule. 

A  notable  degree  of  flattening  of  the  chest  at  the  summit  is  strong 
evidence  against  dilatation,  the  depression,  thua  limited,  in  this  affeo. 
lion  never  being  strongly  marked. 

I  The  absence  of  the  rational  evidence  of  phthisis,  derived  from  the 
biHtory  and  symptoms,  applies  with  greater  force  to  the  diacrimina- 
tion  wben  the  question  relates  to  the  presence  of  sacculated  dilata- 
tion or  phthisis  advanced  to  excavation,  for  a  longer  dnraiion  of  th« 
tuberculous  disease,  if  it  exist,  is  implied,  and  therefore  the  cventa 
and  results  characteristic  of  the  latter  affection  are  less  likely  to  bo 
wanting.      A  cavity  without  notable  emaciation,  loss  of  strength, 

» pallor,  hstmoptysis,  lancinating  pains,  recurring  diarrliiea,  frequency 
of  pnlae,  hectic  fever,  night  perspirations,  or  chronic  laryngitis,  but 
associated  with  more  or  less  cough  ami  expectoration  of  long  dura- 
tion, may  be  attributed  to  dilatation  with  considerable  confidence. 
|In  this  statement  it  is  of  course  understood  that  cavities  from  ab- 
1,  or  circumscribed  gangrene,  are  excluded. 


'4«6 


BtSIASEB    OF   THB    BBSPIRATOBT    OR0A5I. 


In  connection  with  the  subject  of  the  tUfTerentikl  dufraooH  of  H- 
l&talioii  nnd  tuberciiloiiift,  llic  fact  is  not  to  be  luet  »)f!ht  of  tliat  botlt 
may  t-xist  conjointly.     A»  rtrmarkeri  by  Wal»lic:  "This  voropuiuij 
etatv  im,  prulmbly,  bcyonit  tbe  reach  of  diagnoets."     Dr.  BowditeV 
giv«8  an  iiiKtance  of  a  youth  who  consulted  him  Eve  minutes  after  an 
attack  of  hicinoptyfii!<,  tiating  that  be  had  been  <]uite  well  op  to  tliis 
occurrence^  wivo  tbitt  he  was  liable  at  time«  to  u  cough,  and  in  e»rlj 
life  had  had  severe  pulmonary  syinptoma.     Expecting  to  find  few  if 
.    any  physical  aigns  of  dj^ense.  Dr.  B.  itas  eurpmed  ut  difcoverini; 
bronchial  and  cavernous  respiration,  with  brooehophony  and  pecto- 
riloquy, throughout  the  whole  of  the  left  lung.     On  ibis  side  ibev* 
was  a  contraction  as  if  from  old  pleurii^y.     Three  raonlhs  afterward 
death  occurred  from  tubercles  developed  in  tbe  other  lung,  and  the 
bronchial  tubes,  enormously  dilated,  were  found  to  fill  up  the  mitjor 
part  of  the  tiing  over  which  had  been  heard  the  phy:<ieal  signs  jtttt 
named.     The  protective  inducnee  of  dilatation  against    tuherck 
was  illustrated  in  this  instance,  the  deposit  taking  place  in  the  long 
free  from  that  lesion. 

A  case  which  recently  came  under  my  obserTation  will  serve  to 
tUuMrale  certain  of  tbe  diagnostic  points  involved  in  the  difTereBlial 
diagnofin  of  dilatation  and  tuberculosis,  and,  at  the  same  time,  the 
difliculty  of  diitcriminating  with  pottitiveneita.  The  patient,  agcd-4^ 
a  blnckiimith,  had  suffered  from  cough  and  expectoration  for  fifteen 
y«art<.  He  9iated  that  he  had  had  several  hemorrhages  from  the 
lungK.  He  had,  however,  continued  to  labor  at  bin  trade  till  within 
a  few  weekfl,  and  was  then  intcrruptod,  not  by  an  increaw  of  hts 
pulmonary  aymptoms,  hut  by  an  afft'Ction  of  a  testicle.  He  was  not 
fimaciateil;  he  liid  not  present  the  aspect  of  a  tuh«rculoiis  patient. 
'  ftnd  he  had  recently  gained  in  weight.  Over  the  left  side  of  the 
chest  the  percussion-reaonance  was  moderately  dull,  with  a  soai»- 
what  tympanitic  quality.  Over  tbe  upper  and  middle  thirds,  in 
front,  of  the  left  side,  bronchial  respiration  was  intense,  the  eipira- 
tion  notably  prolonged,  and  high,  in  pitch.  Strong  bronchophonj 
ooeiiated,  the  voice  seeming  very  near  the  ear.  Whispered  words 
were  accompanied  by  a  strong  soupe,  and  transmitted  to  the  ear  with 
ooDC'idcrable  distinctness  (whispering  pectoriloquy).  Tbe  right  side 
presented  a  well-evolved  and  perfectly  normal  vesicular  respiration, 
with  clear,  vesicular  percussion-resonance. 


Toung  Sto(ho«oc>piiit,  »oond  edition,  pa^  tM. 


SCMJiABT    or    TBB   DIAONOSTIC    OHARACTBIIfl. 


t 
I 


Th«  history,  sjniptonis,  and  signs  in  this  case  certainly  point  to 
dilaUtion.  Dut  tlie  occurrence  of  liaemopijsiH  renders  il  doubtful 
whether  the  case  be  not  one  of  tuberculosis,  presenting  deviations 
from  the  usual  course  of  that  disease.  I  cite  the  case  to  show  the 
uncertainty  which  must  frequently  attend  the  diagnosis. 


tome 

ft 


SUMMABT  OF  THE  UORE  IMPORTANT  0?  TQK  DIKFKRENTIAL  DTAOXOB- 
TIC  CHAEACTIiRS,  AS  CONIIIASTED  WllH  I'XEIi.VlOSlTIfi  AHV  PLL- 
UONAKV  TUItERCULUSU). 

The  physical  signs  accompanying  cylindrical  dilalution,  vii;^ 
bronchial  respiration,  exaggerated  vocal  resonance,  broiichopbouy, 
and  increased  vocal  fremitus,  found  to  be  persistent,  and,  unless 
acute  bronchitis  exist,  unattended  by  any  of  the  signa  anil  nymp- 
toms  of  acute  pneumonitis.  If  acute  bronchitis  coexist,  certain  of 
he  signs  and  symptoms  distinctive  of  acute  pneumonitis  aWnt, 
lanciDating  palna,  bloody  or  rusty  expectoration,  and  ihc  crcpi- 
itrale.  The  bronchial  respiration  and  bronchophony  nut  dimin- 
ished, and  perhaps  increased,  after  the  symptoms  of  acute  brondutiH 
have  disappeared.  Tliu  prcvioiw  history  not  chowing  the  existence 
of  prior  acute  pucumonttiv,  which  is  gvuerally  true  of  cases  of 
chronic  pneumonitis.  Tho  bronchial  re<ipiration  and  bronchophony 
oftcner  found  over  the  upper  than  over  the  lower  lobe.  Frccjucnlly 
a  disproportion  between  the  auscultatory  phenomena  and  the  evi- 
dence of  aolidiGcation  afforded  by  percujrsioD.     The  general  symp- 

MitOiDs  denoting  a  Ins  grave  affection  than  chronic  pueumonitio. 

'  Contrasted  with  phthinis,  the  auscullatory  phenomena,  vin.,  bron- 
chial   ix^spiration,  bronchophony,   cnvcriioua  respiration,  gurgling, 

Kjand  pectoriloquy,  rurely  found  at  the  summit  of  the  chest.     Prc- 

'  qncnlly,  the  dulness  on  porcus»iuii,  relatively  to  these  awcultatory 
phenomena,  proportionately  le^i*  than  in  moat  cases  of  liibcrculosiit ; 
ftod  in  some  instances  no  dulucaa  existing,  the  percustiioD-rcBonance 

(being  undiminished  at  the  summit.  The  physical  signs,  when 
strongly  marked  and  diffused  over  a  considerable  space,  luelusivo 
of  the  phenomena  due  to  cavities,  frequently  limited  to  one  side  of 
the  chest.  The  cavernous  «igiis  not  preceded,  but  sometimes  fol- 
lowed, by  nutiiblo  dulneai'  on  percus.iiuu.  The  physienl  phenomena 
[persisting  for  a  long  period  without  any  mAt«rial  alteration.  Ab- 
\  Benee  of  the  rational  evidence  of  phthisis  derived  from  the  symptoms 


&58 


DISBASBS 


tATORT     OROAKS. 


and  eRects  of  the  Utter  affection,  sucK  as  great  emaciation,  fMblmeii, 
anieinia,  hiemoptysU,  sharp  |ilenritic  pains,  tuWrculouit  f^ver,  hecW, 
night  perspirations,  ami  dironie  afTevtion  of  ilic  larj'tiz. 

CONTFCACTION    OF   THE    BrOXCBIAL   TuBBS. 

Abnormal  diniinntioD  of  the  calibre  of  the  bronchial  tubes  mir 
be  produced  io  different  modpie,  and  it  occurs  in  Tariona  pathologic^ 
oonnections.  It  varies  in  extent,  being  somettmea  limttcd  to  a 
small  space,  and  io  other  instances  extending  to  considt-rable  dia- 
tancA.  Its  sitaalion  ma;  be  near,  or  more  or  Ie«!i  remote  from  the 
primary  bronchoft.  In  degree  it  is  variable.  It  mny  end  in  com- 
plete obliteration.  Oblileration  of  the  bronchial  liibc!>,  tttrktly 
oonaidercd,  is  a  lesion  distinct  from  contraction.  For  pracltcal 
purpoHea,  however,  it  suffices  Io  notice  both  nnder  the  head  of  con- 
traction. As  occurring  in  conneelion  with  the  diffL-ront  varieties  of 
bronchitis,  contraction  and  even  oblileration  of  the  tuhcH  hflre  b«fD 
already  referred  to.  Exclnsivc  of  these  connections,  existing  a» 
permanent  lesions,  tlicy  arc  rare,  and  to  delenniito  their  cxi«inicc 
during  life  by  signs  and  symptoms,  in  the  great  majority  of  instancta. 
is  impossible.  To  the  diagnostician  tbcy  arc  interesting,  chiefly 
in  the  light  of  disturbing  elements,  as  it  were,  in  physical  explora. 
tion,  giving  rise  to  phcTiomena  which  may  simulate  other  affiee- 
tions  or  modify  their  characters,  occasioning  embarrass  meat  and 
error. 

The  attention  of  pathologists  was  first  called  to  the  ooeannnal  oc- 
cnrrencu  of  permanent  contraction  and  obliteration  of  the  bronchial 
tubes  by  a  French  observer,  M.  ReynauJ,  in  18S5.'  Beynaad  wa* 
led  by  Ilia  observations  to  the  opinion  that  bronchial  obliterations 
were  not  very  uncommon.  Hasse,  however,  »nggeais  that  he  may 
not  have  disliuguinhed  iu  .all  instances  between  the  simple  obstm^ 
ticiii  produced  by  the  presence  of  exudation  of  lymph  in  plastic 
bronchitis,  and  obliteration  arising  from  adventitious  tissue,  or  ad- 
besioii  of  the  walls  of  the  tubes.  As  described  by  Keynaud  and 
others,  contraction  and  obliteration  may  be  continnotis,  extending 
Nihcr  over  a  single  tube  or  a  series,  and  sometimes  all  the  tube*  of 
a  lobe,  compared   by  Prof.  Gross,  to  continuous   stricture  of  the 


>  M«m.  At  I'A^'od^mic  Boy.  ie  ll«d.  ml.  W,  ISCK. 


COSIRACTtOK    OF    THE    BBOHCHIAL    TUIIK6. 


359 


t 


I 

I 

I 


I 


nrethrn,  or  ihe  tubes  may  be  narrowed  or  cloBed  at  one  or  more 
points,  as  if  ft  tigsturc  tnd  been  applietl. 

The  obetruction  incident  to  obliteration,  or  a  ooiiaideniblv  <Ic'gro« 
of  contraction,  induces  other  physical  changes  in  the  pulmonary 
organs.  Dilatation  of  the  tubes,  forming  etth<>r  a  pouch-likft  cavity 
just  before  the  point  of  tlte  obstruction,  or  an  enlargement  extend- 
ing  more  or  less  along  the  tube  leading  to  that  point,  ii<  apt  to  fol- 
low. Beyond  the  contracted  or  obliteraled  tubes,  the  pulmonary 
lobules  dependent  thereon  for  their  supply  of  air  become  atrophied, 
shrivelled,  or  collapsed.  And  in  consequence  of  ihesv  «irect«  the 
surrounding  loboles  are  likely  to  become  abnormally  enlarged,  bc- 
eoraing,  in  other  words,  emphyttcmatouB.  This  compound  slate 
defies  diagnosis. 

It  is  obviou»,  the  extent  of  the  consecntivc  pulmonary  changes, 
togelber  with  the  symptoms  and  signs,  will  dcpt-nd  on  the  size  of  the 
bronchial  tube,  or  tubes,  contracted  or  obliterated,  as  well  as  on  the 
amount  of  obstruction,  provided  complete  occlusion  does  not  exist. 
Continuous  obliteration  affects  usually  the  smaller  divisions  of  the 
tubes.  Contraction  or  obliteration,  if  limited  to  a  small  section,  is 
observed  principally  in  the  second  or  third  bronchial  subdivisions.* 
Obotruction  more  or  leMi  eomplelc,  however,  hiut  been  met  with  ut 
different  'situations  between  the  primary  bronchi  and  the  minute 
ramifications.  Seated  in  a  primary  branch,  or,  if  the  contraction 
or  obliteration  be  continuous,  extending  over  all  the  tubes  of  an 
entire  lobe,  the  functions  of  the  lobe  will,  of  course,  be  interrupted 
or  suspended,  according  as  the  supply  of  air  is  more  or  less  dimin* 
isfaed  or  cut  off.  The  atrophy  and  collapse  of  the  lobe  which  ensue 
arc  proportionate  to  the  obstruction.  These  result*  will  ho  less  ex- 
tensive, of  course,  in  proportion  as  the  obstruction  is  limited  to  the 
smaller  tubes. 

The  immediate  local  causes  of  diminished  calibre  of  the  tubes, 
and  obliteration,  are  either  situated  within  or  exterior  to  the  brou- 
ebial  tnbes.  Within  the  tubes,  they  con«ist  of  exudation  upon  the 
nocons  surface ;  a  tuberculous  deposit,  occurring  at  the  siinii:  time 
within  the  vesicles ;  hypertrophy  of  the  mucous  membrane ;  morbid 
cxcresoencM  npringing  thvrefrom ;  contraction  from  cicatrized  ulcers; 
forcigD  substances  received  from  without,  and  solid  morbid  products, 

*  Thflio  two  vsrietfM  aro  dMi.'rlt>f>d  dnd  flguri>d  in  GriMt'«  Fatbologic*)  An- 
aCMny,  to  whbb  Iha  r«ader  U  refiTrcJ. 

*  Grou'i  Patli.  Aast.,  psge  410. 


DISKASBS    OF    THK     R  KS  l>  I  H  ATO  R  Y     OKOASa. 


vis.,  calcareous  fonnntions,  melanotic  eyfits,  or  ac^phalDc^rats  gusiog 
entrance  into  the  tube  from  within.  In  the  list  of  causes  c«at«d  n 
the  interior  of  the  tube  arc  also  to  be  included  aubmacoua  depoeja 
of  sennn,  or  Ijtnpb,  en rdnom atone  matter,  etc  The  causes  ritoated 
exteriorlj  act  by  producing  prrssurv  on  the  ivhe,  or  tubes.  Anxmg 
the  nnmerons  eaases  embraced  in  this  class  are  enlarged  bronclial 
glands,  masses  of  tubercle,  ancurismal  or  other  tumors,  and  pka- 
ritic  effusions.  Several  cases  were  reported  some  years  ago  by  Ui. 
T.  W.  King,  of  London,'  in  which  pressure  of  the  left  auricle,  n 
connection  with  enlargement  of  the  heart,  was  found  to  have  occa- 
sioned considerable  flattening  of  the  left  bronchus,  reducing  il» 
calibre  sufficiently  to  produce  partial  obstruction.  From  the  fore- 
going enumeration,  it  is  evident  that,  as  already  stated,  the  patlio- 
logical  relations  of  contraction  and  obliteration  of  the  tubes  are 
Tarious. 

That  these  lesions  give  rise  to  important  symptoms  ami  signs  is 
certain.  Embarra.«smcnt  of  rf«piratioD,  rannife»le<I  by  dyspnoa, 
may  accompany  cases  in  which  the  obstruction  is  sealed  in  a  bron- 
chial tube  of  large  sise,  more  especially  when  the  obstrtictioo  is 
rapidly  Induced,  and  If  it  occur  in  connection  with  some  other  aSec- 
tion  which  compromises  the  pulmonary  functions.  Kotbing,  how- 
ever, pertaining  to  the  embarrassment  of  respiration  would  indicate 
specially  these  lesions.  The  signs,  theoretically  determined,  are 
dulness  on  percussion  in  proportion  to  the  number  of  pulmonary 
lobales  shrivelled  or  collapsed,  provided  emphysematous  dilatation 
of  the  surrounding  cells  be  not  sufficient  to  compensate  for  the  con- 
densation ;  in  the  latter  case  the  resonance  may  be  preserved,  and  it 
will  be  vesiculo-tympanitic  in  character.  Both  conditions,  t.  e.,  the 
collapse  of  certain  lobules,  and  the  OTer-diatenaioo  of  others,  com- 
bine to  render  the  respiratory  murmur  feeble  or  inaudible.  The 
phenomena  incident  to  bronchial  dilatation  may  coexist,  and  anper- 
sede  those  due  directly  to  the  contraction  or  obliteration  of  the 
Inhes.  In  like  manner  the  signs  belonging  to  the  latter  may  be  loft 
among  tbose  to  which  the  various  associated  morbid  conditions  gire 
rise.  If  the  situation  and  degree  of  the  obslruotiou  be  snob  as  to 
occasion  collapse,  more  or  less  complete,  of  an  entire  lobe,  d^re^ 
non  of  the  thoracic  walls  viU  follow.    This,  as  well  as  the  other 


>  OnT'i  IlMpital  Ite|mru,  April,  198ft.  For  miminsrT,  •«•  Grow'*  Path.  Aoat, 


PBBTCSeiS — WHOOPTFO-OOOOH. 


861 


I 

I 

I 


eigna,  will  be  likely  to  be  prescBtod  over  tlio  superior  and  middle 
ihirda  in  front,  owing  to  ilip  fact  that  the  lesions  have  been  oftener 
found  in  the  upper  than  in  the  lower  pulmonary  lobes. 

Finally,  to  determine  positively  the  existence  of  the^e  lesions 
during  life,  as  already  stated,  is  not  to  be  expected  in  the  great  ma- 
jority of  instances.  The  coexistence  of  feebleness  or  absence  of 
mpiratory  sonnd,  with  dutness  and  perhaps  depression,  under  cir- 
cumstances when  this  combination  of  signs  is  not  otherwise  explic- 
able, points  to  obstruction  of  a  large  bronchial  tube,  and  this  opinion 
may  sometimes  be  forme<l  with  considerable  confidence.  The  grounds 
for  ibis  opinion  tire  less  in  proportion  as  the  contraction  and  oblitera- 
tion arc  limited.  The  Knme  combination  of  signs,  situated  elsewhere 
than  at  the  Kummit  of  the  chest,  warrants  a  suspicion  of  the  exist- 
racc  of  these  lesions.  This  suspicion  may  be  entertained  the  more 
if  the  patient  have  fnifFi-rfd  from  chronic  bronchitis ;  and  still  more 
if  lymph,  in  the  form  of  bronchial  moulds,  has  been  expectorated. 
Situated  at  the  summit  of  the  chest,  these  signs  irould  be  considered 
to  denote  a  tuberculous  di-posit;  and,  it  is  not  improbable,  as  inti- 
mated by  8tuki^,  that  in  a  certain  proportion  of  the  instances  in 
which  a  false  diagno;»is  of  phthisis  is  made,  the  pliysioian  is  misled 
by  the  phenomena  due  to  pcrinuiient  oWruction  of  bronchial  tubes, 
'prtunnlely  for  diagnosis,  the  lesions  arc  extremely  rare. 


PsaTtrssiB— Whoopibq-Coboh. 


f 

m         The  seat  of  whoopiDg-congh  is  indeterminate ;  but  its  primary  and 
I     prominent  symptoms  appear  to  depend  on  a  morbid  condition  of  the 
■    bronchial  tubes.     Nosologically,  it  may  properly  enough  be  classed 
tmong  neurotic  affectiuni;,  and,  like  other  neuroses',  it  is  devoid  of 
_     any  appreciable  anatomical  characters.     The  morbid  appearances 
H     found  after  death  do  not  belong  intrinsically  to  the  disease,  but  are 
due  to  its  complications,  independently  of  which  it  very  mrely,  if 
_     ever,  proves  fatal.     The  most  frequent  complications  are  bronchitis 
f     and  pneumonitis.     Others   loss   common,  arc  tuberculosis,  croup, 
pleuritia,  enteritis,  and  convulsions.     Collapse  of  pulmonary  lobules 
and  emphysematous  enlargement  of  the  lobules  which  arc  not  col- 
lapsed, have  been  observed  after  death.     I  have  observed  abdominal 
^rmpanites  irrespective  of  any  other  apparent  intestinal  complica- 


862 


DISEASES   Ot   TUB    BBSrlSATOBY    OROAXS. 


tion,  A  Bymptom  mentioned  bj  M.  Blache  as  incident  to  diii 
ofTeetion. 

BriiDchial  dilatation  and  pulmonary  emphysema  are  occaeiual 
neciiii-lit  of  wliooping-oougb,  the  latter,  according  to  Rilliet  and  Ba^ 
thcz,  much  less  frequently  llian  is  generally  supposed.  Eit 
emphysema  of  the  areolar  tissue,  from  rupture  of  the  lungs,  I 
hcen  known  to  be  proiliiced  by  the  violence  of  the  cough. 


J*/i>/»iral  Signt  and  IHagnottt. — There  are  no  physical 
chnrncteri^tii:  of  whooping-cough.  During  the  development  of  t( 
dtscaKc,  the  bronchinl  rales  incident  to  bronohitia  may  h«  heard,  and 
a1«o,  more  or  Wh,  iltiriug  the  continuance  of  the  disease.  These,  of 
eoarsc,  only  show  coexisting  inilammalion  of  the  mucons  membrane. 
During  the  paroxysina,  the  Aerie»  of  expiratory  eSbrta  exhau&t  the 
quantity  of  air  in  the  pulmonary  cvllx,  sufficiently  to  produce  an 
appreciable  diminution  of  the  percuflsion-resonance ;  and  during 
the  prolonged  whooping  inspiration,  the  expansion  of  the  cells  is  tu- 
accompHniod  by  tin  auililile  vesicular  murmur. 

The  diagnosis  of  whooping-cough  is  to  be  based  on  the  symptoou 
and  laws  of  the  di:<>c3iM;.  These  are  »o  striking  and  di»tincuve  that 
it  is  recognised  in  the  great  majority  of  ciivrs  without  difficulty 
after  the  characteristic  traits  become  developed.  During  the  early 
period  the  disproportionate  riolence  of  the  congh  in  compsrison 
with  the  other  pnlroonary  symptoms,  its  abruptness  and  paroxysms! 
character,  with  more  or  less  of  the  peculiarities  which  are  afte^ 
ward  so  prominent,  furnish  grounds  for  a  probable  diagnosis ;  bat 
without  the  opportunity  to  observe  for  himself,  relying  upon  the 
description  given  by  others,  the  practitioner  is  often  at  a  loss  to 
form  a  positive  opinion  until  the  affection  has  passed  to  the  tpaa- 
modic  stage.  At  this  period,  in  children,  there  is  tittle  room  for 
hesitancy,  save  when  the  symptoms  are  so  extremely  mild  that  the 
special  characteristics  are  not  prominent.  Cases  of  ihb  kind  are, 
however,  extremely  rare.  In  adults,  the  affection  is  less  readily 
recognised  from  the  fact  that  the  whooping  inspiration  la  le»s  uni- 
formly present.  Moreover,  from  the  infrequcucy  of  case*  of  the 
disease  in  adults,  it  may  escape  detection  beeausc  the  posnbilityof 
iu  existence  may  not  occur  to  the  toiud  of  the  physician. 

Physical  exploration  may  furnish  nscful  information  concenung 
complications  which  are  liable  to  become  developed  in  the  course  of 
the  disease.     The  presence  of  the  tlry  and  bubbling  rales  dtiring  tbt 


ASTHMA. 


368 


in t^rmi anions  between  the  paroxyitinii  of  congliing,  uliovit  llie  oo- 
existence  of  bronchitis,  nnd  by  tbcir  charnctor,  extent,  and  sitiift- 
tion,  the  prnctitiuniT  i«  GtiiittlGiJ  to  judge  of  the  number  anil  fizc  of 
ibe  ttibes  affected,  as  in  cnttps  of  primnrj  bronchial  inflammation. 
Negatively,  the  absence  of  physical  signs,  or  the  presence  only  of 
those  belonging  to  bronchitis,  is  important  in  determining  the 
Don-existence  of  other  and  more  serious  complications,  vie.,  pneu- 
raonitis,  tuberculosis,  plcun'tis,  and  emphysema.  The  existence  of 
any  one  or  more  of  the  complicntions  juet  named  is  to  he  dctcr- 
mtcicd  by  means  of  the  physical  evidence  of  their  presence,  taken  in 
connection  wiih  vital  phcnomenn.  But  inasmuch  as  the  dingnoi^is 
of  these  several  affections  vrill  be  conifidered  fully  hereafter,  and  the 
points  involved  in  their  discrimination,  when  they  are  superadded  to 
whooping-cough,  arc  essentially  the  same  as  when  they  are  primary, 
it  would  involve  a  needless  anticipation  of  future  topics  to  treat  of 
their  eymplonu  and  signs  in  this  connection. 


A6TUMA. 


The  term  aslbcnn,  formerly  applied  to  dyspnoea  occurring  ati  m 
symptom  of  different  disensi-s  of  the  organs  of  respiration  and  of 
the  circulation,  should  be  rcstneted  to  a  paroxyRmn]  iiffcetion,  the 
primary  local  manifestations  of  which  contiittl  in  spasmodic  contrac- 
tion of  the  circular  muscalar  fibres  of  the  .tmallt-r  bronchial  lubes. 
Like  the  affection  last  considered  (whooping-couglj),  it  beiongR,  noso- 
logically,  among  the  neuroses,  and  is  conRequenlly  wanting  in  ap- 
preciable anatomical  charnctcrs.  Although  not  a  very  rare  form  of 
disease,  it  is  very  rarely  met  with  in  practice  as  a  purely  nourotio 
affection:  in  other  words,  in  a  large  proportion  of  eases  it  is  asso* 
cisted  with  morbid  conditions  other  than  spasm,  to  wbiuh  it  stands 
in  the  relation  either  of  cause  or  effect.  Its  existence,  however, 
independently  of  other  affections,  is  sufficiently  establiHhci]. 

Pkytical  Siffna. — The  physical  signs  during  the  paroxysms  of 
asthma  arc  not  in  a  positive  sense  distinctive.  Exploration  of  the 
chest  is  useful  chiefly  in  a  negative  point  of  view,  enabling  the  prac- 
titioner to  exclude  other  affections  accompanied  by  dyepno^n,  and 
alao  to  detect  complications.  Percussion  elicits  an  exaggerated  res- 
onance. From  the  very  frequent  coexistence  of  emphysema,  the 
percuseioD-resotianoe,  in  the  majority  of  cases,  is  more  intense  thaa 


864 


SISBASBS    OP    THB    fiESPIRATOBT    ORGAI 


in  health,  and  v«R)calo- tympanitic  in  chamctir.  It  ig  ttxtti  bj 
WHlshe  that  if  cmpbjsenia  be  noi  present,  ihe  volume  of  t)i«  laagi 
maj  be  reduced  b;  the  expiratory  eiTorts  so  •»  to  diroiaisli  sppre- 
ciablj  the  clearness  on  percussion.  As  a  role,  however,  the  vuUim 
of  the  lungs  is  increased  b;  an  abnorraal  accnmalation  of  air  wiikis 
the  cells;  that  is,  a  temporary  emphyseniaioua  conditiuu  eiistt. 
Owing  to  the  ohstmction  to  the  entrance  of  air  into  the  celli^  tht 
lungs  mar  not  expand  sufGcicntly  to  Gil  the  vacuum  cauMd  by  ikc 
enlargement  of  the  chest  by  inspiration.  Uence,  the  presmire  of  ibt 
atmosphere  occasions  obviona  retraction  of  the  epigastrium,  of  ito 
thoracic  vralU  of  the  lower  part  of  the  chest  in  front,  and  M>metiaM» 
depression  above  and  below  the  clavicles,  with  the  initpiratoiy  acta. 
The  veeiculsr  marmar  is  scarcely  or  not  at  all  appreciable,  attd  it 
replaced  by  sibilant  and  sonorous  rales,  commingled  in  vnried  aad 
constantly  varying  proportions,  the  former  generally  predominaat 
vilh  inspiration.  The  dry  rales  also  accompany  the  act  of  oxpira> 
tion,  the  sonorous  ofteiier  predominating  during  this  act.  The 
rales  with  inspiration  frequently  merge  into  those  attending  expira- 
tion, so  that  they  appear  to  be  continuous.  They  are  ditTusetl  ex- 
tensively over  the  chest  on  both  sides,  and  the  sounds  are  generally 
loud  and  diversified,  whistling,  chirping,  cooing,  snoring,  etc.,  in  al- 
ternation, or  heard  simultaneously  in  ilifferent  portions  of  the  clirst 
The  moist  or  bubbling  rales  are  rarely  present  during  the  severity 
of  the  paroxysm,  but  they  may  be  observed  towanl  its  cloec,  at  tbe 
time  when  expectoration  is  apt  to  occur.  After  the  paroxysm,  bron- 
chial rales  generally  continue  to  he  heard  for  several  days,  and 
finally  cease,  provided  the  patient  does  not  lahor  under  a  persisring 
chronic  bronchitis. 


Diagnotit. — The  diagnoais  of  asthma  rests  on  the  occurrence 
paroxysms  of  labored  respiration,  presenting  the  physical  phenoin- 
enn  just  described,  and  the  exclusion  of  other  aflectioDB  which  may 
give  rise  to  paroxysmal  dyspntca,  resembling,  more  or  less,  that 
originating  from  spasm  of  the  bronchial  muscles. 

In  a  child,  an  attack  of  asthma  may,  at  firvt,  excite  suspicion  of 
eronp.  Bat  a  little  examination  suffices  to  show  that  the  obstruc- 
tion is  not  seated  at  the  larynx.  The  absence  of  the  striking  chat^ 
acters  pertaining  to  the  voice  and  cough,  when  the  aperture  of  the 
glottis  is  diroinbhed,  whether  it  be  from  exudation  or  spasm,  war- 
rants the  exclusion  of  cronp.     From  the  infreqnency  of  caaea  of 


II 


ASTHMA. 


363 


astbtna  in  childhood,  the  dieease  ia  not  cxpcctcti,  nud  hence,  when 
it  does  occur,  other  affections  more  common  in  curly  life  arc  ins- 
pected ontil  the  diagnosis  is  settled.     In  the  mluU,  Inryngcnl  sfTcU' 

Btiona  Bocotnpanied  bj  difficult  respiration,  vis.,  ocdcmn  i^luitidis, 
Mate  laryngitis,  and  oc<M.*ion«ny  spasm  of  the  glottis,  are  referred 
to  their  true  Kitunlioii  with  ttiill  greater  facility  than  in  the  child. 
In  addition  to  the  circumstances  Just  nnmed,  vhich  are  equally  ap- 
plicable, (he  patient'a  scnsaUons  indicate  correctly  the  seat  of  the 
obstraction. 

B  Dyspn<ea,  occurring  in  paroxysms,  is  incident,  in  certain  cases,  to 
disease  of  the  heart,  giving  rise  to  what  )ia«  been  known  by  the 

Ijumeeardiae  atthma.  The  cxislcnoc  of  heart  disease  may  be  pos- 
itirely  ascertained  by  meaos  of  physical  signs.  It  is  true  ihat  dila^ 
tation  of  the  heart  occurs  as  a  complication  of  aslhma;  but  under 
these  circnms lances  asthma  is  known  to  have  existed  for  a  long 
time,  and  it  is  associated  with  cmphy^citm.  The  dyspnoea  occa- 
sioned by  embarraesment  of  the  pulmonary  circutnlion  differs  in 
several  obvious  particulars  from  that  cawscii  by  obstruction  of  the 
smaller  bronchial  tubes.  It  is  accompanied  hy  palpitation,  by  marked 
H  irregularity  in  the  heart's  action,  by  a  sense  of  distri'ss  rcft-rred  to 
the  praecordia.  and  a  feeling  of  impending  dissolution.  Tht  thoracic 
walls  do  not  contract  with  inspiration,  and  the  dry  bronchial  rales 
[are  either  absent,  or  do  not  exist  in  that  degree  which  characterises 
an  attack  of  asthma.  Disease  of  heart,  occasioning  intense  par- 
oxysmal dyspnoea,  generally  produces  more  or  less  habitual  difficulty 
breathing,  or  at  least  dyspnoea  is  frequently  excited  by  slight 
i-4IU)b  as  exercise,  etc. 
^Acilte  Vinnohitifl  occurring  in  a  person  affected  with  emphysema 
may  give  rise  to  great  dyspnoea.  Under  these  circumstances,  bron- 
chial spasm  is  frequently  a  contingent  clrmi-nl  of  the  disease.  The 
paroxysmal  increase  of  the  dyspnoea  generally  depends  on  this  ele- 
i'ment.  But,  in  to  far  as  the  difficulty  of  respiration  proceeds  from 
the  bronchitis  in  combination  with  the  omphyscmo,  irrcKpoctive  of 

I  spasm,  it  is  more  pcriiisting  than  in  cases  of  pure  asthma.  It  pursueti 
a  oourke  corrcspontling  to  that  of  the  bronchial  inflnmmntion,  being 
developed  less  suddenly  ihnn  when  due  to  spasm  nlonc,  continuing 
during  the  continuance  of  the  inflammatory  condition  of  tbc  mem- 
brunc,  and  disappearing  gradually  in  proportion  as  resolution  of  the 
bronchitis  takes  place.  It  is  accompanied  with  more  cough  and  ex- 
pectoration than  belong  usually  to  pure  asthma,  and  the  matter 


366 


Dt£BA6ES    OF    Tj 


OKOAXS. 


expectorated  preaenis  the  characlers  of  roacoaa  infiammation.  The 
moist  bronchial  rales  are  more  likelv  to  l>e  present  than  in  caa«a  of 
pure  aalhoia.  The  existence  of  eniph  vsema  b  ascertained  bj  meani 
of  its  characteristic  aijins,  which  are  hereafter  to  be  considered. 

The  d^rspncea  vhich  forin^i  the  most  prominent  sjrinploni  in  capil- 
lary bronchitis,  on  a  superficiui  exiiminalion,  might,  for  a  time,  lead 
the  practitioner  into  ihc  error  of  suppoaiitg  the  cat«  to  be  iam\iij 
an  attack  of  at>thm&.  But  a  proper  iMvestigation  should  speedilj 
correct  thin  error.  Ciipillary  bronchitis  generally  saccevda,  or  b 
coincident  with,  inlliimniution  afTcciing  the  larger  bronchial  tubes. 
The  local  KyniplQin»  of  hronchitiK  are  present,  vii.,  ooogh,  expec- 
toration of  inucu8  more  Or  IcM  inodified,  and  substernal  soreneta. 
Tlic  respirations  are  much  more  frequent.  Great  acceleration  of  th« 
pulse  is  a  distinctive  feature.  The  sub-crepitimt  rale  is  di^overed 
on  auscultation.  The  dyspnoea  and  associated  s^ptoms  are  per- 
sistent, increasing  until  the  inflammation  reacSes  its  acme,  and 
slowly  diminishing  n»  the  inHnminiitory  condition  subsides,  present- 
ing, thii!«,  in  its  course,  a  striking  contrant  to  an  asthmatic  paroxyiim. 
Id  capillary  bronchitis,  a»  in  ordinary  bronchial  inHammation  com- 
bined with  emphysema,  the  dy«pnu>a  may  present  exacerfaaiiooa 
which  are  due  to  spnam;  but  the  spasm  is  only  an  incidental  ele- 
ment of  the  affection,  not,  as  in  pure  asthma,  the  primary,  and,  in 
relation  to  the  bronchial  obstruction,  the  chief  pathological  condi- 
tion. 

In  oonolnsion,  the  dingnottis  of  asthma,  in  moat  oases,  is  very 
easily  made.  The  fact  of  it*  extsiencc  is  generally  well  knowa  itt 
the  ni-irs  which  the  physicinn  meetn  with  in  practice,  repeated 
attacks  having  been  already  experienced.  It  is  only  when  few  or 
no  paroxysms  have  previously  occurred  that  there  ia  room  for  mo- 
mcDiary  doubt,  and,  in  such  »««»,  the  distinctive  symptomatic 
ebaraotera,  taken  in  connection  with  the  absence  of  the  physical 
evidence  of  other  affections  giving  rise  to  embarranment  of  respi- 
ration, Htilliei!  for  a  prompt  and  postliTe  discrimination. 

As  alrcndy  remarked,  insinuocs  of  simple,  uncomplicated  aaihma 
are  rare.  In  most  caws  of  confirmetl  aaihma,  the  practitioner  may 
expect  to  discover  emphysema,  and,  in  a  certain  proportion  of  cases, 
disease  of  heart.  The  existence  or  non-existence  of  these  affections 
is  to  be  determined  by  the  presence  or  absence  of  their  diagnoatio 
symptoms  and  signs. 


HCHHAaT   OP   PHTSICAL   SIQNa   BBLONGIKO  TO   ASTHMA.    367 


SOUUABT   OF   PHYSICAL   BIOKB   BSLONaiNe  TO   ASTHMA. 

Exaggerated  percussion-resonnnce.  Retraction  of  the  base  of  the 
cheat  in  front  and  the  epigastrium  in  the  act  of  inspiration.  Vesic- 
ular murmur  enfeebled  or  abolished.  Sibilant  and  sonorous  rales, 
with  both  respiratory  acts,  loud  and  divereified,  extensively  diffused 
over  chest.  Moist  rales,  in  some  cases,  at  the  close  of  tbe  par- 
oxysm. 


CHAPTER    III. 

PSBUMOSITIS— IMPERFECT  EXPANSION  (ATBLECTA816)  ASD 

COLLAPSE. 

PmoMOKiTie,  or  inBainraatton  of  the  poImoriKry  parenchyma, 
one  of  tht>  moat  int«retit!ng  and  important  of  itie  i'lficMts  «ffMtiiig 
tlio  respiratory  orgaiitt,  occurs,  gt^nnrally,  as  an  acute,  but  occaaiou- 
ally  as  a  chronic  afTection.  In  connection  with  tliU  afTocitou  will  b« 
conBJdt're']  imperft^ct  cxpanition  of  more  or  lexB  of  the  pulmonary 
lobules  after  birth  (ateU'ctasJii),  and  collapse  of  pulmonary  lobule*, 
the  latter  having  been  heretofore  kuown  a«  lobular  pneomoaitu. 

Acute  Lobar  Pseumokitib. 

The  ordinary  fonn  of  acute  pneumonitis  in  the  adult  ia  called 
£i?Air,  tlii^  name  importing  that  the  iciflainmatioii  extendi  over  an 
entire  lobe  of  thi^  lungn.  This  ih  true,  nt  least  in  (he  great  majority 
of  casus,  providi'd  the  piieumoiiiti!i  be  primary.  Seeondary  or  in- 
tercurrent pneumonitis  miiy  be  more  or  less  circumscribed.  Pri- 
mary lobar  pneumonitis  U  of  frctiuent  occurrence.  The  disease  if 
often  nssucinted  with  periodical,  continued,  eruptive,  puerperal,  ftad 
rhcunmlic  fevers,  and  with  purulent  infection  of  the  blood.  It  9 
dcvelopi'd  also  u»  a  complication  of  croup,  whooping-cough,  acute 
afTectionsof  the  henrt,  etc.  In  these  vnriou«  paihologiciil  eonnec- 
tion»,  the  vital  phenomena,  or  symptoms,  are  presented  with  sd& 
tiona  and  modilicattonK  which  tterve  to  enhance  the  importance  of 
the  phy.'iical  signs  in  the  diagnuai.t  of  the  disease. 

Author!!  make  several  varieties  of  pneumonitis,  based  mainly  on 
Bemeiological  distinctions.  So  far  as  relutefi  to  diagnosis,  it  will 
Buflice  merely  to  enumerate  the  varieties  generally  recognised. 

If  the  phenomena  of  the  disease  indicate  purely  an  acute  inflam- 
mation unattended  by  any  unusual  fcatore»,  it  is  frei^ucntly  styleil 
frank  jmrumonitit.     A  better  title  is  timple  acute  pneumonitis. 


ACOTB    LOBAR    FHBDM0MITI8. 


809 


I 


Accompanied  by  a  marked  i!«gre«  of  prustration.  and  more  oa- 
pecially  passive  or  low  delirium,  it  is  culled  ttfphoiti  pncttmoHt'tit. 
Primitive  pneumonitis  sonietiini-s  prusciits  these  c1iaracter«,  but  ty- 
phoid fever  and  typhus,  nomplicaied  nitb  iDiluniniation  of  the  luogSf 
and  pneumonitis  presenting  wbnt  are  ordinarily  known  as  typhoid 
BymptomSi,  are  sometimes  oon founded. 

Occurring  ns  a  com  plication  of  bronchitis,  which  is  apt  to  be  the 
case  when  tlie  kttcr  nRrction  prcvaiU  epidemically,  conBtituting 
influCDia,  the  disease  has  been  distinguii^bcd  n:t  catarrhal  pneumQn- 
iti$. 

When  it  folloniii  a  iround,  or  some  cxU-nial  injury,  it  is  traumatic 
jmenmonilit. 

The  teno  bilioui,  applied  in  an  indefinite  eenso  to  various  alfccttooK, 
u  frwiuvntly  naod  in  oonnection  with  thii)  disease.  In  its  applica- 
tion to  CiiHC«  eoiiiplicatcd  vith  ictcru)>,  the  term  has  an  obvious  eig- 
itifieaiice  which  is  less  apparent  when  it  is  extended  to  cases  in 
which  the  only  evidence  of  disordered  function  of  the  Uver  are  sal- 
lowDMs  of  the  complexion,  a  greenish  or  yellow  coating  of  the 
tongue,  dulncss  of  the  intellect,  and  a  sense  of  uneasiness  in  the 
epigastrium.  In  districts  known  as  miasmatic,  the  disease  is  called 
btiiou9 pneumonitis,  and  it  is  often  combined,  in  these  localities,  with 
the  phenomena  of  the  periodical  fevers. 

Pneumonitis  is  called  intent,  aa  already  stated,  when  it  cxiata 
without  the  local  vital  manifestations  which  are  usually  present.  So 
far  as  diitgnostic  symptoiiia  are  concerned,  it  is  sometimes  remark- 
ably latent ;  but  under  these  circumstances  the  existence  of  the  dift- 
ease  may  always  be  ascertained  by  means  of  physical  exploration. 

In  a  large  proportion  of  cases,  lobar  pneumonitis  is  confined  to 
ono  side  of  the  chest.  In  a  certain  proportion  of  oases,  however, 
the  in  flam  mat  ion  affects  both  sides.  This  ctHistitutes  a  variety 
fldled  Aw6^  pneumonittJt.  When  con6ned  to  one  side,  usually  a 
lilfglv'bbe  only  lA  affected,  but  not  very  infrequently  the  inflamma- 
tion extends  over  the  whole  of  one  lung.  This  might  properly 
Cboagh  be  considered  a  variety  of  the  disease,  but  it  bos  no  distinc- 
tive name. 

Most  of  the  foregoing  varieties  of  pneumonitis,  it  will  be  observed, 
relate  to  the  disease  occurring  as  a  primitive  affection.  It  is  devel- 
oped, M*.  already  stated,  in  the  course  of  numerous  diseases.  Occur- 
ring thus  secondurily,  it  is  often  wanting  in  diagnostic  symptoms,  or 
^cy  arc  masked  by  the  phenomena  of  the  disease  of  which  it  is  a 

24 


870  DISKASBS   OP    TnS    KBSPtRATORT    OROAItS. 

complication,  m>  tlmt  without  tlic  Kid  of  phjaienl  signs  it  woal<I  fr«- 
qucntlj"  r«CHpe  detection. 

Following  Laennee,  ]Wtliologi»i«  sgree  in  dcMribiog  the  snatom- 
iciti  characters  in  acut«  pRciimoDilis  as  belonging  to  lhrc«  diffeimt 
pcriotis.  The  career  of  tho  disease  is  divided  into  surges  eorre- 
Mponding  to  these  periods,  and  e»ch  etagv  or  period  daring  life  is 
chnracteriied  by  phenomena,  vital  snd  physical,  which  »rc  more  or 
Ic«s  di)4tinctive.  The  Grat  period  constitutes  the  atsge  of  tn^fon* 
matirnf  engnrgtmtnt ;  the  second,  the  SUge  of  toUdijie^ion  or 
Hfpatixatif/H :  the  third,  the  suppurative  period,  stage  of  purolcnt 
infilimtinn,  or  gratf  hrpatiiation.  For  a  dotatlcd  description  of  ibe 
anatomical  characters  belonging  to  the  different  stages,  tiic  reader 
is  referred  lo  works  which  treat  of  the  morbid  anatoniir  of  the 
affection.  The  essentia)  anntomie^)  characters  which  arc  particn- 
larlj  involved  in  the  production  of  the  physical  eigBs  belonging  to 
the  disease,  are  the  following.  Fir»t  stage.  Increased  densitr  from 
engorgement,  and  the  presence  of  a  viscid  Suid  within  the  brondu- 
oles  and  vesicles,  which  arc,  as  yet,  not  closed  to  the  entrance  of 
air;  coexisting  plenrilii.  Second  ttage.  Solidification  in  coose- 
fjoence  of  closure  of  the  greater  part  of  the  vesicles  of  the  affected 
portion  of  lung  by  morbid  <-x  udation ;  increased  volume  of  the  affected 
lung,  and  its  incapacity  for  collapsing  in  expiration.  Exudation  of 
flbrine  on  the  pleura,  with,  in  some  cases,  more  or  less  liquid  effusion 
within  the  pleural  sac.  Third  ttafff.  Puriform  fluid  escaping  from 
the  cells  into  the  bronchial  tubes  in  greater  or  le^  abnndancv ;  per- 
sisting iiolidi6cation ;  in  some  cases  formation  of  collections  of  puri- 
form matter  resulting  in  cavities. 

Pht/neal  Signs. — The  several  methods  of  exploration,  with  tbt 
single  exception  of  succussion,  may  all  furnish  signs  in  cases  of 
lobar  pneumonitis.  The  signs  pertaining  to  the  disease  are,  there- 
fore, numerous;  but  it  will  he  seen  that,  as  regards  particular 
phenomena  and  tbeir  combinations,  uniformity  in  the  different 
stages  of  the  disease  and  in  the  same  stage  in  different  cases  does 
not  exist.  This  want  of  constancy,  however,  is  rarely  the  source 
of  diBUculty  in  the  way  of  diagnosis,  although  it  renders  an  aequaiDt- 
anco  with  the  variations  which  arc  liable  to  occur,  in  a  practical 
point  of  view,  important. 

The  percussion-resonance,  in  the  first  stage,  or  stage  of  engorge- 
ment, may  be  diminished ;  in  other  words,  the  sound  over  the  affected 


ACUTB    LOBAR    PXEUMOSITtS. 


S71 


lobe,  compared  with  that  elicited  in  a  corresponding  situation  on  the 
unaffected  side,  is  more  or  less  dull.  This  statement  accords  wiih  the 
views  of  most  practical  writers,  but  an  opposite  opinion  is  held  by 
SIcoda.  He  maintains  that  the  percussion -sound  remains  unaltered, 
be  the  engorgement  never  »o  great,  prior  to  exudation.  This  vim, 
in  faet,  the  opinion  of  Laennec.  Innsmucb  as  a  fatal  result  verj 
rareljr  occurs  in  the  stage  of  engorgement,  opportunities  to  demon- 
stratc  the  incorrcctnew  of  this  opinion  are  seldom  offered.  An  in- 
stance has  fallen  under  my  observation,  in  which,  owing  ro  the  dis- 
ease being  developed  in  a  palieni  affpuled  with  great  enlargement  of 
the  heart,  death  took  place  b<rforc  the  local  chaugva,  m  proved  by 
.Itoontopv,  Iwd  ndvanecd  to  the  second  8tngc.  In  thiv  cni>c,  the 
t'ltniHsllPChsafliMtcd  lobe  (the  lower  lobe  of  the  right  lung)  hml  been 
easily  defined  by  dulnesii  on  percusflion,  together  with  the  presence 
of  the  crepitant  rale.  In  gent-rnl,  however,  it  is  probably  true  that 
if  the  resonance  be  diminished  in  a  marked  degree,  exudation  has 
occurred,  a  result  which  tnny  follow  within  a  few  hoiir«  from  the 
first  appearance  of  locnl  symptomi*  of  the  diseane.  In  proportion 
OS  the  »oli<lifi cation  becomes  more  and  more  complete,  the  normal 
rcAOnanee  progressively  diminishes.  Other  things  being  equal,  the 
toss  of  vesicular  resonance  is  a  measure  of  the  amount  of  solidiGca- 
tion.  The  vesicular  resonance  may,  in  fact,  be  abolished ;  but  it  is 
rarely  the  case  that  absolute  flatness  exists.  If  a  certain  proportion 
of  the  air-vesicles  of  the  affected  lobe  do  not  still  contain  air,  the 
broDcbial  lubes  are  not  completely  filled  with  morbid  products. 
The  quantity  of  air  which  the  latter  contain  is  sufficient  to  prevent 
total  extinction  of  sound.  In  this  respect  the  loss  of  resonance  in 
cases  of  solidification  differs  from  that  which  attends  large  pleural 
effusion.  In  the  Inner  the  abolition  of  sound  is  complete;  in  other 
words,  absolute  flatnentt  exists. 

In  proportion  as  the  density  of  the  pulmonary  parenchyma  is  in- 
creased, first  by  engorgement,  and  next  by  solid  exudation,  the 
sense  of  resistance  felt  in  percussing  over  the  affected  lobe  is  greater 
than  in  a  corresponding  Kilualion  on  the  healthy  side  of  the  cheat. 
Thissign  exists  in  a  marked  degree  in  the  second  stage  of  pneumon- 
itis, and  constitutes  a  means  by  which,  to  some  extent,  the  amount 
of  solidification  may  be  estimated. 

The  resolution  of  the  infinmmation  is  accompanied  by  a  return  of 
the  recicular  resonance,  and  the  normal  elasticity.  Percussion,  thus, 
enables  ns  to  determine  the  progress  made  in  the  removal  of  the  solid 


81 


DISBiSEg  OP   TBB    RESPIBATORT   0ROA5S. 


depavit,  s»d  the  coinplvtcncH  of  the  flntl  restonttion  of  the  affecitd 
portion  of  the  pulmDiiKry  organs. 

Tlie  phenomena  elioit«<I  b>-  pcrcuiwiOD  which  bare  just  been 
»tAi«d  r«kte  inunly  to  v«»icular  rv»oiiancc.  The  cffectx  on  the 
•onorHHsnc*^  of  th«  clivst,  wliicli  oiav  be  produced  by  the  anaiomical 
ehangeft  in  pneumonitis,  are  not  fully  embraced  in  the  roregoicg 
dcMriptioD.  Over  lung  completely  8vli<IiGcii  by  intru-voeicnlar  de- 
pMit,  wliatever  «oiiorotisneM  reuniins  inu^t,  of  courM,  be  ooD-resic- 
iilar,  nntl  coii»ei)neiilly  tympuDitic.  Exclusive  of  the  rare  in!iaDc«* 
in  which,  under  these  circumstuDveH,  there  exists  absolate  flatness, 
the  reticular  Is  replaced  by  a  tympanitic  reaoiutDoe,  which  may  be 
more  or  Iomm  nmrkeJ.  The  term  tympanitic  expressing  an  sbnomttl 
quality  of  Hound,  irrospcctivc  of  its  intensity,  the  resonance  may  be 
in  a  narked  degree  diminished,  and,  indeed,  but  feebly  appreciable, 
iriiile  its  non-vcsiculitr  character  is  sufficiently  apparent.  In  the 
second  stage  of  pneumonitis,  then,  if  there  be  not  total  extinction 
of  sound,  a  tympanitic  resonance  will  be  obserted. 

In  some  instances  the  veaicular  resonance  is  replaced  by  a  pretty 
intense  tympanitic  sound.  In  intensity  the  resonance  over  the  solid- 
ified  lung  may  even  exceed  tliat  on  the  unalTccted  side.  IM  aon> 
Tesiciilnr  character  and  hlghnest)  of  pitch  are  the  more  striking,  «s 
COQtriwted  with  the  normal  resonance,  in  proportion  to  its  intensity. 
Well-marked  cracked  metal  and  amphoric  reM>nance  arc  occasion- 
ally  observed  over  the  upper  anterior  portion  of  the  aflecti-d  side. 
The  sense  of  rcfltHlnnce  on  percussion,  in  addition  to  other  circum- 
stances, serves  to  distinguish  the  tympanitic  resonance  occurring 
over  solidiGed  lung,  from  tliut  of  pncumo- thorax,  and  from  the  vesio- 
iito-tympanitic  resonance  of  emphysema,  the  thoracic  parietie^  re- 
taining their  elasticity  in  the  latter  aBoctions.  In  cases  of  pneu- 
monitis affecting  the  left  lung,  a  tympanitic  resonance  may  be  due 
to  (liatenaion  of  the  stomach  with  gas.  This  source  is  often  suEB- 
cieiiily  evidenced  by  the  gastric  character  of  the  sound,  ris.,  nota- 
ble acuteness  of  pitch,  and  a  metallic  quality.  In  some  instanoes 
ia  which  the  upper  ns  well  as  lower  lobe  is  solidified,  the  gastric  note 
is  manifested  al  the  inferior  portion  of  the  chest,  while  orer  the  supe- 
rior part  the  tympanitic  rcscnanco  is  lower  in  (Htcb  and  without  any 
metiiUic  tone ;  and  a  tyuipiinitic  resonance,  in  cases  of  pueamoniti* 
affecting  the  entire  left  lung,  may  be  marked  over  the  upper  and 
middle  portions,  while  flatness  exists  at  the  base.  On  the  right  side 
a  tympanitic  resonance  may  be  transmitted  from  the  distended  colon; 


ACDTB    LOBAR    PN  E  U  MOK"  ITIS. 


878 


ovt  !t  is  obsorv«d  ov^r  the  superior  and  ihe  tuiddle  third  on  this  side, 
in  cases  in  which  below  the  upper  boundary  of  the  liver  percuBsion 
elicits  a  flat  sound.  The  tympanitic  resonance  due  to  solidiBcstioD 
of  Innj;  is  much  oftcner  marked,  in  coses  in  which  the  upper  lobos  are 
nffccted,  on  the  anterior  surface  of  the  chest,  and  especially  over  the 
middle  third.  Excepting  in  cases  in  which,  on  the  left  side,  a  gastric 
sound  is  transmitted,  it  is  rare  that  on  the  posterior  surface  more 
than  an  obscure  or  feeble  non-vesicular  resonance  is  discoverable. 

Id  eases  in  which  an  entire  lung  is  solidified,  I  have  obscrred  a 
tympanitic  resonance  in  different  parts,  varying,  not  only  in  intensity, 
but  in  pitch.  Thus,  in  a  case  in  which  the  right  lung  was  solidified, 
the  percussion -sound  at  the  summit  was  feeble,  but  distinctly  tympa- 
nitic and  high  in  pitch ;  over  the  middle  third  the  pitch  was  con- 
siderably lower,  but  the  tympanitic  quality  more  intense;  in  the 
nxilliiry  region  tho  tympanitic  quality  was  also  marked,  and  thu  pitch 
•till  lower  than  over  the  middle  anterior  third. 

In  some  instances  the  tympanitic  resonance  persists  from  day  to 
day,  during  the  course  of  the  disease,  gradually  diminishing,  re- 
gaining by  degrecR  the  vditioular  quality  of  sound,  becoming  veaicnlo- 
tjmpanitic,  and  finally  iittauming  the  normal  character.  But  in 
other  instances  marked  variations  are  observed  at  examinations  re- 
peated on  successive  days;  on  one  day  the  sound  may  be  dull, 
amounting  almost  to  absolute  Elatness,  and  on  the  next  day  it  tufty 
become  highly  tympanitic.  I  have  observed  this  change  to  occur 
within  Ihi!  fpace  of  an  hour.  Without  entering  into  a  dificuiision  of 
tliese  fluctuations,!  will  niinply  remark  that  a  tympanitic  re^onanoe 
viicilcd  over  lung  coinplctely  solidified,  if  not  due  to  gas  in  the 
stomach  or  inleHlincs  muat  be  due  to  the  presence  of  air  within  the 
bronchial  tubes'.  The  varying  oondilion  of  the  tubes,  as  retipects  the 
aocumulation  of  mucuH  or  other  morbid  products,  will  perhaps  ac> 
oooot  for  the  existence  of  »onarouanesa  at  one  time,  and  dulnces 
araonntiog  nearly  to  flntneas  at  another  time.  The  situation  in  whieh 
the  tympanitic  resonance  ii^  apt  to  be  most  marked,  y\z.,  over  tho 
larger  tubes,  favors  tho  junt  given  explanation. 

In  ease*  of  pneumonitis  affecting  the  lower  lobe,  the  percussion- 
resonance  over  the  uniiffictcd  lobe  on  the  ^ame  side  is  generally 
exaggerated  or  vesiculo-tynipanitic ;  that  i»,  the  sonorousness  is 
greater  than  in  corresponding  situations  on  the  opposite  side,  higher 
io  pitch,  and  vesiculo-tympnnitic  in  quality.  These  characters  are 
more  marked  ou  tho  anterior  surface  of  the  chest,  but  they  are  ap- 


»lt>4AB3  OF    TDE    SESPIBATOBT  OftSASS. 


;  poMcriorlj  in  the  upper  scapuUr  region.  In  Itk«  mnmmt 
ike  npper  lobe  is  totidified,  the  resonance  oT«r  the  lo««rU* 
ii  OMggenttd,  or  veaicalo- tympanitic.  If,  m  not  tafrtqfdy 
bsppem,  the  npper  and  lower  loltc  of  the  right  long  be  mbfiCii, 
the  middle  lobe  remaining  intaet,  the  fMonaacc  otct  tbt  httvit 
BOtsbl;  inleoae  and  Tesicnio- tympanitic.  On  the  tide  free  froa  Cr- 
ease the  resonance  t«  uduallj  stronglj  marked,  and  highly  rewahc; 

Bj  means  of  percussion  the  limitii  of  pneninoniiis  id  the  aecaaj 
•tage  maj  generally  be  defined  without  difficulty.  The  ehange  bvm 
the  Te«icuUr  or  a  Te:ticHlo>tympanilic  resonance  to  dulnNs,  flatBem, 
or  a  tympanitic  rcMonnncc  is  generally  abrupt,  and  the  line  of  de- 
marcation bctwi-cn  the  henithy  and  8olidi6rd  lung  i«  tfaos  easly 
traced  on  the  chceU  In  view  of  the  fact  that  lobar  pncnmooitis  ex- 
tends over  an  entire  lobe,  and  m  the  majority  of  cases  is  limited  t* 
a  single  lobe,  tbe  line  bounding  the  limits  of  theaffectcl  portion  sf 
the  lung  will  be  foimd  to  pnrsue  a  direction  coincident  vith  thai  of 
the  intorlobiir  fissure.  Thus,  if  the  lower  lobe  be  affected,  the  line 
intersecting  the  several  points  at  which  the  change  in  the  pcrcnssioii- 
Boand  is  observed,  extends  obliquely  upward  and  outward,  from  be- 
tween the  fifth  and  sixth  ribs,  in  a  direction  toward  the  rertebnl 
extremity  of  the  spinous  ridge  of  the  scapula, — this  being  thi;»ttaa- 
tioii  of  the  fissure  .teparatlug  the  upper  and  lower  lobes  on  the  left 
side,  and  the  middle  and  lower  lobes  on  the  right  ude.  On  the  right 
eide,  in  cases  in  which  the  inflammation  extends  to  the  middle  lobe, 
the  line  pursues  a  direction  upward  and  outward  from  the  fourth  car- 
tilage. This  is  a  point  not  only  of  interest,  but  one  which  may  be 
ID  Bome  iiistanoes  of  importance  in  diagnosia.  In  the  absence  of  the 
anscultatory  phenomena  distinctive  of  solidification  of  lung,  which, 
although  generally  present,  may  be  absent,  the  que«tioo  will  perhaps 
arise  wlicilitT  marked  dulnesa  or  Satness  on  percussion  be  not  doe 
to  li<iuid  cffuiiion  ;  in  other  words;,  the  differential  diagnosis  between 
pneumonitis  and  picurilis  is  to  be  made.  Vow,  if,  under  these  cir- 
ctimstaiic««,  the  line  denoting  the  limits  of  the  dulnesa  or  flatness 
be  found  to  occupy  the  situation  of  the  interlobar  fissure,  while  the 
body  of  the  patient  is  in  »  rerticai  position,  the  question  may  be 
considered  almost  or  (|uitv  settled. 

During  the  resolution  of  pneamoiiitiii,  in  proportion  as  the  solid 
exudation  disappears,  the  vesicular  resunanec.  as  already  stated,  re- 
turns. This  \»  gradual,  though  freqaently  much  progr«»s  la  made 
itttuna  short  space  of  tiiue.    Tbedulness  is  sometimes  observed  to 


ACUTK    LOBAR    PKEDHOKITIg. 


876 


I 


■ImMD  mat«iisll^  in  Iwenty-four  hours.  It  is,  koircvor,  oftvn  long 
liefbre  complele  equality  in  tho  rcitonance  of  tlic  two  Hi<l«s  in  restored; 
&  marked  disparity  muy  vxht  for  ifeekn  uftcr  the  putient  huK  uppa- 
renlly  rccotenjd  perfect  henlth. 

Auscultation,  in  most  avtfn  of  pocumonitiB,  furnt«hee  importfiot 
sigii.t.  Ai  the  inflummatioti  does  not  invade  Bimultaneously  the 
wholv  of  a  lobe,  but,  commencing  at  one  or  more  pointu,  Kdvancco 
thenoe  in  all  directions,  a  eorluin  period  may  elapse  before  any 
positive  auflcultatory  phenomena  art:  discoverable.  This  will  be  the 
cue  eopecially  if  the  points  of  dcpnriitrc  of  the  inflammation  be 
centrally  situated.  The  beitltby  parenehytna  sarruunding  the  por- 
tion inflamed  prevents  the  aiiitcultatory  sign.*  of  the  latter  from 
reaching  the  ear.  Under  these  circumstances,  according  to  Fournet. 
the  dia^nosi.4,  taking  into  aeoounl  tJic  symptoms,  may  sometimes  h« 
based  on  an  exaggerated  respiratory  murmur  over  a  portion  of  the 
chest.  He  states  that  the  vesicles  surroiiiidiug  an  inflamed  portion 
of  a  lobe  take  on  a  supplementary  activity,  and  gire  rise  to  an  ab- 
normally loud  respiration.  It  is  stated  also  by  Stokes  that  the  first 
effect  of  inflammation  prior  to  the  production  of  the  crepitant  rale, 
is  an  exaggerated  mnrniur.  On  the  other  hand,  Grisolle  states  that 
the  effect  of  inflammation  upon  the  adjoining  lung>substanee  lA 
oftcner  to  diminish  its  activity,  giving  rise  to  an  abnormally  weak 
rcspiraUon.  Both  thcHc  statements,  although  they  appear  to  be 
contradictory,  arc  correct;  in  other  words,  the  respiratory  sound  in 
the  immediate  vicinity  of  an  innitmei]  portion  may  be  either  exag- 
gerated or  weakened.  The  upportnnity  of  observing  one  or  the 
other  of  these  elTccts  is  occai^onally  presented  in  cases  in  which 
the  existence  of  central  pneumonitis  is  indiculed  by  eliantct^-ristic 
symptoms  prior  to  the  development  of  distinctive  signs,  the  latter 
shortly  making  their  appearance  and  showing  that  iht  inflamuia- 
tion  has  extended  from  its  central  situation  to  the  surface.  Tlit; 
opportunity  is  also  presented  in  cases  in  which  the  inflammation 
passed  from  one  lobe  to  another,  gradually  invading  the  latter.  I 
h&ve  noted,  under  thc«e  circumstances,  in  diflerenr  cases,  both  ex- 
aggerated n»d  weakened  respiration;  and  in  the  same  case  I  have 
ohservctl  on  two  successive  days,  in  the  same  situation,  first  rxng- 
geraled,  and  next  weakened  reapirnlion.  In  some  instances,  while 
tiie  area  of  the  inflamed  lung  is  limited,  especially  if  it  be  situated 
near  the  surface,  a  broncho- vehicular  respiration  precedes  the  a[»- 
pearance  of  other  signs. 


I 


87(t 


DI8SASBS  0?  THB  J&BBPIBATO&X  OBOASS. 


The  twr1i(!!it  hbi  moal  ehftractertstic  of  tli«  poflitive  a»ga*  of  [him- 
tnonitiA,  in  tht^  err/n'lant  rale.  This  aigu  is  incident  Co  phync*!  no- 
ditioiiH  belonging  to  tho  primary  local  ofTecte  of  inflaramation,  and 
•\»  hnri)  when  the  inflamed  portion  is  sufficiently  large,  and  near 
enough  to  the  surface  for  the  sound  to  be  transniitied.  Contrarr 
to  the  opinion  of  Skoda,  it  is  present  in  a  majoritjr  of  the  eases  of 
pneumonitis.  Out  of  fortv-four  cases  taken  in  regular  order  »itli 
a  view  to  an  analjrsis  of  the  recorded  physical  signs,  in  thirtj-tvo 
a  crepitant  rale  was  observed,  and  in  twelre  its  presence  was  not 
noted.  But  of  the.^o  iwelrc  coses,  in  eight  a  single  examinaiioB 
only  tras  made,  and  in  all  it  was  made  at  a  period  tnore  or  less  r«- 
mote  from  the  comraenocraeiit  of  the  disease.  It  is  probable  that 
repeated  examinatiiin*.  made  st  an  earlier  period,  would  not  have 
been  iiegattre  as  regards  this  sign  in  the  greater  proportion  of  tbe 
f«ff  instances  in  which  it  was  notdiKcovercd.  Of  I4d  exaiiiitiaiiona, 
in  fortj-five  ca«e«,  made  at  different  periods  in  the  progrew  of  the 
disease,  the  prMciiee  of  the  rale  is  nowd  tn  eighty-five,  and  its  ab- 
Bence  in  sixty-fonr.  The  frcijuoncy  of  the  rnle  in  neote  primitive 
pneuinoTiitis,  affecltng  the  adult,  is  shown  by  the  exlcnsire  resvarchei 
of  Grisolle.  This  author,  in  hi»  treatise  on  pDeumoiiitis,  bused  OD 
an  analysis  of  373  caxes.  states  that  he  has  only  met  with  four  in- 
stances in  which  this  sign  was  not  discorered  at  some  period  during 
the  course  of  the  disease.  Different  cases,  however,  present  great 
differences  as  respects  its  abundance,  loudness,  proximity  or  remote- 
ness, diffusion  and  continuance.  The  period  when  it  is  osoally  most 
abandsnt  and  loudest  is  early  in  the  disease,  prior  to  the  time  when 
the  physical  evidences  of  solidification,  more  or  less  complete,  are 
present;  thai  is  to  say,  during  the  first  stage.  During  this  stage, 
in  some  cases  it  exists  in  a  marked  degree,  occupying  the  whole  or 
the  greater  part  of  the  inspiratory  act,  in  other  instances  being 
comparatively  feeble,  and  beard  only  at  the  end  of  inspiration.  In 
some  case«,  even  during  this  stage,  it  is  not  discovered  in  ordinary 
respirations,  but  is  developed  by  forced  breathing,  and  especially  fay 
the  deep  inspirations  which  precede  and  follow  aoia  of  coughing. 
In  a  small  proportion  of  oases  the  methods  jast  named  fail  to 
elicit  it,  and  the  diagnosis  must  be  based  on  other  ugns.  It  may 
be  detected  in  many  cases,  for  a  greater  or  less  period,  after  the 
disease  has  advanced  to  the  second  stage.  It  is  then,  generally, 
confined  to  the  end  of  the  inspiratory  act,  and  much  more  friNju.-titly 
re([uircs  for  its  production  that  the  force  of  the  act  be  roluntarilT 


ACCTB    LOBAR    P!t RtTHOKITIS. 


377 


increased.  In  botli  stages  it  may  be  hearJ  at  iliflerent  situations 
over  the  affected  lobe  or  lobes,  or  it  mav  be  confined  to  a  few  pi>ints. 
It  is  much  more  api  to  be  diffused  in  ihe  first  stage,  this,  in  fact, 
Wing  verv  rarely  the  case  in  the  second  sta^.  Sometimes  it  seems 
to  arise  in  close  proximity  to  the  ear,  and  at  otber  times  it  appa- 
rently originates  at  a  distance.  It  may  be  appreciable  during  the 
whole  career  of  the  disease,  even  into  convalescence,  or  it  may  cease 
at  a  period  more  or  less  removed  from  this  epoch. 

Laennec  described  the  crepitant  rale  as  generally  disappearing  in 
the  progress  of  the  disease,  and  afterward  returning  during  the  pc> 
riod  of  resolution.  This  must  be  rnnked  among  the  instances  (sin- 
gularly few  in  number),  in  which  the  observations  of  the  founder  of 
auscultation  were  biassed  by  speculative  notions.  Moreover,  the  dis- 
tinctive trait*  of  the  true  crepitant  rale  were  not  fully  known  by 
Laennec,  and,  hence,  it  was  confounded  by  him  with  the  sub  crepi- 
tant.    The  observer  who  seeks  by  daily  explorations  dnring  the 

;  career  of  pneumonitis  to  verify  the  crepitant  rale  reduz,  will  often 
meet  with  disappointment.  The  crepitant  rale,  as  just  stated,  may 
oonlinne  through  the  whole  course  of  the  diseoiie.     It  may  disap- 

Ipear  and  reappear  at  irregular  intervals.  I  have  known  it  to  be- 
com«  more  marked  afYer  the  lapse  of  several  days  than  at  an  early 
period  in  the  diitcaiiv.     I  have  obtterved  it  to  become  developed  as 

\'\*U>  M  tlie  17th  day.  when  it  had  not  been  previously  discovered; 
l>ul  the  regular  occurrence  of  a  returning  crepitant  rale,  as  a  har- 
binger of  recovery,  cannot  with  propriety  be  said  to  belong  to  the 
natural  history  of  pneumonitis.  As  s  rule,  when  the  rale,  after 
continuing  for  a  greater  or  less  number  of  dnys,  di.tappears,  it  in 
not  reproduced,  except  as  the  sign  of  a  new  focus  of  inltnmitiiition. 
The  Bub-cropitant  rale — a  bronchial,  not  a  vesicular  rale,  convey- 
ing the  idea  of  small  but  unequal  bubbles,  wanting  the  cqunlity,  the 
dryness,  and  the  extreme  fineness  of  the  true  crepitant,  and  not  lim- 
ited to  the  inspiratory  act — may  occur  at  any  period  of  the  disease. 
Preient  on  both  aides  of  the  chest  eiirly,  and  diffused  especially  over 
the  posterior  base,  it  denotes  capillary  bronchitis.  The  crepitant  and 
the  sub-crepitant  rale  may  be  conibiiiud  and  distinguished  from  each 
other,  the  crepitant  appearing  at  the  end  of  the  inspiration,  and  the 
Bub-erepitanl  in  both  acts.  Exclonivs  nf  the  very  rare  instances  in 
irbich  pneumonitis  and  capillary  bronchitis  artr  asitoeiated,  the  sub- 

■  crepitant  rale  i»  more  likely  than  the  crepitant  to  occur  at  a  late 
period  in  the  diseaac,  during  the  progress  of  resolution.     Developed 


878 


filSBASBS   OF    TUB    KESPtRATOKT  OKOAXS. 


under  these  circuraotnncc*  it  i«,  in  fact,  the  rctuminf;  crepitant  rait 
of  Lscnncc.  The  true  crepitant  rale,  bowever,  does  occur  in  a  ext- 
l«tn  proportion  of  cn«c«  in  the  Uiird  Mage,  and  it  nay  be  combJtitil 
vith  the  stib-crepitant  in  this  stage. 

The  bronchial  rnle«,  other  than  the  f>itb> crepitant,  both  nioi«t  aoJ 
drj,  arc  liable  to  occur  in  casein  of  pncuntonitis.  These  rales,  if  dif- 
fused over  both  sides,  denote  (hat  the  pneumoaitJB  is  a  complieatton 
of  bronchitis,  which  is  rftrc ;  if  present  only  over  the  lobe  or  lohM 
nflV'oled  with  pneutiioDitis,  thej  denot«  bronchitis  limited  to  the  af- 
fected lobe  or  lobes;  and  the  existence  of  bronchitis,  thus  circmn- 
Hcribcd,  in  coses  of  pncutnonitis,  is  the  rule.  Clinical  obscrratioai 
»hojr  that  th^se  rules  are  far  from  being  common  in  cases  of  piwa- 
moniliR.  In  the  majoritj  of  cases,  examinations,  repeated  at  differ- 
ent periods,  do  not  show  their  exist«nce.  except  occasionally,  aitd 
transiently.  It  is  rare  for  them  to  be  prominent  in  cases  in  whki 
the  diseAsc  does  not  advance  beyond  the  second  stage.  In  the  third 
stuge,  the  moist  or  bubbling  rales  are  much  more  likely  to  occur  than 
in  the  two  preceding  stages. 

The  infrequcDcy  of  the  occurrence  of  the  bronchial  rales,  irre- 
spective of  the  sub-crepitani,  in  ordinary  cases  of  pneumonitis,  it 
ebown  by  the  following:  of  148  examinations  at  different  periwb 
in  forty-five  cases,  a  sibilant  rale  is  noted  in  seven,  «  sonoroos  ia 
six,  and  a  mucoua  in  three  instances. 

A  friolion-9ound  ia  sometiniea  discovered  in  auscultating  over  aa 
inflamed  lobe,  but  the  proportion  of  instances  in  which  this  siga 
occnrR  in  pneumonitio  is  small.  In  forty^five  cases,  out  of  149  ex* 
nminationn,  it  in  noted  in  five  examinations  made  in  three  cases. 

In  addition  to  advenlitioufl  Rounds,  the  vast  majority  of  caM*  of 
pneumonitis  arc  characteriRed  by  important  modifications  of  the  re- 
spiratory sounds.  The  modifications  oonstiluling  the  bronchial  and 
the  broncho- vesicular  re.*  pi  rati  an  are  very  rarely  wanting  in  the 
course  of  the  disease.  The  bronchial  respiration  fails  in  but  a  small 
proportion  of  instances.  Of  the  forty. five  eases  which  I  have  selected 
for  analysis,  commencing  vith  the  last  caM  reconled,  and  rejecting 
none  till  this  number  was  completed,  in  five  either  the  examinations 
were  beguu  t«o  late  in  the  disease,  or  tlte  records  are  imperfect  with 
respect  to  this  point.  Excluding  these  6ve  cases,  out  of  the  remaik. 
ing  forty  the  bronchial  respiration  was  more  or  less  marked  in  thirty- 
seven.  In  two  the  modification  did  not  exceed  that  constituting  the 
broncho-vesicular  respiration;  and  in  the  other  exceptional  case  the 


LOBAR 


S79 


patient  died  od  tbc  second  dny  in  the  stsg«  of  engorgement,  tbo 
disAHiic  boinj;  coinplieiLtcd  with  dilntntion  of  the  heart.  In  the  l&rgc 
collection  of  cu»c«  analyzed  by  Grisollc  (3731.  the  bronchial  respi* 
ration  was  obscrvci]  to  cciisi;  two  dnys  before  death  id  oqo,  and  vns 
not  dereloped  in  another  of  two  cases  m  which  the  inflammation 
extended  over  an  enlire  lung;  and  of  the  cii^eH  in  which  the  inflam- 
matioD  was  limited  to  a  tiingle  lobe,  it  was  wanting  in  nine.'  The 
absence  of  the  bronchial  respiration  In  certain  caaes  may  he  due  to 
the  diminution  or  arrest  of  the  respiratory  movements  on  the  nffccteil 
•ide.  This  aign  is  more  likely  to  be  absent  if  the  entire  lung  bo 
solidifipfl,  than  if  the  pneumonitis  be  limited  to  a  single  lobe;  and  in 
tliG  former  case,  the  movements  of  ihc  affected  i^ide  are  more  dimin- 
ished or  more  likely  to  be  arrested.  The  presence  of  liquid  effusion 
mav  Bccoant  for  its  absence  in  some  cases.     Obstruction   of  the 

0 

bronchial  lubes  is  probably  another  cause  of  its  absence  and  feeble- 
ness. 

The  bronchial  respiration  is  a  sign  of  complete  or  considerable 
solidification.  In  connection  with  percussion  it  affords  evidence  of 
the  disease  having  advanced  to  the  second  stiige.  It  denotes  the 
continnance  of  the  solidified  state  of  the  lung,  and  indicates  by  its 
gradual  disappearance  the  removal  of  the  solid  exudation.  As  re- 
gard.t  its  development,  it  occurs  much  earlier  in  some  cases  than  in 
others.  I  have  known  it  to  take  the  place  of  the  vesicular  murmur 
in  Ihc  spnee  of  eight  hours.  It  may  not  appear  (ill  the  second  or 
third  day  after  the  dntc  of  the  attack,  or  even  still  later.  In  a 
Tcry  large  proportion  of  hospital  caaea  it  is  found  when  patients 
first  coroe  under  observation.  If  we  have  an  opportauity  of  watch- 
ing its  development,  wc  may  observe  that  the  transition  from  the 
Twicular  murmur  is  not  abrupt,  but  takes  place  gradually,  the 
b ron eh o- vesicular  preceding  a  welUmarkod  bronchia!  respiration; 
that  is  to  say,  the  inspiratory  sound  loses  the  vesicular  quality  by 
degrees,  until  at  length  it  becomes  entirely  tubular.  In  some  in- 
stances the  presence  of  the  crepitant  rale  prevents  us  from  apprc- 
Mcting  a  woll-mitrked  alteration  affecting  the  inspiration,  until  the 
^Nind  bccomt^  distinctly  bronchial,  the  rale  then  either  ceasing, 
or  being  heard  only  at  the  end  of  the  act.  In  the  progress  of  the 
disease  the  bronchiiil  rcspimlion  attninK  its  maximum,  as  respects 
intensity  and  completenesif,  continues  without  much  diminution  or 


Op  oil. 


880 


DISEASES  OP    THE    RESPIRATORY   ORGAXS. 


•Itention  for  a  certain  poriwi,  and  gritiiiiully  becomes  ]ea»  inieaie 
UhI  cOraplvlc,  at  Icnglh  merging  into  tliv  bronclio-rctiicular  re:ipir»- 
tion. 

The  bronchial  respiration  in  acut«lo1)«r  pneumonitis  i9>,  in  genml, 
not  »  rnriahlc  or  fluctuating  sign.  As  a  rule,  nfior  it  is  ileii'vlope^ 
it  maj  be  iliscoTcriil  at  each  iiucce«»ivc  cxaminalion,  ontil,  in  tW 
progress  of  tho  disease,  it  declines  and  disappears.  There  nrv,  ho*. 
erer,  occasional  exceptions  to  this  rule.  I  hare  known  ittobt 
nbscot  and  ehortly  reappear,  its  temporary  cessation  being  perhapi 
dit«  to  caaoal  obstructioit  of  the  tubee.  Such  obstrvctioD  daring 
the  period  of  the  disease  when  the  bronchial  respiration  may  be  ex- 
pected to  be  present,  rarely  occurs  in  ordinary  cases  of  pnciiiaoDitis. 
During  the  progress  of  the  disease  in  40  cases,  the  bronchial  respira- 
tion existed  in  147  out  of  146  examinations  made  on  different  days. 
Of  the  remaining  89  casea,  in  7  there  was  absence  of  respiratory 
Mund,  and  in  33  the  modification  came  under  the  denomination  of 
broncho- vesicular.  Thexe  ennmeratioas  show  the  pcrsisiency  of 
this  sign  in  cases  of  pneumonitis. 

The  intensity  of  the  bronchial  respiration  and  other  of  it*  cbar> 
KCteri*,  vary  in  different  cases.  Generally  c«»e*  of  pncninooitM 
present,  for  a  greater  or  less  period,  all  the  vlcmenla  which  tbis 
physical  sign  in  its  completeness  embraces,  viz.,  a  tubular,  shortened, 
high-pitched  inspiration,  followed,  after  an  interval,  bj  an  expira- 
tion, prolonged,  more  intense,  and  higher  in  pilch  tlian  the  sound 
of  inspiration.  Of  -7  cases,  in  the  records  of  which  the  bronchial 
respiration  is  described  as  respects  the  presence  or  absence  of  these 
several  elements,  in  24  they  were  all  present  for  a  period  greater  or 
IcMH.  In  two  cases  a  tubular  inspiration  existed  without  any  sound 
of  expiration,  and  in  one  case  an  expiratory  soaod  existed  alone. 
Enumerating  the  successive  examinations  made  on  different  days  in 
these  *27  cuses,  and  the  result  is  as  follows :  Out  of  86  exuminattooa. 
in  6.5  all  the  elements-of  the  bronchial  respiration  wore  present.  Of 
the  rrmAining  31  examinations  a  tubular  inspiratory  sound,  withoat 
a  sound  of  expiration,  existed  in  11.  and  an  expiratory,  without  an 
inspiratory  sound,  in  10.  In  6  of  the  Utter  10  instances,  how- 
ever, the  inspiratory  sonnd  was  drowned  by  the  crepitant  rale. 

It  was  stated  by  Jackson,  and  it  is  repeated  by  Grisolle,  that  in 
the  development  of  the  bronchial  respiration  the  abnormal  modifica- 
tion is  first  manifested  by  a  prolonged  expiration.  The  earliest 
change  is,  to  say  the  least,  generally  more  obvious  in  expiration 


iOUTB   LODAH   PK81TM0XITI8. 


itSl 


I 

I 
I 

t 

I 


tli»n  In  inspimion.  Tho  foi-mer  frequently  is  not  only  prolonged, 
but  b«cotnes  intense  and  high  in  pitch,  nhile  the  latter  is  ooinpum- 
tively  feeble,  and  atill  retains  more  or  leiS  of  the  vesicular  ({iiiility — 
in  other  wordti,  is  hroncho-vesicutar.  It  is  ncrcr  the  ca«v,  that  in 
conneRlicin  nith  a  prolonged,  intense,  high-pitched  cxpirnlion,  the 
inspiriitory  sotiiul  ia  not  al  the  same  lime  more  or  \e«»  allrrcil, 
being  less  rcsloular  and  higher  in  pitch  than  on  the  opposite  side  of 
the  chest,  and  also  shortened  or  nnlini^hcd.  On  the  other  hand,  at 
a  later  period,  when  the  hronchiiil  is  about  to  merge  into  the 
broncho  ■vesicular  respiration,  the  change  is  frequently,  if  not  gene- 
rally, first  manifested  in  the  in^ptrntiou,  which  hccomett  weaker 
and  astumcs  more  and  more  the  vesicular  quality,  while  the  expira- 
tion remains  prolonged,  high-pitched,  and  relatively  moi-e  intense. 
At  a  still  later  period  the  expiratory  sonnd  may  disappear,  leaving 
the  inspiration,  still  less,  vesicular  and  higher  in  pitch  than  the  nor- 
mal marmar. 

The  transition  from  a  bronchial  to  a  broncho-vesicular  respira- 
tion, like  that  of  the  percussion-sound  from  marked  to  moderate  or 
alight  dulness,  is  gradual;  yet  in  the  one,  as  in  the  other  case, 
frequently  a  considerable  alteration  is  often  observed  to  take  place 
within  a  short  itpnco  of  time.  A  striking  diminution  in  inlcn- 
«ity  of  the  bronchial  respiration,  end  the  conversion  of  a  purely 
tnhalnr  to  a  vcsicuto-tuhular  inspiroticm,  are  BOmelimcs  observed  by 
comparing  the  examinations  of  two  successive  diiy«.  A  return  to 
the  normal  vesicular  murmur  is  nircly  complete  for  some  time  after 
convalescence  is  established.  Etcd  when  the  patient  is  sufficiently 
restored  to  he  out  of  dnors,  the  respiration  over  the  affected  lobe,  or 
lobe^may  continue  to  be  broncho-vesicular.  When  the  characters  of 
the  bronchial  and  tho  broncho-vesicular  rcspirtklion  have  disappeared, 
the  respiratory  sound  over  tlie  affected  lung  is  often  abnormally 
feeble,  being  sometimes  scarcely  appreciable  except  the  breathing 
be  forced;  and  for  a  time  the  vesicular  quality  of  the  inspiratory 
sound  is  notably  marked,  and  the  piti.'h  is  low.  Founict  stait-:*  that 
the  bronchial  respiration  is  apt  to  be  succeeded  in  tbu  affected  por- 
tion of  Inng  by  an  exaggerated  vesicular  murmur.  Judging  from 
the  case*  that  I  have  observed,  I  should  soy  (hat  the  rule  is  directly 
the  reverse.  With  respect  to  this  point,  the  following  are  the  ob. 
servations  of  GrisoUe:  Of  103  convalescents  discharged  from  hoB- 
pita),  between  the  twentieth  and  fifty-fifth  days  of  the  disease,  S7 


DISBABBS  or   TBK    RISPTS ATOBT  OtLQAHS. 


had  no  morbid  signs ;  in  S6  the  respiration  was  weak ;  in  14  iW 
retpir»tiftn  was  sligbtlv  Mowing;  and  in  \C>  Uicre  existed  mb-cttpi- 
tant  or  other  bronchial  ralsA. 

In  the  majority  of  canes  of  pneumonitis,  the  diseavc  being  limited 
to  the  lower  lobe  of  one  lung,  (he  abnormal  modifications  of  the 
re^iratorj  sounds,  as  well  as  other  physical  phenomena,  are  to  he 
sought  for  cftpectnlly  on  the  posterior  surface  of  the  chest  belov  the 
spinous  ridge  of  the  Hcitpulit.  They  arc  ■!«>  manifested  on  the 
latcnil  surface  below  a  diagonal  line  corresponding  to  the  interlobar 
fissure.  Anteriorly  the  bronchial  respiration,  and  al^o  the  crepitant 
rale,  may  be  discovered  at  [h<'  basic  of  the  chest,  but  it  not  infre- 
quently happens  that  over  the  soiall  portion  of  the  lower  lobe  which 
cxtend.t  In  front,  auscultation  fails  to  detect  any  morbid  pheoomeaL 
Tostcriorly  and  laterally,  if  the  stethoscope  he  employed  by  passing 
the  instrument  over  successive  portions  of  the  chest,  from  above 
downward,  the  change  from  the  vehicular  murmur  to  the  bronchial 
respiration  is  found  to  be  abrupt,  not  gradual.  If  the  line  indica- 
ting the  situation  of  the  interlobar  fissure  have  been  already  traced 
by  the  change  in  the  percuss!  on -sound,  the  transition  from  the 
vesicular  murmur  to  the  bronchial  respiration  will  be  found  to  take 
place  on  the  same  line.  The  limits  vf  solidifieatton  may  thus  be 
defined  by  auscultation  as  well  ns  by  percussion,  and  it  is  in  some 
cases  easier  to  trace  the  boundaries  by  means  of  the  former  than  by 
the  latter  method.  On  the  back,  the  characters  of  the  bronchial 
respiration  arc  shown  in  striking  contrast  by  auscultating  alternately 
above  and  below  the  spinous  ridge  of  the  scapula. 

If  the  whole  lung  bocomc  affected,  the  different  lobes  being 
attacked  in  succession,  the  bronchial  ntspiraiion  will  present  differ- 
ences as  respects  intensity,  and  other  characters,  in  different  situa- 
tions. On  the  right  side  in  front,  I  have  observed  a  striking  dis- 
parity, in  pitch  and  other  points,  over  the  upper,  middle,  and  lower 
lobes,  the  pitch  and  intensity  diminishing  from  above  downward  in 
these  three  situations.  The  same  disparity  I  have  also  observed 
over  different  points  within  the  boundaries  of  the  same  lobe.  In  ac- 
cordance with  the  fact  that  when  an  entire  lung  is  affected,  even  if 
the  upper  lobe  be  invaded  secondarily,  resolution  takes  place  first 
in  this  lobe,  the  bronchial  rcspirnlion  will  be  found  to  continue 
longer  posteriorly  below  the  spinous  ridge  of  the  scapula,  than  over 
the  upper  and  the  middle  third  in  front.  It  will  be  found  frequently, 


ACVTE   LOBAR    PXECMOSITI*. 


S8S 


N 
^ 


I 


)f  not  generally,  to  continue  longer  in  the  lower  scapular,  than  in 
the  infra  scapiiliir  region;  but  this  is  probably  owing  to  the  prox- 
jntitj,  in  the  former  region,  to  the  larger  bronchial  tnbes. 

The  bronchial  rvitpirntion,  if  intense,  may  he  beard  at  some  dia- 
tancc  beyond  the  vitiintton  of  the  oolidified  portion  of  Inng.  Thus, 
vhen  the  lower  lobe  of  one  lung  li  aolidilied,  the  sound  may  be 
hcanl  beyond  the  spinal  column  on  the  oppottite  side ;  or  the  sound 
may  be  hesrd  above  and  below  the  aReoted  lobe  on  the  affected  side. 
The  expiratory  »ound,  being  more  intense,  is  propagated  further 
than  the  inspiratory  sound.  Somctiinvs  over  healthy  lung,  situated 
neftr  a  solidified  portion  of  lung,  »  normal  vcsienlar  inspiratory 
sound  19  followed  by  a  bronchiiil  expiratory  sound:  the  former 
emanating  from  the  liealthy  luug,  nnd  the  latter  propagated  from 
the  solidified  portion. 

Over  tho  unaffected  side,  in  cases  of  pneumonitis,  ibe  respiratory 
murmur  is  frequently  int(<ni>e,  and  the  voMicular  quality  highly 
marked,  in  short,  exaggerated.  If  the  affection  be  limited  to  a  lobe, 
according  to  Fournet,  the  respiratory  sound  over  the  unaffected 
lobe  is  eren  more  exaggerated  than  on  the  opposite  side  on  the 
chest.  So  far  as  my  experience  goes,  the  reverse  of  this  is  nearer 
the  truth.  The  murmur  over  the  upper  lobe  on  the  affected  side, is 
sometimes  extremely  feeble,  almost  null,  eo  that  conjoined  with  a 
Tesieulo-tympanitic  resonance  or  percusHion,  the  physical  evidences 
of  emphysema  are  present.'  I  have,  however,  observed  an  exagge- 
rated respiration  in  the  upper  lobe  when  the  lower  was  soHdified,  the 
intensity  being  notably  greater  thau  over  the  upper  lobe  in  the 
unaffected  side. 

Auscultation  furnishes  important  v<>cal  pkgTwmena  in  poenmonitis. 
In  the  second  stage,  over  tlic  solidified  lung,  bronchophony  occurs  in 
B  Tory  large  proportion  of  cases.  Of  27  coses  in  the  histories  <^ 
which  is  noted  cither  the  presence  or  absence  of  this  sign,  it  was 
observed  in  26,  and  not  discovered  in  two.  By  bronchophony,  it 
will  be  borne  in  mind,  I  do  not  mean  exaggerated  vocal  resonance, 
but  a  greater  or  lc»»  apparent  approach  of  the  voice  to  the  ear  of 
the  aui<eultator,  and  the  pitch  notably  raised.  In  many  oases,  this 
iDcreased  proximity  of  the  voice  is  accompanied   by  an  abnormal 

>  la  Pari  I,  1  have  tiiggeatod  tbnt  an  omphymmatouii  condition  accoanu 
for  the  T<ai«ulo-l7iiipanitic  rcionftnca  vbich  to  ttfquiiat\j  exiata  over  tho  upper 
loba  wbon  tli«  low«r  U  «t>ll()illo(L 


884 


DI8BASBS   OF   THE    RRSPIRATOBT   OIIOAX6. 


inU'Dsitj  of  reson&Dce,  but  not  invariibly.  TLe  voice  soaMduM 
M!eRi»  vrr;  near  tbe  ear,  and  Ute  piuh  is  notably  raised,  when  ibt 
rctKitiniice  U  but  tittle  exaggerated.  An  increased  ribratioD  or 
tbrill  i»  iiomctimes  fell  l>j  tbe  ear  applied  eitlicr  directlj  to  tbe  cbcsl, 
or  to  tbe  Hlethoscope ;  but  broncbopbony  not  infreiiaentlj  exiui 
witboui  increase  of  fremituji,  and  ibe  latter  may  be  le«&  tttan  in 
heallb.  The  broncbopbony  in  difTercnt  caacft  of  pneumonitia  b 
variable  in  degree.  Tbe  voeal  found  appears  in  »oine  inttancea  M 
emanate  directly  beneath  the  car  or  »lctbo!'cope,  and  betiiMD  t]iif 
Diaxiinum  and  a  8ligbt  bronohophonic  alteration,  every  gradttioa 
nay  be  obHervcd  in  difTerciit  caflM,  aitd  in  a  series  of  sacc««stTc  u- 
aminaiions  in  the  siame  cane.  When  the  bronchophony  t»  aecos- 
paiiied  by  a  notably  intense  resonance  the  vocal  oound  in  eoinc  ia- 
eiaiicos  appears  to  strike  the  ear  with  forci*,  giving  rise  to  a  utM 
of  c«iicus»iun  or  shock  like  that  fell  when  auscoltation  of  the  voice 
IS  practised  over  the  trachea.  The  pitch  of  the  vocal  M>und  in  lamt 
inittnuL-cs  is  Dotably  high,  exceeding  that  of  the  tracheal  voice. 
Other  things  being  «(|ual,  the  maximum  of  tbe  degree  of  cotnplelt- 
ncs8  to  which  bronchuphony  atlaina,  in  the  progress  of  pneumonJIu, 
denotes  the  grcalu«t  »moiiiit  of  solidification.  It  coexist*,  therefore, 
ftith  the  grciitost  losi  of  vehicular  rcHonaoce  on  pcroiueion,  and  with 
the  mnximum  of  intensity  of  the  bronchial  recpiration.  As  the  dis- 
ease pursues  its  course,  this  vocal  sign  reaches  its  maximum  by 
degrees,  and  gradually  become*  wcnVer  as  the  solidification  de- 
creases in  the  progress  of  resolution,  tn  this  retrograde  course, 
when  bronchophony  and  exaggerated  resonance  are  ojuociated,  the 
former  disappears  first,  tbe  tatter  continuing  to  be  more  or  len 
marked  for  a  period  varying  considerably  in  difierent  cases.  With 
respect  to  the  vocal,  as  wcU  as  the  respiratory  signs  indicative  of 
solid  ill  cation,  often  a  marked  diminution  is  observed  to  occur  within 
a  short  space  of  time,  and  occasionally  they  disappear  rather  ab- 
ruptly. 

The  dnration  of  the  vocal  signs  in  different  cases  of  pneamonittt 
ia  variable.  Of  8S  examinations,  made  on  different  days  iu  27  ca5«s, 
bronchophony  existed  in  61  and  was  absent  in  27.  Tbe  examinalions 
in  which  it  was  absent  were  mostly  made  during  the  Utter  part  of  the 
disease,  the  sign  having  probably  existed,  but  disappeared.  When, 
however,  it  is  once  developed,  it  is  a  persisteDt  sign  until  it  disap- 
pears as  the  consequence  of  the  progress  in  resolution ;  that  is,  it  it 


ACOTB   LOBAR    rSBrMOSITIfl. 


885 


\ 


I 


I 


gcncroUy  found  at  nich  successive  examinstioit.  Tliis  siatcmvnt  is 
in  opposition  to  the  opinion  of  Skoda,  who  maintains  (h»t  thv  bron- 
chophonic  voice  is  constantljr  fluctuating,  sometimes  even  appearing 
and  disappearing  in  the  course  of  a  few  moments.  An  nnal  v«is  of 
ft  series  of  recorded  examinations  shows  this  opinion  to  be  incorrect. 
Of  the  88  examinations,  in  £7  cases,  just  referred  to,  in  hut  two  in- 
stances was  the  sign  absent  when  its  existence  was  noted  nt  the  ex- 
amination preceding,  and  at  that  succeeding  the  one  on  which  it 
was  found  to  be  wanting. 

Bronchophony  in  tlie  fianne  case,  at  the  same  moment,  is  Ly  no 
means  equal,  as  regards  intensity,  at  different  points  over  the  af- 
fected lobe  or  lobes.  Its  greatest  intent^ity  is  in  cases  in  which  the 
upper  lobe  is  affected,  over  the  portion  of  the  aiiromit  of  the  clicst, 
in  front,  situated  nearewt  to  the  largest  hronohial  divisions.  Poste- 
riorly, when  the  li>w*'r  loV-  i:«  affected,  it  is  geniTally  more  marked  in 
the  lower  sctpulnr  than  in  the  infra-scapular  region.  VVelUraarked 
bronchophony  may  exist  over  the  larger  bronchial  tnbe»,  whilo  at  a 
litile  diclance  from  them  the  vocal  resonance  is  simply  exaggerated. 
It  is  not  uncommon  to  find  bronchophony  over  the  scapula,  aod  ex- 
•^erated  resonance  below  the  sctipula. 

By  means  of  nn  abrupt  change  in  the  vocal  sound,  limiting  by 
the  use  of  the  stethoscope  the  space  from  which  the  «tound  i»  re- 
ceived, the  interlobar  fissure,  in  cases  of  pneumonitis  affecting  a 
single  lobe,  may  be  often  traced  on  the  chest  as  well  as  by  the  per- 
cossion  and  the  respiratory  sound,  in  the  manner  already  described ; 
and  when  this  has  been  done  by  means  of  the  latter,  the  ausculta- 
tion of  the  voice  furnishes  another  method  of  verification. 

The  transmission  of  the  articulated  voice,  or  speech,  that  is,  pec- 
toriloquy, is  a  physical  sign  occasionally  observed  in  cases  of  solidi- 
fication from  pneumonitis.  In  2  of  27  cases  words  (numeral?)  >ipokea 
aloud  were  transmitted.  In  2  other  cases  whispering  pectoriloquy 
was  complete,  and  in  several  instances  whispered  word.*  were  imper- 
fectly transmitted.  Contrary  to  the  opinion  of  Walshc,  who  regards 
whispering  )teet«rilo<)uy  as  eminently  distinctire  of  a  cuvlty,  I  have 
found  it  oftener  present  in  connection  with  solidification  than  the 
transmission  of  words  spoken  aloud. 

As  stated  in  the  first  pari  of  this  work,  pectoriloquy,  both  with 
the  loud  and  whispered  voice,  wheu  due  to  solidiBoaciun  of  lung, 
liresents  features  which  distinguish  it  from  cavernous  pectoriloquy. 

36 


SI8BASBS  or    THK    RSSPTSATORT  OROAKS. 


The  di»tinctiTcfeulare»  are  those  which  belong  to  bronchophony  wMi 
the  loud  and  the  vrhUpcred  voice.'  In  pneumooitis,  pectoriloquT,  if 
present,  is  incident  to  bronchophony. 

Whispering  bronchophony  and  the  exaggerated  bronchial  wbisptr 
&re  vocal  signs  which  claim  the  attention  of  the  anscnltator.*  Ii 
pneumonitis,  and  other  affections  involving  solidification,  r.  g.,  tu- 
berculosis, thcj  constitate  valuable  physical  iiignt>,  their  signiftcaace 
boing  the  same  as  bronchophony,  exaggerated  vocal  resonance,  and 
the  bronchial  respiration.  They  are  valuable,  not  only  as  confima- 
tory  of  the  fact  of  solidification,  associated  with  the  xigtts  jut 
named,  but  still  more  because  they  may  be  prvit^nt  in  ftome  insiaaca 
in  nhicb  tbos«  signs  are  vanting. 

In  some  cases  of  pDeumouitis,  it  is  stated,  the  Toic«  in  patting 
through  the  chest  acquires  the  tegoplionic  character^  via.,  trenn- 
lousness,  with  acalcncss  of  pitch.  Some  observers,  indeed,  have 
discovered  strongly  marked  legophony  in  pneumonitis;  and  it  b 
claimed  that  this  vocal  sign  may  occur  in  coses  in  which  there  is  no 
pleuritic  effusion.  The  latter  point  it  is  dilficnlt  lo  establish,  since 
if,  in  fatal  cases,  no  liquid  be  found  after  death,  it  may  have  existed 
dnriog  life  and  been  absorbed. 

Inspection  of  the  chtrst  discloses,  in  a  certain  proportion  of  cases 
of  pncumoiiiiis,  abnormal  appearances  deserving  attention.  Coinci- 
dent with  tbe  Atlaclc,  the  movcmenia  of  the  afiecled  side  may  be 
visibly  restrained,  attribatuhip,  at  this  stage,  to  the  pleuritic  pain 
which  is  generally  present  in  the  early  part  of  the  disease.  At  a 
later  period,  during  tbe  second  stage,  if  a  single  lobe  be  affected,  a 
disparity  in  expansion-movement  at  the  inferior  portion  of  tbe  chest 
is  sometimes  obvious,  mid  in  other  instances  not  apparent.  If  the 
entire  lung  become  alTected,  a  disparity  it  frequently  marked.  It  is 
more  marked  if  the  breathing  be  labored,  or  voluntarily  forced- 
Under  these  circumstnnees,  the  three  types  of  breathing  may  be 
conspicuous  on  the  unnHcctcd  side,  while  tbey  are  but  fc«bty 
manifetied  on  the  side  diseased.  The  deficient  expansion  of  the 
aflfected  side  when  pain  has  ceased  to  be  a  prominent  symptnm,  in 
other  words,  in  the  second  stage,  is  attributable  lo  the  uiigmenied 
tise  of  the  lung,  and  the  loss  of  its  contractility.  The  tide,  in  fact, 
is  in  a  measure  dilated  permanently,  and  the  incompressibility  of  ibe 
solidified  lung  prevents  its  conlraotioa  to  the  same  exirat  u  in 


fule  page  24i. 


•  V^iJ«  put  1,  {>•(•  MOi 


ACVTB    LOBAR    I'M BUKOKITIS. 


387 


health.  The  diaparitj,  under  these  circumstances,  is  incrcacod  by  the 
Iu-*Uliy  side  Inking  on  a  h  apple  me  ntarv  activity.  This  etntement  ia 
ill  oppojiilioii  to  llio  opinion  of  (irisolle,  who,  exclusive  of  instaucea 
in  which  the  movemCTitd  arc  restrained  by  excensive  pain,  does  not 
admit  m  dii«purity  belvrccn  the  two  sides  in  this  respect. 

Tho  intercostal  dcpresoions  are  not  lost,  except  in  certain  cases 
chaniutcrizcd  by  the  presence  of  liquid  t-fTusinn. 

Aficr  the  stage  of  resolution,  raore  or  less  contraction  of  the  chest 
tuny  be  evident  on  inspection.  It  has  been  doubted  by  high 
authority'  irbethcr  this  ever  occurs  except  as  the  eequel  of  pleuritic 
effusion  which  coexisted  with  pneomonii;  solidification.  On  this  point 
my  own  obaerrations  lead  me  to  accord  with  the  opinion  of  Stokes 
and  Wnlshe,  which  refers  the  contraction  sucecciling  pncunioniti*  in 
certain  cases,  to  the  diminished  hulk  of  the  affected  portion  of  the 
lung  in  consequence  of  the  removal  of  the  solidifying  deposit,  and 
the  contraction  of  the  fibrinous  exudation  on  the  surface. 

With  regard  to  mensuration,  my  recorded  observations  do  not 
fnnii«h  suificienl  data  to  serve  as  the  basid  of  any  concluntone. 
WaUhc  stdtcs  that  in  a  minority  of  eases  he  bus  found  positive, 
tliough  slight,  increase  of  site  at  the  base  of  the  chest  on  the  af- 
fected side  io  the  second  iftsgo  of  the  disease.  The  occurrence  of 
contraction  of  the  affected  side  after  recovery  is  indubitable.  The 
only  qncHtion  relates  to  the  pre-cxisteuco  of  liquid  effusion  in  all 
Buch  cases. 

Finally,  palpation  furnishes  physical  phenomena  in  different  ca«eA 
of  pneumonitis  somewhat  contradictory.  As  a  rule,  the  vocal  frem- 
itus is  increased,  in  the  second  stage  of  the  disease,  over  the  solidi* 
fied  lung.  But  the  exceptions  to  this  rule  are  not  very  infrequent. 
In  some  of  the  exceptional  instances  no  disparity  as  respects  this 
sign  is  apprecinble  on  comparing  the  two  sides  of  the  chest.  In 
other  instances  the  fremitus  is  greater  on  the  unaffected  side.  If 
the  loft  long  be  the  seat  of  the  disease,  the  explanation  may  be  that 
the  fremitus  over  the  solidified  lung  is  not  increased,  as  it  is  nor- 
mally more  marked  on  the  right  than  on  the  left  side.  Bnt  I  hsve 
observed  the  fremitus  to  be  greater  on  the  left  side,  when  the  pneu- 
monitis was  oeated  on  the  right  lung.  This  shows  that  an  effect 
of  solidification,  under  certain  circumstances,  is  a  diminution  of  the 


Woillcx,  Groolle. 


888 


DI88A8KS    OF   THB    RBSPIR^TORT    OBOA^tS. 


natural  fremitua.     The  abBenco  of  fremitas,  or  its  dhniltiilioa,  mv 
be  accounted  for  in  some  oaaee  by  the  presence  oF  liquid  effusioa. 


f>utt/n&$it. — The  space  which  has  been  devot^  to  the  coosiden- 
tiuii  of  tilt;  pliytiicul  »\gn»  bt-lunginf;  to  pneiiinflniti»  may  lead  Hit 
rcadtT  not  practically  conrersunt  with  the  subject  to  suppose  that 
the  diitgnosi;*  involves  greater  difficaltin  than  actually  exist.  The 
truth  i»,  with  n  knuwlcdgo  of  the  ncmciologtcal  phenomena  of  (he 
disease,  and  an  acijunintuncc  with  the  diognoMtic  fealurc*  of  uther 
aficctiona  presenting  hoidc  characters  in  common,  it  ii*  recognizt4 
viih  protnptncH  and  positivenoss  in  the  great  loajority  of  coms. 

If  a  person  be  seised  with  a  chill,  which  itt  followed  by  high  febrit* 
movement  and  lancinating  pain  in  the  chest  referred  to  the  neigh- 
borhood of  the  nipple,  accompanied  by  cough  with  an  adhesive, 
rnstv  expectoration,  and  a  well-marked  crepitant  rale  be  found  on 
auscultating  the  posterior  surface  of  the  chest  on  one  side,  it  is  at 
once  evident  that  be  is  attacked  with  pneumonitis  seated  in  on  in- 
ferior lobe.  This  group  of  diagnostic  phenomena  is  presented  in  • 
pretty  large  share  of  the  cases  of  simple  acute  pneamonitis  at  tlie 
time  when  they  first  come  under  the  obs«^^'atioD  of  the  medical 
practitioner.  Of  these  phenomena  the  characteristic  expecIoraiioB 
and  the  crepitant  rale  may  be  said  to  he  pathognomonic.  A  r'tsai 
expectoration,  containing  a  variable  qnantitv  of  blood  in  inliisate 
combination,  is  a  symptom  belonging  exclusively  to  inflaiRmation  of 
the  pulmonary  parenchyma.  If  this  statement  be  not  correct  is 
the  most  rigorous  sense,  it  may  at  all  ercnta  be  prKclieally  m  re- 
garded.' tio  wiih  regard  to  the  crepitant  rale,  if  we  are  sure  of 
its  presence,  that  is,  if  the  charuetcrs  which  distinguish  it  from  other 
rales  are  clearly  made  out,  and  it  occur  in  the  situation  and  in  cob- 
neclion  with  the  symptoms  just  mentioned,  it  affords  positive  pnwf 
of  the  existence  of  pneumonitis.  It  is  only  when  more  or  less  of 
the  distinctive  features  of  the  disease  are  obscure  or  wanting,  that 
there  is  room  for  delay  and  doubt,  as  regards  the  diagnons. 

>  According  to  lh»  olxn-TBtionii  of  Ur.  KnoBk,  of  Bcitin,  if  tb«  tpata  ttvm  ■ 
[■attmt  ■fl'cicud  with  pncumonilii,  a(\rr  baviag  Imcb  macoralcd  for  lom*  Uni#  In 
wHtiT,  W  pUcvd  on  ilftrk-culorMl  glaw,  and  anfUIIf  examined,  micut*  Bbriiunu 
ConcTDtiotii  may  be  ditcovcred,  wbich  >n>  probaUy  t*»t»  mosldifd  la  tlw  utnalr 
liroDcbial  rtiuiillraliuii*.  Ur.  R«iiuilc  lUMerdcil  in  diieovariDg  Obrlnviu  caala  iB 
M  fucMBUTo  ca*«,  bcttriicn  llic  third  and  Mvootb  daj*  if  the  diicwc  Oihst 
»l>MrT«n  have  not  met  with  rqual  »uucaH.  Ptif  ArL  !>}'  l>r.  Da  L'otta,  Aiu. 
Jour,  of  M«d.  ScieneM.  Oct.  1865. 


ACOTB  LOBAR    PNBUUOXITIS. 


889 


I 


The  gronp  of  ph«nomona  charnctcrixitig  tlie  neccss  of  pacumonitis 
is  sometimes  incomplete  during  tlic  tlcvclopinciit  of  tlic  diwjaisc,  vfliilo 
tlie  irifliimniatioD  i.s  coiiGiit'd  lo  il  limited  space,  porhapH  ccDlrnllj 
situated,  nnd  grudunlly  extcniliug  over  tbc  lobe.  Under  these  cJr- 
camslanccK  the  rustj'  cxpecturution  may  bo  present,  indicating  the 
nature  of  the  alTcction  before  any  positive  physical  evidence  ia  dis- 
eoTcrablc.  In  a  esse  in  which  the  symptotiiB  denote  some  acute 
pulmonary  disease,  if  the  characteristic  expectoration  be  obserTcd, 
physical  exploration,  although  at  lirst  negative,  may  be  expected 
Boon  to  famish  the  signs  of  pneumonitis,  and  should  therefore  be 
often  repented.  In  such  a  case,  should  the  respiratory  murmur  or 
one  side  be  found  abnormally  feeble  or  exaggerated,  or  if  the  sound 
be  somewhat  changed,  presenting  the  characters  of  the  broncho* 
ve»iculnr  modificHtion,  these  physical  phenomena,  although  not  in- 
irinsicully  stguiGcant  of  pucumonilis,  taken  in  connection  with  the 
■ssociotcd  circumstanccsi,  render  it  probable  that  inflammation  ex- 
101*.  but  as  yet  confined  to  a  portion  of  the  lobe.  On  repeating  the 
vxaminations,  a  crepitant  rale  may  be  at  length  satisfactorily  made 
out.  and  the  fact  of  pneumonic  inflammation  is  then  establinhcd. 

The  characteristic  expectoration,  however,  is  by  no  means  uui* 
formly  present  in  eases  of  pneumonitis,  and  if  not  altogether  nb- 
eent,  it  is  not  always  iim'mg  tlir  earlici^l  symptoms  of  the  disease. 
Under  these  oircuiastanccff,  if  tbc  pathugnomontc  sign,  vis,,  the 
tOrepitant  rale,  he  discovered,  the  diagnosis  is  promptly  made.  But 
rjtirill  soraetimea  happen  that  boih  these  oharaeU'rintics  are  absent: 
B  tittle  delay  is  then  r«4uisite,  until  the  symptoms  and  signs  iaci- 
dent  to  the  second  stage  of  the  disease  become  developed.  This 
delay  is  much  oftener  rcc^uUiie  in  cases  of  pncumonitt.H  nfFceiiiig 
children.  In  children  the  expectoration  is  generally  swallowed,  and 
hence  its  diagnostic  ciiaracters  are  unavailable.  The  crepitant  rale 
is  also  frequently  wanting.  .Adding  to  the»e  circumstances  the  dif- 
ficulty frc(]uenlly  experienced  iu  innking  a  sntisfnctory  exploration 
of  the  chest,  owing  to  their  timidity  or  restlessness,  the  means  of 
determining  positively  the  character  of  the  disease  are  often  insuffi- 
cient until  the  signs  of  solidification  are  apparent. 

Pneumonitis,  as  has  been  seen,  in  general  runs  rapidly  into  the 
second  stage.  In  this  stage  new  diagnostic  features  arc  added.  The 
rusty  expectoration  and  crepitant  rale  may  continue,  but  generally 
they  become  less  marked.  The  added  symptoms  and  signs  pertain 
chiefly  to  the  solidified  condition   of  the  lung.     The  function  of 


890 


DISEASES  OF  TBI!  RBSPIRATORT  OROAXS. 


hicinatosis  being  cotnpromiscd  in  a  greater  degree,  the  respintiom 
are  accelerated,  eaterU  parHiu»,  in  pro|>ortion  to  the  coii>plet4*t>ew  of 
the  solidificaiioD  and  the  extent  of  the  pnlmouary  organs  inrolveil. 
The  alie  nasi  dilate,  and  there  may  be  liridily  of  llio  prolahta  and 
the  face.  The  cheeks  often  prc«ent  a  circumwjribeiJ  fliwh.  The  ac- 
ecleralion  of  the  bronihiiig  \»  out  of  proportion  to  the  fr<'quencT  of 
the  pulse.  Tlic  physical  evidence*  of  volidificntton  are  easily  ascer- 
tained. On  percii»«ion,  the  elie»t  over  the  inflamed  lobe  a  found  to 
be  notablj  dull,  with  a  miirked  increawe  of  the  sense  of  resistanee 
and  diminished  cliiMticity.  In  the  majority  of  rasea,  as  has  been 
repealed  more  than  oiioe,  a  single  lobe  only  is  infiamed,  and  this  b 
the  lower  lobe.  It  is  important  for  the  student  to  reeollect  the  rela- 
tions of  the  inferior  lobe  to  the  anterior  and  to  the  |>oHterior  edt- 
face  of  the  chest.  So  small  a  portion  extends  in  front,  that  id 
many,  if  not  most  instances  physical  examination  anteriorly  i--'  com- 
paratively unimportant.  The  signs  emanating  from  ihe  aflectrd 
lobe  are  to  be  sought  after  behind,  below  the  spinous  ridge  of  the 
scapula.  The  interlobar  fissure  crosses  the  lateral  earfiiee  of  tbe 
chest  obliquely,  and  its  sitnation  is  generally  detenninablc  by  tlic 
abrupt  change  in  the  percussion-ROnnd.  The  fact  of  «  line  Uldic*^ 
ing  the  limiia  i^if  duliicHs  on  the  lateral  surface  of  the  che«t,  corre- 
upoiuling  in  direction  with  the  interlobar  fissure,  and  not  varying 
with  the  position  of  the  pulieni,  ia  a  diagnostic  feature  in  itself  al- 
most conclusive.  Asauming  the  inferior  lobe  to  be  the  seal  of  solid- 
ification, ill  the  lower  scapular  and  the  infra- scapular  region,  and 
lut(.Tally  below  the  lino  of  the  interlobar  fissure,  more  or  less  of  the 
cbaracturs  embraced  in  tbe  brontrbial  respiration  arc  present  in  the 
vast  miijority  of  cases.  Either  bronchophony  or  exaggerated  vocal 
resononoe  is  present  al»o,  with  few  exceptions;  also  the  corit- 
aponding  signs  produced  by  whispered  wordti.  If  the  npper  lobe  be 
primarily  the  seat  of  the  iiifliimuiatioii,  the  physical  phenomena  will, 
of  course,  be  mniiifeslcd  wltiiin  its  liniiis,  via.,  in  front  abore  tbe 
fourth  rib,  behind  iu  the  upper  scapular  region,  and  laterally  above 
the  interlobar  fissure.  The  occurrence  of  highly  marked  tympanitic 
percussion-resonance  over  solidified  lung,  espr<cially  anteriorly  when 
the  superior  lobe  ia  afiectod,  is  a  point  not  to  be  forgotten.  It  is 
superfluous  to  add  that  if  the  inBammation  extend  beyond  the  lobe 
primarily  attacked,  an  event  liable  to  occur  at  a  period  more  or  less 
remote  from  the  date  of  the  attack,  the  local  phenomena  will  be  re- 
produced over  the  lobe  or  lobos  successively  affcctct). 

Of  the  signs  which  enter  into  tbe  physical  diagnosis  of  pncumonitia 


ACUTE  LOBAR   PNEUMONITIS. 


391 


I 


advanced  to  the  second  stage,  excepting  the  crcpitiirit  rale,  none  are 
pvculiar  to  tliis  iliacase.  Dulness  on  perciiBsion.  the  broiichinl  rpspi- 
ration,  brono!ift[ilion  v,  exaggerated  vocal  resonance,  the  wUiiipcring 
signs,  and  incrensed  freinituH,  may  all  be  fotind  in  connection  vrilh 
other  ufTectionH  involving  pulmonary  solidification.  The  situation 
and  limitation  of  the  poniont)  of  the  chest  in  nbich  the  signs  arc  oV 
scrTCt),  together  with  the  antecedent  and  concomitant  symptoms, 
auffiec  for  the  discrimination  of  the  soliditication  which  anscii  from 
lobar  pneumonitis.  But  ihe.circiiraHtances  involved  in  the  differentinl 
diagnotfis  vill  be  noticed  pre-^ently. 

The  sign*  by  nliioh  the  progress  of  the  disense  from  the  first  to 
the  iscconil  «t»gc  is  attcertaimHl,  have  been  alreudy  sufficiently  con* 
Bidercd.  It  remuing  to  devuto  a  few  remarks  to  the  diitgnostio 
characters  which  belong  to  the  third  or  purulent  stage.  The  trans- 
ition to  this  stage,  in  the  rare  inntnnccs  in  which  it  occurs,  is  not, 
like  that  of  the  first  to  the  second  »tage.  signalized  by  the  devclop- 
inenl  of  a  new  series  of  striking  physical  phenomena.  The  signs  of 
solidification  conlinuo,  and,  in  fact,  there  are  no  criteria  by  which 
the  occurrence  of  the  third  stage  may  bo  in  nil  instances  positively 
I  uoertaiDod.  The  existence  of  this  stage  is  to  be  inferred  after  a 
protracted  dnralion  of  the  disease,  when  the  evideneeii  of  resolution 
of  the  disease  fail  to  occur,  and  the  symptoms  denote  an  unfavorable 
termination,  not  directly  in  consequence  of  the  extent  to  which 
hicmatosis  is  compromised,  but  as  the  result  of  asthenia  and  apnoea 
combined.  A  symptom  which  has  a  positive  hearing  on  this  ques- 
tion IB  an  abundant  pnriform  expectoration,  sometimes  taking  place 
rapidly  like  the  discharge  from  a  ruptured  abscess,  and  occasionally 
emitting  a  fetid  odor.  I'iiyaical  evidence  \i  afforded  by  abundant 
moist  bronchial  rales,  at  a  late  period,  not  having  been  preceded  by 
general  broiiohiiis  coexisting  with  the  pnettmonitis,  the  dulnes*  on 
percussion  remaining  undiiniuiNhcd,  the  bronchial  respiration  and 
voice  becoming  less  marked,  these  circumstances  being  taken  in 
connection  wilh  symptoms  denoting  a  fatal  tendency,  vis.,  pros- 
tration, frequency  and  feebleness  of  the  pulse,  delirinm,  etc. 

The  formation  of  abscesses,  and  their  evacuation  into  the  bronchial 
tvbe«,  leaving  cavities,  are  among  the  ooca«ioDal  events  incidental 
lo  the  progress  of  this  discAse.'     Do  excavations  thus  formed  give 


'  Of  ToOcit"-!  tri-sU"]  inilii'  tlotpitnl  of  Vionnft,  from  ISii  Wi  1 860, pulmonary 
■JwcaM  wai  obtcrvcd  in  but  b  tiaglo  injtuinca. 


892 


DtSSASBS  OP  THE   RESPIRATOBT  0R0AS3. 


riM  to  distinctive  signs,  viz.,  the  cav^rnouA  reiipiration  and  T«i«e, 
and  tjmpiinilic  rcsonauce  on  pi.'rcus9ion,  with,  in  tome  iiisiancti, 
tlio  crHckcd-mi-lal  iDtonation  ?  My  own  observations  do  not  mpplj 
facta  beariog  on  this  (|Ui-»tion,  cxn,-pt  m8  regardjt  the  cnvt-rnous  ins- 
piration. This  sign  was  well  marked  in  a  CMM  of  pultoonarj  a^ 
scess  following  pncnmonitis,  which  enmc  under  my  ol)»ervatioD  a 
the  New  Orleans  Charity  Iloxpilal.  On  this  point  Bkoda  rcnarki 
as  follows:  "I  have  frc<jm'utly  exnaiinod  patients  suffering  from 
pneumonia,  in  whose  lungs  newly  formed  nti.4ce»i>e»  were  found  after 
death;  but  I  have  never,  in  any  single  intlanec,  recognized  the 
presence  of  abscesses  by  the  aid  of  uaiicultatiou  or  percussion.  Is 
every  case,  the  abscess,  though  commnuicuting  with  the  bronchial 
tubes,  was  filled  with  pus  or  sanies."' 

The  progress  of  the  resolution  of  pncnmonili*  is  indicated  by 
diminnlioD  of  the  dulncss  and  the  sense  of  rcfislimee  on  percuMioa; 
decrease  of  the  intensity  of  the  bronchial  respiration,  which,  be- 
coming first  broncho- vesicular,  gradually  ni^sunies  the  normal  cbar< 
acters;  cessation  of  bronchophony,  and  the  return  to  the  noma! 
vocal  resonance,  the  resonance,  perhaps,  being  exaggerated,  without 
the  bronchophonic  characters,  for  a  certain  period;  disappeannc* 
cf  an  undue  vocal  fremitus,— these  changes  in  the  physical  phe- 
nomena associated,  of  course,  and  generally  succeeding,  rather  than 
anticipating,  a  marked  improvement  in  the  oough,  respiration,  etc 

pDCumonitis,  »o  fur  ns  nymptoms  are  concerned,  is  sometimes  re- 
markably latent.  Expvclomtion,  cmigh,  pain,  way  all  be  wanting, 
and  the  respiration  may  be  but  little  or  not  at  all  increased  in  fiv 
quency.  The  disease  fails  to  present  its  tuaal  symptomatic  phe- 
nomena when  it  is  consecutive,  much  oftencr  than  when  it  is  pri- 
mary; as  when  it  is  developed  in  the  course  of  fevers,  purulent 
infection  of  the  blood,  etc.  Under  these  circumi^tances  the  diag- 
nosis is  to  be  bnsed  almost  exclusively  on  the  physical  signs.  But 
as  regards  the  Utter,  the  disease  may  be  to  a  greater  or  Icn  extent 
latent;  in  other  wonU  pbyKieal  phenomena  which  are  uaoally  present 
in  a  marked  degree,  may  be  obscure  or  absent.  Thus,  not  only  it 
the  crepitant  rale  sometimes  wanting,  bat  also  the  bronchial  respi- 
ration, bronchophony  and  exaggerated  vocal  resonance,  and  frem- 
itus. The  solidification  occurring  in  the  latter  stage  of  fevers 
and  other  aGTections,  and  characterised  by  the  absence  of  the  nsual 


>  OpL  cil..  Am.  «dilioii,  pn^  811. 


ACTTTB  LOBAR  PSSTTUOSITIS. 


granular  deposit  (bypoatfttic  pneamonitis),  is  the  form  most  apt  to 
be  duftcient  in  the  group  of  signs  juat  named.  Instances  in  vhich, 
togcilicr  with  these  Hign^  all  the  ilis  it  motive  ajrcnptoms  are  also  want- 
ing, must  be  exceedingly  rare;  y«t  it  is  not  impossible  that  snob  a 
cue  may  be  mftt  with.  The  diagnosis  would  then  rest  mainly  on 
the  evidence  of  nolidificatiun  oxlending  over  &  lobe,  which  by  means 
of  percuMion  would  still  he  available.  Fortunately  a  clinical  prob- 
lem so  intricate,  although  within  the  limits  of  possibility,  is  far  from 
probable. 

Tlio  ilifTiTCnt  oflvctious  from  which  pneumonitis  is  prticticnlly  to 
bo  discriminated  lire,  aewt«  ordinary  bronchitis,  cnpilhtry  bronchitis, 
•cntc  plouritis,  dilntntion  of  bronchial  tubcK,  acute  phtliini^s  and 
pulmonary  ccdcmu.  I  will  consider  briefly  th«  moro  importiint  of 
the  pouits  involved  in  the  differential  diagnosis  from  these  aflc-ctions 
respectively.  With  a  proper  knowledge  and  application  of  physical 
exploration,  pneumoniliM  need  never  be  confounded  with  acute  or* 
dinary  bronchitis;  but  guided  exclusively  by  symptoms,  the  dis- 
criminstion  is  not  always  easy,  and  in  some  cashes  it  is  impracticnhle. 
Moreover,  the  two  affections  may  be  conjoined,  and  under  these  clr- 
Onmstances  the  question  whether  the  bronchitis  be  complicated  with 
pneumonitis,  or  not,  is  to  be  iclllod  muinly  by  the  pliy^ioKl  signs. 
Simple  bronchitis  and  simple  pneumonitis  present  a  striking  con- 
trast in  several  prominent  symptoms.  7'be  pnin  in  pueumonitis  is 
sharp,  lancinating,  and  generally  referred  to  the  vicinity  of  the  nip- 
ple. In  bronchitis,  if  pain  be  present,  it  is  dull,  couiusive,  and 
situated  beneath  the  sternum.  The  expeclorfction  in  bronchitis 
r»rely  contains  blood,  nnd,  when  present,  it  in  in  tlie  form  of  bloody 
points  or  streaks.  In  pneumonitis,  bloody  expectoration  is  common, 
and  the  blood  is  intimately  mixed  with  viscid  mucus,  giving  rise  to 
tho  characteristic  rusty  sputa.  The  febrile  movement  in  cases  of 
acute  pneumonitis  is  generally  intense,  whereas  in  ordinary  bron- 
chitis, however  acute,  it  is  only  moderate.  More  or  less  accelera- 
tion of  the  breathing  generally  characterises  caseii  of  pueumonitis, 
and  occurs  rarely  in  ordinary  bronchitis. 

But  the  physical  phenomena  are  more  distinctive.  The  crepitant 
rale  is  wanting  in  bronchitis,  nor  in  the  ordinary  form  of  that  affeo- 
tion  is  there  any  rale  approximating  to  the  crepitant  sufficiently  to 
occasion  any  liability  to  error.  The  sonorous,  sibilant,  and  mucous 
rales  may  be  prcient  more  or  less  conibiued,  nnd  these  rales  are  rarely 
prominent  in  cases  of  pneumonitis,  except  it  be  associated  with  gen* 


S94 


DIBbTbbW^F  THK   RBSfftjitOftT   ORQABE. 


era!  bronchilis.  Wlien  observed  in  cues  of  pneumoDitis  not  uso- 
oikted  wttli  general  bronchilltt,  thcv  arc  limited  to  one  side  of  Uw 
chetit,  ssve  in  the  rare  iDslanceR  of  double  pneomoDitis ;  but  io  Wob- 
Dhilix  ihvy  are  found  on  both  sides-  llie  chent,  iu  cases  of  broo- 
cb!ti»,  vvrrjwlKTi;  pR-scrvc*  it»  normal  *onoroiuine«s  Ml  percncaoa. 
In  pDcumaiiitis,  on  tlio  other  hand,  soon  after  tho  MC«*i  of  the  dk- 
MCe,  marked  dulneitH,  icilh  increased  sense  of  resistoncc,  ia  found 
to  exist  over  a  epace  corresponding  in  extent  and  silantton  to  one  rf 
the  pulmonary  lobes.  The  bronchial  respiration,  broncbophosf 
■with  the  loud  and  whispered  voice,  exaggerated  vocal  resonance,  u4 
increase  of  fremilus,  belong  to  the  history  of  pneumonitis,  and  art 
never  produced  as  effects  of  bronchitis. 

Between  pneumonitis  and  capillary  bronchitis  there  are  auat 
points  of  similitude;  novcrtbeless,  the  points  of  dissimilitude  art 
ampljr  aufficieiit  for  the  difTcrcnlial  diagnosis.  Capillary  bronchitis 
is  accompanieil  by  greater  embarrass  in  cut  of  reKpiratinn  and  suffer* 
ing  from  defective  htemalosis,  than  obtain  in  pneumonitis.  Tbe 
ncceieralion  of  the  pulse  is  greater.  The  nwly  8put»  arc  want- 
ing; blood,  if  prcT(-iii,  in  iti  streaks.  Reliance,  however,  mast  be 
placed  cbicHy  uu  the  physical  signs.  The  percnssion-resoaiooeii 
capillary  bronchitis  generally  remains  undiminished,  and  may  Ite 
abnormally  increased.  If  dulness  occur,  it  arises  from  collapsed  lob- 
ules, and  is  not  found  to  extend  over  a  spacQ  corresponding  to  ai 
entire  lobe.  Auscultation  discloses  the  sub-crepilant  rale,  which 
may  succeed,  or  coexist  with  the  sibilant  rale,  and  is  present  on 
both  sides  of  the  chest.  The  existence  of  this  rale  on  the  two 
sides  is  a  fact  eminently  distinctive,  but.  aside  from  this  fact,  the 
intrinsic  differences  between  the  sub-crepitant  and  the  tnic  crepitant 
rales,  which  have  been  fully  pointed  out,  suffice  for  their  diserirat- 
nation  from  each  other.  Finally,  in  capillary,  as  in  ordinary  acute 
bronchitis,  bronchial  respiration,  bronchophony  with  tlie  loud  and 
whispered  voice,  and  increased  vocal  resonance,  are  wanting. 

The  diagnostic  features  of  scute  pleuritjs  are  to  be  considered 
bereafter.  It  suffices  for  the  present  object  to  stale  that  the  mert 
important  of  these  features  arise  from  the  accumulation  of  more  or 
less  liquid  effusion  within  the  pleural  sac.  The  phytucai  sigotd^ 
noting  the  presence  of  ilnid  in  the  chest,  together  with  the  absence 
of  the  crepitant  rale,  and  of  the  i<igns  denoting  a  marked  liegrM  of 
pulmonary  solidificallon,  establish  the  differential  diagnoai*.  More- 
over, in  pleuriiis  the  febrile  movement  is  less  intense  than  in  acuie 


ACDTB  LOBAR  I-SBDH0NTTI8. 


8fl5 


pneutDonitis ;  cough  and  expectoration  are  frequently  sllglit,  or  alto- 
gether absent;  the  rusty  sputa  are  wanting,  and  the  matter  of  the 
expectoration,  unless  bronchitis  be  asaociaterl,  is  unallerei]  mnciis. 
It  is  not  rery  uncommon  for  practitioners  possessing  an  xmjuiTfcct 
knowle<]gc  of  the  princlplt-s  anil  pnictict  of  physical  (^xpKnalion  to 
mistake  pneumonitis  for  jileuritis,  »ni)  virf  vfrta.  Due  acquainlniice 
with  the  circumstances  involved  in  distinguishing  pulmonary  solidi- 
fication from  liquid  effusion,  will  obviate  the  liability  to  ihls  error. 
The  pointii  of  distinction  between  these  tuo  morbid  conJirions  have 
been  already  considered,  and  will  be  recapitulated  iu  conuectiun  with 
tlie  subject  of  plouriliB. 

Dilatation  of  the  bronchial  tubes,  in  connection  with  an  attack  of 
acute  bronchitis,  may  give  rise  to  certain  or  the  pliysieal  signs 
present  in  pneumonitis,  vit.,  bronchial  respiration  and  broncliophony 
or  exaggrraU'd  vocal  rfimniinco.  together  with  dulnvss  on  percussion. 
The  symptoms  incident  to  the  acute  bronchitis,  associated  with  the 
physical  phenomena  pertaining  to  the  bronchial  dihttation,  if  the 
practitioner  be  nut  awuro  of  the  previous  existence  of  this  lesion, 
might  lead  to  tlie  siiispieion  of  pneumonitis  ndruneed  to  the  singe  of 
solidification.  An  investigation  of  the  previous  history  and  present 
phenomena,  in  such  a  case,  will  show  that  chronic  cough  and  expecto- 
ration have  existed  for  a  greater  or  less  period  prior  to  the  attack, 
and  that  the  signs  suggesting  pneumonic  solidification  are  not,  as  in 
lobar  pneumonitis,  either  bounded  by  a  line  coincident  with  the  in- 
terlobar fisjiure,  or  extending  over  the  entire  lung  on  one  side.  In 
the  progress  of  the  case,  after  the  symptoms  of  the  acute  bronchial 
inflammation  are  relieved,  percussion  and  auscultation  show  the  phy- 
UObI  phenomena  still  persisting,  owing  to  the  permanency  of  the 
lesioD.  DilaUitioTi  of  the  bronchial  tubes  is  of  suoh  rare  occur* 
rence  that  it  falls  to  the  lot  of  but  few  physicians  to  be  called  to 
discriminate  between  it  and  other  affections. 

CiKCM  of  rapid  and  extensive  tuberculosis  may  present  a  group  of 
symptoms  and  «gn«,  which,  without  due  attention,  may  for  a  time 
deceive  the  praetitioner,  Dalnens  on  peroisHlon,  the  bronchial 
respiration,  bronchophony  with  the  loud  and  whispifrcd  voice,  ex- 
aggerated vocal  resonunco  and  whisper,  and  fremitus,  with  the  sub- 
crepitanc,  and  possibly  a  crepitant  rale,  may  coexist  with  accelerated 
breathing,  frequent  pulse,  cough  and  expectoration,  lancinating 
pains,  tlivse  symptoms  hat  ing  been  so  rapidly  developed  as  not  to 


8M 


DI8BA6BS  OF  TOR  RESPIRATOItr  ORGASri 


cuggCAt  *t  onc«  tlie  ii]c«  of  tuberculosis,  Csrefo]  and  cootiawj 
invcstigntioit,  however,  irjll  load  to  the  discoT^rj  of  certain  of  At 
{Kiaitiv«  features  of  phthi.4is,  ani)  nt  the  nanie  time  authorise  ib«  ex- 
oloMon  of  pneumonitis  b;  the  ab»>eDce  of  wme  of  its  distinctive 
traits.  In  the  vast  niajorily  of  chaos  of  plitlii^iv,  the  di'iK^it  ocean 
first  near  the  apex  of  the  liiiig».  Tbc  physical  signs  will,  ibertforc, 
be  found  at  the  summit  of  the  chest.  pDeumooitis  attacks  the  vpfU 
lobe  primnrilir  in  hut  a  smaU  proportion  of  cases,  and  hence,  llw 
situation  of  tho  pbjMcal  phenomena  in  itself  should  excite  suspicion 
of  tubercle.  A  tuberculous  deposit  rarely  extends  within  a  brief 
period  over  an  entire  lobe,  so  that  the  signs  will  be  likely  to  be 
limited  to  a  space  more  or  less  circumseribed  below  the  Havicle, 
when,  if  the  affection  were  simple  pneumonitis,  the  entire  lobe  woold 
he  soon  invaded,  and  its  boundary  line  determined  by  means  of  pw- 
cufision  and  auscultation  to  be  in  the  situation  of  the  interlobar  fis- 
sure. Hemorrhage  will  be  likely  tu  occur  in  connection  with  tuber- 
culous disease,  and  not  in  pneumonitis,  except  in  so  far  a^  it  cnten 
into  the  produotion  of  the  runty  sputa.  The  lancinating  pninn  ia 
phthisis  are  geuerally  referred  to  the  summit  of  ilie  cbcst,  or  they  we 
seated  benenth  the  scapula,  not  fixed  in  a  point  at  or  near  the  nipple, 
as  in  pneiimouitis.  The  chnniclcrif  of  the  puW  in  "tuberculoya 
fever"  differ  from  those  which  belong  to  (he  febrile  movement  jiymp- 
tomutio  of  an  acute  local  influtninativn.  In  the  former  tbv  pulse  is 
often  very  frc(|ucnt,  i-ibratory  or  thrilling,  denoting  irritaljility 
rather  than  increased  force  in  the  ventricular  coutruction.  In  the 
latter  the  pulse  is  less  rapid,  but  stronger,  indicating  abnorna] 
power  in  the  action  of  tho  heart.  Rapid  loss  of  weight  chnraclerius 
acute  phthisis.  Diarrhcca  frequently  occurs.  The  patient,  notwith- 
standing the  greater  frequency  of  the  pulse,  and  with  an  equal,  if 
not  greater  disturbance  of  the  respiration  than  ordinarily  attend* 
pneumoniiie,  docs  not  yield  to  the  disease  and  take  to  the  bed,  u 
whcu  attacked  with  pneumonic  inQiiuimtition.  Acute  phthi>is,  vbea 
it  is  most  rapidly  doveloped,  docs  not  present  the  abrupt  acccM 
which  generally  eharaetcrizes  cases  of  pneumonitis. 

The  difFcrentiuI  diagnosis  may  be  more  difficult  when  the  tuberen- 
loua  deposit,  in  dcxnation  from  the  usual  course  of  the  disease,  taket 
place  Hrst  at  the  base  of  the  lung,  and  gradually  extends  upward. 
This  unusual  course  of  tuberculous  disease,  accordiug  lo  the  obser- 
vations of  Dr.  II.  I.  Dowdiicb,  occurs  in  a  ratio  of  1  to  from  160  or 


S97 


I 
I 

I 

I 


I 


20O  cases.*  The  greater  liability  to  error  of  diagnosis  in  this  vsriety 
of  plitlii.tix  arises  from  the  pbj!«i(;Hl  signs  being  mnnifcsteJ  in  the 
snino  sitiintinn  as  in  inoNt  un«i>»  of  pneunionilii!,  viz..  on  the  posterior 
Bnrfaci!  of  the  chest,  cicpccially  bi'luw  the  scapula,  and  also  from  the 
prcKcncc  of  the  crepitant  rale,  which  was  observed  in  seven  of  eight 
caws  reported  by  Dr.  Bowditch.  The  cuiubinatiou  of  phyeicat  signs, 
ID  fact,  may  be  precisely  that  which  characterizes  pneumoniiis.  The 
invongruousness  of  the  nssoeiated  eymploms,  on  the  supposiiion  that 
pneamonitie  exists,  and  the  presence  of  certain  of  the  trails  signifi- 
cant  of  phthtflis,  point  to  the  nature  of  the  di^eaac.  With  the  physt- 
cat  signs  juat  mentinn<^d,  patients  preserve  flrcngth  suflicienc  to  bo 
up  and  out  of  doors.  The  disease,  even  if  rapidly  ik-veloped,  is 
always  more  gra<1iial  than  pneumonitis.  Hemorrhage  occurs  in  a 
certain  proportion  of  oases.  Tlie  ragged  opaque  sputa  of  phthisis 
are  sometimes  observed.  Acute  Rymptoui.i  are  by  no  means  uni- 
formly present  in  ibis  variety  of  tubercidoai*  dineasc.  The  crepitnnt 
fale  is  persistent,  continuing  for  weeks  and  even  months.  Although, 
therefore,  the  combination  of  physical  signs  and  their  situation  are 
the  same  as  in  pneumonitis,  ihv  asnociated  circumstances  and  the 
progress  of  the  disease  present  points  of  disparity  which  speedily 
lead  to  the  correction  of  an  error  id  diagnosis  liable  to  arise  from 
inadrcrtency  or  a  premature  conclusion. 

(Edema  of  the  lungs  extending  over  one  or  more  lobes  may  give 
rise,  to  some  extent,  to  the  physical  signs  incident  to  the  stage  of 
solidification  from  pneumonitis.  Over  (edematous  lung  there  will  be 
dnlness  on  percussion,  with,  possibly,  bronchial  respiration,  bron- 
chophony or  exaggerated  vocal  resonance,  and  fremitus.  Those  bus- 
cnllatory  phenomena,  however,  arc  rarely  marked,  and  often  absent. 
A  well-marked  crepitant  rale  is  sometimes  observed,  but  the  8ub> 
crepitant  is  much  oftcner  present.  (Edema  occurring  always  as  a 
secondary  affection,  from  hypoi*tatio  congestion  in  fevers,  from  a 
changed  condition  of  the  blood  leading  at  the  same  time  to  t<crotiB 
infiltration  in  other  parts,  from  Uie  obstruction  proceetJing  from 
disease  of  bcurl,  etc.,  its  existence  may  be  presumed  wlien  the 
physical  signs  denoting  solidification  become  developed  in  those 
pathological  connections,  without  being  preceded  or  accompanied  by 

1  Cnuaof  Anomalnui  DovetojimeDt  of  Tuberc!«,  etc.,  by  Henry  I.  BowillKh. 
Anmrlmn  llBdicitl  Muiitlily,  N.  Y.,  IHiiG.  From  tba  number  of  inntBOoui 
wLkli  I  havu  oliturvvd  tinou  ihu  flnt  •diliun  of  ihU  wcrk  wiit  [iiibliihcd,  1 
should  isf  ihst  Lbn  ptfrcnntngo  U  largnr  thui  i>  citimstcd  bjr  Buwditoh. 


«98 


DIKBA6ES  OF  THK   BKSPtRATOKT    ORGAXS. 


tlie  ajmptoniB  of  acute  pneumonitis.  Moreover,  the  csiues  pre- 
daciog  the  eedema  acting  equally  oo  both  lungs,  the  local  endeoea 
of  the  eolidiGcatioQ,  are  found  on  each  side  of  the  chest. 

An  (cdcmatoua  condition  may  occur  as  a  sequel  of  pnpumon'iiis  in 
the  portion  of  long  which  has  been  the  s<eat  of  the  iiiflainiiiaUoD. 


SUMUART  OF  THK  PBTdlCAL  EtOXS   BBLONQIMI  TO    ACUTB  tX>BAS 

I'SEUJCOSITIS. 

The  veaicutar  percusftion-rcsonancc  diminisbed  during  the  stage 
of  engorgement,  but  in  a  more  marked  degree  after  solidiGcatids 
hna  taken  place;  seniio  of  resistance  notably  increatiei];  the  limia 
of  the  iliiliicits  and  lo«>s  of  eliMticity  corresponding  to  the  boundarin 
of  tlie  aifecled  lobe;  the  vesicular  rcaoiiance  Mtmelimes  replaced  by 
a  tympanilio  sonorousness,  more  or  lew  marked ;  the  cr«>piunt  rale 
generally  discovered  by  iiusciiltation,  nccoinpanicd  or  followed  by 
the  broncbo-vesicular  and  tlie  bronchial  n.^spiration ;  bronchopbooy 
with  ihe  loud  and  whispered  voice  generally  pre«'nt;  incrcatcd 
vocal  fremitus  over  tlic  solidiGod  lung  existing  iu  a  certain  propor- 
tion of  cases;  occasionally  pectoriloquy;  the  crepitant  and  the  sub- 
crcpitant  rale  during  the  resolution  of  the  disease  in  some  instances; 
the  moist  and  dry  bronchial  rales  occasionally  beard,  but  rarely 
prominent  unless  the  disease  advance  to  the  stage  of  purulent  infil- 
tration, when  the  tnoisl  rales  may  be  more  or  less  abundani;  a 
friction-sound  heard  in  a  small  proportion  of  instances;  on  the 
unaffected  side  exaggerated  respiration;  diminished  respiratory 
movements  on  the  aR'ected  side  sometimes  apparent  on  inspectioB, 
if  the  affection  be  limited  to  a  single  lobe,  oftener  obaerred,  and  in 
ft  more  marked  degree,  if  the  iuilammation  extend  over  an  entire 
long;  contraction  of  the  side  affected  aller  resolution  in  some  ca«es. 


Impebfect  Expansion  (Atklectasis)  asd  Collapse  of  Pct- 

MOKART   LOBVLES. 

The  morbid  conditions  dcnoied  by  the  terms  atelectasis  and  col- 
lapse of  pulmonary  lobules,  liave  heretofore  been  considered  as  arising 
from  inflammation  which,  instead  of  extending  orer  an  entire  lobe, 
is  circumscribed,  being  confined  to  lobuU-s,  either  isolated  or  in 


rULUONART   LOBVLBS. 


899 


I 


closters,  situated  at  difTerenc  points,  more  or  less  numerous  anil  dis- 
seminated in  the  |:iiilmonary  orfiaiifl  on  butli  aides  of  lliv  clicst.  Tfaeee 
ConditionH  were  first  doacrib«d,  under  llie  name  lobular  pneumoititia 
occurring  in  cliildren  under  six  ytvirs  of  ngc,  in  thia  countrjr  by 
Gerhard,'  and  in  France  by  Ilufz,'  Rillict  and  Bnrthci/  Valleix,* 
And  others.  As  di^itcribrd  by  llic  wriiors  jii»t  mentioned,  the  eo-called 
lobalar  pneumonitis  cmbruecs  c»»cs  in  wblcb.  after  death,  the  luoge 
■re  found  to  present  solidifiei)  p'lrlJcms  varying  in  size  from  a  pea 
lo  a  filbert,  scattered  irregularly,  occasionally  confined  to  one  side, 
but  much  oHener  distributed  over  botli  lunga,  varying  in  number 
from  "2  to  yO ;  tlif  intervening  parenchyma  preserving  the  characters 
of  the  normal  spongy  tituue.  This  pathoiogieal  condition  in  a  large 
majority  of  instances  is  associated  with  the  anatomical  characters 
of  bronchitis,  and  hence  the  affection  wa»  called  hroncho-pneajnonia, 
bj  a  Cicrman  author,  Seifert. 

Researches  mure  recent  have  shed  new  light  on  the  morbid  anatomy 
and  the  pathology  of  affections  heretofore  included  under  the  appel- 
lation of  lobular  pneumonitis  and  broncho- pneumonia.  In  1^32, 
Prof.  Jcirg.  of  Leipsic,  published  an  account  of  a  morbid  condition 
found  in  the  bodies  of  newly  born  children,  analogous  to  that  re- 
garded as  cbaraclmslio  of  lobular  pneumonitis,  which  he  attributed 
to  imperfect  expansion  of  the  lungs  by  the  fir^tt  inspirations  after 
birth;  in  other  words,  more  or  leas  of  the  lobules  remaining  in  the 
fatal  state.  To  this  morbid  condition  be  applied  the  name  aUlea* 
tatu.  This  condition  \\iu\  been  previously  described  by  a  French 
vriler,  M.  Dug<!.'<,  in  1B21,  in  a  thesis  which  failed  to  attract  atten- 
tion to  the  subject.  The  anatomical  characters  regarded  as  dislinc- 
tivc  of  a  persisting  foetal  condition,  are  as  follows:  the  solidified 
lobules  giving  rise  to  depressions  on  the  surface  of  the  lung;  tliepleii> 
ral  covering  retaining  its  glistening  piili.thi'd  aspect;  the  size  of  the 
lobules  affected,  and  of  the  lobe  in  which  they  are  found,  not  aug< 
meated,  but  diminished ;  tho  cut  surfaces,  when  the  solidified  lobules 
are  incised,  not  having  a  granular  appeiimnee,  but  smooth,  like 
mit^le,  and  the  tissue  not  sofcened  or  friable  us  it  is  in  the  second 
Stage  of  ordinary  pneumonitia.  The  morbi4  appearances,  in  other 
words,  are  those  which  belong  to  the  condition  called  earnificatirm. 
An  importiint  point  of  evidence,  according  to  J«rg,  of  the  morbid 


I  Am.  Jour,  of  M«iJ.  SilencB*,  ISM. 
>  Journ.  do  Coim.  Mfdico-Cblr.,  ISitC. 


•  Tmitii  Af»  MalBiliFt  &u»  Bafstu. 

•  Il)i<].,  nouv.  Bii,  18S8. 


400 


DISEASES  OF  TBB  BESPIBATORT  0B0AK3. 


condition  called  by  him  atelectasis,  was,  that  by  tnsnfflstioa  Ibc  cob- 
dcnsvd  lobules  are  capable  of  being  brought  to  a  normal  coDilrtim,* 

Still  more  recently,  the  researches  of  Legendre  and  Bailly,  of 
Paris,  demonstrated  that,  in  a  certain  proportion  of  the  caM-a  of  m- 
callcd  lobular  pneumonitis,  in  which  the  affection  is  developed  at  a 
period  more  or  less  renDot«  from  birth,  the  affected  lobules  are  in  a 
condition  analogous  to  that  of  f<etai  life :  that  is  to  say,  the  ebarao- 
ters  pertaining  to  the  condensation  are  those  of  camification  as  ifis- 
tinguiahed  from  red  hepati nation,  and  the  fact  (hat  the  air-vesicltl 
■re  not  occluded  by  a  solid  deposit,  as  in  oases  of  ordinary  lobai 
pn<!iitnoiiitis.  Is  shown  by  the  solid iScation  being  removed  by  inasf- 
flation.  The  authora  just  named  first  suggoat«d  thb  ^mple  test  of 
the  fact  of  condensation,  occasioned  by  morbid  causes  acting  after 
birth,  being  due  lo  it  return  to  the  fcetnl  Mate,  although  the  same 
means  had  b^cn  previously  resorted  to  by  JSrg  in  e»»ea  of  atdec- 
tasis.* 

The  distinctive  nppenrnnecs  of  the  pnrla  in  the  one  case  pi 
ing,  and  in  the  other  cn^e  resuming  a  fcctal  state,  had  by  no 
escaped  the  notice  of  earlier  writers  on  the  subject  of  lobular  pnra- 
Tnoi)iti».  Tiiey  had,  however,  attributed  the  prwluclion  of  ihi*  mor- 
bid condition  to  iullummation,  attributing  the  differencen  in  ihe 
aiintomicnl  characters — absence  of  the  granular  deposit,  want  of 
friability,  etc., — to  modifications  of  the  inflammatory  processes  pecu- 
liar to  early  life.  The  investigations  of  Jorg,  and  Legendre  and 
Itailly,  led  to  the  conclusion  that  the  cases  of  so-called  lobular  pnea- 
inonitis,  in  which  the  lobules  are  in  the  foetal  state,  or  camified,  do 
not  involve  the  existence  of  inflammation  of  the  air-cella  or  paren- 
chyma, and  that  they  are  not  properly  cases  of  pneumonitis. 

Puehs,  of  Leipsic,  and  W.  T.  Gairdner,  of  Olksgow,  hare  published 
facts  tending  to  show  that  condensation  of  more  or  less  of  the  pul- 
monary lobules  often  occurs  as  the  effect  of  collapse  of  ihe  air-cells, 
due  lo  partial  obstruction  of  the  bronchial  tubes  from  accumulation 
therein  of  inflammatory  products;  and  in  proportion  as  the  nam« 
lobular  pneumonitis  is  applied  to  cases  of  solidification  thus  pro- 
duced, the  lesion  is,  in  tact,  incident  to  bronchitis,  and  the  affection  ia 
not  rightly  called  cither  lobular  pneumonitis,  or  broncho-pneumonia. 

■  Tbectuw^ven  by  Vnltdx  and  otlKTiof  lobular  pncumonitiiinttill  or  nt'wly 
born  chlMron,  tuppuHod  lo  hav«  «il«tMl  In  latra-ut«rm«  Iir«,  utrt  probably  < 
of  aiplvctiuia. 

•  ArchlvM  GtnjralH  do  Medecine,  IMS. 


PULMOHART    LOBOLBS. 


401 


I 

I 


As  s  complication  of  bronchial  inflanimation,  lobular  coltapse  baa 
be«n  already  referred  to  in  connection  with  the  conflidcration  of 
bronchitis.  The  researched  of  fiairdner  render  it  probable  that  col- 
lapse of  portions  of  the  lung  Is  by  no  means  an  erent  exeluairoly 
pertaining  to  early  life,  and  that  bronchial  obt>truGtion  suRtains  an 
important  pathological  connection  with  an  afTcction  to  be  next  con- 
BJdercd  (emphyscinu).  It  is,  however,  entirely  foreign  to  the  plan 
of  this  work  to  engage  iu  in<|iiiric»  or  difousttionit  relative  to  ques- 
tions which  coRocm  the  ivtiology  of  the  diseases  affecting  the  respi* 
ratory  organ*,  or  their  pathological  churactor  and  relations,  except 
so  far  as  such  qiic»tion«  are  nccedwirily  involved  in  the  subject  of 
diagnoHiK.  In  the  present  instance,  the  very  brief  history  nhich  hat 
been  given  of  the  ecientific  developmenta  pertaining  to  lobular  pneu- 
monitis, has  seemed  to  be  requisite  for  a  proper  uiiderHtauding  of 
the  affections  heretofore  so  called. 


I 


PhtftieoX  Signa  and  Diagnont. — In  cases  of  iroperfiwrt  ei^ansion, 
or  atelectasis,  dulness  on  percussion  is  a  physical  sign  ftvquently 
available.  The  existence  of  condensed  lobules  in  both  limgs  is  an 
obstacle  in  the  way-  of  a  comparison  of  the  two  sides ;  but  the  con- 
densation being  usually  more  extensive  on  one  side  than  on  the  other, 
s  disparity  in  the  percussion-resonance  may  be  obvious.  A  greater 
relative  dulness  nill  ofteuer  be  found  on  the  right  than  on  the  left 
side,  the  right  lung  being  more  apt  to  suffi^r  from  defective  expan- 
sion, A  judgment,  however,  may  be  formed,  to  some  eiiiciit,  of  an 
abnormal  deficiency  of  resonance  on  both  sides,  irrespective  of  a 
comparison  between  them,  the  sound  being  manifestly  more  dull 
than  if  the  cells  were  fully  expanded.  Feebleness,  or  absence  of 
respiratory  sound,  will  be  likely  to  be  the  result  obtained  by  auscul- 
tation. The  force  of  the  respiratory  movements  is  probably  inade- 
quate, in  most  iiiittunccs,  to  develop  the  bronchial,  or  even  a  well- 
tnarki'd  broncho- vesicular  respiration,  the  existence  of  which,  in 
Ticw  of  the  solidification,  might  be  rationally  anticipated.  Over 
the  non-Bolidified  portions  of  lung,  the  vehicular  murmur,  instead  of 
being  aupplemcntarily  exaggerated,  will  be  abnormally  feeble,  owing 
to  tlie  same  cause,  vie.,  the  weakness  of  tbc  inspiratory  efforts.  The 
latter  is  also  consistent  with  the  fact  that,  for  some  time  after  birth, 
in  health,  the  vehicular  murmur  is  feeble,  although  subsequently  it 
ac<]uire«  an  iulenaily,  afterward  again  loat,  constituting  what  is 
known  as  the  puerile  respiration.    Inspection  shows  the  visible  move- 

26 


408 


DISBA8KS   OF  THE   RHSPIRATOBX    OBOANS. 


meats  of  r«»piration  to  be  un  natural  I;  feeble,  the  t^e  of  bmthiag 
being  abi]cimiiiitl ;  ami  it  has  b««n  poioted  out  by  I>r.  G«orge  A. 
B«ea,  of  London,  tlint  tlie  lower  riba,  inttiead  of  espaoditig  witli  the 
descent  of  the  diupliragiu,  contract  during  the  act  of  inspiration. 

Witli  Uicsc  sigiin,  tiilten  in  coiinvction  with  ibe  syraptoros  which 
have  been  menltoiied,  the  diagnosis  of  imperfect  expnnsion  or  u«- 
Ifotaais  may  be  mude  nitK  much  poftitiveness. 

Ill  c»!»»  of  lobular  condt-ii»atiun  from  collapse,  if  it  bo  snSdeat 
in  cxt«»t  to  give  rife  to  coiisideraMc  embarrassment  of  reapiraiion, 
I>crcu8)tion  m»y  be  expected  generally  to  furniali  evidence  of  tiolidi- 
fie«tioii.  The  dulness  will,  of  course,  he  marked  in  proportion  to 
the  number  of  lobules  collapsed,  and  their  proximity  to  the  thoncje 
vails.  Next  to  these  conditions,  the  greater  amoant  of  oollsp»e  os 
one  side  of  the  chest  is  the  circumstance  most  importanr,  rendering 
the  dulness  obvious  by  contrasting  the  percussion-sound  on  the  two 
aides.  If  the  condensed  lobules  are  in  small  disseminsted  clusten, 
and  not  far  from  e<]ual  in  both  lungs,  the  advantage  of  a  comparison 
of  the  two  sides  is  lost,  and  the  fact  of  dulness  may  not  be  dete^ 
Diinable.  The  proportion  of  such  instances  in  cases  of  collapse  r^ 
mains  to  be  ascertained  by  numerical  investigationa,  bat  it  ia  rare  to 
find  a  near  approach  to  equality  in  the  amount  of  oondensatton 
existing  in  bolh  lungs. 

The  crepitant  rate  of  pneumonitis  does  not,  of  oonrae,  belong  to 
this  form  of  disease.  Auscultation  discovers  more  or  less  of  the  dry 
and  mucous  rali-s  in  certain  cases,  hut  not  unifonnly.  CollapM  ia 
Dot  always,  although  in  the  large  proportion  of  cases,  associated  with 
bronchitis ;  and,  moreover,  the  bronchial  rales  are  far  from  being 
constant  in  cases  of  bronchial  inflammation.  More  or  less  of  tbe 
characters  of  the  bronchial  or  the  broncho-vesicular  respiration,  lo> 
gethcr  with  exaggerated  vocal  resonance,  increase  of  fremitus,  and, 
possibly,  weak  bronchophony,  are  present  in  a  certain  proportion  of 
cases. 

The  suddenness  with  which  the  physical  evidence  of  solidification 
becoine«  developed,  n  part,  for  example,  being  found  to  be  notably 
dull  on  percust<ion,  when  the  day  prcviooa  there  waa  no  apparent 
diminution  of  rcsonauoc,  ia  n  point  possessing  diagnostic  importanofr 
Tbe  symploiiis  and  attendant  circumstances,  taken  in  connection 
with  tfae  physical  signs,  haw  an  important  bearing  on  the  diagnosis. 
Among  the  symptoms  the  absence  of  febrile  movement  is  highly 
siguiGcanl.     The  abrupt  occurrence  of  difficult  breathing,  together 


CBROMO    PKRUM0KITI6. 


•103 


■witli  the  eriilcntcs  of  defcctiTc  lucuialosis,  i»  nnnthcr  point  pos**-**- 
ing  a  certain  amount  of  sigiiificaiicc-.  Tin-  stittc  of  tlio  mu^fculur 
power,  at  the  time  the  vital  and  pbyeical  evidonco)  of  coui}cn«atiaii 
become  apparent,  is  to  be  cont>iderc(l.  Occurring  during  great  ex- 
haustion, when  the  force  of  the  iniipiratory  effort  might  be  expected 
to  be  greatly  reduced,  the  probability  of  collapse  is  certainly  much 

^ greater  than  under  opposite  circumsiances. 


COEONIC   PSEUWOSITIS. 


Following  the  example  of  writers  generally,  who  have  treated  of 
dieeases  affecting  the  rcs'pirntory  organs,  I  shall  dispose  of  the  sub- 
ject of  chronic  pneumonitis  in  a  siimmary  manner.  Our  knowledge 
of  this  form  of  disease  is  imperfect.  Lsenncc  questioned  its  exis- 
tence. Nearly  all  pathological  observers  arc  agreed,  as  respects 
the  infrequencT  of  its  occurrence,  and  different  opinions  on  this 
point  may  he  in  a  great  measure  accounted  for  by  difference  of 
riews  as  to  the  morbid  conditions  to  which  the  name  of  chronic 
pneumonitis  is  properly  applied.  Some  writers  (Andral,  Ilasse), 
who  regard  it  as  not  very  unoomraon,  embrace  nnder  this  title  cer- 
tain cojiea  of  tnberculoHis,  characterized  by  Rolidiflcation  of  the  puU 
monary  parenchyma  between  the  tubercultniH  lU-posit.  Uinler  ihe^e 
circumstances  the  morbid  condition,  admitting  it  to  be  chronic 
pneumonitis,  is  incidental  to  tuberculosis,  and  it  is  not,  therefore,  to 
be  considered  n  separate  form  of  disease.  It  is  probable  that  cases 
of  collapse  have  been  sometimes  set  down  as  instances  of  chronic 
pneumonitis,  For  example,  a  case  reported  by  Requin,  and  de- 
tailed by  Grisolle,'  in  which  the  lower  lobe  of  the  right  lung  was 
found  after  death  firmly  condensed,  non-granular,  without  tubercles 
or  miliary  granulations,  may  be  suspected  to  have  been  of  that  de- 
scription. The  same  remark  will  apply  to  eases  of  carni6catian 
supposed  to  result  from  chronic  inflammation  of  the  pulmonary  par- 
enchyma. An  instance  of  this  kind  ia  quoted  by  Grisolle,  from 
Rilliet  and  Barthez. 

According  to  Rokitansky,  the  morbid  condition  characteristic  of 
chronic  pneumonitis  consists  in  the  presence  of  inflammatory  exuda- 
tion within  the  areolar  tissue  uniting  the  pulmonary  lobules,  and  the 


<  Traiti  Prnti^ua  dn  la  Pnoumoni*,  p.  8G1.    Tbit  cue  i*  rftferred  U>  by  Or. 
Walibv,  under  tbu  head  uf  Cliruolo  PueutDoiiia. 


404 


DIBBASBS  or  THE  KBSPIBATOKT  OROA!Cit 


smaller  gronpfl  of  air-cells,  ani]  lio  nppHcs  to  this  form  of  dise&se  Hit 
title  of  hiterstitial  pneumonia.  Thia  infiltration  within  the  iDter- 
Btilial  tissue,  he  states,  in  the  progress  of  time  becomes  organitod 
and  coalesces  with  the  latter,  so  an  to  form  a  dense  eellnlo-fibroii! 
BuliBtance  which  compressefl  and  obliterates  the  air>eel!it,  leaditif;  It 
oontraction  of  the  thorax  and  dilatation  of  the  bronehial  tnba. 
This  is  essentially  the  form  of  disease  descritwd  \>j  Corrigan.  and 
deiiignated  by  him  cirrhosis  of  the  lung,  to  which  reference  bay  beeo 
made  in  connection  with  the  diagnosis  of  dilatation  of  the  broncliial 
tubes. 

As  a  se<inel  of  acute  inflammation,  chronic  pncimionitis  is  exceed- 
ingly rare.  Qrisolle  in  his  treatise  giving  the  result*  of  the  aDalysis 
of  873  cases  of  pneumonitis,  stales  that  hu  hii»  tnct  with  but  a  single 
instance  in  which  the  acute  terminated  in  a  chronic  form  of  the  dis- 
ease. M.  Barth  found  but  a  single  instance  in  a  collection  of  129 
ease*  of  acute  pneumonitis.'  It  is  true  that  frequently  after  acute 
iiiBummation  the  physical  evidences  of  solidification  continue  for 
eonie  time,  not  disappearing  entirely  for  weeks  or  even  months.  It 
vould,  however,  be  incorrect  to  say  that  under  lhe»e  ctrcumstanc«e 
the  diseaiie  was  perpetuated  in  a  chronic  form.  Id  cases  of  reritable 
chronic  pDeumonitis  euccveding  the  acute  disease,  the  acute  symp- 
toms disappear,  but  more  or  less  febrile  movement  continues,  occur- 
ring in  paroxysms,  or  with  marked  exacerbations ;  cough  and  ex- 
pectoration persist,  the  latter  not  preserving  the  characters  siguifi- 
cant  of  the  acute  di<>ease ;  the  respiration  is  accelerated,  with 
dyspnoea ;  the  appetite  does  not  return,  or,  if  it  return,  speedily, 
fails;  the  patient  loses  strength  and  weight,  and,  at  lengili,  dies, 
alV-r  the  lapte  of  two  or  three  months.  The  physical  sigus  of 
sol  idifica  lion  persist  during  the  progress  of  the  chronic  disease,  vts., 
notable  duliiess  on  percussion,  with  bronchial  respiration,  increased 
vociil  resonance  and  fremitus,  eto.  In  the  case  reported  by  Keqaio, 
above  mentiunvd,  the  auscultatory  phenomena  denoting  solidification, 
vis.,  bronchial  respiration  and  exaggerated  vocal  resonance,  were 
wanting.  This  occasionally  happens  in  acute  pneumonitis.  Whethrr 
il  is  more  likely  to  occur  in  the  chronic  form  of  the  diiwaw,  it  is 
impossible  to  say  in  riew  of  the  limited  number  of  cases  of  the  Uttrr 
which  have  been  reported. 

It  is  evident  from  the  foregoing  brief  account  of  obronie  pneumo- 


*  TaUsli,  op.  elt. 


CnKOETtO  PKRDMOSITIS. 


I 


nitis  ttiat,  exempt  no  far  as  il  ia  involved  in  a  1e»ion  already  enn- 
sidered,  viz.,  dilatation  of  the  bronchial  tiiW<i,  it  it*  an  ftfTection  poft- 
sesaing  coiiiparatiTelv  Bmal)  intore^tt  and  importance  in  a  praotioal 
point  of  view.  Although  the  phjitician  is  very  rarely  called  upon 
to  make  the  diagiio!ti»,  the  fact  of  ita  occasional  oceiirrence  is  not 
to  be  lost  sight  of.  In  eases  in  whltrh,  nfier  acute  pneumonitis, 
pliysical  signs  denoting  aoliilifiention  arc  found  to  remain,  associated 
with  syraptoins  wliith  indicdtc  a  grave  malady,  viic,  febrile  exacerba- 
tions, lo»s  of  stnmgth  and  weight,  congh  and  expectoration,  etc., 
the  question  may  arino  whether  the  patient  lie  affected  with  chronic 
pneumonitis  or  tuberculosis.  If  the  phvAieal  signs  denote  solidifi- 
cation of  the  upper  lobe,  and  especially  if  they  denote  that  the 
solidification  is  confined  to  a  portion  of  the  tobe,  the  chances  against 
thfl  existence  of  tubercle  are  exceedingly  small.  The  chances  are 
grcjitly  increased  if  the  local  affection  be  seated  in  the  lower  lobe; 
but  this  situation  is  not  conclusive  evidence  against  the  exii^tenco  of 
laborclc,  for,  as  exceptions  to  the  general  law,  the  tuberculous  de- 
(  in  some  insltinoes  take^  place  first  in  the  lower  lobe.  The 
rential  diagnosis  rests  miiinly  on  the  presence  or  absence  of  the 
ereute  characteristic  of  the  progress  of  tuberculous  disease,  viz., 
b^ptnoptvfiis.  pleuritic  pains,  nocturnal  sweats,  etc.,  together  vitfa 
the  physical  evidences  of  the  local  changes  incident  to  phthisis,  viz., 
softening  of  the  tuberculous  matter  and  the  formation  of  cavities. 


CHAPTER    IV. 


EMPHYSEMA. 


Tbb  t«riD  cmpbj»emu  is  iue<l  to  dv^ignau  two  quite  difierent  pul- 
monnrjr  uSi-ctiuns.  Id  ono  of  tbetw  KflfectioDH  the  morbid  oonditiaB 
ConsiaU  in  ma  ■IjDOrroal  incrcxM!  iii  sisc  of  the  nir-wllf.  and  coast- 
quvitt  ovcr-ticcuinuUtioD  of  air  within  them.  This  U  by  f&r  tbe  more 
frequent  in  occurrence  of  th«  two  affections,  and  is  f;cncnilW  nnder- 
Stootl  wben  the  word  emphysema  is  applied,  without  any  qualifiotioa, 
to  I  morbid  condition  of  the  lunge.  The  t«ria  is  mnnifefily  inappro- 
priate, since  there  is  only  a  remote  analog  of  ibis  pulmonary  aStc- 
tion  to  the  extravasation  of  air  into  areolar  structure,  the  Utter 
being  the  morbid  condition  designated  by  friupbyBema  wben  it  is  nted 
witliout  special  reference  to  the  pulmonary  organs.  D3atation  ej 
the  air-etlh,  and  rar^aetion  of  the  lun^,  are  terms  more  cxpremve 
of  the  morbid  condition,  and  are  to  bo  preferred.  V04ieuiar  trnphf 
$ema  and  trut  pulmotuiry  cmph>/»rma,  arc  exprexxions  employed  by 
Laennco  and  subaequvnt  writers  to  distinguish  the  aflection  now  re- 
ferred to. 

The  other  affection  to  which  the  name  of  emphysema  is  applied, 
consistS'in  the  extravasation  of  air  into  the  areolar  structure  uniting 
together  the  pulmonary  lobules,  and  connecting  the  pleura  with  lbs 
HiperficicM  of  the  lung.  This  morbid  condition,  more  correctly  tliaa 
the  first  styled  empbysematoas,  is  distinguished  as  interlobular  and 
nb^leural  empht/«ema. 

These  two  forms  of  the  disease  claim  separate  coasideration ;  but 
the  latter  will  require  comparatively  brief  space. 

L  YmcuLAK  Emphisbua, 


VbicwUB  Emphtsema;  DUdlatioH  of  the  Air-eeUt:  Rarffae- 
tian  of  Lung. — Laennec  was  the  first  to  give  a  clear  description  of 
this  affection ;  and  in  view  of  the  origioality  and  vslae  of  his  re- 


TK8I0VLAB    BHPHTBBHA. 


407 


I 

I 


.  diitttngiiuihei]  morbi<l  anatoniiitt  of  the  pri»<>nt  day'  has 
flsid  that  "had  Liii'niii'O  ilont-  nothing  che  for  modical  science,  hia 
discovery  of  this  di.st-a»iil  condition,  nod  of  the  caii»eft  giving  riiie  to 
it,  would  have  iiuffici.'(l  to  render  his  nuiiit-  immortal."  The  piitho- 
Jogical  rel«t40iis  of  dilnlntion  of  llie  uir-cclls,  imd  the  mode  in  which 
the  lesion  is  produced,  nrc  subjects  of  much  intercitt  ami  importanee, 
concerning  which  conflicting  opinions  are  mainl«ini'd  by  diffurent 
l>iit«i«.  Conformity  to  the  pUn  of  this  work  renders  it  neei-SMry 
to  forego  any  consideration  of  these  subjects,  limiting  the  sttentioii 
to  the  physical  signs  and  the  diagnosis  of  the  affffction.* 

The  following  lawH  of  emphysema,  considered  as  an  iDdiridual 
affection,  are  important  to  he  horno  in  mind  with  reference  to  diag- 
DO«is.  Both  lunga  arc  affcated  in  the  great  majority  of  cases.  The 
affection  may  be  limited  to  the  upper  lohes,  and  it  is  more  marked 
in  the  upper  than  the  lower  lobeti,  if  it  extend  to  both.  The  two 
upper  lobes  are  very  rarely,  if  ever,  equally  affected ;  that  is,  the 
emphysema  is  greater  on  one  side.  According  to  my  experience, 
the  emphysema  is  greater  on  the  left  side  in  the  great  majority  of 
cases.  The  almost  constant  association  of  emphysema  with  clironio 
bronchitis,  and  the  freijiiont  association  of  asthmu,  urc  to  be  recol- 
lected. 

Phftiintl  Siipit. — Dilatation  of  the  air-cells  is  acoompanicd  by 
physical  signs  which,  eoinbincd,  are  quite  distinctive  of  the  affection. 

Percussion  elicits,  with  few  exceptions,  an  exaggerated  resonance. 
The  resonance  is  delicient  tn  vesicular  quality  and  the  pitch  is  raised. 
The  sound,  in  other  wordo,  wiihonl  becoming  purely  tympsnilie, 
acquires  more  or  less  of  the  tympanitic  character;  it  is  vesiculo- 
tympanitic. The  cmphysemn,  existing  on  both  sides,  is  usually 
greater  on  one  side  than  on  the  other,  and  hence  a  disparity  between 
the  two  sides  is  apparent.  The  vcsiculo-tympanittc  character  of  the 
sound  is  obvious  on  both  sides,  but  tins  character  is  more  strongly 
narked  on  the  side  which,  at  the  eamo  time,  presents  other  signs 

<  Bokitaniikf . 

»  Tho  muthor  onnot  forbear  reftrrlng  Ihe  reader  to  ih«  view*  rMpnettn);  iho 
paltiuUic'cot  rvlHtiont  uid  llic  prtxluctioii  of  dilBtatiuu  of  tbo  cellii.  which  bnvq 
brwn  odvancod  bj-  Dr.  W.  T.  Ga[rdni>r«r  Killnbur;;h.  Thiwo  vlpwimm ceriainly 
higlilj  iiil<ii.'4tiii);  Hnd  iii^'nioua,  if  tlivv  arunotdnlinodlocfToct  b  radjonl  cbiinga 
Id  tbc  opinions  coDimonljr  bdM  on  ihrao  tntiJcRU.  V'irfr  Rrit.  Hnd  For.  XnA.  Chtr. 
Bevlew,  AjiHl,  18B8;  or  ■  Irualuu  entitlni  "On  Ibo  Pathologwdl  Anutomjof 
Broncbi^i.  snd  the  Dincuict  of  tho  Lung  canncctml  with  Bronulilal  Ub>l ruction. " 
Ediiiburt'b,  ISGO.     (SoVe  iii  flnl  editloD.) 


406 


DI8SA8BS  OF  THB  RBSPIBATOHT  ORaAXS. 


(l<-noUng  a.  gronter  amount  of  dilntation  of  the  air-c«1U.  Occamul 
exeoptioiift  to  lliv  nilc  of  vxagj^crsted  resonnnco  arc  observ^.  The 
rcifioiiance  on  tlio  isvIq  on  which  tho  ciiiphyKctna  is  greatest  mar  W 
dull  as  compared  with  the  oppoaile  side. 

When  a  notable  digparity  an  regards  intensity  of  resonuic?  be- 
tween the  two  sides  exists,  dulneas  maj  be  supposed  to  exist  on  iht 
side  yielding  the  lesser  degree  of  resonance,  without  due  t»tt. 
This  error  may  always  be  avoided!  by  attention  to  the  pilch  of  the 
sound  on  both  sides.  If  the  disparity  in  the  degree  of  resobaace 
between  the  two  sides  be  due  to  dalne««  on  one  side,  the  pitch  of 
sound  is  higher  on  the  dull  side;  if,  on  the  other  hand,  the  disparity 
be  due  to  exaggeration  of  resonance  on  one  side,  the  pitch  of  aonad 
is  higher  on  this  side,  and  the  ve^iculo-tympanitic  quality  also  raon 
marked.     To  the  rule  Just  slated  there  are  no  exceptions. 

The  sense  of  resistance  is  increased  orcr  emphysematous  lun^tn 
proportion  to  its  increase  of  volume.  In  cases  in  which  the  chest 
is  partially  or  generally  enlarged,  this  sign,  incidental  to  the  act  of 
percussion,  is  present  in  a  marked  degree. 

An  abnormal  intensity  of  resonanoc  is  found  in  the  pr»cordia. 
The  heart  may  be  removed  from  contact  with  the  walls  of  the  chest, 
and  c>irri[-(l  downwurd,  m>  Ihiit  hotwtren  the  sternum  and  nipple  thi 
chciit  bttconic*  highly  n-HOimiit.  If  the  einphyseina  affect  the  lower 
lobes,  thv  pulmonary  re«onance  extends  below  its  normal  limiia,  to- 
ward th«'  Uaw  of  the  chest.  For  example,  oii  the  right  mlv,  in 
front,  the  line  of  hepatic  flatness  may  be  dcprcHscd  to  tlio  ninth  or 
tenth  ribs  on  a  vertical  line  through  the  nipple;  and,  owing  to  thv 
permant-nt  expansion  of  the  lung,  this  line  is  found  to  vary  but  li 
with  the  successive  acts  uf  inspiration  and  expiration,  even  w 
they  are  voluntarily  invreased.  A  similar  extension  of  the  space 
occupif^d  by  pulmonary  resonance  is  apparent  on  the  lateral  and 
posterior  surfaces  of  the  chest  at  the  base,  and  also  at  the  summit, 
in  some  instances,  above  the  clavicle,  and  at  the  upper  part  of  th* 
sternum,  where,  from  its  relation  to  the  trachea,  the  normal  re»- 
nance  is  tympanitic. 

The  auscultatory  phenomena  due  to  the  emphysema  are  to  he  dis- 
tinguished from  those  attributable  to  bronchial  inflammation  which 
so  frecjiicntly  coexist.  Exclusive  of  the  sign*  to  which  the  hri>i>. 
chitis  gives  rise,  the  signs  pertaining  to  the  reiipiration  are,  in  tbera- 
•clves,  highly  characteristic  of  the  nffuction,  and  in  combination 
with  the  evidence  derived  from  percussion,  their  diagnostic  signiG- 


TE6ICCLAK    EMPHYREUA. 


409 


ee  i»  quite  pRBitire.  Feeblnitesa  of  the  reopiralory  murmur  is 
one  of  llie  distinctiTe  fealurea.  In  some  instances  a  r«8piratorj 
sound  is  inapprentalile  willi  the  ordinary  stethoscope  or  by  imrae- 
(ttnti;  auscuitiition,  and  is  scarcely  heard  with  Cammann'a  instru- 
ment. Oilier  things  being  equal,  the  feebleness  is  proportionate  to 
the  degree  of  the  emphysematons  condition.  A  disparity  exists  be- 
tween the  two  sides  in  this  particular,  and  the  greater  feebleness  of 
reipiratory  sound  is  on  the  side  presenting  the  greater  intensity  and 
vesiculo- tympanitic  quality  of  percussion-resonance ;  the  respiratory 
marniur  may  be  almost  or  quite  null  on  this  side,  and  the  intensity 
relatively  greater  on  the  other  side,  bat  yet.more  or  teas  below  the 
BOrmal  amount.  Apparent  exceptions  to  this  rule  may  be  found  at 
times,  if  the  bronchial  tubes  on  the  side  least  affected  happen  to  b« 
obstructed  from  an  aoctimuUtion  of  mucus ;  under  these  circum- 
stances, at  some  examinations,  the  respiratory  murmur  may  be 
stronger  on  the  side  most  emphysematous.  An  exaggerated  respira- 
tion may  exist  over  the  portions  of  long  to  which  the  emphysema 
doea  not  extend.  When  the  emphysema  is  confined  to  the  upper 
lobe,  the  respiratory  murmur  betow  the  scapula,  behind,  will  be 
found  to  be  in  a  marked  <Iegn>c  more  intense  than  at  the  summit  in 
front,  the  rever»e  being  the  ciiiX'  in  health. 

The  n-stpiratory  «ound  is  frequently  alicrod  in  other  respects  than 
intensity.  It  is  olmn^oil  in  rhythm.  The  inspiration  is  shortened. 
The  inspiratory  sound  i»  deferred ;  that  in,  more  or  less  of  the  tn- 
epiralory  act  takes  place  before  the  sound  is  appreciable.  Some- 
times a  very  brief  sound  only  is  heard  at  the  close  of  the  act.  The 
expiratory  sound,  on  the  other  hand,  is  often  prolonged,  sometimes 
exceeding  considerably  in  dnrntion  the  sound  of  inspiration.  The 
expiratory  sound  is  always  more  or  less  feeble,  but  its  intensity 
may  be  greater  than  that  of  the  sound  of  inspiration ;  the  latter 
may  be  almost  inappreciable  while  the  former  is  distinctly  although 
faintly  beard. 

i  The  respiratory  sound  also  undergoes  a  change  in  qaality.  It  is 
said  to  become  rough.  The  inspiratory  sound  has  less  of  the  vesic- 
ular quality  than  belongs  to  the  normal  murmur,  and  is  raised  id 

[pitch.     So  far  it  presents  the  characters  of  that  abnormal  modifica- 

ioit  generally  distinguished  as  roughnesg.     It  has  not,  however,  the 

■bnlosiiy  of  the  broncho-vesicular  respiration  which  represents  a 

inorLid  condition  the  opposite  of  rarefaction,  vIe.,  increased  density 

of  the  pulmonary  structure.     The  prolonged  expiration,  if  it  be  a 


410 


DISKASBS  or  TBB   BBSPIRATORT  0R0A59. 


pure  resptrstory  souml  wlthoab  &d  admixtare  of  k  eibilsnt  rale,  i* 
lower  in  pilch  than  ihe  Bound  of  inspir&iioD,  whereas  in  the  lirmt- 
cho-vesicutsr  reapii-xlion,  the  pitch  of  ih«  prolosged  expiratot; 
eonnd  is  higher  than  that  of  the  sound  of  inspiration.  In  emphjrgcm 
the  expiraUHTj  i»  generaU;  continaons  with  the  ioepiraiorT  soud. 
In  condensation  of  lung  a  brief  interval  separates  the  two  aonnds. 
The  shortened  inspiration  in  emphysema  is  deferred;  in  condenaa- 
lion  it  is  iiniiniMfttd. 

In  the  majority  of  inntancos,  at  the  time  the  afTectioa  comes  Dufcr 
the  observation  of  tlie  physician,  it  Mt  associaliMl  with  bronchitis,  and 
frequently  with  bronchial  Hpasm  constituting  an  attack  of  asthma. 
Under  these  circumfilnnces,  physical  Btpns  ar*  prcwjnt,  due  to  the 
coexisting  affections,  but  more  or  less  mi>difie<l  liy  the  vniphysosa. 
The  DioiAl  bronchial  rales  are  observed  in  a  certain  proportion  of 
cased,  consisting  of  the  line  mucous  or  tfao  sotM^repilant  Tariety, 
if  the  inflammation  ext«nd  to  the  smaller  tubes.  Much  ofieoer  the 
dry  rules  nre  present — the  sonorous  fln<l  sibilant.  Id  asthmatic 
paroxysms  these  rales  are  loud  and  difirut>ed.  accompanied  by  wheel, 
ing which  maybe  heard  at  a  considerable  distance  from  the  patiraC 
Exclusive  of  asthma,  they  denote  bronchial  inSammation  superadded 
to  the  emphysema.  The  rales  often  take  the  plac«  of  the  respiratory 
sound,  t.  e.,  nothing  else  is  heard.  They  are  generally  more  marked 
in  expiration  than  in  iii»piration;  and  the  sibilant  is  oftener  beai4 
than  the  sonorous,  exolusire  of  the  complication  of  asthma. 

Auscultation  of  the  voice  furnishes  negative,  or  at  loaat  doablfal, 
results  in  case;)  of  emphyst'roa.  .Judging  from  my  own  observaiioH, 
I  would  Hay  that  the  vocal  resonance  does  not,  in  general,  undergo 
either  marked  increase  or  diminution  in  (his  aSection.  It  is  c«rtsiB 
that,  if  it  bo  miiterially  modified,  the  modifications  arc  occasiooal, 
Eiot  constant.  I  have  observed  the  naturally  greater  vocal  reso- 
nance of  the  rijfht  side  to  be  presterved  when  the  emphysema  was 
limited  to  the  left  side  (us  di^termined  ly  other  signs),  and,  on  the 
other  hand,  I  have  observed  the  same  natural  disparity  when  the 
greater  amount  of  emphyseniu  was  on  the  right  side.  Walshe  states 
that  intense  bronchophony  may  exist  over  lung  greatly  rarefied. 
I  cannot  but  suspect  in  such  instances  that  it  is  due  to  a  normal 
peculiarity,  existing  irrespective  of  the  emphyM>ma. 

Auscultation  in  the  prrecordial  region,  with  reference  to  the  pul- 
monary and  cardiac  soundn,  affords  a  means,  in  addition  to  perens- 
sion  and  palpation,  of  determining  whether  the  heart  be  abnormally 


TB8IC0LAR    KUFOTSEHA. 


411 


'overlapped  by  lung,  or  displaced  from  its  normal  Rituation.  The 
pr«soDee  of  a  layer  of  lang  between  that  organ  and  the  thora<:ia 
vails  may  be  shown  by  a  feeWo  respiratory  iniirranr,  or  by  ihe  Iiron- 
chial  rales  difTused  over  llie  whole  of  the  prteconlia.  The  hcnrt. 
sounds,  under  these  circumotancoR,  are  faint  and  dititant.  They  may 
be  inappreciable  in  the  prrecordla,  lint,  if  ihc  displneerncnt  hv  down- 
war«I  lowanl  the  epigastrium,  they  may  be  heard  with  di^tiiiclnesB 
in  the  latter  situation. 

Inspection  furnishes  striking  corroborative  evidence  of  the  exist- 
ence of  emphysi'iiia.  The  frequency  of  the  roitpirations  is  often  abnor- 
mal. Habitually,  if  dyMpnocn  bo  absent,  nnil  the  breathing  slightly 
or  roodt'ratcly  labored,  the  number  of  respirations  per  minute  may 
be  found  to  he  below  the  normal  average.  This  may  be  the  case  if 
obstruction  of  the  bronchial  tubes  from  bronchitis  or  spasm  aecom- 
panicfl  the  emphysema.  Slowness  of  respiration,  however,  by  no 
means  characterizes  all  cases  of  the  affection.  If  the  emphysema 
be  sufficient  to  give  rise,  of  itself,  to  dyspno^a  whenever  the  circu- 
lation is  accelerated,  or  from  other  causes  irrespective  of  bronchial 
obstruction,  and  eHpecially  if  the  emphysema  involve  atrophy  as 
a  predominant  anatomical  element,  freijuency  of  the  respirations 
may  be  a  prominent  feature.  In  a  case  of  atrophous  emphysema, 
I  have  obser^-ed  the  number  of  respirations,  on  exercise,  increased 
to  60  per  minute. 

W  In  eases  of  general  or  extensive  dilatation  of  the  cells,  the  rhythm 
of  the  respiratory  act:*  is  altered,  ihf  deviation  corresponding  to  that 
of  the  respiratory  sounds.  The  inspiratory  movement  is  shortened. 
The  lunps  being  permanently  expanded,  ihc  extent  of  their  farther 
expansion  with  the  inspiriitory  act  is  proportionally  lessened  ;  the 
act,  therefore,  i«  more  quickly  performed,  and,  moreover,  if  dyspncea 
be  present,  the  want  of  a  fre«h  supply  of  atmospheric  air  causes 
the  act  to  be  hurried.  The  expiration,  on  the  other  hand,  is  pro- 
longed in  consequence  of  the  impaired  contractility  of  the  pulmonary 
organit,  and  because  more  expiratory  force  can  be  exerted.  When, 
in  addition  to  the  impaired  contractility,  the  bronchia]  tubes  arc  ob- 
structed, which  occurs  if  the  emphysema  be  complicated  with  in-  " 
flammalion.  or  spasm  affecting  the  smaller  bronchial  lubes,  the  ex- 
piratory  movement  is  still  more  prolonged,  owing  to  the  obstruction 
offered  to  the  passage  of  air  from  the  cells.  Under  these  oircum- 
9Cf*,  ami,  indeed,  from  the  impaired  contractility  of  the  lung 


413 


DISSASIIS  or  THB  BBBPIRATOBT  OROAITS. 


Blonc,  th«  Ubor  Ani  slovncM  vith  which  expiration  U  perfonntJ 
increase  from  tlio  bpginiiini;  to  tlie  v1o»«  of  the  act. 

Certain  charnctvmtio  i^igns  pertain  to  the  appctwrance  of  the  chM 
while  in  rest  and  in  motion.  If  the  volume  of  tho  upper  lohei  be 
con»icIerab1j  augni'tutetl,  the  fonn  of  tlie  che»t  is  aUered.  Tbt 
superior  and  midiili;  thir<]»  prest-nt  an  unnoturallj  roundnl,  gloholu, 
barrel -shapcil  appeurance.  This  change  in  tome  ca«e«  amoanU  to  a 
dvfonnity  which  iKpathognomonie  of  the  affection.  It  is  more  apt  (oW 
marked  in  case*  in  which  the  cmphj'semn  lias  been  of  long  etandini;, 
and  has  existed  from  early  life.  Partial  vnlargement  between  the  cUt- 
icle  and  a  point  at  or  a  little  below  the  nipple,  the  degree  of  enlarge- 
ment approaching  to  that  of  full  inspiration,  is  not  tmeommon.  Thii 
abnormal  fulness  will,  of  conrsc,  he  greater  on  one  side  than  on  the 
other,  owing  to  the  fact  that  the  two  lungs  are  rarely  equallj  affected; 
and  as  tlie  left  lung  is  oftener  more  augmented  in  rolume  than  tli« 
right,  it  will  he  oftener  observed  on  the  left  side.  In  eomparing 
the  two  sides  with  reference  to  lliis  point,  it  is  to  be  borne  io  mind 
that  normally  n  disparity  exists  in  the  anterior  portion  of  tW  chert 
in  many  persons.  According  to  the  observations  of  M.  Woillei, 
the  left  flide  preHeots  a  projection  obviously  greater  than  the  right, 
above  a  point  at  or  a  little  below  the  nipple,  in  about  26  per  cent, 
of  persona  free  from  diseaee  or  deformity.  It  b  not  improbable 
that,  owing  to  this  natural  .diaparily  having  been  overlooked,  » 
greater  relative  fulness  of  the  summit  of  the  left  aide  may  in  some 
instaneea  have  been  incorrectly  attributed  to  a  larger  amount  of 
emphy»oma  en  that  Kide.  A  tedt  of  the  prominence  here  or  e1ae> 
where  being  due  to  the  pros.*ure  of  rarefied  lung,  is  aff'onled  by  the 
re«iilts  of  pcrcuDKimi  aud  auncultitlton. 

In  some  ca^ea  of  emphysema  the  expanded  lung  effaces  the  de- 
pression existing  above  the  clavicle,  cauaing  a  bul|png  in  this  situ- 
tion.  Tliif,  when  present,  is  highly  cbaraclerislio,  bat  it  is  rarely 
observed. 

The  inferior  portion  of  the  chest  may  appear  to  he  cooaiderablj 
contracted.  Tlus  is  in  part  apparent,  rather  than  real,  in  eonae- 
qucDce  of  the  enlargement  of  the  superior  portion,  but  it  ia,  also, 
in  some  cases,  to  a  greater  or  lees  extent,  real ;  the  dimensions  of 
the  chest  at  its  lower  part  are  actually  les~4ened.  On  the  other  hand, 
the  upper  part  of  the  abdomen  may  acquire  an  unnatural  fuliKia 
and  resistance  to  pressure,  owing  to  the  flattening  of  the  diaphragm 
which  pres-iea  downward  and  outward  the  organs  lyiug  below  tt. 


TISIOPLAB   BMPBT8BHA. 


418 


A  close  examination  of  ihc  expanded  portion  of  the  chest  E^howv 
be  Bome  relalionH  of  its  different  purts  which  ohtain  m  health  at  the 
ltd   of  a  fiill  iriiipiratioti,  vi;i.,  the  obliqttity  of  the  ribs  U  diniin- 
shed;  the  ribs  and  costal  cartilages  are  nearly  on   a  line;    the 
[ihoiildcrs  are  raised;  the  intercostal  spaces  are  narrowed  at  the 
tuinmit,  and  widened  over  the  middle  of  the  ohe.<)t. 

Fktionts  who  have  suffered  long  from  eraphysemn  gcnemlly  pre- 
wnt  spinal  curvature  more  or  less  marked.    The  dori<at  curve  is  in- 
creased; the  lower  angles  of   the  ocHpulre   project,  and,  hence,  a 
stooping  gait  is  somewhat  charecleristic.     These  changes  arc  some- 
I  times  highly  marked. 

The  condition  of  the  intercostal  spaces  in  parts  of  the  chest  en- 
larged by  the  distension  of  emphysematous  lung  has  been  a  mooted 
poitiL  According  to  Dr.  Stokes,  the  effect  is  never  to  efface  the 
depression  between  the  ribs.  Observation,  however,  appears  to  have 
established,  what  would  rationally  be  expected,  thut  at  the  enmmit 
fof  the  chest  the  imercostnl  muscles  yield  to  the  pressure  of  the  lung 
wore  readily  than  ibc  rib:*,  and  hence,  that  the  ileprei'sionB  in  per- 
son.'* in  whom  they  arc  visible  in  thi«  situation  in  health  become  di- 
minished, if  not  effaced.  That  this  is  rarely  observed  at  the  lower 
part  of  the  cliest  in  front  and  laterally,  where  the  depressions  are 
most  conspicuous,  is  true.  One  reason  for  this  is,  the  emphy- 
sema is  limited  to,  or  is  mach  greater  at,  the  upper  portioti  of  the 
lungs.  Another  reason  is,  the  traction  of  the  diaphragm  renders 
the  depressions  deeply  marked  during  inspiration,  notwithstanding 
the  increase  of  the  volume  of  the  lung. 

Characteristics  relating  to  the  movement*  of  the  chest  are  not  less 
[Btriking  than  those  incident  to  alterations  in  size  and  configuration. 
When  the  au^ented  volume  of  the  lung  U  sufficient  to  keep  the 
.  chest  permanently  dilated  at  a  point  not  much  below  the  limit*  of  a 
,  full  inspiration,  of  course  the  range  of  expansive  movement  in  res- 
piration is  correspondingly  restrained.  The  thoracic  walls  at  the 
[tiipcrior  and  middle  portions  contract  but  little  with  expiration,  and 
tthe  enlargemeul  with  inspiration  is  slight.  The  dyspnua,  however, 
I'aspccially  when  increased  by  any  superadded  cause  affecting  hsema- 
|tMJ8,  such  H8  ozereise,  the  existence  of  bronchitis,  or  bronchial 
jive*  rise  to  extraordinary  efforts  to  expand  the  chest.  The 
these  efforts,  so  fur  as  they  are  exerted  on  the  thoracic 
falls,  i«  to  elevate  the  ribs ;  and,  as  the  costal  cartilages  are  already 
P.  straightened  by  the  permanent  cxpanaioD,  the  elevation  of  the  ribs 


414 


DI8BA8R8  OP  TBR  RBSPIKATOBT  OBOAITS. 


oarriea  Ute  8t«rniun  opirard,  so  that  the  whole  cfacst,  mclnding  in 
some  inetances  the  clavicles.  rUes  and  fnlk  with  8ucceuiv«  ncpin* 
lory  8ct8,  as  if  it  were  a  solid  bony  case. 

The  diaphragm  participates  in  these  cxaj^gvralcd  effort*;  fast  if 
the  einphysoma  extend  to  the  lower  lobes,  the  range  of  the  dinphrif 
matie  movenient  Is  diminished,  and  the  rising  and  falling  of  the  ab- 
domen is  less  than  in  health.  If  the  emphysema  be  acconpaBM 
by  broDchinl  obstruction,  the  lower  part  of  the  sternum,  the  rptg»- 
trium,  and  inferior  portion  of  the  chest,  laterally,  arc  dcpreatJ 
with  JDspiratioii,  the  natural  movements  being  rcvei^sed.  This  ariMS 
from  the  depression  of  the  diaphragm  elongating  tb«  tting,  prodnciif 
a  vacuum  which  is  not  filled  with  sufficient  rapidity  by  the  air  re- 
ceived into  the  bronchial  tubes,  and  consequently  the  weight  of  the 
atmosphere  presses  the  walls  of  the  cbest  inward.  This  is  let 
marked  in  aged  persons  in  whom  ossification  of  the  costal  cartilage* 
has  taken  place. 

The  lateral  niiteriur  intercostal  deprcHiions  at  the  lower  part  of 
the  che^t,  arc  gcni-rnlly  deeply  marked  with  the  act  of  inspiration 
ID  proportion  to  the  exaggerated  diaphragmatic  effort;  and  at  tbe 
summit  of  the  cheat,  the  Hpaccs  above  and  below  the  claricles  are 
not  infrequently  (lepreiwed  with  this  act. 

The  foregoing  account  of  the  aberrations  of  motion  have  rcfw 
encc  to  appi'unincm  manifested  on  both  sides  of  the  cheat.  CaM 
in  which  the  emphysema  is  limited  to  one  side  are  extremely  rare  if 
they  ever  exist;  but,  as  has  been  seen,  when  both  lung^  arc  affected,il 
is  seldom  that  there  does  not  exist  an  inequality  in  thcsiooant  of  the 
affection  in  the  two  sides.  The  eRecls  on  the  respiratory  nov» 
uienl»,  as  well  us  on  the  size  and  form,  will  then  be  monr  markeil 
OD  the  side  which  i«  most  affected,  the  disparity  as  regardw  the  Eigni 
furnished  by  inspection  corresponding  to  the  differences  developed 
by  a  comparison  of  the  results  of  pcrcuxt^ion  and  auscultation. 

Mensuration  affords  a  means  of  verifying  the  abnormal  changul 
in  size  and  the  aberrations  of  motion,  which  are  determineil  »uffi. 
cicntly  for  diagnosis  by  inspection.  To  state  the  resulta  funii^hed 
by  this  method  would  be,  for  the  most  part,  to  repeat  what  has  jut 
been  presented. 

Palpation  fumishea  same  signs  of  importance.  The  altcralioM 
in  shape,  the  condition  of  the  intercostal  spaces,  the  nobility  of 
portions  of  the  chest,  the  direction  of  the  ribs,  and  their  moTcmcnu 
relatively  to  each  other,  are  pointa  which  ate  ascertained  by  the 


TRSIOULAB    KMPHYSBUA. 


415 


Ttoach  as  Tell  as,  and  in  some  resp^U)  better  tlinn,  by  the  rT«.     The 
iMiiHC  of  reaUtance,  of  whieli  a  judgment  i»  formed  incidentally  while 
If  ractifing  iirrcuasion,  may  be  made  a  separate  object  of  vxamioa- 
[tion,  and  it  then  falls  under  the  head  of  palpation.     Am  rcttpccte 
the  vibratory  thrill  communicated  to  the  thoracic  walls  by  the  voice, 
And  felt  by  ihe  hand  applied  to  the  chest,  in  other  wordti  the  vocal 
[fremitus,  it  is  found  to  vary  in  different  cnacs,  being  in  some  in- 
stances increased,  oftener  diminished,  and  in  other  instances  re- 
■saining  unaffected.     There  is  no  constancy  of  relation  between  this 
sign  and  the  affection;  hence,  in  its  bearing  on  the  diagnosis,  it  is 
unimportant. 

Examination  with  the  hand  is  important  in  order  to  ascertain  the 
[•itualion  of  the  heart.  The  absence  of  the  cardiac  impulse  in  the 
pnci'onlia  xhow.*  tins  organ  to  be  removed  from  coniuet  witli  the 
thoracic  walls.  When  it  is  depressed  to  the  neighborhood  of  the 
cpignMrium,  it«  pnlsations  may  he  fcilt  to  the  lefl  of  the  ensiform 
cartilage.  Tbc  impnlic  is  not  infrequently  transferred  to  this  situ- 
ation. 


Diagnotit. — The  physical  phenomena  incident  to  vesicular  em- 
phytema,  as  already  remarked,  are  highly  distinctive  of  the  affec- 
lion.  With  an  ade'iuate  knowledge  of  iheae  phenomena  the  diag- 
nosis is  sufficiently  easy  and  positive.  Without  the  advantage  which 
ibis  knowledge  aiforda,  the  symptoms  might  be  supposed  to  denote 
Bome  other  disease  of  which  dyspniEa  is  a  prominent  feature,  for 
example,  disease  of  the  heart,  aortic  aneurism,  chronic  pleuritis, 
pneumo- by  d  roth  oral,  capillary  bronchitis,  pneumonitis,  and  pul- 
monary tuberculosis.  It  will  suffice  to  mention  the  more  important 
points  involved  in  Ihe  differential  diagnosis  from  the  several  affec- 
tions just  named. 

From  heart  disease  emphysema  is  diatinguisbed  by  the  absence  of 
the  physical  signs  of  the  former,  except  it  has  become  developed  aa 

complication.  If  the  complication  have  occurred,  the  previous 
'Iiistory,  in  general,  affords  evidence  of  disturbance  of  the  respira- 
tion for  a  long  period  prior  to  palpitations,  or  other  symptoms  of 
cardiac  disturbance.  With  or  without  the  conjunction  of  the  symp- 
toms and  eigne  of  disease  of  heart,  the  existence  of  emphysema  js 
evidenced  by  the  combined  physical  phenomena  distinctive  of  the 
affection,  which  have  been  fully  considered. 

Aneurism  of  the  aorta,  may  cause  &  partial  enlargement  of  the 


416 


DISBASKS  OF  THE  RSSPIRATORT  OROAMS. 


clicflt  from  tlie  pressure  of  the  tumor.  Bat  over  the  eDlargtannt 
Uw  purciiMion-Jtouiid  will  \xi  dull  or  flal,  in  place  of  the  incresMd 
rmonanov  due  to  r»rffiod  lung.  The  positive  ngns  of  empbjwu 
vill  be  wanting,  while,  on  the  other  hand,  an  aneurismal  tcuBer  bu 
iu  positive  signs,  vis.,  pulaalioD,  thrill,  and  a  bellows'  Maftd  fjn- 
chronous  with  the  heart's  action. 

From  pleuritiii  with  effusion,  empbyaema  is  distinguisihed  b;  tht 
enl»rf;ciii<-nt  of  the  chciit  (if  it  exist)  being  on  both  sidea,  atid  nt  ibe 
summit,  iiiMtcad  of  the  base,  and  by  the  absence  of  Hnlncn  i<r  fiat- 
nrs3  on  percussion,  extending  orer  more  or  leas  of  one  side 

So  fur  aa  physical  atgna  arc  concerned,  the  affection  to  which  nn- 
physcina  bears  the  nearest  resemblance  is  pneumo-hydrolborax.  la 
pneumo-bydrothorax  the  presence  of  air  in  the  plearal  hc  cauMi 
dilatation  of  the  chest,  abnormal  sonorousness  on  peretu»ioR.  and 
suppression  of  the  vesicular  murmur  of  respiration.  Bat  as  regard* 
thv  physical  phenomena,  circumstances  distinguishing  the  two  affec- 
tions are  sufficiently  marked.  In  pneumo-hydrothorax  the  percoa- 
eiun-resuiinnvf  is  purely  tympanitic,  whereas  in  etnpbyacma  the  reno- 
ular  quality  of  sound  h  diminished,  hut  not  Inst.  The  latter  affeo- 
tion  nuvcr  acquires  the  oxtretnu  druto>likc  sonoroiumcxs  which  diar- 
acterizcs  dilatatiun  of  the  chest  from  air  within  the  plcnral  sac  Is 
pncumo-hydrothorax  thv  aonorousnett  frequently  «xt«Dds  lo  a  co^ 
lain  distance  from  the  euiiimit  of  the  chest,  and  below  the  pouii  to 
which  it  extends  there  exists  flatness  on  percussion,  owing  to  the 
presence  of  liquid;  iu  emphysema,  when  the  aflfcction  is  limited  i« 
the  superior  portion  of  llic  lung,  percussion -resonance  exiatd  ai  the 
lover  part  of  the  chettt.  Pneumo-hydrothornx  is  always  conSned  to 
one  side  of  the  chest ;  this  is  very  rarely,  if  crcr,  true  of  emphy- 
sema. Moreover,  pncumo-hydrothorax  has  its  characterisiio  phyn- 
cal  signal,  which  never  occur  in  connection  with  emphysema,  rii., 
amphoric  respiration,  metallic  tinkling,  splashing  on  succussion.  Ib 
the  vast  majority  of  cases,  piicumo-hydro thorax  oecars  from  perfo- 
ration in  the  course  of  tuberculosis  of  the  lungs,  and  the  existence 
of  tlie  latter  disease  Is  shown  by  the  pre-existing  and  coexisting 
signs  and  symptoms. 
I  Emphysema  complicated  with  ordinary  acute  bronchitis  presents 
certain  of  the  diagnostic  features  of  bronchial  inflammation  seated 
in  the  minute  tubes.  In  capillary  bronchitis  the  percussion-wnnd 
may  be  exaggerated,  and  become  vesicalo-tympani tic  TbedyspfKH 
in  both  cases  may  be  extreme.     The  one. affection  is  atl«ode<l  with 


VKSICULAE    SMPHYSEMA. 


417 


I 

I 
I 


mg^r,  the  oll»;r,  Iiowerer  distrestiing  tbc  svinptoms.  is  rnrcljr 
iw.  The  syniiitoiii.*  ani]  signs,  tnk<'n  in  eoiiiiectiun  with  the 
previouit  bistury,  suflice  for  the-  iliHuriminiition.  Cnpillnr;  brondiiiis 
is  nccouipiiiied  by  great  acceterntion  of  ihc  piil*e  ;  in  emphysema 
with  ordiiinry  brunchitii*  the  puUc  is  nimlcriitelj,  if  ut  nil,  iRcrensc<I 
in  frefiueiicy.  In  cnpillnry  bronubitiM  Hic  Kub-crcpitnn(  rnlo  is  dif- 
fu.«ei]  over  the  chest  on  both  *idcs,  ci'peoinlly  over  the  poslerior  «iir- 
fnce;  in  cmphysfiuu  it  is  nn  oecn«ionitl  tsign,  ani]  never  *io  timeb 
dilfuMvii.  CapiUnry  bronchilis  occurs  especially  in  childhood  ;  cm- 
pfivauma,  sufficient  to  give  rise  to  great  dUturbance  of  the  respira- 
tion in  connection  wiih  ordinary  bronchitis,  is  rarely  observed  in 
cnrlj  life.  In  cases  of  emphysema,  in  which  the  symptoms  arc  ren- 
dered severe  by  an  intercurrent  ordinary  bronchitis,  the  previous 
liistory.  in  the  vai^t  majority  of  «ai^cs,  shows  clearly  the  existence, 
for  a  long  period,  of  dilatation  of  the  cells,  and,  in  a  large  propor- 
tion of  instances,  the  patient  is  subject  to  attacks  of  asthma.  These 
circumslances  have  an  important  bearing  on  the  differential  diagnosis, 
from  not  only  capillary  bronchitis,  but  other  affections  with  which 
emphysema  may  possibly  bo  confounded. 

From  pneumonitis  and  phthisis  the  differential  diagnosis  is  settled 
at  once  by  the  plmieal  si^ns.  In  each  of  these  alTecliona  there  arc 
present  the  physical  phenomenu  denoting  so  lid  i  Gentian  of  iuiig,  vis., 
dulncss  on  percussion,  bronchial  or  broneho-vcsicular  respirnlion, 
incrci«cd  vocal  resonance  or  bronchophony,  exnggcrntcd  bronchial 
whivper  or  whispering  bronchophony,  and  increase  of  fremitus. 
TbM*  points  of  distinction  are  abundantly  sufficient,  irrespective  of 
those  pertaining  to  symploraa  and  pathological  laws  which  arc  also 
distinctive. 

In  ooncluiiion,  the  diagnosis  of  emphyacma  requires  only  sn  bo- 
quaintance  with  itK  symptoms,  signH  and  pathological  laws.  ^Vith 
this  knowledge  it  is  recognised  without  dilTicully  in  ca»e8  in  which 
the  dilaiKtion  of  the  cells  is  suflJcieut  to  give  rise  to  the  churaclcr> 
istic  phenomena  of  the  affection. 


SVMUAItr   OF  TBR   PHYSICAL  BIOKS    DCLONOIXO   TO  TESICUI.AK 

RMPIITSEMA. 


Ezitggcrstod  resonance  on  percussion,  with  b  few  exceptions,  and 
Ui*  resonance  vcsiculo- tympanitic     Sense  of  resistance  increased. 

2T 


418  DlgBASES  OP  THE  BB8PIKAT0BT  OBOAVS. 

FflobleiiL'M.  and  in  t<omc  iitfltnnceM  iiuppre'«»ion  of  ttie  respiratory 
tnurmur.  Inspiratory  sound  shortened  (dcfprn.-d) ;  «xpir»tioii  pnh 
longi-d,  but  the  pitch  of  expiration  not  bigbtr  tlian  ()iat  of  inspira- 
tion. The  bronchial  rales  denoting  bronchitiii,  or  »p«siD,  o(te« 
prL-«ont,  esp&cinlly  the  dry  ralps,  ftnd  nsunlly  more  marked  vilk 
expiration.  The  ini-pirAtory  movemcnU  quicki'iiPH]  and  shorteued, 
and  those  of  expiration  prolonged.  The  upper  anterior  portion  of 
the  chest,  enlnrged.  more  or  lees,  within  the  limits  of  a  full  iuHpir*- 
tion.  The  space  above  and  belov  the  clavicle  occa»ionally  bulging. 
Curvature  of  the  dorsal  portion  of  the  spine  fwrwarti,  if  the  dip- 
ease  hare  been  of  long  standing.  The  whole  chest,  in  c«m«  is 
which  the  affection  is  sufScient  in  degree  and  extent  to  give  rise  to 
dyspnena,  elevated  as  one  pieee,  in  inspiration,  vitb  but  slight  ex- 
pansion. The  movementa  of  the  diaphragm  reslraincd.  The  beatinf 
of  the  heart  not  felt  in  the  pnecordia,  but  in  some  iastances  at  tlic 
epigastrium. 

Ihtbblobulab  Emphysbha. 

In  this  form  of  empbysetna  air  is  extravasated  into  the  areolar 
structure  uniting  together  the  pulmonary  lobules,  The  morbid  con- 
dition is  identical  with  emphysema  seated  beneath  the  external  tegu- 
ment of  the  body.  To  the  latter,  inde«d,  it  may  give  rise,  the  air 
following  the  root*  of  the  lungs  into  the  mctlinittinum,  thence  into 
the  ftiilicntftueous  areolar  tissue  of  the  ncfk,  and  becoming  more  or 
le^  diflfiised.  Interlobular  emphysema  is  almoHl  invariably  trau- 
matic, arising  from  rupture  of  the  air-vesicles  in  conseqnencc  of 
violent  respiratory  efforts.  It  is  a  rare  affection,  llie  anatomical 
characters  consist  of  enlargement  of  the  interlobular  septa,  tlie  in- 
creased size  being  greater  toward  the  surface  of  the  lung,  causing 
them  to  assume  a  wedge-like  shape,  and  detachment  of  the  plroia 
by  the  pressure  of  air  beneath  this  membrane,  producing  air-bladder*, 
variable  in  size,  and  more  or  less  numerous.  These  air-bladders 
somclimes  attain  to  a  considerable  she.  I  have  seen  a  globalsr 
tumor  thuH  formnd,  »»  large  ii»  an  English  walnut,  and  they  have 
been  observcil  still  larger.  In  a  oase  reported  by  BonilUnd,  there 
existed  a  sac  flo  large  that  it  reoeiubled  the  stomach.  Tbey  are 
movable  by  pressure,  niid  if  there  he  several  they  may  be  made  to 
coalesce.  Similar  sacs  are  sometimes  found  beneath  the  surface, 
differing  from  those  caused  by  coalescence  of  the  air-vesicles  in  the 


TNTBRLOBTILAIl  EHPHTSKUA. 


419 


I 


I 


',  tliivt  tliey  &rc  se»tcd  in  the  mlcrlubuliir  areolar  structure.  In 
some  caocti  the  surfnce  of  the  lung  is  studded  with  numerous  small 
elevations  of  the  pleura,  presenting  bd  appearunce  couspareil  by 
Bokitansky  to  that  of  froth.  Close  examination  of  sections  of  lung 
affected  with  interlobular  emphysema  shows  the  air-vesicles  to  be 
unaffected,  except  by  the  pressure  of  the  enlarged  septa,  and  the 
cavities  formed  in  the  areolar  tiasue. 

This  form  of  omphyseina  occurs  in  children  more  frequently  than 
in  adults.  It  is  oftcner  situated  in  the  upper  tbun  in  the  lower  lobes, 
aitd  is  most  prone  to  occur  along  the  niitorior  borderit  of  the  upper 
lobes. 

The  symptoms  are  tlioste  incident  to  defective  liwmatwis,  this 
being  proportionate  to  the  extent  to  which  the  nir-vc»iclca  arc  com- 
pressed by  the  abnormal  size  of  the  iiiteretitinl  areolar  tissue,  and 
to  the  mechanical  obstacle  to  the  expansion  of  the  lungs  from  the 
presence  of  !<ul)-iileiiritl  extriivusation  of  air.  CaseH  hnvc  heen  re- 
ported in  which  sudden  death  was  attributed  to  the  raptd  escape  of 
air  from  the  cells  into  the  areolar  tiiisue.  Rupture  of  the  pleural 
air-bladders  may  take  place,  giving  rise  to  pneumothorax,  and  col- 
lapse of  the  lung.  Owing  to  the  great  infrequency  of  the  affection, 
the  historiej*  of  well-attested  ciiscs  have  not  as  yet  accumulated  suf- 
ficiently to  furnish  data  for  determining  its  symptomatic  characters ; 
or,  at  all  events,  an  analysis  of  recorded  casea  is  yet  to  be  made. 

The  remark  just  made  with  respect  lo  symptoms,  will  apply  equally 
to  physical  phenomena.  Laonnec  attributed  to  this  affection  two 
signs,  neither  of  which  have  been  found  by  subsequent  observation 
to  possess  the  significance  attached  to  them  by  the  discoverer  of  aus- 
cultation. One  of  these  is  the  indeterminate  sign  styled  by  Laennec 
the  dry  crepitant  rale  with  large  bubbles  (rale  crepitant  »eo  a  groiigea 
bullea) ;  and  the  other  a  friction  sound  (bruit  df.  /rottement).  The 
first  of  these  two  signs  is  so  doubtful  in  its  character,  ttA  well  as  in 
its  relation  to  pathological  conditions,  that  it  is  clinically  unimpor- 
tant. The  second  may  possibly  be  present  in  some  cases  of  inter- 
lobular emphysema,  but  occurs  in  the  vuist  proportion  of  instances 
in  connection  with  inflammation  of  the  pleura.  The  rarefaction 
of  lung  induced  by  the  presence  of  air  in  tbe  areolar  structure 
must,  of  cotirse,  give  rise  (except  the  tension  of  the  thoracic  walls 
bo  very  great)  to  exaggerated  resonance  on  percussion  ;  and,  also,  to 
feebleness  of  the  respiratory  murmur  in  proportion  as  the  air-vesicles 
are  compressed  and  the  expansion  of  the  lung  restrained.     The 


420 


DI8BABBS  OP  THB   RI3PIRAT0RT   OROAKS. 


combioalion  of  the  phjaica]  nigiiH  fumiiilied  by  percossion  a&d  ttu> 
cuUation  is,  thus,  the  wime  as  in  tlw  ordinary  form  of  emptiTMDU, 
viz.,  dilatation  of  the  air-cells.  The  differotitial  diagnosis  from  iht 
latter,  with  our  f  retwnt  knovledgv  of  the  oubjcct,  eo  fur  m  the  rjin^ 
toms  and  iignf  rcfcrHble  to  the  chest  >re  concerned,  would  he  \m- 
practicable.  Circumslanws  in  some  cases  incidental  to  the  affection, 
may  enable  the  phvsician  to  make  the  discrimination  clinically.  If 
the  physical  signs  and  symptoms  denoting  rarefaction  of  long  W 
developed  suddenly,  or  with  more  or  less  rapidity,  e*idenlly  procced- 
inj;  from  an  injnry  occurring  in  comiectioti  vith  some  unusual  effort 
of  the  respiratory  organs,  for  example,  after  violent  coagbing,  the 
straining  of  parturition,  a  strong  mental  emotion,  etc,  the  proba- 
bility is  that  the  emphysema  is  traumatic  and  interlobular.  If  sab> 
cutancoufi  emphyu-ma  of  the  neck  follow  under  these  circntn^tanctf, 
the  <Iiagno»tfi  is  rendered  quite  positive.  External  emphysema,  how- 
ever, unless  it  occur  in  eonjnnciion  with  the  physical  signs  dcnodag 
rarefaction  of  lung,  is  not  evidence  of  this  niorhid  condition,  for  it 
may  proceed  from  rupture  of  the  iraclioa  or  bronchi  exterior  to  th< 
pulmonary  organs.  Happily,  owing  to  the  great  infrc<|ucncy  of  this 
Tariety  of  cmpiiysciua,  the  absence  of  traits  sufficiently  distinct)r« 
to  warrant  a  positive  diagnosis  in  all  instances  is  rarely  tlio  occui«ii 
oF  flmbarrusfioient  in  medical  practice. 


CHAPTER    V. 


PCLHONABY  TUBEKCULOSIS-BRUNCBIAL  FBTHISia 


TuK  affection  called  palinonarv  tuberniiloBis,  phthisU  piilmonalis, 
or  puttnonnry  conaumptinn,  involves,  as  llio  point  of  departure  for  a 
Beries  of  destructive  processes,  the  deposit  in  the  lungs  of  the  mor- 
bid product  called  tubercle.  The  nature  of  thia  product,  the  pre- 
cise stttintion  in  whtcli  it  is  6rst  deposited,  its  var^'ing  charaelera, 
the  ni('tiiniorpti«w;s  which  it  undergoes,  and  ihc  Hlmcturai  cliaiigcs 
incident  to  the  progress  of  the  disease,  are  subjecis  vfhich  could  not 
be  touched  upon  without  risk  of  being  K>d  into  details  incoTisi.''tont 
with  the  limits,  as  well  as  the  plan  of  this  work.  Presuming  the 
reader  to  have  a  general  acquaintance,  at  least,  with  the  morbid 
anatomy  of  the  diswisc.  I  shall  jiimply  enumerate  the  abnormal  con- 
ditions which  stand  in  immediate  relation  to  the  phonomcna.furnisbed 
bj  physical  exploration.  Tbe  prem-nco  of  Inberclc  causey  in  pro- 
portion to  it«  quantity,  an  increased  density  of  tho  afl'cctcd  lung. 
Existing  in  the  form  of  small  isolated  deposits,  more  or  less  numer- 
ous, the  intervening  pulmonary  pttrcnchynia  being  healthy,  it  con- 
stitutes a  form  of  miliary  and  flisseminalvil  tubercles.  The  increased 
density  dne  to  the  presence  of  tubercles,  either  discrete  or  distrib- 
tited  in  small  clusters,  may  be  but  slight,  but  will,  of  course,  cor- 
respond to  their  abundance  and  approximation  to  each  other.  Ob. 
atruction  to  the  entrance  of  air  into  the  cells,  froro  the  pressnre  of 
the  tubercles  on  tht!  sinall  bronchial  tubeit,  may  not  only  ttbridgc  the 
respiratory  processes  in  the  part  or  parts  affected,  but  cmisc  n  re- 
duction in  volume  by  collapse  of  more  or  less  of  tie  cells  not  filled 
with  lubcrculou!t  luattcr,  and  thus  the  density  is  still  farther  in- 
crcued  by  eondensntion.  Tho  physical  conditions  represented  by 
certain  signs  under  these  circumstances  generally  fall  short  of  those 
iuciilent  to  a  more  ubunilant  exudation,  when  the  deposits  no  longer 
remain  isolated,  but,  enlarging  by  constant  accretion,  they  at  length 
coalesce  and  form  continuous  solid  masses.  frequoDlly  attaining  to  a 
considerable  size.     The  Ultor  constitutes  more  emphatically  tuber< 


4S3 


DISEASES  OF  THE   BBSPIRATOBr  OBOAMi. 


cu]otis  solidification,  and  a  corresponding  diflereoce  pertains  to  Hit 
reprc«entative  phvsicsl  signs.  So  also  if  ttie  taberclea  be  dinea- 
inaled,  and  the  intervening  par«Rc1iyma  become  consolidated  by  i»- 
Saminatory  exudation  (irhich  not  infrequently'  occurs),  the  phrskal 
conditions  nre  the  same,  a  continuous  solidification  in  this  case 
equally  existing. 

The  occurrence  of  circuntscribed  inflammation  of  the  pulmonary 
parenchyma  surrounding  tuberculous  deposits,  may  give  rise  to  ike 
atmciiU.ntory  sign  palliognomonic  of  piieumoiiitis,  riz.,  the  crepitant 
rnle,  and,  takon  in  connection  vith  certain  circuni»tance»,  aa  will  be 
seen,  this  sign  is  eridence  of  tuberculon*  dtsciute. 

The  processes  of  softening,  ulceration,  and  cvacnatjoo  of  the 
liquefied  tuberculous  matter,  leaving  pulmonary  excsTatiotus  give 
rise  to  anatomical  conditions  quite  difi'ercnt  from  those  ubich  per* 
tain  to  the  presence  of  crude  tubercle,  and  these  new  couditioiis  are 
repi-caented  by  peculiar  signs.  But  vherea«,  the  fresh  depoailioD  of 
tubercle  is  usually  going  on  white  cavities  are  forming,  and  after 
they  have  formed,  tuberculous  solidification  generally  surrounds  ibe 
excavations,  and  crude  tubercles,  in  greater  or  less  abundance,  are 
distributed  throughout  the  pulmonary  parenchyma.  Hence,  the 
physical  »igni*  of  dlfiVTUiit  stages  of  the  progress  of  tubercuious  dis- 
ease, vii.,  solidification  and  excavation,  are  likely  to  be  conjoined. 
The  sixe  of  excavations,  their  situation,  their  number,  and  the  firn- 
ness  of  their  walls,  as  well  as  the  varying  contingent  conditions  re- 
lating to  their  contents,  are  found  to  affect  the  physical  pbeDotncna 
to  which  they  give  ris«. 

The  hronohinl  tubca  iti  proximity  to  tuberculous  deposita  and  ex- 
cavations are  the  source  of  physical  Ngns.  Circumscribed  hrot>- 
efaitis,  n»  will  be  seen,  is  evidence  of  the  existence  of  (abcrcnlo«is. 
The  presence  of  liquid  in  the  tubes,  either  produced  by  brouchilU 
or  derivftl  from  cavities,  and  the  perviousucss  of  the  bronchial  tubes, 
oouBtttutc  iiDportBut  physical  conditions. 

The  loss  of  expansibility  of  lung  solidified  by  tubercle,  and  the 
reduction  in  its  volume  which  frequently  ensues  from  collapM)  and 
doMtruction  of  pulmonary  tissue,  furnish  conditions  which  are  repre- 
sented by  physical  signs. 

The  attacks  of  circumscribed  dry  pleuritia  which  occur  from  time 
to  time  almost  uniformly  over  tuberculous  portions  of  lung,  may 
also  give  rise  to  phenomena  which  become,  iufcrenliully,  evidence  of 
tuberculosis. 


PDI.UONARV   TUBERCULOSIS. 


4S8 


Abnormal  tlilaUtion  of  air-c<>1lB,  or  empliTsema,  affvctirij;  more 
or  1e»a  of  (he  lobiil«!8  in  llie  vicinity  of  tuborciiluus  dcpofiiti,  is 
another  morbid  condition  incitl^ntnl  to  tlic  diM^n^e  in  a  ct-rl»in  pro- 
portion of  cHiios,  modifying  the  physical  plicnomena,  and  is  not 
tbcTcfore  to  he  lo^l  night  of  in  physical  explorationn. 

SyAlcmatic  writera  generally  divide  Inbcreulmm  ili^case  of  the 
luDg  into  thrc«  stages,  viz.:  1.  Stage  of  crnile  tuhi^rck';  2.  Stngo 
of  softening;  8.  Stage  of  excnvnlion.  With  rcforonce  to  the  study 
of  physical  signa  and  (heir  applicntion  to  diiigiio.^i.-),  n  more  cunvc- 
Di«nt  division,  iis  it  fieeniH  to  me,  'n  the  following:  (a.)  Small,  dis- 
seminated tuberculous  deposits;  {f>.)  Abnndunt  deposition,  involring 
COnHJdcrablu  solidificntiun;  (e.)  Tuberculous  disease  advuncod  to  the 
forniiition  of  cavities.'  I  shall  con^der  the  phystcal  signs  aod  the 
diagnosis  with  reference  to  these  three  forms  and  periods  of  the  dis- 

The  following  laws  of  pulmonary  tuberculosis  will  frequently  be 
referred  to  :  The  depo^^it  in  the  vast  majority  of  cases  takes  place 
first  at  or  near  the  apex  of  the  lung.  Exceptions  to  ibis  law  are 
occasionally  observed.  Tlio  deposit  takes  place  at  the  summit  of 
the  lung  on  one  aide  before  the  other  lung  h  attacked;  but  the  op- 
poaite  lung  in  jnibsequcntly  affected  in  the  vu»t  inujonty  of  iuj^tances. 
Hence,  in  the  bodies  of  persons  vrho  have  died  with  tuberculosis, 
Uie  two  lungs  almu#t  invariably  are  found  to  be  diseusetl,  but  the 
asit  is  most  nbundnnt  or  the  ravages  are  more  extensive  on  one 

He.     These  laws  are  of  fundamental  importance  in  dingnosis. 

The  clums  of  pulmonary  ttiberculosia  on  the  attention  of  the 
medical  student  and  practitioner  are  sufiieicntly  obvious  \a  view  of 
it*  great  prevalence  and  mortality  in  all  countries.  But  the  study 
of  it«  diagnosis  is  rendcrci]  iuimunscly  important  by  the  fact  that 
the  prospect  of  exerting  a  control  over  the  disease,  and  diminishing 
its  tendency  to  n  fatal  issue,  is  in  proportion  to  its  rurly  recognition. 

Pulmonary  tubcrculot-is,  as  a  rule,  is  essentially  a  chronic  affec- 
tion. The  chronic  form  is  understood  by  the  simple  expression  pul- 
inoDsry  tuberculosis.  Occasionally,  however,  the  rapidity  of  its 
career  and  the  intensity  of  its  symptoms  denote  an  acute  aSectton. 


■  T«  conitd'^r  m  *ta{co  »f  nofti-ninit.  nil  dinllnct  from  tho  itngu  of  Picavalion, 
mav  be  purri'ct  as  rvgnrtls  tbo  uorlild  Biintonij'  of  thu  dlncHUV,  but  cllnli^lljr  It 
■Mini  to  me.  to  be  r  nopillciii  divUion.  Thn  phyaical  aiKH*  >iippoii.>d  to  inilli'ulu 
Mcli  a  ilagr  aru  uf  duublfitl  t>):iiillcBri(.'«.  Upni'v,  il  will  lio  obanrred  dial  1  do 
aot  undertiik*  to  point  out  mean*  by  wbicb  it  maf  be  rceogniiud. 


434 


DI&BA3BS   OF  TDB  RERPIRATOBT  OBOAITR. 


Acnt«  phthisis,  I  skill  notice  briefly  uii<Icr  a  distinct  head.  Tfaii 
chapter  will  also  etnbrac«  a  few  r^mnrkH  on  tbc  rrlroe^rctirf  disg> 
noats  of  pulmonnry  tuberculosis,  sotl  on  tlie  diagnons  of  broDcbti) 
phthisis. 

Phyncal  S^n». — The  cUnieal  history  of  palmonary  tubercutwis 
embraces  signs  famished  b;  all  the  dtSerent  methods  of  pbynetl 
exploration. 

The  plicnomenn  developed  by  pereaMJon  are  highly  imponant. 
They  are  by  no  nienn«  altogetht-r  uniform  at  di(ri>retit  periods  of  the 
disease,  nor  in  diflcrent  caves  at  the  Hame  period,  but  they  vary 
with  Ihc  various  aDstomicnl  conditions  just  cnutncniled,  and  tbry 
•rcHUo  affected  by  circuniiiCHnces  not  includeii  in  that  enuRieratiou. 

Diiniiiiition  of  the  normal  vcS'iciilnr  resonance  isa  pretty  constant 
result  of  a  tuberculous  d<;pcii^it  siilficienl  in  amount  to  give  ri»e  to 
oilier  signs,  or  to  marked  pulmonary  symptoms.  The  varieties  of 
perenstfion-sonnds,  in  general,  consist  of  abnormal  tnodifications  of 
Sioiind  superadded  to  dcficieiioy  of  vesicular  resonance.  Simple  dal- 
nc'ss,  slight  or  moderate  in  degree,  and  more  or  less  extcni^ire,  at 
the  Ritmmit  on  one  side,  compared  with  the  resonance  on  the  other 
side,  is  ilic  evidence  commonly  afforded,  by  percussion,  of  the  exist- 
ence of  small  disseminated  oolk-etions  of  tubercle.  To  determine 
the  fact  of  slight  or  moderate  rolntiro  dulnesv,  percussion  i<  tobe 
practised  alternately  at  corresponding  points  on  the  two  sides,  ob- 
serving all  the  precautions  which  have  been  pointe<l  out  in  the  chap- 
ter on  percussion  in  tbe  first  part  of  this  work.  These  precnntioiif 
are  essential  if  we  would  avoid  errors.  The  symmetricJiI  conforma- 
tion of  the  two  sides  of  the  chest  1.5  to  be  a.'iccrtaincd.  Slight  or 
moderate  dulness,  on  one  side,  ceases  to  be  a  morbid  sign  if,  from 
spinal  curvature,  Jintccedenl  pleurisy,  or  Other  causes,  this  symmetry 
be  dtstifrbed.  The  niiiural  dl.tparity  between  the  two  sides  at  the 
summit,  which  is  hahittial  in  many  persons,  must  also  W  taken  into 
account.  It  la  to  be  borne  in  mind  that,  as  a  rale,  in  the  majority 
of  healthy  persons  with  well  formed  chests,  the  percuss!  on -sound  in 
the  lefl  infra-clnvicnlar  region  has  more  sonorousness,  more  of  the 
vesicular  quality,  and  L*  lower  in  pitch,  than  on  the  corresponding 
region  on  the  right  side.  Hence,  distinct  dulness,  however  slight, 
on  the  left  side,  is  highly  signiScant,  whereas,  on  the  right  side,  if 
slight  or  moderate,  it  is  to  be  taken  as  a  morbid  aigo  with  consid- 
erable reserve.     Distinct  dulness  at  the  left  summit,  be  it  never  so 


fClMOSART  TFBESCrtOSIS. 


I  slight,  in  connection  with  th«  diagnostic  symptoms  of  tuber«n!ngiA, 
inav  alraoiil  Huffice  to  eatabtiah  th«  fact  of  the  exiatence  of  the  dis- 
ease, n-hen,  if  situated  on  the  right  side,  other  corroborative  evi- 
detice  is  required. 

Delicacy  of  hearing,  and  a  nicety  of  discrimination  acijmred  by 
practice,  undoubtedly  enable  one  person  to  detect,  promptly,  n  dis- 
parity  in  souudt)  elicited  by  percussion,  when,  to  a  person  «ho$e 
auditory  sen»c  \»  more  obtuse  und  uiiciillivnted,  it  is  not  nppiLicnt. 
A  person  with  a  miisicnl  enr  recognixea  ii  vnri»tion  in  the  pilch  of 
sound  niorv  rcndily  ihnii  n  difltrencc  in  the  amount  of  soni>roHi>nfS», 
or  of  vcsiculur  qnsliiy ;  hcnc«,  it  is  useful  to  bcnr  in  mind  tltnt, 
wlicn  the  sound  \»  dull  it  is  rniscd  in  pitch.  In  making  a  close  com- 
pArison,  however,  the  Attention  should  be  directed  to  the  several 
elements  combined  in  diminislied  vesicular  resonance,  vi«.,  lessened 
sonorousness,  deficiency  of  the  vesicular  quality,  and  elevation  of 
pitch.  But  it  is  rarely  the  case  that  the  quantity  of  tuberculous 
deposit  is  so  small  as  to  require  extraordinary  skill,  either  in  elicit* 
ing  or  appreciating  the  resnlta  of  percussion. 

In  practising  percussion  at  the  summit  of  the  chest  with  reference 
to  the  existence  of  small  tuberculous  dcpositst,  the  clavicalar,  post- 
clnviculfir,  nnd  Infrn-clnTiciilar  regions  in  front,  and  the  upper  and 
lower  scapular  regions  behind,  nrc  to  be  examined.  Owing  to  the 
diSiculty  of  making  equal  percussion  in  tlie  post- clavicular  region, 
n  di>piLrity  limited  to  this  situation  is  to  be  distrusted,  unless  it  be 
extremely  marked.  I  have,  however,  noted  very  distinct  dulness 
here,  in  undoubted  cnsee  of  tuberculosis,  when  it  was  not  appre- 
ciable in  the  clavicular  and  infra-clavicular  regions.  Over  the  scapula 
I  the  evidence  afforded  by  percussion  is  often  extremely  valuable,  cor- 
roboratiug  that  obtained  in  front,  the  disparity  sometimes  being 
marked  in  this  situation  when  it  Ls  slight  and  even  wanting  in  the 
'  .anterior  regions.  Percussion  here  is  the  more  valuable  because  a 
''Mtural  disparity  between  the  two  sides  exists  less  frequently  than 
in  front;  when  it  does  exist,  tho  rule  is  the  utme,  vis.,  less  res- 
onance and  elevation  of  pitch  on  the  right  side. 
Of  the  relative  proportion  of  instances  in  which  dulness  is  found 
in  the  several  regions,  respectively,  at  the  summit  of  the  chest,  in 
cases  of  small  tuberculous  deposit,  some  idea  mny  be  formed  by  the 
following  analytical  results :  Out  of  100  examinations  in  different 
cases  of  tuberculosis,  in  22,  from  the  aggregate  of  physical  signs, 
the  quantity  of  tubercle  was  presumed  to  be  small.    In  each  of 


I 
I 


426 


DI8BASRS  OP   TliS    RESPIUATORT  OKSAKS. 


these  22  examinationa  <IuId«rs  at  llic  summit  wkn dintinei, being eiOicr 
uliglit  or  moderate  in  degree.  In  14  caacs  tbe  fact  ofdulnnsal 
tlic  Aumniit  is  flimplj  recorded  ;  in  9  caws  the  particitinr  e>iiuaiwu 
of  the  dulneaa  arc  specified.  Of  the  latter  9  cases,  the  dulneu  ex- 
isted in  the  [lont-claviciilar  region  io  7,  io  ihc  claviculnr  rrgioa  m  6, 
in  the  infrft-clnviciilar  region  in  6,  sad  orer  the  iM^^puIar  in  9.  Of 
the  22  cs»o»,  in  10  the  cvidcnccii  of  the  deposit  were  manifreted  on 
the  left,  und  in  12  on  the  right  side.  Tb<«L-  100  catvf,  whJdi  will 
be  repeutcdiy  referred  to,  arc  taken  in  order  from  my  clinical  re- 
cords, beginning  with  the  last  osc  recorded.  Tlic  number,  which 
might  hnve  been  much  larger,  is  presumed  to  he  sofficicDt  for  the 
present  purpose. 

]f  the  tuberculous  deposit  be  abundant,  the  cTidcnce  of  ite  pret- 
ence afforded  bj'  percussion,  in  general,  consisls  in  a  correspondii^ 
amount  of  dulncss.  The  disparitj  at  the  summit  of  the  chest  ii 
Bufficientljr  obvious,  requiring  no  unusual  delicacy  of  manipulatioB, 
or  of  the  sense  of  hearing,  to  elicit  and  discover  it.  The  degree  of 
diminution  of  the  vesicular  resonance  is  a  measure  of  the  degree  of 
solidi&cution,  and  the  area  over  which  this  reeonance  is  found  to  be 
impaired  or  lost,  is  proportionate  to  the  extent  of  the  solidificaiioii. 
Dulness  under  these  circumaianceti  i^  not  invariable.  In  compIeU 
and  considerable  solidificalioti  iit  the  summit  of  the  cfaest,  the  per- 
cu^ion-aound  may  be  considerably  inlensc.  On  the  left  side  this 
may  be  due  to  transmitted  gastric  resonance ;  if  so,  the  g«8tri«  rc*- 
onance  will  be  marked  over  the  stomach  and  the  inferior  portion  «f 
the  ehest.  If  not  thus  aecouutcd  for,  the  resonance  must  be  due  to 
air  in  the  bronchial  lubes.  Tlic  retfonunce  is  not  vesicular,  but 
tympanitic ;  that  'i»,  it  is  devoid  of  tlic  vesicular  quality,  and  raised 
in  pitch.  With  due  ultentiou  to  the  <|uality  and  pilch  of  the  sound, 
it  need  never  be  mistaken  for  a  normal  resonance,  and  the  leaser 
tonorouSDcsH  of  the  opposite  side  be  attributed  to  disease.  Other 
aigns,  moreover,  will  concur  to  prevent  such  an  error. 

An  exaggerated,  or  veiuculo-tympanitio  resonance,  in  some  tut*, 
exists  over  a  modernto  or  even  a  considerable  deposit  of  tubercle, 
arising  from  emphysematous  lobules  in  the  vicinity  of  the  tnberco- 
lous  deposits.  Percussion  alone,  in  these  cases,  might  lead  to  the 
error  of  supposing  the  affection  to  be  emphysema.  This  error  is 
ftfoidcd  by  taking  into  account  the  signs  obtaJDcd  by  ansculiaiioo. 

An  abnormal  sense  of  retistanco  is  a  valuable  collateral  means  of 


PULHONABT  TOSEBCOLOSIS. 


437 


I 


detrminiag  the  fiict  of  tuberculous  solidiJication,  in  the  practice  of 
percussion.  Espi-cialli;  is  this  point  important  vrhcn  there  U  found 
to  bo  only  »  TnodiTtttu  ruliitiru  dulii«i(8  ou  the  right  Hidv,  which  we 
ntftj  not  be  altogether  certain  is  not  duo  to  unutuml  disparitj.  An 
increased  sentic  of  resistunco,  in  concurrcuce  with  the  dulness,  con- 
firms its  morbid  charnctcr. 

Dulness  on  percussion,  more  or  tess  marked,  as  alre&dy  stated, 
over  the  site  of  an  abundant  tubercalous  deposit,  is  the  rule.  Out 
of  100  examinations  of  different  cases  of  puUnouarj  tuberculosis, 
of  which  I  have  transcribed  the  reconJed  physical  tiigns  for  the 
mke  of  reference  in  writing  these  remarks,  exdmliiig  the  chai's  in 
which  the  quantity  of  tuberculous  deposit  was  ^lunll,  and  ako  the 
cases  in  which  the  evidences  of  excavation  were  ascertained,  65  cases 
remain  of  solidiReation  depending  upon  abundant  tubercle.  In  SS 
of  these  cases  the  dulness  is  noted  to  have  been  marked,  and  in 
several  instances  the  fnct  of  dulness  is  alone  stated  without  express- 
ing its  degree.  In  five  instances  there  was  almost  flatness  on  percus- 
sion. In  three  cases  only  wft»  there  greater  sonorousness,  tympanitic 
in  quality,  over  the  solidified  lung,  nn<I  in  each  of  these  instances 
the  left  side  was  the  seat  of  tlic  solidification,  and  gastric  resonance 
was  marked  over  the  whole  of  the  left  side.  With  a  single  excep- 
tion, whenever  the  different  regions  of  the  summit  were  specified, 
the  diminished  resonance  was  observed  over,  above,  and  below  the 
clavicle  in  front,  but  frequently  it  was  more  marked  over  the  scapula. 
In  the  single  exceptional  instance  just  referred  to,  a  disparity  wos 
marked  over  the  eoapula  and  not  in  front.  It  was  often  suffi- 
ciently obvious  that  the  resonance  wa.t  diminished  at  the  summit  on 
both  widea.  The  existence  of  marked  relative  dulness  in  front  on 
one  kMc,  and  an  equally  marked  relative  dulness  over  the  scapula 
on  the  other  side,  is  also  noted. 

When  tuberculosis  has  advanced  to  the  formation  of  cavities,  the 
phenomena  furnished  by  percussion  vary,  not  only  in  different  cases, 
but  of^n  in  the  same  case  at  different  examinations  made  during 
the  same  day,  the  latter  variations  depending  on  the  state  of  the 
excavations  as  respects  their  liquid  contents.  More  or  less  tubercu- 
lous solidification  continues  after  cavities  are  formed;  and  if,  in  ad- 
dition, the  cavities  are  filled  with  liquid,  the  physical  conditions 
favorable  to  marked  dulness  or  even  flatness  on  percuiision  are  enu- 
oently  present.     But  if  they  be  empty,  and  of  considerable  size, 


4S8 


DI8BA8IB  OF  TDK   EEgPIRATOET  OBOAVS. 


tbcy  inn;  give  rise  to  a  tytnpsiiitic  resonance,  vrhicb  occasioiull/ 
presents  other  &n<I  more  cbkrnctortstic  modifications  of  qualitv,  riz., 
the  nmpltoric  und  llio  cr»ckvil-metul  ruriety  of  tone.  So  far  u 
pcrcussioD  is  concerned,  the  evidence  of  the  cxiiitcoco  of  excava- 
tions consists  in  the  signs  just  mentioned,  viz.,  tympanitic  resonance 
and  itic  nniphoric  nud  cracked- me  till  modifications,  llov  far  are 
these  phenomena  available  in  dctcrminiDg  the  existence  of  excava- 
tions? A  tympanitic,  as  vrc  Iiave  m-cn,  maj  replace  the  vesienlar 
resonance  over  tuberculous  solidification.  Wlicn  incident  to  solidi- 
fication, the  tympanitic  quality  is  considerably  diffosed.  Oa  tbe 
other  hand,  if  it  be  due  to  the  presence  of  air  in  a  cavity,  it  is  cir- 
cuinacribed  in  proportion  to  the  limited  siee  of  the  excavation.  This 
is  a  differential  point.  Another  point  relates  to  the  percussion* 
aound  over  the  portions  of  the  chest  adjoining  tbe  space  to  wbicb 
the  tympanitic  resonance  is  limited-  Tuberculous  excavations  being 
luiually  surrounded  by  solidified  lung,  the  limits  of  the  circuinscnbul 
tympanitic  resonance  may  be  somewhat  abruptly  defined  by  a  dol* 
neas  which  contrasts  strongly  with  the  sound  elicited  over  the  cavi^. 
It  is  possible  in  some  instances,  by  careful  percussion,  to  deliufote 
on  the  chest,  by  lueana  of  this  abrupt  change  from  a  clear  lo  a  (tiiJI 
Mond,  the  aitO'Or  an  excavation.  Tbe  alternate  presence  and  ah- 
•euec  of  tympanitic  resonance  in  the  .<>ame  situation  at  different  «!• 
soiinatioii8  is  a  diagnostic  point.  By  taking  paina  to  practise  per- 
cussion very  early  in  the  morning,  before  Uie  eonteuts  of  an  cxcava- 
don  are  expelled,  and  subscquVTitly  after  an  abundanl  expectora- 
tion, the  change  from  marked  dulneas  to  elearueas  of  resonaDce  in  a 
partieular  part  of  the  cbcst  may  be  aACcrtained,  and  thus  shone  to 
depend  on  tbe  removal  of  morbid  product^  which,  in  view  of  other 
ngo»  ami  symptoms,  we  cannot  doubt  came  from  a  cavity.  I  have 
met  vtiih  a  case  in  which  tympanitic  resonance  over  a  cavity  was 
replaced  by  notablo  dulncss  arising  from  hemorrhage  within  the 
cavity  which  was  found,  on  examination  after  death,  filleJ  with 
coagula.  The  modifications  of  tympanitic  resouance,  called  am- 
phoric and  cracked- metal,  in  themselves  are  highly  significant  ofa 
tuberculous  cavity.  Both  may  occur  independently  of  excavation, 
ms  lias  been  pointed  out  in  Part  I,  but  tbe  instances  are  exceptional 
and  rare.  Inasmuch,  however,  as  these  modifications  are  observed 
in  only  a  certain  proportion  of  the  cases  in  which  cavities  undoubt- 
edly exist,  tboir  absence  is  not  evidence  of  the  noQ-existonec  of 


PCLMOXAST  TtrUBROULOSIS. 


429 


ca^'ities.     Thej  have  n.  positive  significance  vhen  present,  but  in  a 
negnlivc  point  of  viev  nre  utiimportnnt. 

In  a  considcrublc  proportion  of  c««o»  of  tiilierciilosiit  mlvancoil  to 
excavation,  pcrcusaion  fnils  to  Jcvclop  nny  distinct  evidence  of  tbc 
existence  of  caviticB.  Tlii«  remark  will  bo  found  pr«i<ciitly  to  be 
also  applicable  to  the  other  methods  of  exploration.  The  reason 
is,  rarious  contingent  circumstances  arc  reciuircd  to  produce  the 
distinctive  signs.  The  circumstances  favorable  for  the  character- 
istic percussion-signs  have  been  already  mentioned  (Part  1),  but 
they  may  be  repeated  in  this  connection.  The  size  of  the  cavity  is 
important.  It  must  have  a  certain  site,  and,  on  the  other  hand, 
should  not  be  too  capacious.     It  must  be  empty,  or  at  least  only 

» partially  filled  with  liquid.  lis  situation  relative  to  the  superficies 
of  tlie  lung  is  important.  The  thinner  and  the  more  condensed  the 
ItTTit'ltTT'  of  lung  separating  the  cavity  from  the  thoracic  vrnll,  the 
gPCBtter  the  tyinpanitie  resonance ;  and  it  is  a  still  morn  favorable 
circnmstance  if  over  the  excavation  the  pleural  surfaces  have  be- 
come  firmly  adherent.  The  incompleteness  with  which  ihccc  cir- 
|ctimtit»nce«  are  conjoined  in  many  i;«:«e*.  and  the  occaitional  absence 
of  the  indispCDStible  condition  pertaininfj  to  the  contents  of  the 
cavity,  sufficiently  account  for  the  infrequency  with  which  the  ei- 
istence  of  excavations  is  positively  ascertained,  especially  at  a  single 
examination. 
Of  the  100  examinations  already  referred  to,  in  18  the  physical 
signs  were  considered  to  denote  the  existence  of  excavations.  It  is, 
I  however,  more  than  probable  that  among  the  65  cases  of  abundant 
H  tuberciiloua  deposit,  were  many  cases  in  which  the  disease  had  ad- 
"    ranced  to  the  formation  of  cavities,  the  physical  signs  at  the  time  of 

I  the  reoorded  examination  indicating  only  solidiBcation.  Of  the  13 
cases,  in  6  circumscribed  tympanitic  resonance  existed,  which  waa 
attributed  to  empty  excavations.  In  some  of  these  cases  the  exist' 
encc  of  cavities  was  subsequently  verified  by  aulopsical  examina- 
tions. In  4  cases  the  amphoric  modification,  and  in  2  the  cracked- 
metal  intonation  was  noted. 
By  means  of  auscultntory  percussion,  tisin^;  for  this  purpose  Cam* 
mann's  stethoscope,  the  pectoral  cslremily  bcinKhrought  near  to  the 
open  mouth  of  the  patient,  umjihoric  and  crack ed-metfil  resonance 
may  often  be  ascertained  when,  without  this  method,  these  varieties 
of  tympanitic  resonance  arc  not  perceived.  Of  this  fact  I  was  not 
aware  when  the  first  edition  of  this  work  was  written.     By  rci»orting 


riSBASBS   OF  THE  RKBPIBATOBT  OROAITS. 

to  this  method,  I  am  now  able  to  make  oat  th«8«  cavernous  tign*  m 
•  pretty  large  proportion  of  cawa.' 

In  loaving  the  percuss! on- signs  belonging  to  ttibcrcuIo«i»,  two  or 
tlirt-e  rules  with  re*pect  to  the  practice  of  percossion  maj  bt  ipeiK 
tioni^tl,  which  are  to  be  borne  in  mind  particularly  in  cases  in  shidi 
the  tuberculous  deposit,  if  it  exist,  be  amall.  The  importanc«  of 
observing  the  general  precautions  pointed  ont  in  the  chapter  on  per- 
cussion in  Port  I,  ]ia»  bei>n  already  adverted  to.  In  canes  of  doubt, 
it  i»  nwful  to  eoinpare  the  chest  as  reganls  the  reiiulta  of  superficial 
and  deep  percuswion  alternately.  Slightly  increased  den.4)tT  near 
the  surfuRc  of  the  lung  on  one  side  may  give  rise  to  dulne«s  on  light 
pcrviisAion,  when  with  forcible  siroke:»  the  diiiparity  may  not  be  ap> 
prceiiihie.  On  the  oihcr  hniid,  deep-NeJited  tuberculous  deposits 
require  a  oeruin  force  to  develop  a  relative  dulnewi  which  may  not 
be  perceptible  if  the  percussion  strokes  are  feeble.  lu  cases  i« 
which  great  delicacy  of  comparison  of  the  two  sides  is  desirahle,  it 
should  be  made,  successively,  after  m  full  ini<piratioD  and  aHera 
forced  expiration.  A  dilfcrence  may  I>e  perceived  when  the  air  con- 
tained in  the  lungs  is  reduced  by  an  expiratory  effort,  which  be- 
comes less  marked  when  the  chest  is  fully  expanded.  It  is,  how* 
ever,  to  be  recollected,  that  a  dispntily  in  this  way  sometimes  be- 
comes developed  in  health.  Percussion  at  the  summit  behind  should 
never  be  neglected.  This  rule  is  to  be  impressed  the  more,  bccaoM 
it  hos  hccD  said  by  a  distinguished  author  on  diseases  of  the  ehe»t 
that  percussion  is  of  no  value  over  the  scapula.  This,  if  I  mlsiake 
not,  is  a  common  impression.  A  comparison  of  the  two  sides  as 
respuets  degree,  quality,  and  pitch  of  resonance,  may  be  made  hert 
as  well  ns  in  other  situations.  My  observations  have  taught  nt 
that  u  rclntive  dulncss  on  one  side  from  tuberculous  depoaition  li 
more  uniformly  appreciable  in  this  situation  than  in  front.  More- 
over, the  tuberculous  deposit  is  in  some  instanees  confined  to  the 
opper  and  posterior  portion  of  the  lung,  and,  under  these  circum- 
Stances,  the  phyMi-al  signs  arc  limited  to  (he  scapular  region. 

During  (he  existence  of  hiemoptysis,  or  in  cues  in  which  this 
syuiptixn  has  very  recently  occurred,  percussion  should  be  employed 
very  cautiously.  Deep  percussion  should  be  refrained  from.  I  have 
known  profuse  hemorrhage  to  follow  so  closely  on  an  examination 


1  VUePMlI.psgelll 


rOLHONART  TOBBBCOLOSIB. 


431 


|of  iho  chest,  that  it  was  fair  to  conclude  the  force  of  the  strokes  to 
jliave  been  the  exciting  cause. 

PiDall^,  a  difference  in  the  degree  of  percussion-reHonance  be<- 
I  tween  the  two  sides,  irrespectire  of  deviations   from  sjrminetrical 
conformation  or  »  natural  disparity,  may  proceod  from  morbid  con- 
ditions other  ihan  tuberele,  so  ihat  this  alone  by  no  means  invari- 
^^sbly  d«not«s  tuberculosis.     A  slightly  emphysematoaa  condition, 
'      for  example,  on  one  side,  gives  rise  to  nn  obvious  disparity  in  the 
degree  of  resonance.     The  converse  of  the  above  statement,  viz., 
^ktfaat  equality  in  ret*oiianc«  may  continue  notwithstanding  the  pres- 
^venoft  of  a  con.->iderabIi>  number  of  disseminated  clusters  of  tubercles, 
^vifl  never  true,     tt  is  stated  by  Fournct  and  other  writers,  that  even 
^p  when  the  tuberculous  solid ifii^ntiun  is  not  .small,  cither  in  degree  or 
extent,  the  duliiv*»  niny  be,  as  it  were,  compensated  for  by  the  em- 
pbyseniAiouM  dilatation  of  adjoining  lobules  which  is  apt  to  take  place, 

»«nd  a  disparity  in  the  pcrcns^ion-SOund  is  not  obvious.  This  is 
true  as  regards  mere  sonoroiwnvss,  or  the  degree  of  resonance,  but 
thv  quality  and  pitch  of  sound  undergo  nn  appreciable  altcrntion: 
the  re)<'Onaucc,  a1tbour;h  not  less  intenitc  thnn  on  tho  opposite  «ido, 
becomes  vesiculo-tympnoitic.     The  importance  of  analytically  re- 

»  solving  the  sound  elicited  by  percussion  over  tlie  chest  into  its  dif- 
ferent elements,  is  illustrated  in  a  case  of  this  kind, 
The  auscull.itory  phenomena  belonging  to  the  clinical  history  of 
pulmonary  tuberculosis  embrace  the  greater  part,  if  not,  indeed, 
I  the  whole  of  the  catalogue  of  the  physical  signs  furnished  by  this 
■  method  of  exploration.  In  their  relation  to  the  disease  the  follow- 
~  ing  distinction  may  be  made:  the  adventitious  sounds,  viz.,  the  rales, 

(are  contingent  or  accidental  phenomena,  occasionally  present,  and 
although  possessing,  when  present,  diagnostic  significance,  th^r 
absence  does  not  constitute  any  ground  for  inferring  tho  non-exiat- 
cnoe  of  the  disease.  On  the  other  hand,  the  signs  which  are  in- 
cluded in  the  class  of  modiRcd  respiratory  sounds  are  more  inU- 
matclyniid  constantly  connected  with  the  morbid  conditions  incident 
to  the  disease.  They  are,  therefore,  more  important  as  diagnostic 
criteria,  and  they  are  important  in  a  negative  point  of  view.  If 
the  respiratory  sounds  arc  free  from  any  abnormal  modification,  a 
tuberculous  deposit  can  hardly  exist ;  the  fact  enubk-s  iis  to  ex- 
clude the  disease. 

In  cases  of  small,  disseminated  tuberculous  deposits,  so  far  as  the 
phenomena  consist  of  modified  respiratory  sounds,  they  will  mostly 


4»i 


DI8IA8SS  OF  THE   EBSPtKATOBT   OKBAKZ. 


eome  vnder  the  heail  ot  broncho-resicoUr  resfMration.  In  the  mom 
in  which  I  have  used  ihU  term,  it  embraces  all  the  modiGcatioos  uf 
KSpirAtorj  aound,  proceeding  froni  parlia)  solidiiication,  in  which 
the  tubular  and  the  veBioular  quality  are  oorabioed,  in  variable  pro* 
portions,  ii)  Uie  inspiratory  sound.  It  ia  the  rudf  respiraiioii  of 
writers  on  the  Htibjcct  of  physical  exploration,  sometitnee  also  styled 
hartk  and  drt/  r«j>pir«tion.  If  ail  tlic  characters  of  the  broncho- 
vesicular  re^piratJon  be  present,  wc  hitvc  an  iii«>piratury  *onn4 
neither  purely  tubular  nor  vesicular  in  quality,  but  a  mixture  of 
both  (broncho-vesicular),  the  duration  sumewhal  shortened  (unSn- 
ishcd),  the  pitch  raised,  and  a  bnirf  interval,  follow^  by  un  expira- 
tory  sound,  prolonged,  longer,  more  inlciisc  than  the  in^pirittion.  ami 
higher  in  pilch.  Sometimes  in  connection  with  »  small  amount  «f 
toberculous  disease  all  these  characters  arc  pre^nt,  bat  oftrn  nors 
or  less  of  ihcm  are  wanting.  The  proseuce  of  certain  of  the  broncho- 
Te»ica]sr  eletnenu,  and  the  absence  of  others,  give  rise  to  consider- 
»hle  diversity  in  different  cases.  The*e  diversities  it  will  be  usefdl 
to  notice  with  a  little  detail.  It  is  needless  to  remarli  that  in  de- 
termining the  existenc«  and  the  characters  of  abnormal  modifio- 
tiona  of  the  reipintlioii,  auacullalion  is  to  be  practised  at  the  utiBBil 
of  the  chest  on  both  sides,  and  the  phenomena  cnrefully  compartd. 
On  the  side  affected,  the  intensity  of  tite  respiratory  sound  may  be 
either  increased  or  diminished;  I  have  noted  cases  in  which  it  wu 
increasud,  but  it  is  oftener  diminished.  When  not  too  feeble  to  be 
distinctly  beard,  if  the  lessened  intensity  be  due  to  increased  deosi^ 
of  long,  it  ia  always  altered  in  other  particulars;  in  other  wordi, 
more  or  less  of  the  bruncho-resicular  characters  gkisi,  thc^e  chani^ 
tvrs  being  independent  of  the  intensity  of  the  sound.  The  fact  JB»t 
stated  will  serve  to  distinguish  the  feeble  respiration  due  to  tuber- 
culous disease  from  that  incident  to  simple  emphysema.  Occ«N0ii- 
ally  the  inspiratory  sound  ia  inappreciable,  especially  if  Oantnuui's 
Bteihoscope  be  not  employed.  On  the  other  hand,  the  inspiratory 
sound  may  he  alone  heard,  /.  e.,  without  any  sotud  of  expiration. 
The  abnormal  modifications  will  then  consist  of  shortened  duration, 
diminished  vesicular  or  aec|tiired  tubularity  of  quality,  and  elevation 
of  pitch,  these  characters  pertaining,  of  course,  exclusively  to  ihein- 
spiralion.  These  three  elutracters  fjo  together.  The  variation  in  pitdi 
is  frequently  the  character  most  readily  recognised.  HuJ^neu, 
harrhnrJiii,  and  drynert  of  the  sound  pertain  to  this  character  together 
with  tltc  tubularity.     These  three  characters  are  »hovn)  by  cvuiratt 


rOLHOKAKT  TCBSROULOfllfl. 


438 


I 

^ 
^ 


vilh  the  longer  duration,  the  more  marked  veittciilar  qunltty,  ■nil  the 
tmparative  lowness  of  pitch,  whicK  belong  to  the  iiispiriitory  sound 
the  opposite  side,  or  over  the  middle  and  lower  tbirilor  ihe  chest 
<m  the  same  side.  If  an  expiratory  sound  be  present,  it  is  often 
more  intense  than  the  sound  of  inspiration.  Its  intensity,  however, 
varies.  More  or  less  prolonged,  its  duration  differs  in  difftreot 
eaaet.  It  is  uniformly  higher  in  pitch  thun  the  inspiratory  itouud, 
the  disparity  being  in  some  cases  much  more  marked  than  in  others. 
As  the  expiratory  sound  is  sometimes  nanting,  so  in  some  tustunces 
it  18  alone  present,  no  sound  of  inspiration  being  discoverable  It 
is  not  uncommon  in  cases  of  tuberculosis  to  find  the  following  ro- 
suits  on  comparing  the  fro  sides  of  the  chest:  on  one  side  a  vesicu- 
lar inspiration,  more  or  Ices  intense,  with  no  expiratory  sound,  and 
on  the  opposite  side  >  prolonged,  moro  or  lc«s  intense  and  high  ex* 
piration,  vith  a  very  feeble  or  scarcely  appreciable  sound  of  inspi- 
ration. 

The  diTcrsitioa  which  diflTcrcnt  cnacs  present  as  respects  the  pres- 
ence or  absence  of  more  or  less  of  tbc  characters  of  the  broneho- 
vesieular  respiration,  are  nut  of  rinportnnce  from  their  po;^sossing 
respectively  »ny  special  signifiennce.  The  simple  point  praoticallj 
is  to  determine  the  existence  of  any  of  the  elements  of  the  broncho- 
vesicular  respiration.  The  broncho- vesicular  respiration,  in  con- 
junction  with  other  signs  and  with  symptoms,  is  diagnostic  of  & 
tuberculous  deposit  not  producing  complete  or  great  solidification. 
Its  availability  in  diagnosis  of  courso  dcpcndn  on  ila  constancy,  and 
tlie  facility  with  which  it  may  be  recognized.  Guided  hy  my  own  ex- 
perience, I  should  say  that  coses  helutigitig  in  Ihe  cUr>«  of  fmall, 
dwscminated  tuberculous  deposits,  are  extremely  rare  in  which  cer- 
tain of  the  elements  of  this  sign  lire  not  sufhciently  marked  to  b« 
•ppreciated  by  one  acquainted  with  the  subject,  and  possessing  a 
fair  amount  of  skill  as  a  practical  uuscnltator. 

In  comparing  the  respiratory  sounds  at  the  summit  of  the  chest, 
in  front  and  behind,  on  the  two  sidc#,  it  is  essential,  if  we  would 
&Toid  errors,  to  make  due  allowance  for  the  points  of  normal  dis- 
parity existing  in  many  persons  in  this  part  of  the  chest.  These 
have  been  conudered  in  the  chapter  on  auscultation,  in  the  first  pari 
of  thia  work.  It  is  to  be  borne  in  mind,  that  on  the  right  side,  at 
the  summit,  especially  in  front,  the  inspiratory  sound  is  frequently 
len  intense,  less  vesicular,  and  higher  in  pitch,  than  on  the  left  side, 
lod  that  a  prolonged  expiration  on  the  right  side,  occa^uonally  more 

28 


484 


DISRABZ8  OP  TKB  RBSPIRATOBT  QEOAKB. 


intense  and  higher  in  pitcli  than  th«  imtpiratorj  sound,  nnd  KomctiuMt 
cxiiitiiig  alone,  is  obserred  in  healthy  perwns.  Hence,  the  chiiractm 
of  the  broncho -vesicular  respiration  should  be  strongtj  inar)ce<i  it 
the  Huramit  of  the  right  side  to  be  considered  as  evidence  of  discwc; 
but,  on  the  other  hand,  if  siinat<>d  at  the  summit  of  the  Icf^  side,tlK7 
almost  aliraV)'  denot-e  a  morbid  condition. 

Until  the  deposit  of  tuberculoas  matter  becomes  abaodasl,  Ow 
broncho-vesicular  modification  of  the  respiration,  tn  the  greater  pro- 
portion of  instances,  is  limited  to  ono  side  of  the  cheet.  This  fact 
obtains  in  cases  in  which  there  is  every  reason  to  sappose  that  bod 
lung*  contain  tubercles.  In  view  of  the  fact  that,  after  a  tuhercnloM 
depiiail  has  taken  place  in  one  lung,  in  a  short  time  the  other  tiiti| 
becomes  affected,  I  bavo  of^cn  been  surprised  at  finding  the  rcspin- 
tion  over  the  lung  least  affected  nearly  or  quite  normal.  It  is  troe 
that  under  these  circumstances  ne  hare  not  a  healthy  lung  to  serve 
ai  a  standard  of  comparison,  but,  without  such  n  comparisoti,  it  is 
practicable  to  judge  of  the  pitch  and  veeicnlar  quality  of  the  inspira- 
tion, and  the  relative  intensity,  duration,  and  pitch  of  the  expiration, 
if  the  latter  ho  present,  and  thus  to  determine  whether  the  respira- 
tion be  broncho-vosiciiUr  or  not.  I  can  only  acconot  for  the  fact 
just  stated,  by  supposing  that  when  the  increased  den&ity  at  the 
summit  of  one  lung  is  sufficient  to  occasion  a  distinct  tnodifieation  of 
the  respiratory  sound,  the  activity  of  the  other  lung  is  sufficiently 
increased  for  the  normal  characters  to  be  maintained,  not  withstand* 
ing  the  presence  of  a  certain  number  of  tuberciea,  without  giving 
rise  necessarily  to  a  welbmarked  exaggerated  n-spiration.  A  well- 
marked  exaggerated  respiration,  as  will  be  pr<'«ently  noticed,  does 
occur  in  the  opposite  lung  in  some  instances  in  which  the  unoiiBt 
of  tuberculous  deposit  is  considerable  on  one  side. 

The  signs  which  are  now  to  be  noticed,  exclusive  of  those  which 
pertain  to  the  voice,  may  be  distinguished  as  the  accessory  signs  of 
pulmonary  tuberculosis.  They  may  be  so  called  from  the  fact  that 
tliey  denote  indirectly  tuberculotm  diseaiie ;  (hat  is,  they  proceed ' 
from  conditions  which  are  incidental  to  tuberculosis.  They  are  often 
of  considerable  value  in  the  diagnosis  of  tuberculous  disease. 

Interrupted,  wavy,  or  jerking  respiration  occurs  in  a  certain  pro- 
portion of  cases  of  small  tuberculous  deposit,  hut  this  sign  is  observed 
occasionally  when  the  other  signs  and  the  symptoms  do  not  denote 
tuberculous  disease.  Its  value  as  a  diagnostic  sign,  therefore,  de- 
pends on  its  being  associated  with  other  evidence  of  tubcrcnlusik. 


HTLMO^TART  TOBSBCClOSIfl. 


435 


I 


Id  the  22  examinfttionii  in  cast*  of  Bmall,  diesemiDaled  tuberolea, 
among  tht*  100  analjieii,  thU  sign  wus  obacrved  io  two. 

Of  adventiliouR  signs  or  riilcn,  lliu  crcpilnnt,  dry  crackling,  crump- 
ling, the  sub-orepilKiit  ami  other  bronchial  rales,  moist  aod  dry, 
are  all  occasionallj  observed  in  mws  of  tubcrculoain.  They  do 
not  indicate  the  distease  directly,  but,  on  the  contrary,  if  we  exce[>t 
dry  crackling  and  crumpling,  they  are  sign*  of  other  morbid  con- 
ditions. Indirectly,  they  bcoonie  significant  of  a  tuberculous  affec- 
tion when  ihey  occur  under  circumstances  which  warrant  the  infer- 
ence that  the  particular  morbid  conditions  which  they  immediately 
represent  involve  the  coeKiAtence  of  tubercles. 

A  veritable,  well-dufined  crt'pitant  rale  denotes  pneumoniliH  in  the 
Ta»t  majority  of  casi-tt.  Pncuinoniti.'^,  if  it  be  circumscribed,  i.  e,, 
extending  over  a  small  portion  of  n  lobe,  and  situated  at  or  near  the 
apex  of  the  lung,  is  highly  Hignifieant  of  tubereulosi*,  becauae,  in 
the  first  place,  nnder  thi^se  circumstancejt  it  ia  not  primary,  since 
primary  pneumonitis  usually  extends  over  the  whole  or  a  greater 
part  of  a  lobe,  and  affects  by  preference  the  inferior  lobe ;  and,  io 
the  second  place,  obaervations  show  that  circumscribed  ]meumonitie 
18  occasionally  developed  in  the  vicinity  of  tuberculous  deposits,  via., 
St  or  near  the  npcx  of  the  lung.  A  crepitant  mic  is  thus  inferen- 
tially  a  diagnostic  sign  of  tuberculosis  when  it  is  found  at  the  summit 
of  tltb  chest,  and  confined  within  n  limited  area.  As  respects  the 
freqoency  of  circumscribed  pneumonitis  in  connection  with  tubercu- 
lona  disease,  as  denott'il  by  a  well-marked  crepitant  rule,  my  vxperi- 
ciiw  aecorda  with  that  of  Dr.  Walsbc,  vij;.,  the  coincidence  is  rare. 
It  is  not>  however,  less  significitut  on  thii  account  when  it  does  take 
place. 

Dry  crackling,  as  distinguished  from  a  well-marked  crepitant 
rale,  consists  of  n»fcw  crepitations  apparently  rcnching  the  ear  from 
o  distance  and  confined  .to  the  end  of  the  inspiratory  act.  Whatever 
opinion  may  be  entertained  of  the  mechanism  of  its  production,  ob- 
servation shows  that  it  frequently  occurs  in  the  early  stage  of  tuber- 
culosis, and  that  it  is  rarely  observed  at  the  summit  of  tho  chest, 
on  one  side,  except  there  exist  a  tuberculous  affection.  Ilence  it 
possesses  a  certain  degree  of  significance,  especially  when  associated 
with  other  signs  and  with  symptoms  having  a  similar  diagnostic 
bearing.  Of  the  22  examinations  in  cases  presumed  to  be  of  small 
diascnunatod  tubercles,  it  was  notcl  in  9.  In  sereral  instances  it 
existed  at  the  summit  of  tho  chest  on  both  sides,  but  was  more 


486 


D18BASBS   or   THB   aBSPIBATOST    0SOAS8. 


marked  on  the  side  vbich  the  mssociated  signs  indicstcd  as  tbe  seat 
of  the  deposit. 

The  enmc  remarks  are  applicable  to  a  crumpling  sound,  except 
that  the  latter  is  much  less  fre^neiitl;  observed  io  cases  of  taberro- 
losie.  For  all  practical  purposes  it  sufBces  to  eonaider  this  as  a 
variety  of  crackling, 

A  Bub  crepitant  rale  is  not  infrequently  developed  in  proxitnitjM 
tubercles,  proceeding  cither  from  the  presence  of  liquid  matter  tt- 
caping  from  the  cclli*  into  the  smalliT  bronchial  tubes,  or  prodnced 
within  the  tubes  as  the  result  of  circumscribed  capillar;  bronckitiL 
Id  either  case  itst  situation  at  tbe  summit  of  the  chest,  and  iW 
limited  spnoe  in  which  it  ia  heard,  are  the  conditions  under  which  it 
is  significant  of  tuberculosis. 

The  occasional  development  of  bronchitis,  not  only  in  tfaesnisnir 
but  the  larger  tubes  in  the  vicinity  of  tubercles,  is  an  event  belong- 
ing to  the  natural  history  of  pulmonary  tnbereutosis.  Hence.  th« 
production  of  sibilant,  sonorous,  and  mucous  rales.  These  rale*  rep- 
rcMint  morbid  conditions  pertaining  (o  bronchitis;  but  bronchitis 
limited  to  the  upper  portion  of  the  lungs,  and  especially  confined  to 
one  side,  is  not  a  primary  affection.  These  reslrictioos  conflict  Kjlb 
the  laws  of  primary  bronchitis,  which  is  one  of  the  symmetrical  dis- 
eases, and  extends  over  the  bronchial  tuWs  diiitributed  to  the  lower, 
as  wi;ll  as  the  upper,  lobes.  The  physical  signa  of  primary  broo- 
cbitja,  as  has  been  seen,  are  especially  manifested,  not  >n  front  at 
the  Bummit,  but  over  the  middle  and  lower  portions  of  the  cbe-st  be- 
hind; hence,  when  confined  to  the  summit,  and  especially  to  one 
aide,  the  bronchitis  is  secondary,  and  in  this  situation  the  proba- 
bilities are  greatly  id  favor  of  ila  being  induced  by  tuberculous  dis- 
ease.* 

Moist  bronchial  or  mucous  rales  may,  however,  he  prodnced  by 
the  escape  of  softened  tuberculous  matter  into  the  tubes  wiibovl 
necessarily  involving  the  coenistence  of  circumftcribed  bronchtti*. 
The  development  of  these  rales  ia  generally  regarded  as  evidrnct 
that  softening  has  taken  place.  It  is  impossible  to  determine  from 
the  characters  of  the  sounds  whether  they  proceed  from  the  presence 


■  A  ulit^king  toundliiuUii^ii  iupp<»>*d  to  be  ■p«u1ly*i|[nlt<-saiof  tfaetinWMI 
of  tuberclw.  It  b  lo,  howcvnr,  itolflj  for  tli»  r«uioi;)  wliich  invat  otbor  bron- 
chlfil  mtm  wilh  thU  RigtilBcanco.  There  nrc  no  )[roiinili  for  rpjfardiaff  lli«  ohtf- 
•ctEf  of  the  •ouQd  M  duliacliv*.  A  cliaking  tuuud  if  hT*rd  in  pnaurjr  a*  vtU 
a«  *eciindAxy  broricbiti*. 


(Mart  tobbri 


437 


I 


I 


I 


or  goflenod  tnbcrciiloii*  mnttcr,  or  from  mucous  Sflcrctions,  or  (m 
miwi  bv  llic  cnxc  firqiicntly)  from  both  combinfJ.  But,  iniismuch 
*»  circimiscribcil  bronchitis  may  nndoubtt-dly  e.vist  before  softeniiig 
of  tbe  tuberculous  matter  ensues,  mucous  rnlcs  nre  heard  before  the 
dincni^c  bn>  advanced  to  tbis  stage.  Not  indicnling  neccBsarily  soft- 
ening, moi»t  rnles  limited  to  the  summit  of  the  cbcst  are  highly 
diagnostic  of  tuberculosis,  and  in  cases  of  doubt  it  is  useful  to  auscuT- 
tst«  repeatedly,  and  especinlly  in  the  morning  before  expectoration 
lias  talcen  place,  in  order  to  diocover  them,  if  tbey  exist. 

It  thu#  appears  that  with  respect  to  all  the  adventitious  sounds 
or  rales  just  noticed,  their  dlngnostic  value  in  cases  of  tuberculosis 
depends  on  thoir  being  limited  to  a  eireumscribed  space  at  the  summit 
of  tlio  chest.  Their  value  !s  enhanced  by  sBsociatloD  with  other 
phenomena,  physical  and  vital,  pointing  to  tuberculoos  disease. 
They  arc  occasionally,  not  constantly,  present  in  cases  of  tubercu- 
losis. They  cannot,  therefore,  be  relied  upon  in  the  diagnosis ;  and, 
u  already  remarked,  although  of  importance  when  present,  we  can- 
not argue  against  the  existence  of  tuberculous  disease  from  their 
absence. 

An  abnormal  transmission  of  the  heart-sounds,  in  the  infra- 
elftvieular  region,  is  a  sign  of  considerable  value  in  the  diagnosis  of 
tnberculous  disease.  The  heart-sounils  in  some  casca  of  a  small  de- 
posit of  tubercle  ore  abnormally  transmitted.  This  sign  is  frequently 
available.  It  is  to  be  reckoned  among  (he  more  important  of  the 
accessory  signs.  Its  availability  is.  in  the  infra-ctuvicutar  region 
only.  A  comparison  of  the  heart-sonnds  in  healthy  persons  shown 
the  following  points  of  disparity  between  the  two  sides  in  the  infra- 
clavicular region  :  on  the  right  side  the  second  sound  of  the  heart 
ia  somewhat  louder  than  the  Grst  sound,  and  on  the  left  side  the  first 
SOUDd  IS  somewhat  louder  than  the  second  sound. 

Passing  next  to  the  auscultatory  phenomena  produced  by  the 
Totc«,  an  exaggerated  vocal  resonance  is  an  important  physical  sign 
of  tuberculosis  when  it  exists  at  the  summit  of  the  chest  on  the  left 
side;  on  the  right  side  it  is  less  available  in  diagnosis.  This  differ- 
ence is  owing  to  the  normal  disparity  fonnd  in  most  person*,  espe- 
cially in  front.  The  greater  intensity  of  vocal  resonance  on  tJic  right 
side  natural  to  many  persons  is  such  that  it  is  not  safe  to  pronounce 
positively  any  amount,  within  the  limits  which  small  disseminated 
tabercles  are  competent  to  produce,  to  he  morbid  when  it  is  observed 
on  this  side.     If,  however,  the  resonance  be  relatively  much  greater 


4S8 


DISBASEa    or    THE    RKfiriBATORT    OKQAKS. 


on  the  right  »id(>,  aiid  there  he  foH[i<I  otlier  ttigos  on  thu  side,  nkicb 
point  io  tubcrculosU,  tlie  cxUtcnce  of  the  »ign  la  renderw]  highlj 
probable.  The  fact  of  the  dijtpAril;  between  the  two  sides  so  oftea 
existing  in  h<?Alth,  renders  an  cxnggerKtcd  rcsoDtncc  on  the  left  nds 
doubly  significant.  It  is  cntittcil  to  great  weigtit  in  the  diagnosis. 
It  ie  Frequently  the  case,  howercr,  thut  Dotwitbvtiinding  a  tnbvm- 
lous  depottit  in  the  loft  long,  the  vocal  resonance  continae*  greater 
on  the  right  side.  The  fact,  therefore,  that  tho  resonance  is  tiot  et- 
aggeralcd  on  the  left  side  doc$  not  militute  against  the  exiitteoce  of 
tuberculous  disciLtc  on  that  side.  Exaggeration  of  the  bronchial 
whisper,  that  is,  the  uornml  brouchinl  whi*per  inereucd  in  intenxitjr 
and  raised  in  pitch,  but  not  sufficicnilj  to  constitute  wlii.tpemg 
bronchophony,'  is  a  sign  of  mnch  value  in  the  diagnosis  of  tubercn- 
louB  disease,  when  the  deposit  is  small.  The  characters  of  the  sign 
are  marked  in  proportion  to  the  niuount  of  tuWreulQUs  deposit,  but 
it  is  not  infrequently  araiLulilc  when,  from  the  snuillncss  of  the  d^ 
posit,  other  signs  arc  obscure.  As  regards  this  sign,  the  points  of 
disparity  between  the  two  sides  in  health  are  to  be  borne  io  tniitd, 
viz.,  the  somewhat  greater  intensity  of  the  bronchial  whisper  on  the 
right  side,  and  the  somewhat  greater  elevation  of  pitch  on  the  htt 
side. 

Directing  attention  now  to  the  phenomena  furnished  by  aoaeulla- 
lion  when  tiic  tuberculous  deposit  is  abundant,  the  respiratory  aoanil 
may  present  still  the  broncho>vesicular  modification,  more  marked 
than  before,  or  the  bronchial  respiration  may  be  present  and  more 
or  less  intense,  or  the  respiratory  sound  may  be  suppressed. 

Suppression  of  the  respiratory  sound  over  tuberculous  solidifica- 
tion, is  rarely  observed  at  the  sutiimit  of  the  chest  in  front.  It  occurs 
oflener,  but  by  no  meauA  frequently,  over  the  scapula.  It  ui  noted 
in  but  5  of  62  examinations.  Diminished  intf n«iily  of  the  res[Hratofy 
sound,  however,  is  a  fri-(|uent  modification.  Of  SH  examinaiiand  in 
different  cases  in  which  the  facts  pertaining  to  this  ptunt  were  noted, 
(he  number  in  which  thvre  was  iliminulion  on  the  side  most  affected 
was  26,  while  the  intensity  wait  greater  on  the  opposite  side  in  12. 
The  diminution  in  different  eases  varies  much  in  degree^  InseverrJ 
instances  among  tho  cases  just  referred  to,  the  souml  was  so  feeble 
as  to  be  Marcely  appreciable,  and  it  was  diOieult  to  study  its  char- 
acters aside  from  the  fact  of  feebleness.     The  characters,  under  these 

1  ViJt  Fart  I.  pa«c  S4a 


•uluomai 


489 


eircninstances,  are  (hose  wbicb  belong  eitber  to  the  broncho-veaicu- 
lar  or  to  the  bronchial  reapiralion.  Occasionalty  tuberculous  solid- 
ification girea  rise  to  a  broncbial  respiration  vhh  all  its  characters 
as  intense  as  in  the  cases  of  pnemuonitis  in  which  it  is  moat  stronglj 
Barked. — the  inspiration  loud,  tubalar,  high  in  pitch,  foUoned,  after 
a  brief  interval,  by  an  expiratory  sound,  prolonged,  higher  in  pitch, 
and  niort)  iuienae  than  the  sound  of  expiration.  Thus  complete,  it 
occurs  in  a  certain  proportion  of  cases.  Ad  inspiratory  sound  may 
alone  h«  heard,  which,  if  bronchial,  is  purely  tuhular,  i.  «.,  devoid 
of  any  vcnicnhir  f|iiulity.  OfU-n,  an  expiratory  sound  is  alone  heard, 
which  is  more  or  Ims  prolonged,  high  in  pitch,  sometimes  lotid  nnd 
Bear  the  ear;  in  other  instaDces  faint  and  distant.  These dircrsi lies, 
when  thi>  quantity  of  tubcroulous  deposit  is  abundant,  aa  well  as  when 
it  is  sniull,  do  not  denote  any  special  pathological  distinctions.  The 
practical  point  is  niniply  to  det«nnine  the  existence  of  the  bronchial 
respiration.  With  an  eijual  amount  of  disease,  owing  to  differeiicoa 
in  the  disposition  of  the  tuberculous  matter,  the  bronchial  respiration 
in  one  case  may  be  intense  and  complete,  and  in  another  case  compa- 
ratively feeble  and  incomplete.  The  most  strongly  marked  bronchial 
reepiratjon  m«.y  only  show  that  the  solidiScation,  in  its  relations  to 
the  larger  bronchial  tubes  and  the  surface  of  the  lung,  is  disposed 
in  a  manner  mail  favorable  for  the  development  and  transuii»iion  of 
the  sign. 

In  cases  of  considerable  tuberculous  soUdifioation  at  the  summit 
of  oQ«  lung,  a  dcpoHit,  more  or  less  in  amount,  exists  at  the  same 
timo  in  tho  other  lung.  Auscultation  on  the  side  opposite  to  that 
most  affected,  may  discover  the  churactorH  of  the  broncho-vesicular 
or  the  bronchial  rcNpiration  more  or  Ices  marked.  An  obvious  dis- 
parity between  the  two  sides  is  usually  apparent;  but  it  is  occa- 
sionally somewhat  difficult,  by  the  combined  results  of  percuasion 
and  auscultation,  to  determine  on  which  side  the  disease  is  roost 
advanced.  This  difficulty,  however,  very  rarely  exists  if  the  disease 
have  not  advanced  to  excavation,  and,  under  the  latter  circumstances, 
it  is  not  often  experienced.  On  the  other  hand,  while  the  physical 
evidence  of  extensive  tuberculous  solidification  on  one  side  exists  in 
some  instances,  on  the  opposite  side  the  vesicular  murmur  apparently 
retains  its  normal  characters.  In  such  cases  the  respiration  on  the 
sido  least  affected  is  supplementarily  exaggerated;  and  this  ab- 
normal development  of  the  vesicular  murtnur  prevents  those  modi6* 


440 


DISEASES  07  TEE   RBSPItAlOftT    aB6AH8. 


cations  from  being  munifotitcd  which  wonid  he  obserred  with  the 
•amc  nmoniit  of  disease  if  the  oihcr  lanj;  were  not  affected. 

Adventitious  oounds,  or  rales,  nre  frequently  heard  in  aageti1t&- 
ting  patients  with  ahondunl  tiiberculovs  deposit.  Including  frietMm- 
sounds,  the;r  are  noted  in  25  of  62  recorded  exaininntion«.  made  to 
different  ainea.  The  rales  noted  in  the«o  cKsioinntionM  nre  cither 
the  crepitant  or  sub-erepilan(  (l)ic  record  sometimes  only  etatiiij 
crepitation)  in  6;  dry  crackling,  in  8;  sonorous,  in  5;  sibilant,  in 
6;  H  clicking  soond  in  3;  inncona  or  bubbling  in  2.  Interrupt^ 
rcspiriktion  is  alno  obserretl  in  n  certain  proportion  of  cases  in  whicb 
lliv  ifunntity  of  tubercle  is  abundant.  It  is  noted  id  5  of  62  eiaml- 
nattons ;  but  >u  three  of  the«e  fire  instances  it  was  obserred  OB  the 
flide  opposite  to  that  most  affected— •  fact  gmng  to  illiutrate  the 
relation  of  thi«  sign  to  a  small,  rather  than  sn  abundant,  depoeitioii 
of  tubercle.  The  raleji  hare  the  same  significance  as  at  &  prior  date 
when  the  qnanttty  of  tubercle  is  small.  The  modified  respiratorj 
sounds,  being  more  constnnt,  in  n  dJagtioetic  point  of  view,  are  of 
more  importance.  The  latter  becoming  generally  more  marked  at 
the  tuberculous  solidification  increases,  the  rules  are  of  less  ra)M 
than  at  an  earlier  period  in  the  disease,  when  the  deviations  from 
the  character  of  the  normal  respiration  are  not  so  appnrent,  and  the 
diagnosis  accordingly  more  difficult. 

A  friction-sound  may  accompnay  a  tuberculous  deposit  small  !■ 
amount.  Instances  nro  rvferrcd  to  in  the  6rst  part  of  this  work  in 
which  this  sign  wiui  due  to  the  pulmonary  pleural  surface  becoming 
roughened  by  the  projection  of  numerous  isolated  miliary  tubercles 
deposited  immediately  beneath  it.  This  is  an  accidental  circam- 
stance  of  very  rare  occurrence.  Tlio  sign  is  significant,  generally, 
of  circumscribed  drypleuritis  over  the  tuberculous  dcposita.  While 
the  quantity  of  tuberculous  matter  is  small,  it  is  extremely  rare  for 
a  friction -sound  to  be  developed ;  nor  is  it  by  any  means  a  frequent 
ngn  of  abundant  tuborde.  Although  circunracribod  pleuritis  b  se 
constant  an  evrnt  in  the  history  of  tuberculosis,  the  superior  costal 
movements  probably  do  not  involve  sufficient  attrition  of  the  rough- 
ened surfaces  to  give  rise  to  an  appreciable  sound ;  and,  moreover, 
adhesion  doubtless  speedily  follows  the  fibrinous  exudation.  This 
sign  was  noted  In  2  of  62  cases  of  abundant  tuberculous  deposits 
In  both  these  cases  the  patients  were  females,  and  it  is  probably 
true  that  a  friction-sound  at  the  summit  of  the  chest  is  oftener  mat 


PDLMOJTART  TCBEBCrLOSTS. 


441 


I 

I 
I 


vith  in  fpmales,  owing  to  the  predominance  in  them  of  the  !iU[>erior 
cottlal  tvpe  of  rcApirntion.' 

Id  cftHCii  of  luberculoun  8ol id ifi cation,  the  HoundA  of  the  heart  are 
found  to  l>c  unduly  audible  in  a  large  proportion  of  the  casea  in 
which  the  attention  is  directed  to  this  point.  Like  the  other  con* 
tingent  phenomena,  however,  this  aigo  is  of  less  importance  than  at 
an  earlier  period  when  the  physical  evidence  of  the  disease  de- 
rived from  percussion  and  the  modiRed  respiration  is  less  clear  and 
positive. 

An  arterial  be  Hows" -murmur,  in  the  infra  or  poet-clavicular  region, 
is  a  physical  sign  occasionally  observed,  and  is  probably  due  to  pres- 
flure  of  a  mass  of  tubercle  on  the  subclavian  artery.  This  sign  has 
Dot  iofrequenlly  attracted  my  attention.  When  present  on  one  side, 
and  not  on  the  other,  and  especially  on  the  side  presenting  other 
pbeooroenx  indicating  tuberculous  disease,  it  is  to  be  included  in  the 
liat  of  contingent  signs  which  concur  to  confirm  the  diagnosis.  If 
it  exist  on  both  sides  it  may  be  an  aniemic  marmur,  or  attributable 
to  proHAiire  of  the  stethoscope.  As  an  isolated  sign  it  is  entitled  Co 
bat  littk-  consideration. 

The  vocal  phenomena  furnished  by  auscultation  are  more  ani- 
fornly  present  »iid  much  more  marked  when  considerable  tubercu- 
loae  solidification  exists,  tbun  In  cmcst  of  Hmall  disseminated  tuber- 
clc».  If  the  right  side  be  the  scat  of  the  more  ahundniit  dcpo!<it, 
the  vocal  rcsonnnce  is  generally  so  diaproportionatvly  intense,  aa 
compared  with  the  left  side,  that  there  can  be  no  quciition  a»  to 
its  not  being  due  to  the  natural  diKparily  existing  holwei-n  the 
'two  aides.  On  the  left  aide  the  intrinsic  evidence  of  itH  morbid 
character  id,  of  course,  still  more  conclusive.  But  the  rule  as  to  an 
increoseil  vocal  rcnonnnce  in  by  no  means  invariable.  Ksceptiou* 
'•re  observed.  There  may  be  no  Appreciable  r^sonnoce  on  either 
aide;  and  wlih  an  abundant  deposit  on  one  side  it  may  be  equal  on 
the  two  sides.  The  latter  will  be  more  likely  to  be  observed  in  cases 
in  which  the  abundant  deposit  is  seated  in  the  left  side;  and  under 
these  circumstances,  the  equality  of  resonance  may  be  evidence  of 
an  abnormal  increase  on  the  left  side,  assuming  that  there  existed 
a  natural  disparity  in  favor  of  the  right  side.  I  have  observed  the 
Tocal  resonance  to  be  more  marked  at  the  summit  of  the  right  aide, 

•  A  Mmloa-«oaaA  al  the  aummit  of  the  ch»t.  developed  in  the  eoiirno  of  pol- 
Lwioiurv  tuberruloaii,  )•  Dlwaj"!  of  the  urif-inK  vurini^' ;  iiuiir  roiij;h  or  rapping, 
>  at  the  lowet  ful  of  th«  che»l  In  «onia  miai-a  uf  gvnrrnl  pltrurlajr. 


443 


DI88ABB8  OF   TDB    RBSPIRATORT    OBdJ 


wluo  otber  physical  signn  slioned  an  abunil»nt  deposit  in  the  left 
lung,  the  resonance  on  the  afTe^led  sMe  either  not  being  exaggerated, 
or  not  BuSiciently  so  to  equal  that  nhich  naturally  existed  on  the 
opposite  side. 

Bronchophony,  as  distinguUhed  from  exaggerated  vocal  resoDaaeei 
is  observed  in  a  less  proportion  of  cases.  Not  infrecjaently,  ho»- 
ever,  it  is  strongly  marked.  I  have  observed,  in  ooanectioD  vith  t 
more  abundant  deposition  in  the  left  than  in  the  right  lung,  that  the 
vocal  resonance  was  greater  on  the  left  side,  while  weak  broncboplh 
ony  existed  on  the  rigbt,  and  not  on  the  left  side. 

I  may  repeat  here,  what  has  been  said  already  in  the  chapter  on 
Pneumonitis,  and  in  the  first  part  of  this  work,  that  when  bron* 
chophony  exists,  it  is  generally  a  persistent  sign,  not  dJsappesring 
and  resppeariog  at  successive  examinations,  as  stated  by  Skoda. 
It  does  not  sustain  any  fixed  relation  to  the  bronchial  respiration.  I 
have  iu  sovcnil  instiinops  observed  strong  bronchophony  in  c*t»  b 
which  A  respiratory  sound  was  so  feeble  as  to  be  scarcely  appre- 
ciable, and  conversely,  there  may  be  an  intense  broncUial  rcspirv 
tion  without  marked  bronchophony. 

The  bronchial  whisper  is  exaggerated  in  proportion  to  the  abm- 
dance  of  the  deposit,  or  the  increase  of  intensity  and  elevation  of 
pitch  may  bo  sufficient  to  coiiaiitute  whiapering  broncbopbooy. 
These  signs  mny  be  present  in  a  notable  degree,  when  neither  brra- 
ebial  respiration,  broneho]>bony  with  tlie  loud  voice,  nor  exaggerated 
TOeftl  resonance  is  strongly  marked. 

In  cases  of  tuberculous  disease  advanced  to  the  formation  of  cavi- 
ties, more  or  less  of  solidification  of  lung  usually  remains;  and  benoe, 
the  auHcuh&tory  phenomena  just  described  do  nol  altogether  i^sap- 
pear,  although  they  may  be  diminished,  combined  with,  and  to  Mtne 
oxtutit  replaced  by  other  signs.  The  characteristics  which  distin- 
guish this  period  in  the  cltninal  history  of  tuberculosis,  consist  in  the 
addition  of  cavernous  signs  to  the  phenomena  denoting  solidification. 
It  sulTiceH,  then,  to  inquire,  what  arc  the  cavernous  signs  fnrDished 
by  aUKCuIlation,  and  to  what  extent  are  tbey  available  in  diagnosist 
As  rug^irds  ciivcrnoiM  riHpiriicion,  observations,  directed  moreMp*- 
cially  to  the  variations  in  pitch  of  r«,spiratory  aonnds,  have  led  me 
to  ascertain  that  the  soundm  caused  by  the  passage  of  air  to  and 
from  an  cxciivation  of  an  adequate  sise,  under  favorable  eirous- 
stanecs,  may  bo  readily  dixtinguishcd;  that  the  cavernous  and  the 
bronchial  respiration  arc  not,  as  far  as  audible  characters  are  con- 


Ptri,»01»A8T  TCBBRCULOSIB. 


cerned,  ideoticul ;  and  that  the  normal  Uryngo-tracheal  respiration 
is  the  type  of  the  bronchial,  but  not  of  the  carernous  reapiralion. 
The  distinctive  features  of  the  cavernous  respiration  have  been 
considered  at  length  in  Part  I.  It  is  suUicient  to  reproduce  a  tiim- 
ple  enumeration  of  ihem  h<>re.  They  are  as  follows :  an  inspiratory 
sound,  non-vesicular,  hollow,  or  blowing,  but  compared  with  the 
bronchial  inspiration  low  in  pitch,  and  more  slowly  evolved ;  ami  an 
expiratory  sound  lower  in  pitch  than  the  sound  of  inspiration.  A 
large  number  of  observations  in  which  these  features  of  the  re!>pir«> 
tioD  ncre  localisted  during  life,  and  found  to  correspond  in  their 
situation  with  cuvitii.-^  ascertained  to  exist  after  death,  haw  li-il  me 
to  know  thai  the  cxislenuo  and  seat  of  excavations  may  be  predi- 
caled  on  the  auscultatory  characters  just  mentioned,  whenever  they 

■  are  distinctly  manifested.  But  owing  to  the  number  of  circuni' 
^MrtMoes  which  must  be  combined  in  order  that  a  cavernous  rc^pira- 
VlHUi  may  be  developed,  it  will  often  happen  that,  when  eavitic^  have 

■  formed,  an  exatsiDaiion  fails  to  discorcr  the  evidence  of  their  cxist- 
enco.  In  some  cases  it  is  only  after  repeated  t-xplorationM  mudc  at 
different  times  and  conducted  with  cure  Hud  pnticncf,  that  tht-y  »r« 

I  detected.  For  an  account  of  the  method  of  prosecuting  a  Kvtircb  for 
cavities,  and  'of  the  circumstances  upon  which  the  development  of 
the  cavernous  respiration  depends,  the  reader  is  referred  to  that 
portion  of  the  chapter  on  Auscultation,  in  Part  I,  which  is  devoted 
to  (his  subject. 
The  cavernous  re§piration,  like  the  bronchial,  is  by  no  means 
always  presented,  clinically,  with  the  sum  of  its  characters  complete. 
The  inspiratory  sound  may  be  alone  present.     Possibly  this  is  true 

inlito  of  the  expiration,  but  I  ciumol  affirm  that  I  have  met  wiih  an 
instance.  The  lowiic's  of  piloh,  together  with  the  absence  of  both 
the  ve»icular  and  the  tubular  quality,  are  the  points  of  di»lincl!on,  if 
an  inspiratory  vound  being  alone  heard,  the  contrast  in  pitch  between 
this  sound  and  thai  of  the-  expiraiion  be  not  avHihihle.    Owing  to  ibc 

■  Bolidilication  generally  surrounding  tubercular  excavations,  the 
bronchial  respiration  \s  frcquenlly  present  in  the  immediate  vicinity 
of  the  cavernous,  and  by  mpans  of  thin  conipurison  the  characters  of 
the  latter  arc  rcndercil  more-  conHpIeiions. 

»       If  the  distinctive  features  of  the  cavernouii  respiration  be  mani- 
featcd  within  a  circumscribed  space,  ami  the  cburaeters  of  the  hroQ> 
ohiat  respiration  surround  this  space,  the  localization  of  an  excava> 
ion  may  be  made  with  confidence.     The  evidence  is  rendered  stjil 


444 


niSBASBS   OF    THE    RBSPIRATOBT    OBOAKi. 


more  complete,  if  At  diflcrent  ]>eriod»  of  the  ilny  tlw  nTernom  rv*- 
piration  be  founi)  to  be  soinetime«  prexcnt,  »nil  iit  other  times  sIvMBtf 
anii  more  eapeciallj  \T,  when  found  to  be  BbKcnt,  it  be  observeO  to  be 
repnxluccd  after  an  abundiiiit  cxpctitornliOD.  And  if  over  this  spict 
s  cireomscribed  tympiinitic  n^sonsnce  on  percmsion  be  fotind  to  co- 
exist with  the  eavemouH  rettpiralion,  and  todiuppoar  when  it  oram^ 
the  resonance  perhapi*  presenting  >n  amphorio  or  cracked- veasd  i^ 
tonalton,  nothing  more  could  be  desired  to  strenglhen  tiic  proof  of 
the  site  of  a  cavity. 

In  Home  cases  a  carernouii  respiration  is  not  thus  circumscribed, 
but  is  more  or  tess  difTused  orer  (he  summit  of  the  chest.  The  eoa- 
ditions  which  may  be  supposed  to  exist  in  these  cases  are  either  a 
very  large  excaralion,  or  numerous  cavities  which,  if  they  do  not 
communicate,  are  situated  in  close  proximity  to  each  other,  the  ag- 
gregate amount  of  oxcavntion  being  snfficient  to  caos^  a  predoni' 
nance  of  the  cavernous  over  the  brouchinl  characters  of  the  rapirv 
tory  sound.  On  the  other  hand,  if  cavities  exist  which  &r«  small  is 
sizp,  and  not  numerous,  the  intervening  solidification  causes  a  pre- 
dominance of  the  bronchial  over  the  e&vernous  characters,  so  that, 
under  these  circumstances,  ausculuiion  fails  to  discover  the  ex* 
istence  of  excavations.  In  auscultating  patients  with  Ciiberenlimt 
more  or  less  advanced,  the  cavernous  and  the  bronohial  resfuraltw 
are  not  infrequently  combined;  in  other  words,  the  rf^piratiM 
presents  the  charscters  of  these  two  signs  mixed,  the  cavernous 
predominating  in  some  cases  and  the  bronchial  in  others.  The  ex- 
istence of  cavities  maybe  predicated  on  such  a  combtDation,  although 
tht'ir  siic  and  situation  are  not  deiermincd.  This  combination  might 
with  propriety  be  atyted  a  broncJio-cat'eniout  respiration. 

An  amphoric  intonation  is  conclusive  evidence  of  the  existenceof 
a  pulmnnary  cavity,  if  pneumothorax  be  excluded.  This  variety  of 
Uiu  cavernous  respiration  is,  however,  not  often  present  in  tobereii- 
loos  excavations. 

Gurgling,  also,  when  well  marked,  is  sufficient  proof  that  the  dis- 
ease has  advanced  to  excavation ;  but  as  the  sound  is  more  or  lefS 
diffused,  it  does  not  serve  to  fix  the  precise  location  of  the  csrily  « 
well  as  the  cavernous  characters  of  the  respiratioiL 

A  cavernous  vocal  sign  is  transmission  of  speech,  i.  *.,  articulate 
words,  to  the  oar  applit'd  over  the  seat  of  an  excavation.  Pectorilo- 
quy, however,  as  this  sign  is  called,  is  not  exclusively  a  carerooni 
sign.     It  occurs,  perhaps  marc  frequently,  over  solidified  lung,  and, 


rOLHOICART  TOBBRCDLOStS. 


445 


^ 
^ 
^ 


bcncc,  it  is  occMsionklly  observed  over  a  mnu  of  crude  tubercle 
before  the  disease  bns  udrnnccd  to  t)ie  formation  of  cariiics  The 
difittnclive  features,  however,  of  cavernous  pcctoriloquj,  bolb  with 
the  loud  and  wbispcred  voice,  have  been  stated  in  Part  I.'  Willi  the 
loud  voiec  the  spcccb  is  transmitted  through  a  CATit;  or  caviiieB, 
when  the  characters  of  broncUophonj,  via.,  prosimity  to  the  ear  and 
elevation  of  pitch,  are  vanting;  and  nbiftpering  pectoriloquy  is 
cavernous  vhen  the  sound  Li  law  in  pitch  and  hollow  or  blowing  id 
qtialiiy  inatead  of  being  high  and  tubular.  Olber  circuniiitttuDcs 
vhich  render  it  distinctive,  as  &  caveriioua  sign,  are  its  being 
limiled  to  a  circumscribed  spaee,  ita  tntermltleney,  and  ita  coexi»t- 
ence  with  cavernous  respiration  and  a  tympanitic  percuAsIon-retto* 
nance  (with  or  without  either  the  amphoric  or  cracked- nielal  intona- 
tion) confined  within  the  same  limila.  An  amphoric  resonance  pro- 
ised  by,  the  voice  is  in  it,self  distinctive  of  a  caviiy,  provided 
lOthorax  be  excluded. 

The  act  of  coughing  may  develop  auscullatory  phenomena  whicb 

i.faigb^  Signifjciint  of  tubercular  excavation.  When  a  uuvily  of 
Idcnble  aize  and  «upi^rficlMi1y  situated  is  empty,  the  violent  ex- 
pirations inctdciit  to  coughinj;  occasion,  within  a  circumscribed  area, 
a  hollow,  blowing  eound,  sometimes  accompanied  by  a  forcible  shock 
against  the  cur  applied  to  the  chest.  If  the  cavity  be  ptirtially  filled 
with  liqnid,  a  load  gurgling  or  splashing  noise  is  frequently  produced. 
The  latier  is  eminently  a  cavernous  sign. 

Finally,  the  physical  sign  which  is  at  once  a  respiratory,  vocal, 
and  tussire  sign,  viz.,  metallic  tinkling,  \*  uccasfionally  produced  in 
connection  with  a  large  pulmonnry  excavation.  The' conditions  for 
ita  production  are  only  present  when  the  cavity  is  extremely  large, 
and  when  it  contains  liquid  and  sir  in  certain  relative  proportions. 
It  ia  so  rarely  incidental  to  a  tuberculous  cavity,  that  it  is  only  inter- 
esting in  this  connection  as  a  clinical  curiosity,  and  as  furnishing 
an  exception  to  the  rule  that  it  denotes  perforation  of  the  lung  and 
pnoumo-hydrothorax. 

In  employing  auscultation  in  cases  of  suspected  tuberculo«>ts,  the 
attention  ia,  of  course,  as  in  practising  percussion,  to  be  directed 
especially  to  the  summit  of  the  chest,  in  view  of  the  fact  that  in  the 
HUU  majority  of  cases  a  tnberculoua  deposit  takes  place  first  and 
ebiefly  at  or  ucur  the  apices  of  the  lungs.    The  occasional  exceptioiu 


Viet*  ptfM  242  and  340. 


446 


DISBASBS   07  TBI    BBSPTAATOBT   OROAKS. 


to  tluB  Uw  will  be  hereafter  noticed.  In  aafcnttHting,  u  in  pcnrra- 
eing,  the  chest  for  the  evidence  of  tubercle,  it  in  equally  impoTtut 
to  examine  behind  over  the  scapulie.  as  in  front.  The  po«t-c1aTiciilar 
space  in  doI  to  be  overlooked,  prorided  the  phj^ical  evidence  of  the 
diRea.4e  b«  not  sufEciently  distinct  in  other  situations.  The  pheaom- 
«Rn  diflcovcrcd  by  auocultation,  aa  well  tut  those  developed  bTp«> 
ciu(«ioii,  nrc  to  be  compared  on  the  two  aides  of  the  chest,  cortv- 
epoiiiliiij;  points  being  sucoewvely  explored.  The  respiratory  Mondt 
beini;  exnminfi]  first  on  one  side  and  next  on  the  other  aide,  and 
contrnstcil  with  each  other,  the  obimrrer  is  to  decide  whether  then 
sounds  nre  equal  on  both  sides.  A  disparity  between  the  two  sidM 
(maLing  duo  allowance  for  certain  natiinti  differences)  indicates  di>- 
e««c.  The  sounds  on  bolh  i<ide«  may  be  abnormal,  but  in  socordinoe 
with  a  law  of  tuberculosis  there  is  almost  inrariahly  the  evideoee  cf 
a  greater  amount  of  disease  on  one  eidc  than  on  tb«  other.  Tlavisg 
discovered  that  an  abnormal  disparity  exists,  the  next  step  is  to  ana- 
lyse the  sounds  on  each  side,  and  ascertain  the  morbid  charaeien 
which  arc  presented.  These  characters  relate  to  the  intensity,  quiJ- 
ity,  pitch,  duration,  and  rhythmical  succession  of  the  inspiration  sad 
the  expiration.  After  such  an  analysis  we  refer  morbid  alieratiou 
to  their  appropriate  place  in  the  catalogue  of  physical  sjgiis :  in  other 
words,  wc  determine  whether  there  be  present  a  broncho-vesicnlw, 
a  bronchial,  or  a  cavernous  respiration.  The  cocxistcoco  or  tht 
absence  of  advL'ntitious  sounds,  or  rales,  are  at  the  same  time  asoef- 
tsined.  It  is  frequently  useful  to  compare  the  phenomena  foosd, 
not  only  in  corre^puuding  points  on  opposite  sides,  but  in  different 
portions  of  the  same  side.  For  example,  the  respiratory  sounds  over 
the  scapula,  above  and  below  the  spinous  ridge  may  present  BtriLing 
poiuts  of  contrast ;  as,  also,  the  post-clavicular  and  the  infra-clavie- 
alar  regions  in  front,  and  different  parts  of  tbc  latter  region.  Tie 
upper  third  of  the  chest  may  bo  compared  with  (he  middle  and  lowcf 
third,  in  order  to  judge  by  contrast  with  respect  to  morbid  changes. 
The  chest-sounds  mny  be  brought  into  comparison  with  the  laryngo- 
tracheal, when  it  is  desired  to  compare  the  former  with  the  type  of 
the  bronchial  respiration.  Similar  comparisons  arc  to  be  insiitsi 
with  respect  to  vocal  phcnoinena. 

Inspection  furniithes  Signs  of  tubercular  disease,  consisting 
morbid  appearances  which  perluin  to  the  size  and  form  of  the  summit 
of  the  chest,  end  to  the  respiratory  movements  in  this  sitnalion. 
Some  depression  on  the  affected  side,  and  diminished  expaosioo  with 


PPLMONABT  lOBKBCOtOBIS. 


447 


I 
I 


I 


I 


inspiration,  are  apparent,  in  a  sninl]  proportion  of  cas^e,  at  an  carljr 
period,  wh«n  the  quantity  of  tuberculouK  matter,  so  far  as  it  can  bo 
eatimatcd  bjr  means  of  other  signs,  is  small.  A  diitpiirity  in  tutiic  and 
motion,  although  less  frequently  observed  at  this  porlod  than  Mubse- 
qnently,  in  of  more  importance  than  when  the  (|QRntity  lK-come« 
abundant,  bccauw  the  diagnosis,  in  general,  Ja  only  difficult  eo  long 
•8  the  disease  haa  not  made  much  progress.  After  the  deposit  hM 
attained  to  a  certain  amount,  involving  considerable  solidification, 
the  evidence  of  its  existence  derived  from  the  combination  of  differ- 
ent ugns  IB  sufliciently  clear  and  decisive.  The  obstruction  to  full 
expansion  of  ibe  upper  portion  of  the  lung,  and  the  oollaps«  of  nir^ 
cells  produced  by  a  fen  small  disseminated  tuborclea,  may  occn!<ion 
an  undue  deprcasion  either  above  or  below  the  clavicle,  or  in  both 
situations,  ascertained  by  comparison  of  the  two  aides.  Moreovor, 
circumscribed  pleuritis,  leading  to  pleuritic  adhesion,  and  thereby 
tending  to  contract  the  apex  and  restrain  iu  expansion,  belongs  to 
the  early  history  of  tuberculosis,  as  is  evidenced  by  the  symptoms. 
In  comparing  the  superior  costal  movements  of  the  two  sides,  ob- 
serving the  precautions  pointed  out  in  Part  I,  in  the  chapter  on 
Inspection,  the  effect  of  forced  as  veil  as  tranquil  breathing  is  to 
be  irinerrcd.  Owing  to  the  limited  amount  of  expansiiin  at  the 
it  of  the  cht-st  in  ordinary  breathing,  a,  dlitparity  in  males  is 
rarely  apparent  except  when  the  intensity  of  respiration  is  in- 
creased; and  in  fcmalrs,  in  consequ^-nRO  of  the  habitual  prodomi- 
Donee  of  the  superior  cost.il  type,  a  disparity  is  manifested  earlier, 
more  frequently,  and  in  a  more  marked  degree.  Mensuration,  by 
means  of  the  graduated  inelastic  tape,  hut  more  especially  witti  the 
chest-measurer  of  Dr.  Sibson,  or  the  stelhometer  of  Dr.  Quuin,  will 
fhow  a  disparity  in  expansive  motion  with  greater  precision.  For 
clinical  purposes,  however,  inspection  suffices.  Callipers  also  enable 
tbc  explorer  to  dctennine,  with  proper  care,  the  exnct  anioant  of 
Tariatton  between  the  two  sides  in  tbcir  sntcro-postcrior  diamctera. 
But  this  exactness,  for  ordinary  practical  purpo»ee,  has  no  adv&n- 
toge  over  tbc  information  obtained  by  tbc  readier  and  more  umple 
method  of  comparing  with  the  eye.  It  is  net  to  be  forgotten  that 
A  want  of  symmetry  between  the  two  sides,  due  to  curvature  of  the 
spine,  former  pleurisy,  or  other  causes,  occasions  more  or  less  dis- 
parity in  sixc  and  expansibility,  irrcspcctivcof  present  disease;  and 
even  when  no  want  of  symmetry  in  the  general  conformnlion  of  the 
chest  IB  discoverable,  a  slight  difference  in  the  curves  of  the  clavicle 


DISBASB8    or    TBI    RISPIRATOKT    OROAVf. 


naj  cause  llie  rr^ona  aborv  nnd  below  tliis  bone  to  appear  on  out 
Btdv  reUlivf  ly  tiomvwiiiit  <leprr8i>ci).  In  inakitig  obs«rvaiion$  on  ihe 
kealth;  cliost,  I  Have  ob^-rvcil  tbat  occ&itionalljr,  even  irhea  it  s{k 
p«ara  to  be  perfectly  well  formed,  lh«r«  exists  a  slight  disparity  m 
motion  at  thr  summit.  Isolutcd  from  oitipr  signs,  therefore,  Tai» 
tions  in  8tE«  and  expan»ibility,  if  slight,  po«M8s  very  little  diagoootie 
value.  Thflr  importaiioe  d<-p«uds  niainlj  on  tht-ir  connection  iriik 
other  signs,  »nd  with  symptoms  which  render  probable,  if  not  certain, 
ike  conclusion  that  they  are  due  to  a  morbid  csnse. 

At  a  later  period  in  the  progress  of  the  discnsc,  irheo  the  Kibcr- 
eolsr  solidification  is  coiiAiderablc,  ani]  when,  m  already  remarked, 
the  signs  furnished  by  inspection  or  by  mciuuralian  are  of  less  iat- 
portancc  in  the  ilingno)<is,  the  depression  at  the  eummit  and  the  de- 
fective expnnsion,  are  generally  conspicnotia.  The  ossee  are  fe«  ii 
number  in  nhtch  these  signs  are  wanting.  Of  S5  recorded  cxamiat- 
tions,  in  difl'crent  cases  io  which  the  appearances  on  inspertioD 
were  noted,  in  all  but  4  there  was  cither sbDormB]  flattening, nrdinuB- 
ishcd  superior  costal  motion,  or  both  were  combined.  Diminbhcd 
motion  WHS  oftencr  observed  than  fluttening,  hut  in  the  majority  of 
instances  both  were  observed.  Depression  is  generally  made  appa- 
rent by  the  greater  projection  of  the  clavicle,  but  it  is  soroelimes  the 
case,  that  this  bone  follows  the  retreating  ribs,  and  then  the  greater 
concavity  above  and  the  apparent  flattening  below  may  be  on  tbe 
tide  least  affected.  In  sacb  cases  callipers  are  requisite  to  dc-mon- 
atrutc  the  side  on  which  is  the  real  reduction  in  size. 

A»  would  be  rationally  inferred,  a  disparity  between  the  iwo  sides, 
at  the  summit,  tn  size  and  expansibility,  continues  after  tuherculosb 
fans  advancod  to  the  formation  of  cavities.  It  is  stated  by  Walshe 
that  in  some  cases  in  which  a  very  large  cavity  has  formed,  the  d^ 
pression  is  leas  marked  than  at  a  prior  period,  and  the  cxpansioo- 
movement  may  be  increased.  An  increa^ie  of  siae  under  ibese  ctr^ 
cumstancea  would  hardly  be  expected  A  priori,  and  its  occurrence 
might  fairly  be  distrusted  except  it  had  been  positively  ascertaiaej 
by  careful  comparative  mcasureiuenls  at  diflerent  periods.  The  in- 
creased expansibilily  is  more  intelligitile.  A  bulging  in  tfae  inter- 
costal spaces  over  a  circumscribed  space,  with  the  act  of  coughing, 
I  have  repeatedly  observed;  an  appearance  indicating  the  site  of  a 
large  cavity  witb  its  walls  situated  near  the  superficies  of  the  lung, 
and  the  pleural  surfaces  adhcreat.  This  conslitales  a  very  striking 
cavernous  sign. 


rVtUOtl AHY  TCBBBCClon 


449 


Palpation  ran;  fumisli  inforniatlon  of  utility  in  ilo  bearing  on  the 
dingtiosis  of  pulmoiinry  luberculwis.  The  incren»rd  sense  of  resist- 
ance to  pressure  ovpr  tuberculnr  ttolidificution  is  n»certninc<I  by  this 
method  more  satisfactorily  than  incidentally  in  tkf  practice  of  per- 
cussion. By  placing  the  hand  on  the  Hummit,  the  extent  of  ^xpan* 
Hive  moreincnt  can  be  cslimated,  and  the  two  sides  compared  in  this 
respect.  But  it  is  especially  with  respect  to  the  vocal  fremitut  that 
this  method  of  exploration  is  applicable.  Its  utility  in  this  point  of 
view,  however,  is  comparatively  slight.  An  exaggerated  fremitus  Is 
nn  occHMonnl,  not  a  constant,  eifect  of  increased  density  of  lung. 
Even  when  solidification  'i»  complete  and  extensive,  as  it  is  in  some 
cases  of  pneumonilts,  an  cxitg;;eration  of  the  fremitua  is  by  no  moans 
uniform.  In  the  partial  and  imperfect  solidilication  from  tubercle, 
the  sign  is  often  wanting ;  especially  in  the  early  period  of  tubercu- 
losis, when  it  is  most  valuable,  it  is  rarely  present.  Another  reason  for 
ihe  frequent  unavailability  of  this  sign  is  the  disparity  between  the 
two  sides  as  regards  the  normal  amount  of  fremitus.  It  is  habitually 
greater  on  the  right  side ;  etjuatity  in  this  particular  constitutes  nu 
exception  to  the  rule.  This  fact  renders  the  sign  almost  nngulory 
in  caaea  in  which  a  greater  fremitus  is  found  on  the  right  eidc.  Ob- 
servations show  that  the  fremitus  may  continue  greater  on  the  right 
side  whcn'other  signs  indicate  unequi vocally  nn  abundant  tuberculous 
deposit  on  the  left  side.  But  this  normol  difference  between  the  two 
sides  renders  the  sign,  in  some  instances  in  which  it  exists  on  the 
left  side,  more  significant  than  it  would  be  were  the  two  sides  equal 
in  health.  A  vocal  fremitus  existing  on  the  left  and  not  on  the 
right  side,  or  more  marked  in  the  former  ^itualioo,  is,  in  fact,  highly 
significant,  but  the  coexisting  signs,  under  these  circumstances, 
leave  no  room  for  doubt  as  to  the  fact  of  solidification  of  the  lung. 
In  accumulating,  however,  data  from  every  quarter,  in  order  cither 
to  render  the  proof  of  tuberculous  disease  conclusive,  or,  on  the 
other  hand,  to  exclude  the  disense,  comparison  of  the  two  sides  as 
reopects  vocal  fr^itus  should  not  be  overlooked,  although  the  in- 
formation, positivo  and  negative,  derived  from  other  methods,  is 
much  more  important. 

By  means  of  palpation  are  ascertained  certain  interesting  facts 
relating  to  the  romovul  of  the  heart  from  its  normal  situation,  ns  an 
effect  of  tuberculous  disease.  In  some  cases  of  advanced  tubercu- 
losis affecting  the  upper  lobe  of  the  left  lung,  owing  to  the  destruc- 
tion of  pulmonary  tissue,  the  heart  is  raised  above  its  normal  eitua- 

29 


490  SiaSAERB    op    THB    KBSPIBATORT    OBOI 

tion.  The  shrinking  awaj  from  the  heart  of  the  anterior  border, 
io  some  caaea,  uncovers  the  pulmonary  artery,  so  that  its  palaatiofii 
an!  felt  in  the  second  int«rroHtal  space  close  to  the  left  margia  «f 
the  sternum.  I  have  met  vith  sereral  cases  in  which  the  destni^ 
tion  of  the  upper  lobe  of  the  right  long  has  led  to  the  lateral  di»> 
placement  of  thtt  heart  to  the  right  of  the  sternum. 

Finallj,  a  succussion-sound,  or  aplathing,  baa  been  observed  wbea 
a  large  tuberculous  cavity  is  partially  filled  with  liqatd.  Ii  is  soffi. 
cicnt  umply  to  mention  this  fact.  The  sign  belongs  in  the  list  of 
phenomena  denoting  a  carity,  but  it  is  so  rarely  available  that  tbe 
importance  of  resorting  to  this  method  of  exploration  hardly  need 
be  recommended. 

DitignotU. — Pulmonary  tubcrculoHis,  although  embracing  in  ita 
career  most  of  tlic  phenomena  furnished  by  the  diifereat  methods  of 
exploration,  lios  no  epecial  pathogntmionic  physical  signs.  The 
signs  which  it  embrace*  belong  also  to  other  affections  ;  they  rep- 
resent morbid  conditions  not  peculiar  to  tuberculosia,  but  existing 
in  other  forma  of  disease.  Isolated  from  other  signs,  and  dissevered 
from  symptoms,  puthological  laws,  and  associated  circumsUnces, 
none  of  the  physical  phenomena  which  have  just  been  oonfidercd 
would  posseifs  marked  diagnostic  importance.  Nevertheless,  from 
their  combinations,  their  conjunction  with  vital  phenomena  and  wtih 
facts  pertaining  to  the  natural  history  of  the  diseaoe,  they  acquire 
a  positive  value,  and  are  hardly  less  significant  than  if  they  belonged 
to  it  exclusivoly. 

Tbesc  general  remarks  are  alike  appUeable  to  the  s^ptoo^^H 
The  semeiology  of  pulmonary  tuberculosis  embraces   a  series  iH 
events  which  are  common  to  this  and  otlier  affections,  and  which, 
in  a  diagnostic  point  of  view,  derive  their  importance  chiefly  from 
association  with  each  other,  from  coexisting  physical  signs,  accom- 
panying circumstances,  and  tbe  laws  of  the  disease. 

The  diagnosis  of  pulmonary  tuberculosis  is  ba«ed  on  the  positire 
ovidcnce  of  its  existence.  If  this  evidence  be  present,  we  do  not 
call  to  our  aid,  save  to  a  very  limited  extent,  the  mode  of  inveftiga- 
tiou  called  "reasoning  by  way  of  exclusion."  Tbo  differential  diag- 
noHis  from  other  affections  hinges  mainly  on  the  presence  or  abse: 
of  the  signs  and  symptoms  which  denote  a  tuberculous  depi 
We  do  not,  in  other  words,  undertake  to  exclude  other  affections, 
but,  on  the  other  hand,  we  direct  our  investigation  to  ascertain 


PDLMOHART  lODSBOirLOSIS, 


451 


I 


vhetber  tlicr«  bo  Bnfficicnt  proof  of  the  exintenoe  of  tuberoulosis. 
Hence  it  follows,  that  in  order  to  make  the  discrimination  clinically, 
and  to  decide  correctly  wliether  a  patient  b«  affected  nith  iIjIh  dii(> 
ease  or  not,  tlic  pliy»ician  must  be  acquainted  with  its  Hymploms 
and  signs,  and  nndcrittnnd  the  conditions  uridcr  wtitcli  tiicy  con- 
stitute poeiiive  evidence  of  il«  existence.  Tbo  pliy«icnl  signH  huve 
been  considered.  It  remains  now  to  cnumernte  tlic  eymptoms  promi- 
nently involved  in  the  diagnosis.  The  latter  I  shnll  notice  briefly, 
limiting  Uie  attention  exclusively  to  diagnostic  points.  And  inas- 
much as  the  diagnosis  very  rarely  presents  difficulty,  except  at  an 
early  period  before  the  disease  has  made  much  progress,  tho36 
points  which  have  relation  to  its  development  and  incipient  stage, 
are  chiefly  important. 

The  circumstances,  then,  vhich  invest  the  various  symptomn  at- 
tending the  development  and  progress  of  pulmonary  tuberculosis 
with  diagnostic  stgnilicance  arc  the  following:  A  cough,  not  origi- 
nating from  a  distinct  attack  of  acute  bronchitis,  and  not  preceded 
by  coryxa,  but  frequently  commencing  so  imperceptibly  thai  the 
date  of  ita  first  appearance  cannot  be  definitely  ascertained;  in  dc- 
gn-e  slight,  moderate,  or  violent,  but  persisting  for  some  time  with 
little  or  no  cxpcctonition.  Dryness  of  the  cough,  continuing  for  a 
greater  or  less  period,  according  to  my  exporicucc,  obtains  in  a 
larger  ratio  of  cases  than  is  estimated  by  WaUhe,  vis,,  one-tentb. 
I  should  say  that  careful  inquiry  of  patients  will  show  it  to  be  the 
rule.  An  expectoration  at  first  small,  transparent,  and  frolhy; 
beceming  gradually  more  abundant,  solid,  opaque,  yellow,  and  uon- 
aerated,  subsequently  consisting  of  sputa  streaked  with  yellow  lines, 
particolored,  and  frequently  presenting  irregular  ragged  edges;  oc- 
casionally including  small  particles  resembling  boiled  rice,  and  a 
grumous* looking  substance  contained  in  a  thinner  fluid,  like  the  de- 
posit in  barley-water.  According  to  Walshe,  from  whom  is  bor- 
rowed the  description  of  the  appearance  last  named,  such  a  depo&it 
occurs  only  in  cases  of  phthisis.  At  a  more  advanced  period,  pur- 
ulent matter,  in  greater  or  less  abundance,  running  together  and 
forming  an  ash-colored  mass,  with  a  nauseous  and  occasionally  fetid 
odor.  Small  fibres  having  the  characters  of  elastic  tissue,  discov- 
ered by  microscopical  examination ;  also  detached  fragments  of  other 
of  the  anatomical  elements  of  the  pulmonary  structure,  and  possibly 
in  some  inslancci*,  the  tubercular  corpuscle.  Aeut«  stitch-pains  at 
the  summit  of  the  chest,  sometimes  in  front,  oflcncr  beneath  the 


453 


DI6BASBS   OP   TBB    RBSFIRATORT    OROAHS. 


Kapula.;  recurring  from  time  to  time;  at  times  Berere,  uid  Wtini 
for  several  daya;  in  other  ioBtanccs  slight  sod  of  brief  duration; 
eipcricDCcd  more  frequently  on  one  side,  than  on  the  other,  bat 
often  occurring  suocejwively,  or  in  alternation,  on  both  sidee.  These 
pains  generally  denote  repealed  attacks  of  circumscribed  pleuritii. 
ChilU  or  sbivcrings,  sometimes  observing  an  approach  to  periodi- 
talj,  and  liable  to  be  attributed  to  an  irregular  or  imperfectly  de* 
Tcloped  intermittent.  UfcmoptyHis,'  frequently  the  first  sympton 
to  create  alarm  in  the  mind  of  the  patient;  aometinies  preceijiog 
Other  aymptomH,  and  all  appreciable  physical  eigns.'  Increased  fre- 
quency of  the  respirations,  other  things  being  equal,  the  iticreaae 
being  proportionate  to  the  abundance  and  rapidity  of  the  tnberculow 
deposit;  want  of  breath  on  slight  exertion,  and  in  some  cases  dysp> 
nosn;  acceleration  of  the  pulse,  not  invariably  but  generally  present, 
and  frequently  a  marked  symplom ;  a  vibratory  or  thrilling  char- 
actcr,  together  vith  frequency,  of  the  pulse,  the  latter  occorring 
vrhon  the  tuberculous  aSection  is  actively  progressing.  Nocturnal 
perspirations,  occurring  frequently  at  an  early  period,  as  well  as 
when  the  disease  is  advanced,  in  the  Utter  case  preceded  by  febrile 
movement,  and  forming  an  element  of  hectic  paroxysms.  Diarrfaoa 
frequently  recurring  or  persisting,  denoting  iutestina]  tubercnWii; 
this  complication  in  some  instances  developed  at  an  early  period, 
but  generally  after  the  pulmonary  affection  is  considerably  advanced. 
Chronic  peritonitis,  which  is  very  rarely  developed  except  as  the 
result  of  tuberculous  deposit  consequent  to  pulmonary  tuberculosis, 
and,  llicrcfore,  iufereniially  evidence  of  the  existence  of  the  latter. 
Chronic  laryngitis,  which  does  not  precede  the  pulmonary  disease, 
as  was  formerly  suppotwd,  but  indicates  a  tuberculous  affection  of 
tlic  larynx,  succeeding  the  deposit  in  tlie  lungs,  and  therefore  in* 
dioativ«  of  the  latter.     Progressive  loss  of  weight,  diminulioo  of 


1  Tho  tiibjectof  hsmoptfiuin  U«  miction  to  tiibnrcul0fi(,lia*  ti««D  vlaboral*); 
InrnitlKatod  by  Pr.  Walabn;  vidt  BrilUb  Mid  Forriga  M«diio<>>Clur.  B«ri«w, 

PW«  on  tbU  itulijeel  a  very  ralusble  paper  by  the  l«t»  Prot  John  Ware.  Pufc- 
li«atluo««f  tho  MaaiBcliUMtta  Uodical  Society,  1860. 

'  lo  01  or  tli«  100  <;as««  which  I  biivu  ■luilyxi.'d,  m  rMpecU  phyfica]  tigtu,  the 
bleturlH)  conlaia  infonnalion  eoncataxng  bii!inopty>U.  It  had  OMnrred  ia  £3 
CBtcB  pri'<r  lo  [ha  tiinn  of  my  oianilnAtian*.  Of  33  i:»nt  of  *niall  lub«ixiilar 
depittiUt  it  '"I'l  accurrwl  in  13.  Of  II  cniu  in  which  the  L-iiitci>c«  of  cavitiM 
wa*  ucoriniiiad,  it  bad  ouflurrwl  la  9.  Of  68  owe*  of  ahundsat  de|iMit,  It  had 
ocuurred  in  Si. 


PCLUONART  TIIBKHCDL0SI8. 


45S 


I 


I 


the  mtiNcuIar  Btrength,  and  a  marfced  anwinic  aspect,  almost  invari- 
ably accftnipanying  and  frequently  taking  precedence  of  prominent 
pulmonary  syraptoma.  Finally,  mental  buoyancy  and  freedom  from 
apprehension  on  the  seore  of  dineaee.  This  list  might  be  extended 
by  th«  addition  of  symptomatic  characters  incident  to  &  period  of 
tha  diaeaRe  vhen  the  diagnosis  is  rendered  sufficiently  easy  by  ob- 
'^ittttf  vymptoins  as  well  as  by  physical  signs. 

In  a  CMC  in  which  arc  combined  the  greater,  part  of  the  diag- 
iti«  point*  jiirt  cnuracratod,  there  would  bo  very  little  room  for 
it  that  the  patient  wu8  affected  with  pulmonary  tubprculoaia. 
il  exploration,  however,  would  at  once  supply  additional 
pointu,  giving  to  the  evidence  of  the  existence  of  the  disease  the 
force  of  demonstration.  The  physical  phenomena  would  consist  of 
tho«e  denoting  increased  density  or  solidification  of  hmg,  at  the 
summit  of  the  chest,  on  one  or  both  sides,  with  perhaps  the  nddilion 
of  the  signs  of  cavities.  If,  in  a  ea»e  such  ns  is  now  supposed,  pre- 
senting a  collection  of  symptoms  indicating  with  a  high  degree  of 
probability  tubcrculuitis,  this  disease  rcnlty  exist,  the  physical 
evidence  of  its  existence  is  almost  invariably  positive  and  easily 
discovered.  But  cases  frequently  present  themselves  in  medical 
practice.in  which  the  diagnostic  symptoms  are  less  marliod.  For 
example,  in  conjunction  with  cough,  which  is  perhaps  slight,  or,  in 
itself,  insignificant,  together  with  a  morbid  a.ipect,  there  may  be 
simply  a  moderate  loss  of  weight  and  strength,  neither  being  very 
apparent  to  the  patient,  and,  yet,  physical  exploration  nay  reveal 
an  abundant  tuberculous  deposit.  Without  the  aid  of  physical  signs 
in  Buoh  a  case,  there  is  only  room  for  the  suspicion  of  tuhcrculosiB ; 
vith  their  aid,  the  existence  of  the  disease  is  determined  promptly 
and  in  the  most  positive  manner. 

To  cite  another  example :  a  patient  may  he  attacked  with  haemop- 
tysis, having  previously  supposed  himself  to  be  in  good  health.  An 
examination  of  the  chest  may  fail  in  detecting  any  signs  of  disease. 
This  is  the  result  in  a  certain  proportion  of  cases.  Or,  on  the 
other  hand,  the  evidence  of  u  tuberculous  deposit  may  be  clear  and 
oneqoivocal.  In  either  ease  the  information  obtained  by  physical 
exploration  is  of  immense  importance. 

As  regards  the  comparative  reliability  of  the  diagnostic  characters 
derived  from  symptoms  and  from  signs,  it  is  to  be  remarked  that 
many  of  the  former  arc  only  occasionally  available.  This  is  true  of 
tho»e  dependent  on  tuberculous  complications,  vis.,  intestinal,  peri- 


464 


DISRA8E8    or  TBB  HBSPIRATORT    OBGAXS. 


toneal,  and  Urjogeal.  nxmoptjsu  occurs  in  onlj  »  certain  prtv- 
portion  of  cases,  albeit  this  proportion  is  large.  The  Io*«  of  -wtigitl 
and  strength  is  not  always  markc<l,  and  may  be  dne  to  a  T»ri«y  of 
morbid  conditione  other  than  tuberculosis.  Chills  and  pkuritie 
pains  are  not  constant  events,  aod  their  significance  depends  on  their 
being  associated  with  other  symptoms.  The  pulse  is  not  invariablj 
aocelerated,  and  the  respirations  may  not  be  increased  in  frequency. 
The  distinctive  characters  pertaining;  to  the  cough  and  expecton- 
tion  may  bo  absent,  or  not  readily  aitccrtaincd.  In  short,  oases  of 
tubercuIoiM  disease  by  no  means  always  offer,  «voo  aft«r  it  hai 
existed  for  some  time,  in  the  symptomatie  oharactera  embrnc^Kl  in 
the  previous  history  and  present  phenomena,  data  sufficient  for  a 
probable,  still  less  a  positive,  opinion  as  to  the  diagno^iis.  On  the 
other  hand,  a  tuberculous  deposit  is  rarely  so  small  id  amount  a* 
not  to  induce  pbysieill  changes  in  the  lung,  adequnte  to  the  pro- 
duction of  signs  indicating  their  existence.  The  fact  just  stawd 
tfi  highly  important  in  its  bearing  on  the  ralae  of  physical  h- 
ploratJon  in  this  disease.  A  tuhercnlous  deposit  sufficient  to  give 
rise  to  the  symptoms  which  lead  a  patient  to  seek  for  medical  sd- 
Tioft,  is  almoflt  invariably  delected  witbont  difficnlty  by  careful 
physical  exploration.  On  this  subject  the  student  or  young  prac- 
titioner is  liable  to  derive  an  incorrect  notion  from  the  strew 
which  is  very  properly  laid  on  the  symptoms  and  signs  concnrriag 
to  establish  the  diagnosis  of  small  dissomtnatcd  tubercles.  That 
instances  do  occur  in  which  the  evidence  derircd  froin  symptoau 
and  signs,  conjointly,  are  slight,  and  the  diagnosis  is  consequently 
attended  with  difficulty,  must  be  admitted;  but  in$twic««  of  thii 
kind  are  exceptions  to  the  general  rule.  Of  the  cases  of  eoapceted 
tuberculosis  which  the  physician  meets  with  in  practice,  if  the  disease 
really  exist,  the  physical  signs,  in  conjunction  with  the  symptoms, 
are  positive  and  easily  determined  in  the  vast  majority.  This 
opinion  is  based  on  a  pretty  extensive  experience  for  the  last  twenty 
years.  Let  the  student,  or  the  practitioner  who  is  not  acoostoined  to 
physical  exploration,  then,  not  be  repelled  by  the  erroneous  idea 
that  the  diagnosis  of  tuboroulous  disease  rery  often  hinges  on  points 
80  delicate  and  difficult  to  be  appreciated,  as  to  oompel  him  to  rely 
in  most  cases  on  the  symptoms  alone.  This  idea,  which  I  know  lo 
bo  common,  doos  injustice  to  the  subject  of  physical  diagnoHis. 

An  important  practical  question  is,  how  few  physical  signs,  taken 
in  couneotiou  with  symptoms  pointing  to  taherculous  disease,  are 


?iriMONABT  TUBEROCLOBIB. 


455 


suffio'icnt  to  cfltabliah  l)io  dingnoms?  Thv  [iliy«ictLl  plionoin4>na  in- 
cidvnt  10  ft  deposit  of  lulierelc  by  no  incAn»  ulwuyti  corroitpoiid  in 
unount  with  the  dJugnostic  cliaractem  pertaining  to  the  itjinploins. 
A  caiM!  amy  present  Hyniptomatic  circutnataoccs  strongly  indicnting 
the  disease,  and  the  signs  be  found  not  to  be  proportionately  marked. 
On  the  other  hand,  it  much  oftener  happens  that  while  the  symptoms 
alone  would  leare  the  diagnosis  extretnely  doubtful,  the  physical 
evidence  is  abundantly  conclusive.  Assuming  the  existence  of  cer- 
tain symptoms  which  give  rise  merely  to  a  suspicion  of  tuhcrculoHis, 
for  instance,  ft  persisting  cough,  with  loss  of  weight  and  a  pallid 
complexion ;  if  distinct  dulaess,  however  slight,  be  discovcrt^il  at 
the  summit  of  the  left  side,  in  front,  or  behind,  and  espocinlly  in 
both  situations,  together  with  an  obvious  modification  of  the  re- 
spiratory murmur,  consisting  in  diminished  vesicular  quality,  vtilh 
ek-vation  of  pitch  of  the  inspiration,  or  in  a  prolongation  with  ele- 
viilion  of  pitch  of  the  expiratory  sound,  in  short,  more  or  less  of 
the  elementary  characters  of  the  broncho- vesicular  respiration,  the 
diagnosis  ia  rendered  nearly  if  not  quite  conclusive.  The  addition 
of  a  highly  significant  symptom,  vis!.,  haemoptysis,  and  of  an  equally 
nguificunt  sign  in  this  situation,  vis.,  inoreaaed  vocnl  resonance, 
scarcely  leaves  any  room  for  doubt.  If  these  same  phyitical  phe- 
nomena ^wbioh  it  is  assumed  are  alight),  arc  found  at  thv  summit  of 
the  right  side,  the  evidence  is  less  conclusive.  The  acces«ory  signs 
are  then  of  much  importance,  na  showing  that  the  disparity  is  due 
to  a  morbid  condition,  and  not  to  a  natural  difTeroncc  between  the 
two  sides.  A  persisting  or  frequently  recurring  sibilant  rale,  a  finu 
tDDCoas  or  suh-crepitant  rale,  dry  crackling,  a  friction  sound,  the 
crepitant  rale  and  an  abnormal  transmtsaion  of  the  beart-sound», 
limited  to  the  eummit,  render  it  altogetlicr  probable  that  the  dis- 
parity is  morbid,  and  hence,  these  signs  become  highly  valoahle  as 
diagnostic  indications.  The  value  of  these  signs  is  less,  under  the 
circumstances  supposed,  on  the  left  side,  because  they  are  compara- 
tively snpertluous. 

Will  an  amount  of  physical  evidence  still  Icsa  than  has  just  been 
assumed  suffioe  for  Lhu  diagnosis?  IVrtincnt  to  this  inquiry  it  may 
be  slated,  as  a  rule,  thnt  the  amount  of  physical  evidence  required 
for  thv  diagnosis  is  »mnll  in  proportion  us  the  rational  evidence  is 
abundant;  in  other  word^,  if  lh<?  diagnostic  eircumsiitnces  relating 
to  the  history  and  symptoms  tend  very  strongly  to  the  opinion  that 
tuberculosis  exists,  fewer  and  less  marked  signs  are  needed,  pro- 


456 


DI6RA8BS    OP    THE    RE8PISAT0BT     ORGAXS. 


Tided,  such  as  ther  taaj  he,  tbe;  are  distinct  and  ane<|airoca] 
their  character.  Id  point  of  fact,  under  tl)c«e  circumat&nces,  t 
pbysic-al  signs  are  generalljr  sufficiently  numerous  and  Dtrikin^.  A»- 
Bumiog,  however,  that,  in  conjunction  nith  certain  yigiiificani  sjra^ 
toniatic  characters,  the  only  physical  phenomena  discovered  are  ef 
the  class  which  I  have  diatingui«he<l  n»  contingent  or  accidcnlal..Tii., 
bronchial  rales,  crepitation,  and  dry  crackling,  iritbio  a  limited  area 
near  the  apex  of  the  lung,  those  aigns  would  authorize  a  highly 
probable  although  not  a  positive  diagnosis.  But  judging  from  my 
own  experieacc,  I  should  never  expect  to  find  these  pheDotncna  per^ 
Bisting  or  present  in  a  marked  degree  without,  at  the  same  tiioe, 
diooorering  disparity  in  the  percussion-resoaance  and  io  the  . 
ratory  mortnur. 

Among  the  drcumstancei  wbieb,  in  a  rational  point  of  viewl 
distinguished  from  physical  phenomena),  are  entitled  to  weight  io 
the  diagnoaia  of  pulmonary  tuberculosis,  hereditary  influence  may 
fairly  be  included.  The  statistical  researches  of  Walsbe  appear  to 
lend  to  the  conclusion  that  this  influence  may  have  been  overrated. 
But  while  we  witness,  as  we  do  not  infrequently,  a  family  of  cbil- 
dreu  springing  from  a  tuberculous  parentage  swept  off  in  snooeuiui 
by  this  disease,  we  cannot  doubt  that  it  IrtoIvcs  in  such  instutcM  a 
congenital  predisposition.'  Age  is  aUo  entitled  to  coDsideratioo, 
since  it  is  sulSciently  established  that  the  development  of  the  i» 
ease  is  muob  more  likely  to  take  place  between  20  uml  30,  thu 
prior  or  subseiiuenl  to  these  periods  of  life* 

Another  important  practical  question  is  the  following:  Do«a  the 
absence  of  any  appiirent  disparity  between  the  two  sides,  no  advea- 
titious  sounds  being  discovered,  the  percussion-resonance,  and  the 
respiratory  murmur  being  apparently  normal,  warrant  a  positire 
Opinion  that  tuberculosis  does  not  exist?  Tliis  question  is  equiva- 
lent to  the  in'iiiiry,  whether  u  tuberculous  deposit  may  exist  in  ths 
lui>gs  in  a  latent  form  so  far  as  concerns  pliyucal  signs.  In  its 
clinical  bearing  this  question  has,  in  fact,  becD  already  virtually 


■  A  rpin>rkat>1:>  In^lDooe  t(  lliis  kind  rDccntlj  came  under  mi  notice.  In  lb* 
•pBCO  of  fivo  ycnn  7  children  died  or  phthinii,  all  batwccn  18  and  23  jr»n  vt 
afo.  Tk«y  eotiititiitud  nil  tho  children  Id  the  ramtly.  Tl>»  mother  di«d  of 
phlhlnU  I'honlf  lH>ri>ru  tba  dpilh  of  the  firtt  child,  ng«d  46  j«Br>.  Tb«  dlatan 
wni  ddvclgpcd  iliortly  afkor  conSnomnnl,  and  tlir  child  diad  in  infaacj'.  Ths 
father  In  living  nnd  In  robuPl  h<.-nltb.  For  other xitnikr  inMaaOMmditPricicipiM 
and  Frnc^tioo  of  JledbiiiD  by  tho  authop. 

'   futt  •Uti«lic»l  research^  of  M.  loJinbard.     Vslldx,  Of.  C(t. 


FULHOSAItT  TTTBBncriOStS. 


457 


I 


I  liarc  8aid,  that  whenever  there  are  prenent  Rjmptoma 
trarrftniitig  a  strong  suspicion  of  a  tHb«reiiIoiis  afTection,  which  in 
reality  docs  exist,  it  tony  be  confiilentlv  cxpccteil  thnt  (he  pUys* 
:•]  evidence  of  its  vxiMteiice  will  be  <li»coverei] ;  nn<t,  moreorcr,  ihia 
•videncc  will  often  be  fomui  when  the  tymptami  ilo  not  stnmgly  in- 
dicate the  <lisenBe.  That  tuburcnloue  ilepoails  may  be  so  Hniall  in 
qoBDtily  and  so  distributed  as  not  to  give  rise  to  appreciable  phya- 
leal  signs,  I  do  not  doubt.  Aiitopsicnl  exitmirintions  of  peraona 
lead  with  different  <Ii»eaMes  appear  to  show  thnt  small  depositions 
ot  infrequently  take  place,  wliich  remain  dormnnt,  become  obso- 
't«,  or  pam  through  their  changes  on  a  minute  scale,  the  conMilu- 
iional  morbid  comlitioii  on  which  the  tleposit  depends  being  from 
some  cause  arreateil.  In  these  cases  it  is  probable  that  the  disease 
is  frequently  latent  as  respects  diagnostic  symptoms  not  less  than 
physical  itigns.  At  mII  events,  judging  from  clinical  experience,  if 
on  careful  and  repeated  explorations,  the  resonance  on  percussion 
and  the  respiratory  murmur  are  found  to  be  normal  and  equal  on 
tho  two  sides,  no  adventitious  sounds  being  present,  it  is  quite  safe 
to  consider  tlie  patient  n  on- tube  re  ulcus.  A  practitioDcr  will,  of 
course,  feel  greater  poaitiveneas  in  the  negative  rosult  of  bis  ex- 
aminations, in  proportion  to  his  conildenoe  in  his  tact  in  explora- 
tion, and  his  ability  to  appreciate  and  compare  physical  phenomena. 
iiWoreover,  he  ia  not  bound  to  commit  bimHcIf  and  the  art  to  an  un- 
qualified opinion,  whatever  may  be  the  strength  of  his  private  con- 
viction ;  it  is  enough  that  he  state  the  absence  of  appreciable  evi- 
dence  of  the  existence  of  the  disease.  iJiscrelion  is,  however,  to  be 
ercised  in  giving  more  positive  assurances  in  cases  in  which  the 
ledtal  inHuence  of  (heir  moral  ofTect  is  desirable.  It  seems  gru- 
to  add  that  the  prudential  course  just  alluded  to  is  the  more 
politio  the  less  ihe  experience  of  the  physician  in  physical  explora- 
tion; but  it  often  hnppens  that  pnlienis  are  pronounced  free  from 
tuberculosis,  when  subsequent  events  show  that  the  hopes  and  wishes 
of  both  patient  and  physician  bod  much  to  do  in  determining  this 
conclusion. 

The  ab.ience  of  apprehension  wbicli  characteriKCs  the  mental  con- 
dition of  persons  affected  with  tuberculosis,  often  makes  them  tardy 
in  seeking  medical  advice.  This  is  one  reason  why,  in  the  majority 
of  cases,  when  the  patients  first  feel  the  need  of  resorting  to  a  phy- 
sician, Ihc  diagnosis  is  sufficiently  easy.  On  tho  other  bund,  in 
various  oflections  in  which  the  mind  is  differently  affected,  the  up- 


4fi8 


DIEBASBS    or    THE    RBSriEATOBT    OROAJTS. 


prehension  of  consumption  is  a.  sonrce  of  great  aaxiet*r,  and  nil 
the  dread  of  this  disease  which  leads  p«iieDts  to  desire  &  phntnl 
exploration  of  the  chest.  The  timidity  and  agitation  which  m 
sometimes  manifested  during  an  examination,  and  the  solicitade 
sliovn  respecting  the  result,  constitute  some  ground  for  a  prtsonp- 
tioi)  that  tiiberoulosi*  dotyt  not  exist. 

or  the  different  non-tuberculous  patients  whose  fears  of  the  dtt> 
co«c  bring  thiMu  un<lt-r  the  cognisance  of  the  ptiysicinn,  »  portioa 
euflfcr  from  intvrco^tiU  neuriUgis.  Thia  cUu  embraces  fettula  la 
much  the  burger  proportion.  They  arc  iwa«11y  anamic  and  s£ecl«4 
with  uterine  disorder  of  some  tort,  togelber  «iih,  not  infrvcinetuJT, 
hysterical  ttymptonis  more  or  Ichs  marked.  Judging  from  the  t«e 
instances  in  wbicti,  8o  far  nM  my  obMrrstioDS  go,  tubereuIoM  il 
found  under  these  circumstancet!,  I  should  esy  that  tho  morbid  con- 
ditions referred  to,  to  say  the  least,  do  not  involve  any  prcdi«poii- 
tion  to  the  disease- 

Another  class  consists  of  dyspeptics.  The  hypochondriasis  whid 
forms  so  constant  and  prominent  a  feature  of  the  uffectioti  known  ai 
dyspepsia,  induces  suspicion  and  sometlint^s  a  fixed  conriction  that 
phthisis  exists,  even  when  there  are  no  pulmonary  symptoms  what 
cvvr,  Tubcrculosia  has  been  vuppoaed  by  some  diatinguitihcd  aotbon 
to  be  often  preceded  and  aeoompanii'^l  at  it.s  coRiiaeiioojnetit  by 
notable  disorder  of  the  digestive  function.'  Such  haa  not  been  the 
fact  in  my  cxpcricnco.  I  have  not  observed  that  dyspeptics  an 
prone  to  become  affected  with  tuberculous  disease ;  and,  couverMly, 
tubercnlosis  has  seemed  to  me  oftener  than  othvrwis«  to  originaM 
without  being  attended  by  any  marked  oridencc  of  gastric  disorder. 
So  far,  then,  from  dyspepsia  coDstituting  any  gTy>und  for  aniidpat- 
ing  that  the  evidence  of  tubercle  will  be  discovered,  I  have  come  to 
regard  it  in  an  opposite  light. 

Auotber  class,  and  for  the  last  few  years  pcrbaps  the  most  snmer 
oos,  is  composed  of  persons  affected  with  chronic  pbaryngitit. 
Chronic  pbaryngitU  b  a  common  affection  not  only  among  clergf- 
inen,  but  with  persons  of  different  callings.  The  attention  wbici 
has  of  late  been  directed  to  it  has  given  it  a  popular  as  well  as  pro- 
fessional prominence;  and  the  idea  is  generally  held  that  it  is  a 
precursor  of  pulmonary  luborculosis.  Moreover,  it  ta  often  accom- 
panied by  more  or  less  oough  and  expectoration.     Having  obs^vwl 


WUion  Philip,  Bir  Jame*  Clutte,  and  TtottMOt  4.  Hug]iM  BmiiiML 


PTTLMOITART  TUBESCFL0SI8. 


I 
I 
I 


I 


•  large  number  of  ciims  in  whicb  clironic  pharjngitis  bas  persisted 
for  ^cnrit,  I  am  »ntisfic<l  tliut  bo  fur  from  the  affection  tending  to 
tnberoulosis,  it  is  rathvr  rnrc  for  tbu  Inttcr  disease  to  become  de- 
veloped in  Ibts  e\tits»  of  pnticnts;  &nd,  in  fact,  I  have  been  led  by  ex- 
perience to  rcgnri]  the  former  as  militating  sgainst  the  presamptioD 
of  the  existence  of  tlic  latter. 

Tuberculosis  is  apt  to  be  suspected  during  the  protracted  conva- 
lescence from  chronic  pleuritis,  since  it  Is  inculcated  hy  most  nriters 
that,  under  these  circumstances,  tuberculous  disease  is  vorr  npt  to  be 
seconitarilj  developed.  Statistical  researches  show  that  chronic 
pleoritis  is  not,  as  is  commonly  supposed,  prone  to  eventuate  tn 
phtbiBis.'  Tuberculosis,  however,  does  occasionally  become  developed 
as  a  complication,  and  as  a  sequel.  The  diagnosis  is  attended  nith 
difficulty,  owing  tn  the  faot  that  the  presence  of  liquid  efTusion  and 
its  permanent  eRects  prevent  a  comparison  of  the  two  sides  of  the 
che&l.  Moreover,  chronic  pleuritis  is  apt  to  be  overlooked,  and  I 
have  known  the  physical  phenomena  at  the  summit  of  the  chest  on 
one  side  due  to  the  compression  by  a  certain  quantity  of  liquid, 
attributed  to  a  tuberculous  deposit,  the  presence  of  the  liquid  escap- 
ing observation  from  the  exploration  being  limited  to  the  mimmit. 
The  permanent  contraction  of  the  chest,  if  not  great,  is  also  liable 
to  bo  overlooked,  without  careful  attention  (the  patient  perhaps  not 
being  aware  that  he  bu«  over  had  chronic  pleuritis,  or  not  deeming 
it  important  to  mention  the  fact,  if  inquiries  arc  not  directed  to  that 
point),  in  endeavoring  to  determine  whether  tuberculosis  exists,  or 
not.  Under  these  circumstances,  ullowanco  is  to  be  mado  for  an 
amount  of  disparity  between  the  two  sides  fairly  attributable  to  the 
past  or  present  pleuritis.  The  characters  of  the  respiratory  sound 
on  the  affected  side  are  to  be  carefiUly  studied.  The  nearer  ihey 
approach  those  found  on  the  opposite  wde,  the  less  ground  is  there 
to  auHpeot  a  tubercular  deposit.  If  signs  of  solidification  be  found, 
after  the  absorption  of  the  whole  or  even  a  considerable  part  of 
the  liquid,  tubcrculusis  is  always  to  be  strongly  suspected;  and  if 
these  signs  are  miirkcd  at  some  distance  above  the  level  of  the  liquid, 
when  the  latter  hn»  not  been  removed,  the  existence  of  tuberculons 
is  altogether  probable.  Id  these  remarks  it  is  supposed  that  the 
tnberouIoDS  deposit,  if  it  exi«t,  is  in  tlte  aide  affected  with  pleurids. 


■  Tu/«  BlakitloD  on  IHsmim  of  the  Cbwt,  sai]  Ewaj  on  Ohrouio  P1i>ur1»y  by 
Jkutbur. 


460 


blBBABES    OF   TOB    BESPIRATORT    OBOAXE. 


The  result  of  an  PX&miDation  of  tbo  side  not  <ifrcctc<l  with  pteitT^ta 
ia  iiuportanU  Assuming  the  side  first  affected  to  b*  that  in  ■tucli 
the  pleuritis  is  or  was  seated,  according  to  a  law  of  tubercotoms 
deposit  will  be  lilcely  U>  take  place  shortly  afterward  in  tlie  otW 
lung:  hence,  we  examine  for  the  phTeicat  signs  donotiDg  disease o( 
the  latter.  The  contingent  phcnomona,  vis.,  sibilant,  iDaeoas,nb- 
crepitant  rales,  and  dry  crackling,  if  limited  to  the  summit  of  Ibr 
che^t  on  either  siJe.  and  more  especially  on  the  side  opposite  to  thai 
affected  with  the  pleurisy,  are  highly  significant  when  taken  in  ow- 
nection  with  symptoms  pointing  to  tnberculous  disease,  anch  m  pan- 
lent  expectoration,  hemoptysis,  and  progressive  emaciation.  He 
latter  are  entitled  to  great  weight  in  the  diagnosis.  I  have  knovn, 
however,  frequent  attacks  of  copious  hemorrhage  to  occur  dvi^ 
recovery  from  chronic  plenritis,  and  eubaeqnent  to  reeoverr.  nhtn 
the  other  symptoms,  the  signs,  and  the  resalt  rendered  it  probaUt 
that  tuberculnoia  did  not  exist. 

The  diagnoaiii  of  pulmonary  taberculosia  being  based,  as  haa  b«ei 
stated,  on  the  positive  evidence  of  itH  exintence  derived  from  phj>- 
ioal  signa  and  »yinptoni»  presented  in  combination  ander  circus- 
stances  which  render  tbcm  diatinctive'  of  the  disease,  it  is  anneces- 
sary  to  dwell  on  the  discrimination  from  other  affections  willi  which 
it  has  Romo  fenttires  in  common.  The  differential  diagnosis,  tn 
general,  hinges  mainly  on  the  answer  to  this  inquiry:  Is  there  ade- 
qiintc  positive  proof  of  tuberculosis?  If  an  inrestigaiion  of  the 
phenomena,  vital  and  physical,  develop  this  proof,  tlic  existence  tt 
the  .disease  is  determined.  If  the  result  of  the  investigation  be 
negative,  the  diagnosis  fails,  and,  observing  proper  care  and  eantioB, 
the  disease  may  be  excluded.  Affections  from  which  it  is  to  be  di^ 
tinguiebed  clinically,  in  addition  to  those  already  referred  to  in  liai 
chapter,  are  chronic  broncbitii>,  chronic  pneumonitis,  dilatation  of 
the  bronchial  tubes,  and  polmonary  apoplexy.  The  points  involved 
in  the  discrimination  from  those  affections,  severally,  will  claim  but 
a  few  words.  With  the  exception  of  the  affection  last  named  (pol- 
monary apoplexy),  these  points  have  been  mentioned  in  preriou 
chapters. 

Chronic  bronchitis  does  not  commence  with  a  slight  and  dry  cough, 
accompanied  by  an  expectoration  at  first  small,  transparent,  and 
frolliy,  and  becoming  more  abundant,  solid,  and  opaque.  On  the 
contrary,  it  gcncrnlly  succeeds  the  acute  form  of  the  dtecaae.  Bm- 
moptysis,  pleuritic  stitch-pains,  chills,  progressive  marked  enncia- 


461 


Ion,  nccclcrnlion  of  llic  reHpirationst,  frequency  of  the  pulse,  night 

rspirations,  are  cvcnte  winch  <lo  not  belong  to  its  clinicnl  history. 

signs  of  Holti]i  Scat  ion  of  tho  lung  anr]  of  pulmonary  excatiitions 

e  wanting.     The  bronchial  rales,  when  prcsont,  are  obsorred  at 

«  inferior  posterior  part  of  the  chest,  not  limited  to  b  situution 

iCJtr  the  apex,  tior  frctjucntly  confinod  to  one  side. 

Chronic  pneumonitis  is  exceedingly  rare.  The  inferior  lobe  is  the 
seat  of  pneumonitis  in  the  great  cfiujority  of  cuses,  whcrciis  n  tubercu- 
lous deposit,  commencing  in  the  lower  lube,  occurs  only  as  an  ex- 
tremely infrequent  exception  to  a  law  of  the  disease.  The  liability 
of  mistaking  tuberculoiiifi  for  chronic  pncumuntlis  is  greater  than 
of  mistaking  the  latter  for  the  former.  This  error  I  have  known  to 
be  committed.  A  case  may  present  itself  in  which  the  error,  for  a 
tiiDe,woiildbevery  likely  to  be  committed.  An  hospitnl  patient,  some* 
what  advanced  in  years,  ia  admitted,  with  acut<!  pneumonitis  affect- 
ing the  upper  lobe.  Taking  the  age  into  consideration,  the  flitiiation 
ftof  the  inflammation  ia  not  remarkable.  The  appearance  of  the  pa- 
tient, and  the  previous  history,  which  ia  not  obtained  at  first  with 
iniDulcness,  owing  to  the  inconvenience  to  the  patient  to  reply  to 
■Auuty  quvsUoiw,  does  sot  lead  to  a  euapicion  of  tuberculosis  existing 
prior  to  the  pneumonitis.  Uo  passes  through  the  acute  disease  in  a 
favorable  manner,  and  appears  to  he  rapidly  convalescing.  Cough 
and  puruloid  expectoration  continue,  and,  on  physical  examination, 
marked  dulncss,  bronchial  respiration,  and  bronchophony,  are  found 
to  persist,  with  very  httle  diminution,  at  the  summit  of  the  chest, 
even  after  the  patient  has  recovered  from  the  pneumonitis  sufficiently 
to  be  up  and  dressed.  For  a  little  time  these  physical  signs  are  sup- 
posed to  iudiciitc  u  slow  resolution  of  the  inflammatory  solidiGcation. 
Their  continuance,  however,  leads  to  a  more  minute  investigation  of 
the  case,  when  it  is  a^'scortuined  that  cough  and  expectoration  have  ex- 
isted for  several  years,  the  patient  retaining  sufficient  strength  to 
labor,  ant)  not  considering  himself  much  of  an  invalid.  On  inquiry, 
it  appears  that  haemoptysis  has  formerly  occurred.  A  careful  ex- 
amination reveals  the  physical  sign  of  di&ease  at  the  summit  on  both 
•ides.  Tuberculosis  is  sufficiently  established,  and  the  progren 
of  the  case  confirms  the  diagnosis.  This  ia  a  transcript  of  the  lead- 
ing circomstancea  of  a  case  which  actually  occurred. 

Dilatation  of  the  bronchial  tubes,  as  has  been  seen  in  treating  of 
this  lesion,  may  present  the  physical  ugns  characteristic  botli  of  tu- 
berculous solidification  and  excavation.     Tho  diagnostic  points  have 


462 


DIBBaBBS    of    THB    BKSPtRATORT    ORGASTS. 


been  Tully  consMcrtil.  A  simple  ennmcration  of  the  more  impoitut 
or  tlii-in  vill  here  suffice  The  significant  sjioptODia  of  tubereuloiii 
are  wanting,  m.,  ba'moptytie,  notable  and  progressive  emaciaiioD, 
night  perspirations.  The  lutastion  of  the  physical  signs  is  test  nu> 
forml;  at  the  summit  of  the  chest.  The  percossion-dnlness  b  not 
proportionate  to  the  iutcndity  of  the  bronchial  respiratioa  ;  and  if 
cavernous  signii  exist,  Ihcj  muy  he  accompanied  vith  little  or  m 
e^dence  of  solidification  surrounding  the  excavation.  These  are 
ni^ativc  points,  which  amy  warrant  the  exclusion  of  tubereuloas  £*■ 
•Me.  lostanocs,  however,  are  occnsionally  met  irith  in  irbich  At 
differential  dingno«is  is  difllcult,  and,  indeed,  cannot  be  made  whh 
positivcneiW.  But  the  infrrquency  of  cases  inrolving  doubt  is  sack, 
that  ovcnsions  for  cinbHmmincnt  belong  among  the  cztrsordinirj 
incidents  of  clinicul  experience.  The  ]>ono<l  of  life  when  dilatatioi 
of  the  bronchial  tubes  is  found  to  exist  sufficiently  to  simnlaM 
phthisis  is  usually  more  advanced  than  that  at  which  tnberculont 
disease  is  more  apt  to  be  developed.  The  age  is  therefore  entitled 
to  some  weight  in  the  diagnosis. 

It  will  seldom  be  »  matter  of  question,  whether  an  existing  affec- 
tion be  luberciiloua  or  pulmonary  apoplexy.  Vet  1  speak  from  per- 
sonal experience  when  I  &ay,  that  to  the  young  auscultator  the  in- 
quiry may  ariae  under  the  following  circumstances  :  A  pcrMa 
believing  himself  to  be  in  good  hcaltli  is  attacked  with  copioni 
hicmopiyvis.  The  hemorrhage  is  not  preceded  by  eough  or  any  ap- 
parent pulmonary  syinptoin^.  For  some  months  afterward  tfaeooo^ 
and  expectoration  arc  slight.  There  are  no  chills,  plcsritie  pain^ 
nor  any  of  the  symptoms  significant  of  phthisis.  The  average  weight 
is  retained.  The  respirations,  when  the  patient  is  tranquil.  Dumber 
only  16.  The  aspect  is  not  morbid ;  the  appetite  and  digestion  good. 
On  physical  exploration,  marked  dulness  is  found  over  tlie  vfipa 
and  middle  thirds  on  the  right  side ;  the  respiratory  sound  searody 
appreciable,  with  no  sound  of  expiraUon,  and  vocal  resonance  mod- 
erately greater  than  on  the  opposite  side.  On  the  left  side  the  per- 
cussion-resonance  is  intense  and  vesicular;  tho  respiratory  mnnnar 
appearing  normal,  except  the  intensity  is  increased.  The  parents 
are  both  living  and  well.  Moreover,  the  patient,  who  is  a  young 
physician,  expresses  the  belief  that  the  dulness  on  the  right  side  is 
less  than  heretofore.  These  are  the  prominent  points  noted  in  the 
history  of  a  case  in  which,  I  confess,  I  was  disjMsed  to  think  saa- 
guineous  infiltration  had  occurred.     On  examination  a  few  months 


PDLXOSARr  TDBRBCCtOSIS. 


463 


I 


I 


afienrard,  the  evidenco  of  tuhercnlons  disease  was  ample,  and  the 
patient  ilieil  with  undoubted  phlhisi!i. 

The  diagnosis  of  pulmonary  apoplexy  is  confessedly  obacnre ;  bat 
of  tliin  it  will  be  more  appropriate  to  apeak  in  connection  nitb  that 
affection,  which  will  be  noticed  in  the  next  cbapte.r.  I  will  only  re- 
mark here,  that  it  is  a  result  in  the  majority  of  cases  of  obstruction 
arifling  from  heart  disease.  This  famishes  an  important  diagnostic 
point,  which  is  the  more  significant,  because  pulmonary  tuberculosis 
is  mrelj  associated  with  cardiac  lesions  involving  obstruction.  Ta- 
bcrctilosis  and  pulmonary  apoplexy  may  coexist.  I  have  known  the 
latter  to  supervene  upon  the  former,  and  destroy  life  so  speedily 
that  a  coroner's  inquest  was  bold  to  determine  the  cause  of  death. 

In  tJte  foregoing  remarks,  under  the  bead  of  diagnosis,  it  hbs  been 
assnmed  all  along  that  tuberculous  disease  commences  always  at  or 
near  (be  apex  of  the  lung  on  one  eidc,  the  other  side  subsequently 
becoming  affected,  as  a  rule ;  and  that  tho  deposit  more  or  leas  grad- 
nally  extends  from  the  superior  portion  downward.  Exceptions  to 
the  laws  of  pulmonary  tuberculosis  just  stated  occasionally  occur. 
The  deposit  in  a  very  small  proporUon  of  instances  commences  at 
or  near  the  base  of  the  lung,  and  extends  upward,  thus  completely 
reversing  the  usual  course  of  the  disease.  I>r.  Bonditch  estimates 
that  these  exceptional  instances  are  liable  to  occur  in  a  ratio  of  1  to 
150  or  200  case^.'  The  instances  observed  by  him  were  character* 
ized  by  a  well-marked  crepitant  rale,  behind,  over  the  lower  lobe, 
persisting  for  weeks  or  months,  followed  by  the  physical  signs  of 
BolidiBcation,  the  disease  finally  extending  to  the  upper  lobe,  affect- 
ing both  sideis  mid  advancing  to  the  formation  of  cavities,  as  in  the 
ordinary  form  of  tuberouloi^is.  The  symptomatic  phenomena  in  these 
cases  did  not  present  any  material  variation  from  those  usually  ob- 
served in  phthisis.  The  diagnonis  involves  discrimination  from 
pneumonitis.  The  physical  signs  are  common  to  the  two  affections, 
bat  with  this  essential  difference:  in  tho  tuborcnloos  affection  the 
crepitant  rale  persisted  for  weeks  and  months,  solidification  being 
slowly  induced.  Limiting  iho  attention  to  the  physical  phenomena, 
this  coarse  bears  but  a  remote  analogy  to  pneumonitis.  Moreover, 
the  history  and  symptoms  embrace  points  which  mark  the  distinction. 
Symptomatic  fever  was  absent  in  the  majority  of  the  cases  aftvr  they 
came  ander  medical  coguiiauue,  and  the  local  mdications  of  inflam* 


*  Loolt  found  luliciculoiu  duvMo  oonfinod  to  tli«  loww  lob«  In  2  of  1:19  ca*M, 


464  DI8BASB8   OP  TQE   RB3PIBAT0RT  OUQASi. 

nutioo.  The  pftUenU  did  not  lose  Uic!r  strength  except  pmiatltj 
in  the  progrosa  of  the  disease,  ns  in  ordinmr;  pbthisi*.  The;  nm 
able  for  a  certain  period  to  be  up  and  out  of  doors.  Certain  of  the 
tyuptoins  highly  significant  of  tuberonloius  were  noted,  viz.,  nggri, 
opaque  sputa,  and  in  two  cmvs  h»nioptjr«i«.  The  occaAtotial  dqio- 
«ition  of  tubercle  priinarilv  at  the  base  of  the  Inng,  enforoet  tlie 
iniporUDOC  of  not  limiting  exploration  for  the  pbjnesl  evidence  of 
the  disease  to  the  summit  of  the  chest.  Vi'hca  the  laws  regnUtiag 
tho  scat  and  progress  of  the  deposit  arc  thu»  reversed,  the  dugMn 
raaj  require  some  delaj  and  repeated  examinations.  The  phrsital, 
taken  in  couDQCtion  with  th«  ttfrnptomatic  phenomena,  will  at  loifth 
furnish  snffioieDt  data  for  a  correct  opinion. 


801IHAKY  OP  TDK  pnTSJOAL  SlOtfS  DUOSOSTIO  0?  PDUICKfASX 
T0BERCDL08IS. 

I>iminishcd  vesicular  resonance  on  percussion  at  the  sommil  of  the 
chost,  vtirying  in  degree  from  slight  dulnens  to  a  near  approach  to 
flalDOes ;  present  on  one  or  on  both  sides,  but  in  the  latter  case  more 
marked  on  one  side;  tlie  dulncss,  in  generel,  proportionate  to  the 
aband«ice  of  the  tuberculous  deposit ;  increased  sonoroagncss  oo» 
sionally  observed,  at  the  summit  of  the  ]ctt  side,  dno  in  eome  eatcs 
to  transmitted  gastric  resonance,  the  sound  tjmpatiitie  in  qiulit; 
and  high  in  pitch ;  a  vesicu1o-ti,-inpanitic  resonance,  more  or  bM 
marked,  in  some  entics,  due  to  emphysematous  lobules. 

An  increased  sense  of  renstanoe  in  proportion  to  the  amovnt  c( 
crnde  tubercle. 

A  tympanitic  resonance  oror  a  circumscribed  space  at  the  eamah, 
present  and  absent  ut  different  examinations,  in  some  cases  pre«eiil- 
ing  either  an  amphoric  or  the  crack ed-mctnl  intonation,  co&stitnting 
the  evidence  atTordcd  by  porcuuion  of  tho  existence  and  siuution 
of  tuberculous  exearutions. 

On  auscultutiun,  the  broucho-vesicular  and  the  bronchial  reepin- 
tion.  Frequently,  with  these  modifications,  diminished  intensity  of 
the  respiratory  sound;  ocoosionally  suppression  of  all  rexpiratofy 
soond;  interrupted  or  jerking  rospiration.  Exaggerated  vesicular 
murmur  on  the  side  either  healthy  or  least  affected ;  the  crepitant, 
Rub-crepitant,  sibilant  or  sonorous,  mucous,  and  crackling  or  cnunp- 
liiig  rales,  occurring  as  contingent  signs,  their  significance  dependent 
on  their  being  found  within  a  circamecribed  are*  at  the  •tunmit  of 


I 


^V  ACUTB   PHTHISIK.  465 

the  clieat;  abnormal  tranamiRflJon  of  the  heart' soumU,  inoreaAed 
TOcal  reaonance,  especially  avnilatile  when  situatvd  on  the  left  oide 
at  the  amninit;  exafcgerated  bronchial  whiaper  anil  whispering  bron- 
chophony ;  bronchophony  nith  the  loud  voice,  and  occasionally 
transmission  of  speech,  coinjilt-lc  or  incomplete,  over  tuberculous 
solidiHcudon  ;  a  friction-soiinil,  limited  to  the  aummit  of  the  cht-st. 

The  euvtrnous  rcspirution,  occtisionaily  obncrvod,  nllcnialiiij;  with 
suppression,  or  gurgling,  oocasionnlly  iimphoric,  niid,  very  infre- 
quently, pectoriloquy,  constitute  tho  evidence  alTorded  by  auscults- 
tion  of  the  cxintcnce  and  situation  of  exciivutions;  the  ehurHcters  of 
tlie  caveriiOHH  iin'l  bronchial  modiGcutivns  of  tho  respiration  soioe- 
titnes  combined  (broncho-cavernous  rc«pirniiou) ;  8phi«hing,  an  jm- 
pul»e,  seen  and  felt,  existing  within  a  circumscribed  «p»cc  at  the 
summit;  signs  of  cavities  furoishod  by  the  act  of  coughing;  occa* 
sionally,  when  u  eovity  is  very  large,  metallic  tinkling. 

By  inspection,  flattening  or  depression  at  the  summit,  either  con- 
fined to  one  side,  or  more  marked  on  one  side  thitn  on  the  other, 
(he  clavicle  generally  more  prominent,  but  occasioiiDlly  receding 
with  the  ribs;  diminished  expansibility  with  the  act  of  inspiration  ; 
the  range  of  motion  found  to  be  lessened,  as  well  at  the  siso  of  the 
chest  at  the  summit,  by  mensuration. 

Disparity  at  the  summit  of  the  chest  as  regards  vocal  fremitus, 
provided  it  be  found  to  be  greater  on  the  left  side. 

A  splashing  succussion-sound  in  some  eases  of  very  large  Qxca- 
vation. 

Acute  pHiniais. 

Pulmonary  tuberculosis  in  the  vast  majority  of  instances  is  emU 
nently  a  chronio  disease,  rarely  terminating  under  several  months,, 
and  frequently  protracted  for  a  scries  of  years.  Occamonally, 
however,  the  disease  runs  u  rapid  career.  In  a  case  observed  by 
Louis,  it  passed  through  its  different  stages,  and  ended  fatally  in  m 
month  after  the  occurrence  of  the  6rst  symptoms.'  A  case  has  fullen 
under  my  observation,  in  which  death  took  place  in  seventeen  days, 
dating  from  an  hicmoptysis  which  was  immediately  followed  by  grave 
pulmonary  symptoms,  the  patient  at  the  time  of  the  hemorrhage 
boing  apparently  in  excellent  health.     A  latent  tuberculous  dcposity 

>  Valkix,  op.  Git. 

I  30 


46(! 


DISBABB8  or  THS   RB8PIRAT0BT  OBQaHB. 


howeror,  probably  existei)  prcvionslv.  A  slight  faiemoptyaa  }ui 
occarr^il  several  nionthi*  before,  nni),  racaowbilc.  there  exbtsj  a 
little  hacking  cou};ti,  mthont  expectoration,  so  trifling  as  not  la  ex- 
cite the  least  apprelieosion.  The  pre-existenee  of  a  latent  tabem- 
lou:^  iti^poMt  ia  perhapH  not  unusual  in  caries  in  nhich  the  duntionaf 
tlie  diiieatte,  as  determined  by  prominent  sTrnptoms,  is  remarkabfy 
short.  In  the  exceptions!  instances  in  which  the  disease  apparenilf 
ends  in  a  few  weebs,  it  is  distinguished  hy  the  name  acute  phihini. 
In  certain  of  the  cases  embraced  under  this  name,  the  aSediou  doa 
not  diffor  in  its  anatomical  characters  from  ordinarj  tubercoloni. 
Tiie  only  differenco  is,  the  deposit  is  remarkably  abundant  and  et> 
lennivo,  nnit  passes  through  its  changes  with  unusual  mpidity,  •oft' 
eninf;  and  excavation  taking  plac«  within  a  very  short  space  of 
time.  But  the  term  acute  phthisis  is  mure  pnrtivii!»rly  applied  te 
an  accumulation  in  great  numbers  of  gray  semi- transparent  graoit 
lations,  which  cither  remain  isolated,  or,  ooalcMcing.  gire  rise  tos 
species  of  infiltration.  Restricted  to  the  conditions  just  mentioud, 
acute,  miliary,  or  granular  phthi»s  {phtfime  grattuleuae),  in  lb 
opinion  of  some  pathologists,  is  essentially  a  different  form  of  dtaeus 
from  ordinary  tuberculosis.'  The  grannlar  deposit  affects  both  \vLp, 
and  may  be  present  in  both  sides,  in  about  an  equal  proportioa, 
death  taking  place  without  softening  and  excaratioQ. 

The  diagnosis  of  the  form  of  disease  just  referred  to  (which  xax] 
be  denominated  acute  in  distinction  from  rapid  as  well  a»  ekreme 
phthiflis],  is  not  unattended  by  difficulty.  The  physical  signs  are 
IcAS  distinctive  than  in  ordinary  tuberculosis.  Owing  to  bothltugs 
being  simiiltnneously  and  in  some  cases  about  equally  affected,  a 
nmrked  di^pnrity  in  the  pcrcnssiun-resonance  is  not  always  apparcoL 
If  the  granulations  rcmun  isolated,  although  very  numerous,  notable 
dulncsB  is  not  produced.  Auscultation  may  not  furnish  morbid  phe- 
nomena other  than  arc  afforded  in  acute  bronchitis,  vii.,  the  vibrat- 
ing and  bubbling  sound*,  inclusive  of  the  sub-ercpitant  rale.  Tht 
vocnl  signs  of  tuberculous  solidification,  viz.,  exaggerated  ixeonanoe, 
bronchophony,  and  fremitus,  are  wanting.  The  prominent  symptons 
attending  the  progress  of  the  disease  are,  chills,  followed  by  fi-brile 
movement,  the  pulse  becoming  rapid,  with  beat  and  dryae«s  of  the 
surface ;  great  muscular  prostration ;  notable  increasa  in  the  fr^ 
quency  of  the  respirjitions,  with  or  without  a  corresponding  degree 


■  M.  Robin,  nictionnalre  de  MMwtnt,  Paiii,  1W&,  art.  nUuA  tigraMmXaSm, 


ACDTB   PHTHISIS. 


467 


fof  snffcring  from  want  of  breath  or  djrfipnoea;  lividity  oT  the  pro- 

labia;  tnnard  the  close  of  the  disease  quiet  delirium;  gultguUut 

\t£aJinum  and  incontinence   of  urine  Boinetimes  occurring  before 

kdeath;  pains  in  the  chest,  which  are  rarely  severe;  cough  more  or 

[less  violent,  drj,  or  accompanied  by  small  expectoration  which  is 

iBonietimca  slightly  bloody;  occasionally  diarrhcca.     Owing  lo  the 

rapid. march  of  the  disease,  emaciation  is  a  symptom  much  less 

marked  th.-iii  in  ordinary  tuberculosis.     I  hare  met  with  a  case  in 

which  the  duration, of  the  disease  was  only  ten  days. 

The  differential  diiignosiii  offers  an  exception  to  the  rule  stated 
with  rtfert-nce  to  chronic  tuberculodix,  via.,  that  it  turns  mainly  on 
the  presence  or  absence  of  the  positive  eharucterg  of  the  tuberculous 
disease.  The  positive  characters  of  acute  phthisis  being  less  dis- 
tinctive, in  discriminating,  clinically,  between  this  and  other  affec- 
tions, the  latter  are  to  be  excluded  by  the  abseocc  of  their  dio^ostlc 
I  trMta. 

The  frequenfry  of  the  respirations,  the  dyspncca,  lividity,and  rapid- 
ity of  the  circulation,  might  lead  to  a  suspicion  of  disease  of  heart. 
The  latter  is  to  be  excluded  by  the  absence  of  the  positive  physical 
signfi  which  denote  its  existence  when  present. 

Pneumonitis  is  excluded  by  the  absence  of  signs  denoting  solidiH- 
entiun  extending  over  an  entire  lobe,  which  is  oftener  the  lower 
lobo;  bj  the  physical  phenomena  showing  the  development  of  di»- 
eMC  simultancou.>«ly  on  both  slides,  the  affection  not  travelling  sue- 
CHUvely  from  lobe  to  lobe,  and  the  upper  portion  of  the  lung  being 
generally  found  to  be  especially  affected. 

The  existence  of  acute  bronchitis,  either  of  the  ordinary  or  capil- 
larr  form,  is  disproved  by  a  disparity,  in  a  e«rtain  proportion  of 
cases,  ex'isling  between  tlie  two  sides  as  regards  resonance  on  per* 
enanon;  by  the  bronchial  rales  being  less  marked  and  moat  muni- 
fMted  at  the  summit  of  the  chest,  instead  of  over  the  inferior,  pos- 
terior surface  ;  by  a  less  abundant  muco-purulent  expcetoratjon ;  by 
the  dyspnoea  and  increased  frequency  of  the  respirations  being,  on 
the  one  hand,  much  greater  than  in  ordinary  acute  bronchitis,  and, 
on  the  other  hand,  less  marked,  the  immediate  dtnger  less  imminent, 
end  the  career  of  the  disease  longer  than  in  acute  capillary  bron- 
chitis. 

The  affection  with  which  acute  phthisis  is  most  liable  to  be  con- 
found^ is  typhoid  fever.  The  latter  affection  is  to  he  excluded  by 
the  absence  of  its  characteristic  abdominal  symptoms,  vh.,  tym- 
panites, iliac  tenderness,  gurgling,  and  diarrhoeo.     Diarrhcea,  how- 


DISEASES  or   THE    RESPIRATORT   0BOAK8. 

ever,  it  is  to  be  borne  in  mind,  i$  occMionaDjr  ■  prmnineat  BjMpUa 
dnring  the  Intirr  pfriod  of  Bcntr  phlhista,  being  rlep^adent  on  •!■■ 
bercnlons  complication  of  the  inlci^tinc?.  The  presence  of  tbetj- 
phoii)  eruption,  if  wfll  tnnrkcd,  settles  the  diagnosis;  but  ibi sbmet 
of  the  eruption  is  not  proof  ihat  the  dixeiise  is  not  typhoid  fnver. 
The  Hceelernted  brMthing  anil  dTspnceA  of  acute  phthisis  do  not 
belong  to  the  natural  hiHlorj  of  typhoid  fever  except  it  beoocoe  co»- 
plicateil  with  pneutnonilin,  and  this  complicmtion  is  ascertained  by 
nicnn#  of  physical  signs  ;  even  with  a  pneoroonic  complication,  itii 
eslreinely  rare  for  the  respiration  to  become  embarrassed  to  the 
extent  which  obtains  in  cases  of  acut«  phthisis. 

Typhoid  fever  U  farther  distinguished  by  being  preceded  byi 
proilromic  period,  by  the  earlier  occurrence  of  the  pecalisr  meatal 
condition,  »»  well  as  its  greater  prominence,  and  by  the  pulmonstj 
eymptoius,  when  present,  being  developed  secondarily,  at  a  perioJ 
more  or  le««  remote  from  the  date  of  the  attack.  It  is  chiefly  wkn 
ca»es  first  come  under  observation  at  a  late  period  in  the  disease, 
and  when  it  is  impossible  to  obtain  an  account  of  the  preriosl 
history  from  the  patient  or  others,  that  the  differential  diagnoM  i> 
attended  with  much  difficulty. 


RSTRORPECTITB   DiAONOSIS  OF  TtlBSROIIMSIg. 

The  frequency  with  which  small  cretaceous  formations,  inilura- 
tions,  and  puckerings  are  found  after  death  in  the  bodies  ofpcrMii* 
who  haw  not  died  from  pulmonary  disease,  renders  it  probable  that 
a  small  tuberculous  deposit  often  tnkca  place  and  is  arrested,  cJllur 
in  consequence  of  a  limilatioa  inherent  in  the  disease  or  froB 
oertain  iiifliiences  broiiglil  to  bear  upon  it,  not  sdrancing  thnMigh 
its  usual  cfaiiiigc»,  and  nut  producing  any  serious  iiyury  of  the  pnl- 
monary  organs.'  Clinical  observations  confirm  the  corrcctneM  of 
the  supposition  that  nn  arrust  of  tubcrculosii!  may  take  place,  tbc 
deposit  ceasing,  the  symptomatic  evidences  of  the  disease,  if  present, 
disappearing,  and  the  patient  recovering  perfect  health.  In  making 
examinations  of  the  healthy  chest,  I  have  met  with  instances  in 

■  Dr.  W.  T.  Gsinluer  luggwla  tliat  the  induration*  frequently  found  in  Ibf 
lunj^  nnd  BltributHl  to  tubnrRuloiii  ilcixwlt,  ar«  IWi)ii«Dtlj  dti*  to  culUpM  rf 
1'iIiiiIml  from  hronuhial  ubitrucCiun.  See  ftrl.  iu  Brit,  aail  For.  Med.  Ciur.  Bev„ 
tklTMuly  refurrcd  to. 


IBTROBPBOTIVB  DIAaHOBIB  OP  TrBKRCDlOfilB. 


469 


I 


which  u  glifrht  (lUpHrity  was  found  in  the  percussion  snd  respiratorj 
Miund^  at  the  summit,  not  attributable  to  any  want  of  fljmnietricnl 
conformaiion,  and  not  in  accordance  with  the  lavfs  reguloting  the 
normal  variations  between  the  two  aidefl.  On  inquiry,  it  appeared 
to  be  a  rational  conclusion  that,  al  a  former  period,  theite  persons 
bad  been  affected  with  a  iimall  tuhvrciiinus  deposit.  The  circuia- 
stances  rendering  this  supposition  probable  were  certain  significaot 
symptoms,  such  as  persistent  cough,  loss  of  weight,  and  bienioptysis, 
which  bad  existed  years  before,  continued  for  a  time,  and  in  the  in- 
termediate period  the  persons  had  been  free  from  any  obvious  indi- 
cations of  a  pulmonary  affection.  The  physical  signs  in  these  cases 
were  dulness  at  the  left  Ruuimil,  and  fecbleneKs  with  diminished 
vesicularity  of  the  respiratory  ^ound.  These  nigns,  if  slight,  in  view 
of  the  normal  disparity  fri'titiently  existing  between  the  two  sidea, 
possess  much  greater  significance  as  evidence  of  pa«t,  aa  well  as  pres- 
ent, tuberculous  disease,  when  they  arc  found  at  the  summit  of  the 
left  side. 

I  have  also  preserved  notes  of  cxaminationa  in  a  pretty  large 
number  of  casc-s  in  which  the  symptunis  and  phjMCul  signs  were 
considered  as  indicating  unequivocally  the  existenve  of  tuberculosis, 
and  the  patients  afterward  recovered  excellent  heallh,  the  pulmo- 
nary Bymptoms  gradually  disappearing.  A  captious  reader  might 
suggest  that  in  some  of  these  instances  an  error  of  diagnosis  was 
committed.  I  am  far  from  professing  not  to  have  Committed  such 
errors,  but  in  the  cases  to  which  I  refer,  the  evidence  was  quiie  posi- 
tive, and  of  a  character  not  easily  mistaken.  In  some  of  these  casea 
I  have  examined  the  chest  after  recovery,  and  found  a  persisting 
disparity  between  the  two  sides,  consisting  of  comparative  dulness 
on  percussion,  with  a  feeble  respiratory  murmur,  or  the  characters 
of  the  broncho-vesicular  respiration.' 

Arrested  tuberculosis,  therefore,  is  to  be  included  among  the  con- 
ditions giving  rise  to  a  permanent  disturbance  of  the  symmetry  of 
the  chest  as  respects  phenomena  furnished  by  physical  exploration, 
presoiii  disease  not  being  thereby  indicated.  In  view  of  this  fact,  it 
is  important  in  examinations  of  (he  chest  which  disclose  a  slight  dis- 
parity at  the  summit,  more  especially  if  the  abnormal  modifications 
are  situated  on  the  left  side,  to  inquire  into  the  prcvioas  history  of 


<  Vide  Anulriia  of  Sixly.two  rnfn  of  Arr«ted  TiibiTcuIoiii,  by  tlie  author. 
Trnnuictuiiu  of  Ihc  Nrw  Yurk  ActidvRiy  of  MMlluiiie,  ISOS. 


470 


VtSBASffS  or   TBI    KBSrtBATOBT  OEOASS. 


the  patient,  in  ord^r  to  ascertain  vbctlier  at  some  fonaer  pcnri 
there  hnd  existed  STinptoms  rendering  it  [irobahle  that  tb^re  vwtl 
that  time  a  tnbcrcuious  deposit. 

But  it  is  snfficientlT  established  that  recorerj  trom  toWmMi 
ma;  lake  place  after  an  abundant  deposit,  and  when  tbediseasehai 
advanced  to  the  forinslion  of  ca\'!liea  of  conuderabte  site.  Gtsdal 
conti^ction  and  cicalritalion  of  excavations  take  pUc«,  or  the;  n- 
main  in  a  stationary  and  innocuous  corkdition;  the  tobefflm 
matter  may  b«  tjuiescent,  and  ita  complete  ahMtrptioo  b  tMt,  a*  hai 
been  supposed,  imposLtiblc*  Inctaneea  exemplifjiDg  recovery  ft«t 
taberculoeis,  even  when  cooRHlerably  adranced,  ibtrrv  is  remam  u 
believe,  are  of  more  frequent  occurrence  now  than  beretsTore.  a 
consequence  of  iinprovc<l  news  of  the  pathology  and  ireattMSt  of 
the  disease.  I  am  ncquatDted  with  two  person*  who  bare  bees  if 
fected  with  tubercnloaia,  as  shown  by  the  prerioia  history,  mm  fo 
21,  and  the  other  for  28  year«.  Both  hare  bad  repeated  ben*- 
rbages,  with  eongh  and  expectoration,  during  the  perioddi  mscJ; 
yet  both  enjoy  a  tulcrabte  amount  of  health.  It  i*  »  curiow  &et 
with  respect  to  thi.'s<-  ar^f,  that  the  patienta  are  bnshand  and  wife. 
The  hiubaud  was  tubercalous  at  the  time  of  his  nwrrtage' ;  the  af- 
fection in  the  ca^  of  the  wife  became  developed  sabanjaently.  It 
is  worthy  of  being  added,  that  in  both  case«  the  disease  ha*  beta 
allowed  to  pursue  its  course  with  very  Ultle  medical  interfcTtwce; 
and  both  have  steadily  continued  to  perform  the  active  datiea  of  hfie^ 
the  husband  as  a  merchant,  and  the  wifeasan active  saperistradfai 
of  bonsehold  affairs. 

An  illsstratioD  of  recovery  from  aa  abondant  taberculons  depest, 
snd  of  the  subsei^uent  physical  aigaa,  is  afforded  by  a  cAse  in  wlbeh 
I  examined  the  chest,  noting  the  resolta,  five  years  api,  and  an  op* 
portunity  presented  of  repeating  the  ezaainatioa  a  fev  BOBths  sJnct. 
At  the  &T9t  examinatioo.  Deeember,  1850,  the  patient,  •  feoHlc, 
aged  19,  had  been  aflVcled  with  the  dueaae  for  two  yeats^  dattog 
h^m  the  occorrcDce  of  htemoptynx  which  was  abortly  followed  by 

■  Ttt  cwrilie  Oe  hwcmuw  i^  whkh  iianij  i*  tAcfad,  Is  wM,  of  eoonii 
|Mfrfal»  ia  Ah  wwk.  for  tte  iW  iM*ir  b  nttm*  m  tat»  trwiww 
lMb,aad««tte(DHKt  afMocbU  aaMci«7.  1  wmU  fMrtkofariT- 
Itsktew— yuateWtwhsitfcy  Prrf- J.Hopfcw  BiaiwVt  of  EdiakirKk,  be  ci>- 
diMt  aad  iDMOatfoM  of  MCMWT  tniM  ffeikHk.  Aad  I  aiwa  ■j«etf  ofihi**^ 
pe>MJwt]rl»nprm»roU%ttkH  toflvC  Bwartl.  fat  tbr  {mvaqpi,  «Uk  ia 
Beabncfc,  U  l»U,  •f  oaaianK  tW  •pnsacu  wUcft  an  tgand  ia  Ml  w«fe. 


BROKCatAL   PnTHISIS. 


4n 


cougb  and  expectoration.  There  existed  marked  dulness  ftt  the  left 
sumniit  in  front  and  behind,  with  diniinisLed  cxptinsibiitt;,  n  feoble 
bronchial  respirstion,  and  weak  bronchopliony.  At  the  summit  of 
tbe  right  side  the  respiration  was  broncho-veeicular.  The  patient 
after  this  examination  passed  from  under  my  observation,  and  I  did 
not  again  sec  her  till  1  was  requested  to  decide  on  the  propriety  of 
b«r  being  admitieda^  a  novice  into  the  order  of  the  Sisters  of  Cliarity. 
Her  aitpcct  was  not  morbid,  she  had  a  fine  complexion,  and  eon- 
sidcrod  herself  well  and  abundantly  able  to  perform  the  dutiv^  of 
the  rclif^ous  vocation  to  which  she  aspired.  She  had,  however, 
slight  cough  and  expectoration,  occurring  chiefly  In  the  morning. 
The  upper  third  of  the  left  side  was  nolubly  depressed,  the  clavicle 
having  al»o  somcwhnt  reccdeil.  Diilnetis  on  pereusnion  was  marked 
in  this  situation.  The  respirtttion  was  feeble  on  the  left  side,  with- 
out obviou«  disparity  in  pitch  or  quality.  The  dtfierenco  in  inten- 
sity was  marked.  A  prolonged  expiration  existed  on  the  left  side, 
the  pitch  being  obscured  by  a  Hibilani  rale;  on  the  right  tide  an 
expiratory  iKiuud  was  Bcarocly  appreciable.  The  vocal  resonance 
was  notably  greater  on  the  left  »ide. 

The  subject  of  arrested  tnherculosis  and  recovery  from  the  dis- 
ease is  one  of  very  great  interest  and  importance  in  its  relations  to 
pathological  inquirii-a  and  the  ,'management  of  the  disease.  It  is 
foreign  to  the  objects  of  this  work  to  consider  it  in  these  aspeoU. 
The  main  purpo;ie  of  these  few  remarks,  as  implied  in  the  heading, 
has  been  to  illuairate  the  applicatloD  of  physical  exploration  to  a 
retrospective  diagnosis  of  the  disease. 


TcBBRCULOSia  OP  THE  BRONCHIAL  GlaHDS — BrOKCHTAL  PiITHIRIS. 

In  a  certnin  proportion  of  the  cases  of  pulmonary  tuberculosis,  the 
tuberoiilvus  affection  extends  to  the  bronchial  glands.  Enlargement 
of  these  glands  belongs  among  the  varied  anatomical  conditions 
represented  by  the  physical  phenomena  pertaining  to  ibe  disease, 
not,  however,  giving  rise  to  any  special  signs  by  which  the  existence 
of  this  complicittion  can  he  determined  during  life.  But  the  tuber- 
culosis iDAy  bo  limited  to  these  glands.  They  may  be  the  seat  of  a 
tuberculous  deposit  involving  a  considerable  increase  in  size;  and, 
by  means  of  processes  similar  to  those  which  take  place  in  connec- 
tion with  tubercles  dopusitcd  within  the  lungs,  cavities  may  be  pro- 
duced eommuniualing  with  the  bronchial  tubes,  opening  occa:>ionnIly 


472 


DISBASES   OF    TKK    BBSPIRATORT    OROAMS. 


into  the  cesophngus,  nnd  RoinetimoK  into  the  ploural  cnfily.  Tbe 
glanilH  first  affected  urc  tlioHc  situotod  near  the  primarj  Wonclii; 
thence  the  iliseuse  extcmlH  to  the  glands  imbedded  in  the  lungs,  in 
the  direction  of  the  bronchial  subdiriaione,  and  also  to  those  in  tbe 
neighborhood  of  the  pcricanlium,  the  (esophagus,  and  the  large 
v«ii8p1k  in  tbe  anterior  mediastinum. 

In  all  these  situations  the  bronchial  glands  are  frequent!/  affected 
RS  n  complication  of  ordinary  pulmonarj  tubercalosis,  ospeciallj  in 
children.  It  it<  only  when  they  are  the  Miat  of  a  Lubcrculoas  deposit 
exclusive  of  pnlmonary  tubercles,  that  the  disease  is  properly  distin- 
guished as  Jco«i?/itii/;>^fAt>i>.  Tuberculosis  limited  to  the  broneliial 
glands  ifl  a  disease  peculiar  to  childhood.  With  this  reslrictiuii  to 
early  life,  it  is  a  rare  form  of  disease,  for,  if  not  preceded,  it  is  apt 
to  be  followed,  by  pulmonary  tabercles.  In  a  certain  proportion  iif 
the  easua  of  true  bronchial  phthisis  recovery  ukes  place.  This  pro- 
portion would  be  larger  than  it  is,  except  for  the  liability  during 
the  cour^  of  the  disease  to  the  occurrence  of  ordinary  pulmonary 
tubcrculosiii. 

The  diagnosis  of  bronchial  phthisis  is  desirable,  especially  in 
view  of  the  fact  that  the  chances  of  recovery  are  more  than  in  ordi- 
nary tuberCHloxis;  and,  on  the  other  hand,  it  is  important  to  dis- 
tinguish it  from  simple  bronchitis  or  periossis, with  which  it  maybe 
confounded,  these  nffccliona  being  attended  comparatively  with  much 
less  danger.  In  either  ca»e  the  discrimination  is  attended  viih 
difficulty,  in  part  from  the  ob»tucle.i  in  the  way  of  a  Mtiafactory 
exploration  of  the  che«t  in  children,  and  partly  because  physical 
ngns  distinctive  of  tlic  disease  are  often  wanting.  The  dilliculty 
of  discrimination  relates  more  particularly  to  the  differential  diag- 
nosis from  ordinary  tuberculosis,  vilb  which  it  is  liable  to  b«  asM- 
cialed. 

The  disease  coexists  with  either  persisting  or  recurring  attacks  of 
bronchitis ;  the  symptoms  and  signs  of  the  latter  affection  are  there- 
fore  likely  to  be  present.  The  cough  is  apt  to  assume  a  paroxysmal 
character,  resembling  that  of  Tphooping-cough.  Oedema  of  tbe  face 
and  swelling  of  the  veins  of  the  necknro  events  which  occasionally 
occur,  nritiing  from  pressure  of  the  bronchial  glands  on  tbe  vens 
cava.  The  respirations  are  more  or  loss  hurried.  The  loss  o! 
weight  is  marked,  but,  in  this  respect,  and  aa  regards  other  symp- 
tomti,  during  the  course  of  the  disease  remarkable  Suctuationa  aro 


BttONCniAt  PBTBlSIfl. 

[oWrvcd.'     The  lymplialic  g]anda  of  the  neck  nre  fircqucntly  «f- 
I  fcctcd. 

An  regards  pliyeiciil  oigtis,  cilher  feebleness  or  siijtpre^ston  of  the 

I  Tespirator;  niurmiir  over  the  whole  or  more  or  less  of  one  mie  is  an 

I  occn^ionn]  ineiilcntnl  ffTict  due  to  piT!<i»iirc  of  nil  ciiliirgcd  gland  on 

,  one  of  the  primary  bronchi  or  its  larger  subdivisions.     Dulne»8  on 

I  pcrcnyeioii  mtiy  bo  uppurcnt  in  tbo  inlcrsciipular  regions.     Broii- 

chiftl  respiration  at  or  near  the  HituatioDS  where  in  heallh  un  up- 

proximalioQ  to  its  characters  ie  not  infreqnently  found,  viz.,  in  the 

inters  en  pular  space  hehind,  and  in  the  neighborhood  of  the  ftcrno- 

I  clavicular  junction  in  front,  may  be  more  or  less  marked.     Mucous 

I  rsles  are  apt  lo  be  abundant,  and  possibly  gurgling  may  be  obserred 

!  in  the  ssmc  vicinity.     Thciie  signs,  provided  pulmonary  luberculosis 

'  bo  excluilo-d  by  the  absence  of  the  phyHical  evidence  of  solidification 

over  the  chest  eWwhere  thun  at  the  parts  juf^t  named,  and  taken  in 

coniiccliun  niih  the  ratiuiiitl  evidence  of  phlhioia,  viz.,  peraiiiting 

I  cough  and  emaciation,  and  sometimos  perapiratJona,  constitute  the 

data  for  the  diagnosis.     Assuming  all  these  data  to  be  available, 

the  dingno^is  may  he  made  with  much  confidence.     Even  if  the 

I  positive  signs  be  wanting,  provided  the  history  and  symptoms  show 

that  the  diecnse  involves  more  than  bronchitis,  and  render  the  exist* 

encc  of  phthisis  altogether  probable,  if  the  physical  lugns  of  pnl- 

monary  tuberculosis  be  also  absent,  reasoning  by  exclusion  there  is 

good  ground  for  the  opinion  that  the  patient  is  affected  with  bron* 

chial  phthisis.     (Edema  of  the  face  and  swelling  of  the  veins  of  the 

seek  constitute,  in  connection  with  other  evidence,  significant  symp- 

[tons.     Enlargement  of  the  lymphatic  glands  of  the  neck  is  also 

entitled  to  weight  in  the  diagnosis. 


■   VUt  Wral  on  D1m<mm  of  Children,  Am.  rd.,  ISSi,  p.  S8T. 


CHAPTER    VL 

PCLMONART  (EDKMA-OASORENB  OF  THE  LUNGS— PrUtO- 
SART  APOPLKXT— CASCEE  OP  THE  LUSGS-CANCEK  IS  TBI 
UBDIASTINUU. 

Tbi  klTectioriB  named  iq  the  Iiea(]uig  of  ihia  chapter  will  Dotnpltie 
the  list  of  those  which,  in  their  anatomical  aeat,  have  relation  K 
the  air-celU  or  pulmonary  parencbynu.  Tbeorderin  whichtiu-Tuc 
enamerated  oorresponds  to  the  reUtire  frequency  of  iheir  occurrcneb 
Collectively  they  claini  a  much  leas-extended  consideration  than  hai 
been  bcaiowed  on  the  affections,  belonging  in  the  same  group,  whidl 
hare  oonstilaled  the  sobjects  of  the  three  preoediiig  cboplcrs. 


POLMOtTART  CEdBUA. 


The  anatomical  characters  of  oedema  of  the  lungs  are  due  to  aeroa 
effusion  taking  place,  according  to  Rokitnnsky,  primarily  and  chiely 
within  the  air-cells,  the  infiltration,  howeTcr,  extending  to  the  are^ 
lar  tissue.  The  volume  of  the  affected  long  is  slightly  aag:mented; 
it  docit  nut  collapse  or  crepitate  on  pressure.  The  yellowish  limjMd 
fluid  whicli  ooKes  in  abundance  on  section,  is  nsoally  elighlly  frothy, 
showing  the  presence  of  a  certain  quantity  of  air  within  the  cells; 
the  texture  is  resisting,  non-elastic,  pitting  on  pressure  as  in  subca- 
tancoos  oedema. 

Pulmonary  oodema,  more  or  lees  cironmBeribed,  is  found  very  fre* 
qnenlly  as  an  anatomical  condition  incidental  to  nearly  all  affec- 
tions of  the  lungs  vrhich  prove  fatal.  It  oecurs  as  a  consequence 
of  the  hvpostatic  congestion  taking  place  in  the  latter  part  of  fevers 
and  various  diseases.  It  may  even  be  a  poat<mortem  event.  De- 
veloped in  conjunction  with  other  pulmouary  affections,  the  phe- 
nomena to  which  it  gives  rise  are  so  interwoven  with  thusc  incidcot 
to  the  coexisting  morbid  conditions,  that  their  rccoguitiuo  is  imprac- 


^^^^  FOtKOIfART  (EDEMA. 

ticable.  It  is  only  as  an  in<Iependent  alTectinn,  i.  t.  d\»x:onn«el«i 
from  other  piilmonary  di)irii«e»,  tlint  it  i^  of  icnporlttnce  in  n  din;;* 
no9tic  point  of  vi«iT.  A»  n  sopumte  piiluiotiAry  diM-atie  it  is  always 
depenilent  on  some  anterior  morbiil  oondition.     It  arisen  s<>cond- 

karilj  ID  the  course  of  orgnnic  di^enscs  of  the  heart  accompanied  by 
nnfrfel  re^^iirgitation  or  obstruction,  and,  more  rarely,  from  hyper- 
trophy affecting  the  right  ventricle.  It  may  also  proceed  from  the 
condition  of  the  blood  which,  nt  the  same  time,  gives  rise  to  dropsical 
effusion  in  other  situation*!;  hence  it  is  liable  to  m-cur  in  Hright's 
disease.  These  pathological  relations  are  important  to  be  borne  in 
mind  with  reference  to  tht  dingiionis.  When  the  serous  infiltration 
takes  place  rapidly  and  cxtenaivcly.  ns  is  sometimes  observed,  indue- 

^feg  death  suddenly,  it  has  been  termed  serous  apoplexy  of  the  lungs. 
Developed  in  the  course  of  heart-disease,  or  general  dropsy,  it  is  not 
always  either  limited  to,  nor  most  niarVc<l  in  the  inferior  and  posterior 
portion;*  of  tliclungs  on  both  sides,  which  is  the  cnsc  when  it  depends 
on  hypostatic  congestion.  It  may  exist  on  one  t'lUt  only,  and  be 
confined  to  the  superior  lobe.  In  a  case  whicb  recently  cnme  under 
my  observation,  the  cedetna  occurring  in  connection  with  hydro-peri- 
cardium and  softening  of  the  heart,  moderate  serous  effusion  existing 
also  in  the  pleura  and  peritoneum,  tbc  upper  lobo  of  the  left  lung 
was  alone  affected. 


Pfii/n'raf  Siffuf. — (Edema  sufficient  in  amount  and  in  the  extent 
of  lung  aflecteil  to  constitute  an  important  pathological  condition,  is 
accontpaiiied  by  either  marked  dulness  or  flatness  on  percussion. 
According  to  Skodn,  the  tympanitic  quality  of  sound  may  be  elicited 
over  lung  containing  tin  abundant  serous  infiltration,  as  in  cases  of 
soliditication  from  inflammatory  exudation  or  tuherele.  The  resist* 
ance  of  the  tliorncic  walls  over  the  cudcmittous  lung  is  notably  in* 
creased. 

Owing  to  the  presence  of  serous  liquid  in  tbc  air-cells  and  minute 
bronchial  tubes,  a  sub-crcpitant  rale  is  discovered  on  auscultation. 
Occasionally,  the  rale  presents  all  the  characters  distinctive  of  (he 
true  crepitant,  vie.,  finer  than  the  sub-erepilant,  dry,  equal,  and 
limited  to  the  inspiratory  act.  Such  instances,  however,  are  excep- 
tions to  the  rule  that  fine  bubbling,  or  the  sub-crepitant  rale,  be- 
longs to  this  form  of  disease.  The  sub-crepitant,  or  the  crepitant 
rale  in  this  affection  is  not  raised  in  pitch,  a  fact  showing  non-solidi- 
fienlion  of  the  lung.' 

>   ViiU,  page  210l 


478 


DISBASBS  OP    TUB    RBSPIRATORT    OROAKS. 


The  respiratory  sonnd,  when  not  obscmred  by  ihe  presence  of  nldJ 
in*y  |x»eibly  present  more  or  less  of  ihe  characters  of  the  brOMlii^ 
reacular  respiratioo;  bnt  in  general,  there  is  either  notable  f«eU^ 
ness  or  suppression  of  the  respiratory  sound. 

The  vocal  resonance  may  or  may  not  be  increased.     Tbe 
remark  is  applicable  to  ihe  vocal  fremitus.     Inspection  fu 
n^ative  results. 

Hiagnotia. — The  symptoms  belonging  to  pnlmonarj  cedent  < 
notbiDg  disgnostic.  With  more  or  less  oough  and  the  cxpectoratitm 
of  a  serous  or  mueo-serous  fluid,  the  respiratory  function  is  cotnprfr 
nised  in  proportion  to  the  degree  and  extent  of  the  oedema.  Tbcw 
are  the  only  symptoms  referable  to  the  morbid  condition  of  tbe 
lungs ;  and  since  the  aflection  occurs  ns  a  cnniplicstion  of  other  di*- 
eases,  symptoms  due  to  the  latter  are  interminglrd.  Thus,  in  the 
larger  proportion  of  cases,  the  symptomatic  phenomena  arising  from 
disease  of  heart  are  present,  and,  in  other  ca*c8,  hydrothorai,  to- 
gether vith  effusion  into  other  serous  cavities,  nnasarca,  kc,  depend- 
ent oti  disease  of  the  kidney».  It  should  be  added  that  congfa  uA 
expectoration,  although  generally  present,  are  80tn«tini«s  wanting. 

The  positive  signs,  as  has  been  seen,  are  dulness  or  flatness  ca 
percussion,  and  a  suh-crepitant  rale.  These  signs  being  present  over 
»  portion  of  the  chest,  on  one  or  both  sides,  with  or  without  the  char- 
acterfi  of  the  broncho-resJcuUr  or  the  bronchial  respiration,  exagge- 
rated vocal  resonance  and  fremitus,  and  accompanied  by  more  or  lea 
acceleration  and  labor  of  the  respiration,  the  diagnosis  involves,  firet, 
their  association  with  diseases  in  connection  with  which  cedema  it 
known  to  occur;  and,  second,  the  exclusion  of  other  afliections  in 
which  solidification  of  lung  takes  place,  more  especially  pnenmoailie, 
and  the  hypostatic  congestion,  or  pseu do- pneumonitis  which  is  inci- 
dent to  the  course  of  fevers,  and  some  other  diseases,  particularly 
toward  the  close  of  life.  If  the  above-named  physical  signs  becone 
drvcl'ipcd  in  the  course  of  an  organic  affection  of  the  heart,  especially 
if  attended  with  obstruction  to  the  pulmonary  circulation,  such  as  is 
incident  to  diseases  affecting  the  mitral  orifice,  orinconjunciJonwilh 
general  dropsy,  the  occurrence  of  cedema  is  established  with  con- 
siderable certainty,  provided  vte  are  satisfied  of  the  non-existence  ' 
the  affections  to  be  excluded.  The  existence  of  ordinary  pneun 
nitis  is  rendered  improbable  by  the  absence  of  pain,  of  the  charac- 
teristic sputa,  of  febrile  movement,  and  of  the  physical  signs  dene 


.  ing  solidification  of  Inng  frnm  the  deposit  of  inllammator^v  «xtidnlion, 

vis.,  n  well-mRrkcd  bronchial  respiration,  hronchophony,  nnd  the 

tme  crepitant  rnle.     The  latter  sign,  however,  it  is  to  be  borne  in 

■'ininrt,  may  occur  in  ca«eB  of  cedema.     Ilypostatic  congestion,  aa 

already  stated,  involves  icdema  as  an  anatomical  element.     To  make 

the  distinction  clinically  under  the  circumstances  which  attend  the 

B  development  of  hypostatic  congestion,  ia  nnimportant.     (Edema  is 

Htewtftpt  to  aSect  the  inferior  and  posterior  portions  of  both  Innga 

'wmltRncoHNly,  but  tliii*  rule  i8  invariable  with  respect  to  hypostatic 

congestion.     The  Inil^r  i-ondilion  is,  therefore,  of  course  excluded 

Iwbrnt-ver  the  phenomena  denoting  cedema  are  manifested  at  the  supe- 
rior and  anterior  portion  of  the  cheat. 
With  bydrothornx,  ledema  need  not  be  confnundcd.  The  change 
of  level  of  the  Hqnid  with  the  different  poHitionR  of  the  patient, 
caiEce  to  indicate  the  former.  Hut  the  two  affectionK  may  coexist, 
and  to  determine  the  fact  of  their  coexistence  may  not  he  eauy.  The 
presence  of  the  Kub-crepitant  rale,  and  the  modiRcationn  of  the  res- 
piratory sound  due  to  sol  id  ifi  cut  ion,  vit.,  the  broncho- vci^ieular  or 
bronchia]  respiration,  unpcradded  to  the  physical  evidence  of  liijuid 

tin  (be  pleura,  taken  in  connection  with  the  existence  of  general 
drop:<y,  miiy  enable  the  dingnostician  to  make  out  this  combination. 
I'rscticBlly,  however,  to  determine  thia  point  is  not  very  important. 

SUUMAKT  OF   PHTSIOAL  StONS   BKLONOINO    TO    PDLHOKART   (EDEMA. 


\ 


Abccncc  of  vesicular   resonance  ou  percussion,  with  increased 

parietal  resistance;  aub-crepitant,  and,  occasionally,  the  erepitant 

tf  Eeeble  broncho-vei<icitlar  or  the  bronchial  respiration  in  some 

^SiiSti,  tut,  in  general,  absence  of  respiratory  sound ;  increased  vocal 

rMonance  and  fremitus  uncertain,  and  rarely,  if  ever,  present  in  a 

marked  degree. 

Gamoh£nb  of  TQB  Ll'MOS. 

Since  the  time  of  Laennec,  writers  hare  considered  gangrene  of 
the  lungs  as  divisible  into  two  forms,  vin.,  diffuMe  and  dreunucrihed. 
In  diffuse  gangrene  a  considorable  extent  of  lung  is  affected,  gene- 
rally the  whole  or  the  greater  part  of  a  lobe,  and  the  boundaries 
of  the  gangrenous  portion  arc  not  sharply  defined.     Both  varieties 


476 


niSBASBS  OP    THE    RBSPIKATOKT  OKQA>0. 


The  retpirator^  sound,  when  not  obticured  hj  the  presence  of  nlea, 
ma^  posiiililj  present  more  or  less  of  the  characters  of  the  brotieho- 
ve!)iciilnr  ronpirntion;  but  in  general,  th«re  is  either  aotabte  feeble- 
DCM.t  or  suppression  of  the  re^piratorjr  sound. 

The  vocal  reoAuance  may  or  maj  not  be  increased.  The  nne 
remark  in  applicable  to  the  vocal  freinilus.  lospection  furaUM 
negative  resull.<». 

Diatom- — The  symptoms  belonging  to  pulmonar;  cedcna  ofltt 
nothing  diiignostic.  With  more  or  less  cough  and  the  cxpccioralio* 
of  »  seroun  or  niuc-o-scrous  Hhii),  the  refpinilorjr  function  is  compt*- 
miaed  in  proportion  to  the  degree  and  extent  of  the  oedema.  Tbew 
are  the  only  eymptoms  referable  to  tbc  morbid  condition  of  tb 
long* ;  and  wince  the  aflecliou  uccnri  as  a  complication  of  other  difr 
eaaea,  symptoms  due  to  the  latter  arc  intermingled.  Thur.  in  the 
larger  proportion  of  cases,  the  symptomatic  phenomena  ariiting  ffoa 
di»ea«c  of  heart  are  present,  and,  in  other  enres,  hydrothorax,  t»> 
gcther  vrilh  effusion  into  other  serous  cavities,  anasarca,  kc,  depead* 
ent  on  disease  of  the  kidneys.  It  should  be  added  that  cough  ui 
expectoration,  sltliougb  generally  present,  are  sometimes  wanting. 

The  positive  signs,  as  has  been  seen,  are  dulness  or  fiatnees  co 
percu^ision,  and  a  sub-crepitant  rale.  These  signs  being  present  OTer 
a  portion  of  the  chest,  on  one  or  both  aides,  with  or  without  the  char- 
acters of  the  broncho-vesicular  or  the  bronchial  respiration,  exagge- 
rated vocal  resonance  and  fremitus,  and  accompanied  by  tnoreorlcM 
acceleration  and  labor  of  the  respiration,  the  diagnosis  involves,  first, 
their  iu**oeialion  with  diseases  in  connection  with  which  oedema  i» 
known  to  occur ;  and,  second,  the  exclusion  of  other  affeciions  ia 
which  solidificalion  of  lung  takea  place,  more  especially  pnenmonitit, 
and  the  hypostatic  congestion,  or  pseudo-pneumonitia  which  is  ino- 
dent  to  the  course  of  fevers,  and  some  other  diseases,  particularly 
toward  the  close  of  life.  If  the  above-named  physical  signs  becom 
developed  in  the  course  of  an  organic  affection  of  the  heart,  especially 
if  attended  with  obstruction  to  the  pulmonary  circulation,  such  as  i* 
incident  to  diseases  affecting  the  mitral  orifice,  or  in  conjunction  with 
general  dropsy,  the  occurrence  of  cedema  is  established  with  con- 
siderable certainly,  provided  we  are  satisfied  of  the  non-existence  of 
the  affections  to  be  excluded.  The  existence  of  ordinary  puenmo- 
Ditis  is  rendered  improbable  by  the  absence  of  pain,  of  the  charao- 
teristic  eputa,  of  febrile  movement,  and  of  the  physical  signs  dcnot- 


477 

ing  8o1t<Iificatiftn  of  lung  rroin  thr  drpoHit  of  inflninniiitory  exudation, 
vit.,  a  wdl -mark I'll  tiroiichial  rospirntitPii,  bronchophony,  nnil  the 
IrHft  crcpiluiit  r«le.  The  hitter  ttign,  however,  it  is  to  be  hornc  in 
tDinct,  mnj  occur  in  oases  of  ccdetiia.  Hypci.«tivtic  cong^ntion,  u 
■ImiilT  f  iHtcd,  involve!*  odcma  m  an  aimlomiciil  element.  To  mnl<c 
the  Jiittinclion  dinic«lljr  under  the  circiimslJinccs  which  iilteiiil  the 
development  of  hypoHtntio  congestion,  is  unimportant.  CEilvma  ia 
most  apt  to  aScct  the  infmbr  and  posterior  portions  of  both  lungs 
simultaneously,  hut  this  rule  is  invariable  with  respect  to  hypostatic 
congestion.  The  latter  condition  is,  therefore,  of  course  vxcludcd 
whenever  the  phenomena  denntin^  oedema  are  ninnifei^ted  at  the  snpo- 
riorand  anterior  portion  of  the  chest. 

With  hydrothoras,  cudema  need  not  be  confounded.  The  change 
of  level  of  the  Ufjnid  with  the  different  positions  of  the  patient, 
suffice  to  indicate  the  former.  But  the  two  affections  may  coexist, 
and  to  determine  the  fact  of  their  coexistence  may  not  he  easy.  Tho 
presence  of  the  sub-crcpitant  rale,  and  the  modifications  of  the  res- 
{Mrstory  sound  due  to  solidification,  vis.,  the  broncho-vesicular  or 
bronchial  respiration,  superadded  to  the  physical  evidence  of  liquid 
m  the  pleura,  talten  in  connection  with  the  existence  of  general 
drop^,  may  enable  the  diagnostician  to  mske  out  this  combinatian. 
Pr*cttcallj,  however,  to  determine  this  point  ia  not  very  important. 


BDMUART   OF   PHYSICAL  SI0N8  BULONOINd   TO   PULMOKAKV   (EUIUIA. 

Absence  of  vesicular  resonance  on  percussion,  with  increased 
parietal  resistance;  aub-crepitant,  and,  occasionally,  the  crepitant 
rale;  feeble  hroncho-Te<iicular  or  the  bronchial  respiration  in  some 
ca«c«,  but,  in  general,  absence  of  respiratory  sound ;  increased  vocal 
redonance  and  fremitus  uncertain,  and  rarely,  if  ever,  present  in  a 
marked  degree. 

GaNOUKNS  07   TUG   LlJKQS. 


Since  the  time  of  Laenncc,  writers  have  considered  gangrene  of 
the  lungs  as  divisible  into  two  forms,  viz.,  diffuse  and  circum»cribed. 
In  diffuse  gangrene  a  considerable  extent  of  lung  is  affected,  gene- 
rally the  whole  or  the  greater  part  of  a  lobe,  and  the  boundaries 
of  the  gangrenous  portion  are  not  sharply  defined.     Both  varieties 


478 


D1SS1SE4  or    THB    KKSPtKATOKY   OBGAXS. 


ftre  nre,  b«t.  of  tbe  cases  that  occvr,  thoae  of  the  diffiue  fonn  in 
1^  Boat  ufreqwnt. 

(SrcHMCtibed  guigrate  is  Uouted  id  extent,  and  a  veD-deGsBd 
fine  of  devareatieii  eefwratee  the  affected  part  from  the  adjucst 
pahaonary  strMSCare.  The  gahgnaovs  poriion  raries  in  size  fi«m 
thai  (tf  a  beaa  (e  «  hea'a  e|g.  The  di«ea£e  ma;  be  confined  to  oet 
pQoit,  or  two  or  mm*  JrtJirt  portions  na;  be  affected.  The  gan- 
pqie  Ua^a  to  dw^ag,  a«  in  other  argaiu.  The  decoapdac^ 
tmfrwhlinei^  redand  to  a  dark,  greenhh,  fetid,  diffluent  mass,  it 
•raeaated  generally  through  the  bronchial  lobes,  but  occasiooall; 
iato  the  plearal  eari^;  tao  iaataaeea  of  the  latter  hare  falla 
aader  mj  ofatrratiao.  It  haa  Wca  known  to  find  ii^  mj  into  tk 
«M0fhaga^8ad  into  the  peritoneal  carity.  .After  the  eTacnatMn 
has  takea  place,  aa  exeaTmiiaa  Iranian  proportionate  in  mm  to  ib 
ext^t  of  the  gai^retke^  In  a  eertata  ratio  of  eaaes,  cicatriianoD 
takes  |daee,  and  a  conplete  care  is  effected ;  or,  if  the  disease  da 
■at  tmA  CuaUj,  a  cariij  wmj  raiaia  for  aa  tadefioite  period.  Dr. 
Cirhard  has  reported  a  caea  in  whi^  an  acaratioii  vas  foond  pod- 
wurttm^  nine  ;ear»  aAcr  the  date  of  the  disease. 

The  aaaM^oal  «oit£tiant  ahieh  are  rcprefcotcd  bj  pbjtkal 
aigaa  are^  ia  the  first  pbee^  "*■**■*''■"  of  the  polmonarj  siructaie^ 
Tf*^"*g  iBtil  the  nlw^hi^t  af  iha  afceted  ponioQ  of  the  Ina^  b 
aeeoaphshed.  The  extent  of  tha  seMitcalion  will  at  least  be  e^ual 
to  the  nae  af  the  gaapeaeas  partisa  ar  poftioiu ;  but  it  is  ofi«n 
■kore  exteasra,  Ibr,  ia  a  eertua  pnipartioa  «f  taaes,  the  gMgrcae 
o«c«rs  in  the  coarse  of  pae—eBitis,  and  when  not  preceded  bj 
patiaaoailin,  iafiiiMitory  eiadatioa  and  mdeaia  taking  place  aie- 
aadarilj,  extend  M  a  greater  er  leas  dutaneearoaad  the  esdiar.  A 
caritj,  left  bj  the  remoral  of  the  deeeaposcd  portion  of  lung,  can- 
9tiiai«3  a  Mooad  aaaioMieal  eandiiion-  7^  «eearrea«e  of  broa- 
duiif  aCectiag  the  tabes  ia  praxnit;  t«  the  gaagrene,  and  the 
prascnoe  at  liqnid  in  these  tnheft,  alto  gire  rise  to  phjsical  cigns. 

Qre— acfiTind  gangrene  is  miat  apt  to  ocear  in  tha  iafigrior  loho^ 
and  it  it  apt  to  he  ataated  near  the  aarfMe,  hat  ocearioaally  it  is 
4eeplj seated;  «•  the  other  hand,  Afcse  gai^reac  altars  b;  pctf- 


iV*^  dyw.—TW  physical  sigas  Ule^iag  to  palMnarygHi- 
grcnc  are  di*inUe  into,  1st,  those  wlueh  reprewnt  the  ooo£iioa 
sf  ssiafifieatiH  prkr  ta  tha  aapataiMt  and  iforal  of  ths  dc«s» 


aAXaRB:;B  op  tbb  lunos. 


479 


I 


I 

I 
I 

I 


posed  palmonary  subatance ;  Sd,  those  du<^  to  tho  circnniscribcd 
bronchitis  incidental  to  the  disease,  and  to  the  preaeitcc  of  liquid  in 
the  bronchial  tubes;  and,  Sd,  those  distinctive  of  an  excnvalion. 
Jnosmach  as  the  diagnosis  of  the  aSieotion,  as  will  W  wen  presently, 
is  rarely  made  prior  to  the  appearance  of  the  ganjrrciioiiM  matter  ia 
the  ejtpectoralion,  and  from  the  insidious  iniinncr  in  which  the  alfoo- 
tjon  is  developed,  exaininiitions  of  the  chest  oflon  being  omitted 
until  the  i-vcnt  just  mentioned  occurs,  the  phenomena  cliaractcristio 
of  this  period  are  determined  inferentially,  and  from  isulatud  cases 

hich  have  been  reported;  deductiune  based  on  an  anitlysis  of 
led  cases  are  wanting,  and  this  dcBidcratiira  is  the  less  readily 
ilicd  owing  to  the  infrequcncy  of  the  dinease.  Dimini.'shi'd 
vetijcular  resonance  ou  percussion,  or  dulness,  more  or  less  luiirkt'd, 
win  be  proportioned  to  the  siatc  of  the  gangreoous  portion  of  lung, 
its  proximity  to  the  surface,  and  the  extent  of  superadded  solidifica- 
tion from  antecedent  or  consecutive  influmoiatory  exudation,  toge- 
tJier  with  oedema.  When  the  gangrene  occurs  as  a  result  of  pneu- 
monitis, tlie  dulness  will  he  likely  to  extend  over  the  space  occupied 
by  an  entire  lobe.  But  if  the  gangrene  be  circumscribed,  seated  in 
the  interior  of  a  lobe,  and  the  surrounding  inHammalory  exudation 
be  limited,  the  dulness  will  be  confined  to  a  comparatively  small 
area,  and  may  not  be  discovered  even  by  the  most  careful  explora- 
tion. If  tbe  affection  supervene  on  an  attack  of  pneumonitis,  per- 
cnseioD  furnishes  no  information  which  could  warrant  a  suspicion 
that  gangrene  had  taken  place;  and  if  the  affection  bo  developed 
vithout  having  been  preceded  by  the  evidence  of  inflammation  of 
the  lungs,  the  existence  of  dulness,  if  discoverable,  will  be  often 
overlooked,  or,  if  discovered,  may  not  be  attributed  to  gangrene. 

Auscultation  over  the  part  of  the  chest  where  dulness  is  fuuwl 
to  exist,  may  furnish  the  respiratory  and  vocal  signs  of  solidiGca- 
tion,  v'tt.,  more  or  less  of  the  elements  of  llie  broncho-vesicular,  or 
tbe  bronchial  respiration,  and  either  increased  vocal  resonance  or 
bronchophony;  or,  during  the  decoinpOBing  processes  leading  to 
eoflening  and  difRuence  of  the  gangrenous  mass,  marked  reebleuess 
or  extinction  of  respiratory  sound,  and  diminished  transmission  of 
the  Toiee.  Bubbling  rales,  the  mucous  or  sub-crepitant,  are  heard 
in  the  vicinity  of  the  affected  part,  extending,  perhaps,  over  a  larger 
space  than  that  corresponding  to  the  gangrenous  portion  of  lung. 
These  rales  arc  due  to  incidental  bronchitis,  and  at  a  later  period,  to 
liquid  in  the  bronchial  tubes  derived  from  the  excavation.     It  u 


480 


VISBAEES  OF    THS    BBSriBATORT  OJtOASe. 


possible  that  a  trne  crepitant  rmlcmiiy  bcprcxlacvdbj  tbeseeooJaij 
inftntnmnlion  of  tbc  pulmonary  p»nnichjiiia  RurrouDding  the  ciran- 
8cribc<l  gsngrcDOus  portion. 

When  >n  excnrstion  has  been  pradoccd  and  a  bronchia]  comiis- 
nication  I'slabli^hcd,  ciircrnOHS  signs  maj  he  di«corcrcd.  Th«  cit- 
ernous  respiration  I  huvc  obucrvod  well  marked  in  a  gangretMoi 
excavation.  Gurgling  will  be  beard  at  variable  periods,  sod  lome- 
timea  pectoriloqaj. 


fHiMgnt>ti». — The  symptoms  of  gangrene  of  the  longs,  before  tbe 
matter  of  expecloratioD  contains  portions  of  (he  decomposed  p(ihii> 
nary  substance,  are  not  distinctive  of  the  affection.  la  a  oertais 
proportion  of  cases  pneumonitis  precedes,  and  the  sjmptows,  «f 
course,  are  those  of  the  Utter  affection.  Exclusive  of  thcM-  caws, 
the  sTmptomatic  phenomena  referable  to  the  lungs  are  oft«n  vagac 
Cough,  and  expectoration,  denoting  bronchitis,  maj  b«  present,  aii4 
«tecur«  pains  in  the  chest,  accompanied  by  febrile  movement,  marktd 
prostration,  and  g«aersl  malaise.  The  disease  may  b«  developtd 
vithovt  any  synptOBs  which  direct  attention  to  the  chest.  Gangrew 
of  the  lottgs,  in  fact,  is  rarely  a  primary  aflectioa.  It  oecvn 
IB  di«  coarse  of  ferrrf,  in  eoantction  with  epilepsy,  cerebral  affee- 
tku  iarolring  iaMoity,  th«  «l«ets  of  intemperance,  etc.  Illustrt- 
ttOBi  of  the  Mvefal  pathological  coaBectioos  just  mentioned  hart 
oone  vnder  my  obMrrftban.  Tb«  dbease  is  rarely  suspected  nnti] 
H  is  dedand  by  AuvOKn  tt  Uw  expectonttion  which  are  highly 
distinctive.  K  remarkable  fetor  of  the  expectoration  is  the  most 
dNivciarirtie totSK.  lV«<krii«r thepecoliarkindcallodgangre-. 
,  wni  b  WMihr  t*  thot  of  oUwr  am*x  tbsacs  undergoing  decom- 
1  while  IB  oostMt  with  living  parts.*  It  is  intense,  rendering 
tko  «f  asphere  of  llhc  •portaiBt  freqaeatly  alnoet  insnpportahb. 
It  HgcMnOy  pereeptMoia  Aapolant'sbreath,  b«t  is  nnch  gmttr 
lof  OBW^a^eTeB  wln«i— ee— panied  by  expeclorauon, 
>oe«  is  wfaej  H  the  bcAth  expired  in  coughing. 
'  ■»pi«<o»n4  is  at  fint  of  «  ia%j  graybh  or  greenish 
be  4Mamkr  4mimmfmtA  — hatanw  of  Inng  fonitd 
the  gingriaaM  |arts  after  Jeiih  ia  casta  in  which  its  removal 
I  aot  heaa  aaeaafKikei  Amag  fiCa.    Safcieytaily  tha  expeeto- 


OAjrOREKB    01 


481 


JratioD  becomes  purulent,  and  the  fetor  diminwheA  and  disnppcars. 
iXren  before  the  eschar  has  been  removed,  the  fetor  is  sonielimes 
^observed  to  be  intermittent,  owing  probably  lo  the  occurrence  of 
ransient  obstruction  of  the  bronchial  tubes  leading  to  the  gangre- 
BOOB  mass.  If  perforation  of  the  lung  enifue,  the  fetor  mny  diminish 
cease. 

The  diagnosis  binges  on  the  distinctive  characlcru  pertaining  to 
tthe  breath  and  expectoration.  Without  these  it  would  bo  impossible 
'to  determine  the  existence  of  gangrene.  But  a  gangrenous  ft'lor  is 
not  alone  sufficient  for  the  diagnosis.  This  is  an  occasional  symptom 
in  bronchitis,  in  abscess  following  pneumonitis,  in  the  cavernous 
stages  of  tuberculosis,  and  in  pneumo-hydrolhorax.  There  uro,- 
EoweTer,  certain  circumstances  connected  with  the  symptom  vrbicb 
render  it  almo.'tl  pal hogn onion ic  of  gangrene,  and  on  the  other  hand, 
irith  due  attention  to  the  point:*  involved  in  the  diflerential  diagnosis 
from  the  several  affections  jiiitt  named,  the  discrimination  is  rarely 
«lt<^ndcd  with  much  ililficnUy.  If  the  cxpectorntion  suddenly  assume 
•  gangrenous  fclor,  at  the  same  lirac  becoming  copious  and  present- 
ing the  appearances  characteristic  of  decomposed  pulmonary  sub- 
Btitnce,  the  existence  of  gangrene  is  quite  certain.  The  diagnosis  is 
rendered  still  more  positive  if,  prior  to  the  irruption  of  this  peculiar 
matter,  the  expectoration,  as  is  sometimes  thv  case,  had  been  slight 
or  altogether  wanting;  and  the  diagnosis  is  established  beyond 
question  if,  prior  to  the  ctiaraelcrijitic  expectoration,  the  physical 
evidence  of  oiraumscribcd  solidification  had  been  ascertained,  and 
subsequently  the  cavernous  signs  arc  discovered  in  the  same  locality. 
In  the  absence  of  the  circumstances  just  mentioned,  precision  of 
diagnosis  is  to  be  based  on  tho  exclusion  of  the  other  uffcclious  in 
which  fvlor  of  the  breath  and  expectoration  occurs,  although  an 
event  of  rare  occurrence. 

Occurring  in  the  course  of  bronchitis,  and  due,  probably,  to  slough- 
ing of  minuto  portions  of  tho  bronchial  mucous  membrane,  fetor 
rarely,  if  ever,  has  the  intensity  common  ui  pulmonary  gangrene. 
It  is  always  preceded  and  accompanied  by  the  symptoms  of  bron- 
chitis. It  is  developed  less  suddenly.  The  gangrenous  matter  is 
not  apparent  lo  the  expectoration,  or,  at  all  events,  is  leas  abundant. 
The  physical  signs  of  solidiGcation  and  subsequently  those  denoting 
an  excavation  are  wanting. 

An  abscess  following  pneumonitis  offers  the  same  physical  signs 
;  88  when  gangrene  results  from  that  disease.     The  purulent  matter 

81 


48S 


DISEA8B8  OF  THB  BESPIBATOKT  0BCAV3. 


expectonted  in  the  fonner  case  is  sometimes  fetid,  but  it  o«r«r  ]at 
tli»t  inlctifle  r«tor  which  occurs  in  the  latter  case.  The  contents  of 
a  ptieiimoiiio  mWesa  do  not  prc4i>nt  the  d»rk,  ranious  sppearun 
vhich  charnctorixea  li<iuelied,  gangrcnoiu  long-HiibataDce.  On  these 
characters,  a9sooi&t«d  witli  inlcnM  fetor,  Koccceding  an  attack  <t 
pncumonitiif,  tnay  be  coDfiilrntlj'  predicated  tbc  opioioa  that  go- 
grene  hiu  taken  ptaco. 

The  sloughing  of  small  portions  of  Inng-snbstance  within  a  taber- 
culoos  carit;  occasionally  commantc&tea  a  gangrenous  odor  to  ik 
expecloratioo,  very  nrely,  however,  to  the  extent  which  oblaiuti 
cases  of  pulmonary  gangrene.  But  the  antecedent  history,  ihepna- 
ent  sj'raptoms,  and  the  physical  signs  at  this  stagi^  of  tubercnlniH, 
snfRciently  eslahlish  the  disease  if  present ;  and  on  the  other  band, 
failure  to  discover  the  evidence  derired  from  these  soureea  disprotn 
the  existence  of  the  disease. 

Pneumo'liydrothorax,  which,  as  baa  been  stated,  m»y  retoll  frta 
pcirfflration  of  the  pleura  in  connection  with  gangrene,  is  sufliciesltj 
evidenced  by  physical  signs,  or  it  is  easily  exolnded  by  the  abseMt 
of  these  Aigns. 

lo  some  very  rare  instances  s  soperGcial  gangrenous  slough,  limited 
in  extent,  mar  escape  into  the  pleural  cavity  without  any  comnioi- 
cation  with  the  bronchial  tubes.  This  occurred  in  a  caM  coming 
under  my  observation.'  Under  these  ctrcnmstsnces  the  diagnostic 
fetor  of  the  breath  and  expectoration  is  wanting.  Acuie  ptearitis 
eventuating  in  pneumo-hydroihorax  will  be  the  result,  and  the  priw 
existence  of  gangrene  may  be  suspected;  bat  to  establish  the  fact  it 
impossible. 

Gangrene  of  the  Inngs  is  to  bo  looked  for  oftenest  in  obildreo, 
next  in  adults,  and  last  m  aged  persons.*  In  four  of  Sve  eases,  oo- 
curring  in  children,  which  were  observed  by  Bondet,  a  gangreiMMU 
affection  was  seated  in  other  organs  as  well  a»  in  the  lung,  and  m 
two  cases  both  lungs  were  gangrenous.  The  coexistence  of  gangrene 
in  other  situations  is  a  point  of  some  importance  with  rcfcrenoe  te 
tJto  diagnosis. 


>  The  cam  U  detailed  in  Em>v  on  Clmiiic  Plcuiitj,  bj  llie  uithoT,  p^a ' 
•  Dr.  Brawl  Boudu,  ta  AKblvM  Ovnoralw  d«  If*d«cia^  *  S«ri«,  IMS. 


PULMOKABV    APOfLKXY. 


483 


fscHHARr  OP  pnrstOAL  nana  iielonoimi  to  nAKOKCNK  or  Tas  lijnos. 

Dulness  on  pp re ubs ion,  varying  in  degree  and  extent,  unleas  the 
Lgangrcnous  portion  bo  ((uile  limited  and  deeply  seated.  Bronohial 
r  broncho- vesicular  respiration  in  some  cases,  but  oftener  fluppremion 
[of  respiratory  sound  ^itbiii  the  arcA  of  dulno^tt  on  percussion;  in- 
Icreased  vocal  reoonance  or  bronebopliony  and  rroiniliiR  oeea^tonally 
present;  mucoui*  or  aub-crepitanl  rales  in  the  vicinity  of  tlic  gan< 
ixons  portion  ;  posslhly,  a  true  crepitant  rale;  subsequent  to  the 
onrrenoG  of  fetid  expectoration,  cavernous  respiration,  gurgliag, 
[«nd  in  some  instances  pecioriloi^uy. 


PiTUfoHAKT  Apoplexy. 

Pulmonary  apoplexy  is  a  term  us^d  to  designate  extravasation  of 
^btood  into  the  parenchyma  of  the  lungs.  Tbe  term  is  an  unfortu- 
nate one,  and  for  the  sake  of  conformity  to  the  nomenclature  now 
in  vogtw,  il  is  desirable  to  substitute  tbe  word  pneumorrh<igia.  Ex- 
travasation may  take  place  either  into  the  air-celU,  or  into  the  in- 
'^tcrlohulnr  areolar  tis.'<uc,  the  Mood,  in  both  cases,  unless  consider- 
able laceration  of  tbe  pnlmonary  structure  be  produced,  coagulating 
and  forming  a  consolidated  mass,  resembling,  so  far  as  density  is 
concerned,  a  hepiitixed  portion  of  lung.  Tbe  space  thus  solidified 
varies  in  siKe,  frequently  being  less  than  a  cubic  inch,  and  rarely 
exceeding  four  cubic  inches.  Tbe  extravasation  may  be  conlined  to 
one  spot,  or  it  may  occur  at  several  isolated  points.  In  some  very 
rare  instances  it  extends  over  a  whole  lobe,  and  even  over  the 
greater  part  of  an  entire  lung.  The  limits  of  solidification  are 
sometimes  extended  by  cciJemn  of  the  pulmonary  subncanee  swr- 
rounding  the  extravasation.  Absorption  of  the  i-lftist'd  blood  is  p08« 
nble;  suppuration  may  ensuei  and  an  excavation  occupy  the  site  of 
tbo  apoplectic  mnss;  occasionally  gangrene  results.  In  some  cases 
the  extravasation  occasions  immediate  and  considerable  laceration 
of  the  pulmonary  structure,  and  s  cavity  is  at  once  formed,  contain- 
ing fluid  and  coagulated  blood_which  has  been  known  to  bo  evacua- 
ted into  tho  pleural  sac. 

Apoplectic  extravasations  are  most  apt  to  occur  in  situaliona 
d«oply  seated  in  the  pulmonary  parenchyma,  near  the  roots  of  the 
luDga,  or  in  th«  posterior  portion  of  the  lower  lobes. 


4M 


DIIBASBS  or   TBI    BBSPIBAtOKT  OkOiVS. 


The  Mcape  of  blood  into  the  bronchial  tabcA,  girrngnwtohistf' 
tysie,  occurs  nben  the  extrsinuMiUon  take*  place,  or  Ute  iivii  pm 
access,  into  the  air-ccllB.  The  eztraTasation  ia  mae  eaaat  b  fiv 
marilj  into  the  wr-tubes,  tlie  btood  being,  drawn  into  the  eeOt  I7 
the  Force  of  infipiration ;  thia  constitntca  tfa«  iammpUit  nifiirdwtf 
Laennec.  In  a  ceruin  proportion  of  cas«s  of  pdloMnMrj  •fofkl}', 
hemorrbsgic  expectoration,  that  is,  hmmoptnia,  doea  oot  take  pbct 

Phjfikal  Sitpii. — Dalness  on  percussion  is  marked  if  ike  pnrMt, 
or  portions,  of  lung  solidified  be  of  considerable  size  atidailB»l 
near  the  pulmonary  superficies.  Bui  if  the  extrarssatioa  be  ad 
or  situated  at  several  poinu  quite  limited  in  extent,  diasenusatt^ 
and  imbedded  beneath  the  surface  of  the  lung,  dolaess  will  be  aEghi 
or  not  appn-ciable. 

The  development  of  auscoltatorj  phenomena  inTolves  the  oat 
conditions.  If  dulne«s  be  upprt^iable,  or  marked,  the  re^iratim 
orer  the  site,  or  sites,  of  the  extravasation  may  be  found  to  be  Mp- 
pressed,  or  to  present  more  or  less  of  the  characters  belonging  t* 
the  broncho- vesiciiliir  or  the  bronchial  respiration.  Bat  if  the  wot 
and  situation  of  the  consolidated  portion,  or  portions,  be  rack  iktl 
no  alteration  of  the  percnsaion-resonanoe  is  appareot,  it  is  oot  prob- 
oblu  that  any  distinct  modification  of  the  respiration  will  be  <£•- 
oororcd.  Exaggerated  vocal  resonance  and  fremitus  hare  bees  ab- 
served  over  an  amount  of  consolidation  of  blood  sufficient  lo  pn 
rise  to  dulne&»  on  percussion. 

Mucous  antl  sub-crepitant  rales  arc  often  beard  in  the  vicinity  of 
the  extravasation.  Occasionally  the  true  crepitant  rale  is  discorered 
over  or  near  the  situation  of  the  solidified  ma&s. 

If  an  excavation  be  produced,  the  cavernous  signs  may  be  A^ 
vclopcd. 

Diaffnotia. — Very  little  was  knovn  respecting  pulmonary  extiara- 
sations  prior  to  the  researches  of  the  illustrious  disoorerer  of  aaseol- 
tation.  Laenneo  supposed  that  they  were  always  accompanied  bj 
hiemoptysis.  Subsequent  observations  have  shown  that  ibis  aymp- 
tom  is  present  in  only  a  certain  proportion  of  cases,  and,  also,  tkit 
of  cases  of  hemoptysis,  extra  vajiation  into  the  pulmonary  parenchyaa 
coexists  in  an  exceedingly  small  ratio.  It  follows  tliat  the  expecto- 
ration of  blood  catinot  be  counted   on  as  a  diagnostic  symptaa 


POLMOSARt  APOrtSXY. 


485 


rhen  pulmonary  apoplexy  exists,  iumI  thnt  still  loss  i«  the  existence 
bf  pulmonary  apoplexy  to  be  predicated  ou   the  expectoration  of 

Laennec  nUa  eutcrtnined  the  belief  that  the  physical  signs  of  an 
Ipoplccitc  extravasation  were  quite  distinctive.  According  to  him, 
lb»enco  of  respiratory  sound  over  a  limited  area,  and  the  presence  of 
the  crepitant  rate  around  the  borders  of  this  space,  constitute  a 
Dmbinalion  which  is  diagnostic.  Observations,  however,  hnvt-  failed 
establish  the  constancy  of  these  associated  signs.  With  refer- 
ence to  the  crepitant  rale  in  this  connection,  it  is  to  be  borne  in 
FBiitid  that  the  distinction  between  it  and  the  sub-crepitant  has  been 
ttaade  since  the  time  of  Luennec. 

The  diagnosis  of  pidmonary  apoplexy,  in  fact,  can  rarely  be  made 
rith  precision,  and  in  many  caitcs  is  wholly  iinpracticnblc.  Tbe 
jmost  experienced  auscultators  concur  in  the  remnrk  made  by  Bouil- 
liaud,  that  the  occurrence  of  extraVH»ation  is  rather  guessed  at  than 
tdiagnosticaled.  Aside  from  hwravptysls,  cough  and  expectorntion, 
ogethcr  with  cmburnissnicnt  of  the  respiration,  arc  incident  to  the 
[-affection,  but  these  symptoms  arc  not  in  themselves  distinctive, 
Binuch  as  they  belong,  also,  to  other  forms  of  disease.  The  sud- 
enness  with  which  miibarrasscd  respiration,  in  connection  with 
bemorrhiige  and  other  pulmonary  symptoms,  is  developed,  is  a  cir- 
cumstance which  should  give  rise  to  a  suspicion  of  extravasation.  A 
patient  attii,cl£cd  at  once  with  these  symptoms,  if  previously  free 
from  all  evidence  of  pulmonary  disease,  has  some  aS'eclion  of  rapid 
development,  and  this  is  accounted  for  on  the  supposition  of  an 
apoplectic  elTusion.  Pulmonary  apoplesy  is  very  rarely,  if  ever,  a 
primary  afTectlon.  It  occurs  secondarily,  and  in  the  vast  proportion 
of  castas,  as  a  result  of  disease  of  heart,  the  disease  being  either 
hypertrophy  of  the  right  ventricle,  or  a  valvular  affection  involving 
obstruction  at  tbe  mitral  orifice ;  with  the  latter  it  is  most  frequently 
associated.  Tbe  symptoms  due  to  the  extravasation  will  therefore 
bo  commingled  with  those  proceeding  from  disease  of  heart.  Its 
connection  with  disen^e  of  heart,  is  a  point  to  bo  taken  into  accoant 
in  the  diagnosis.  The  signs  and  symptoms  pointing  to  pulmonary 
apoplexy  derive  considerable  force  from  the  coexistence  of  cardisc 
lesions,  especially  contraction  or  patesccncy,  or  both,  of  the  mitral 
orifice. 

Dulness  on  percussion  over  a  limited  space  not  situated  at  the 
sutDmit  of  the  chest,  and  more  especially  if  found  on  the  lateral  or 


486 


VISBABRS    OF   TKB    BBSPIKATOBT    OBOAjre. 


posterior  surfacn,  an<I  the  aoscullatory  erideoce  of  solidiScatioa,  <e 
snpprvsyjon  of  respiratory  sound,  accompanied  hy  difficnltj  of  nb- 
pintion  tuddenlv  developed,  irarnnt  a  strong  suspicion  of  ciirirt- 
ution.  The  sudden  derelopment  of  embarrassed  respiration  U  a 
point  of  fiijrnifi<:ance;  but,  so  UtT  aa  physical  signs  arc  conceraH, 
tli«rv  \*  nothing  in  ihcm  by  nhich  they  are  to  be  disiingnisbed  &Qa 
tiic  eiiiiic  ^ignn  iis  pnxluced  by  gangrene,  cedema,  or  cstcinomt.  B 
hiemopty«i)i  be  added,  or  if  the  expectoration  consist  is  part  of  i 
dark,  grumouK,  bloody  liqnid,  there  is  ground  for  a  prcsnmptioo  ol 
the  existence  of  pulmonary  apoplexy.  The  non>occurreiice  of  fetid 
expcctornlion  strengthens  this  presumption  by  oxt^luding  gangrene. 
A  bloody  expectoration  may  occur  equally  in  carcinoma,  but  other 
symptonis  and  signs  denoting  cnrciuoma  may  be  absent  so  as  to 
render  it  highly  probable  that  tliU  affection  does  not  exist. 

If  llic  physical  signs  which  I  have  supposed  to  be  present  le 
fouuil  at  the  summit  of  the  chest  in  front  or  behind,  a  tubercoknit 
deposit  is  vastly  more  probablo  than  an  apoplectic  vxtravasatioa; 
and  under  these  circumstances  the  occnrrence  of  beeinoptysis  renders 
the  fact  of  tuberculo§is  still  more  probablo.  The  liability  to  altrib- 
ato  (ubvrculous  solidification  accompanied  by  hncmoptysu!,  in  ccrtun 
cases,  to  puluionary  apoplexy,  has  he«n  referred  to  in  the  cbaptir 
on  pulmonary  tuhi:rculo.4is.  In  attempting  to  make  the  differential 
diagnosis  from  a  tabercutons  deposit,  situation  is  an  important  point, 
observations  shoving  that  exlravasatioti  is  not  likely  to  occur  at  or 
near  the  apices  of  the  lungs,  irhere  tubercle  is  first  deposited  in  the 
vast  majority  of  cases.  The  coexistence  of  heart-disease  is  another 
point  posoGSsing  diagnostic  significance  in  this  discrimination,  since 
it  is  rurcly  fonnd  a^ociated  with  pulmonary  tnbercalosis. 

It  is  tliuH  seen  that  considerable  anoertainty  attends  tbe  diagnosis 
in  caitcs  in  which  the  extravasation  is  sufficient  in  amount  to  girt 
rise  to  well-marked  physical  signs  ;  and  it  is  to  be  borne  in  atind 
that  in  a  certain  proportion,  perhaps  the  majority,  of  cases,  the  n^ 
snlt  of  physical  exploration  is  negative.  In  the  absence  of  physical 
signs  it  is  in  vain  to  attempt  to  reach  even  a  probable  opinion  aa  to 
the  existence  of  llie  afiection. 

The  difficulties  in  the  way  of  the  dJagnoms  of  pulmonary  apoplciy 
render  its  infreqnency  a  subject  for  congratulation,  irrespcctin 
of  the  danger  to  life  which  belongs  to  it.  The  diagnosis  involves 
s  grave  prognosis.    In  a  case  tinder  my  observation,  in  wludi  it 


CAXCBR    OP  THE   LVVOS. 


487 


occurred   as  »  complication  of  tuberculous  diseue  of  the  longs, 
dcnth  took  plncv  so  suddcolj  as  to  call  for  a  coroner's  inquest. 


I 

I 

I 

I 


SUUUART  OF  PHTSICAL  SIHSS  BBL0X0IK8  TO  PCLMOHiRT  APOPLEXY. 

The  evidence  of  circuniHoribed  HoUdificaiion,  furnislied  by  pcrcius- 
■OD  and  anscultatiori,  present  in  a  certain  proportion  of  caeeii  only ; 
'inoiat  broncliial  ralt-s  occAMonally  observed;  cavernous  signs  suc- 
ceeding liiose  deuoting  euliilincatioii  in  some  instanceft. 


Cakcbr  ov  THB  Ll^KQS. 

Notwithstanding  the  extreme  infrcqnency  of  cancer  of  the  lungs, 
the  disease  posoesses  practical  interest  in  conee<)uenco  of  the  recent 
inrestigations  of  Stokes,  WaUhe,  and  others,  with  referrencc  to  its 
diagnostic  characters,  which  are  better  established  and  more  rc> 
liable  than  in  the  instance  of  the  affection  last  considered.  The 
Tariely  distingni&hed  as  encephaloid  is  that  generally  present  when 
the  Inngs  arc  the  seat  of  carcinamatoiis  disease.  Examples  of  the 
variety  called  colloid  are  exceedingly  rare.  The  morbid  deposit 
is  either  in  circuui scribed  masses  or  nodules,  varying  from  the  sixc 
of  a  haeeliiiit  to  that  of  an  orange,  more  or  lesa  numerous,  Home- 
times  limited  to  one  lung,  hut  ofiener  existing  in  both  sidcK;  or,  it 
is  infiltrated  more  or  less  extensively  into  the  air-oella,'  giving  rise 
to  a  condition  analogous  to  hepuLiKation.  It  is  stated  that  when 
the  disease  is  primary  the  cancerous  deposit  is  inliltrati>d,  and  that 
the  nodulated  form  occurs  when  the  disease  is  developed  in  tlio 
pnlmoTiary  organ*  scuonilurily,  t.  e.,  suh»ei[ueMt  Ui  a  depoBit  in  other 
organs.  According  to  Rokitaoeky,  the  latlor  is  mvi  with  oftener 
than  the  former  rariety. 

In  proportion  to  the  cancerous  growth  the  pulmonary  structure  ts 
destroyed,  and  the  snrronnding  parenchyma  undergoes  compru:t«toa. 
Solidification,  then,  is  a  morbid  condition,  incident  to  the  dlseaso, 
which  is  represented  by  physical  sign$.  In  some  oases,  soft^-ning  and 
elimination  through  the  bronchial  lubes  of  the  morbid  material  ensue, 
giving  ri«c  to  the  presence  of  li(]uid  in  the  tubes,  and  the  formation 
of  cavities.  Hero  are  otlxr  conditions  originating  physical  signs. 
Id  infiltrated  cancer  the  affected  lung  suffers  reduction  in  volume, 


■  RokiUtukj'a  Ptth,  Aaat.  Ant.  Ed.  1855,  to],  iv,  p.  100. 


488 


DIS) 


rUB    RESPIRATORT    ORQAXl 


»nd  contrnctjon  of  the  clicst  followa.  In  this  form  tbedieease  U  unwilj 
limited  to  one  side.     The  bronchtnl  ginnds  nrc  gcncrnll^  iDTolvuJ. 
Liquid  clTusion  within  the  pit-oral  t^c  not  infmiuciitlj  cocxiAt». 
Cancer  is  vorjr  nnly  found  u^ouiatcd  irith  a  taborcnloos  deposit. 

Phytkal  Sigm. — If  the  deposit  consist  ofa  Tew,  small,  disfiominated 
nodules,  the  intervening  parencbjnia  being  healthy,  physical  explo- 
ration inaj  fail  in  furnishing  positive  reaults.  If  sufficiently  large, 
numerous,  or  aggregated,  and  especially  if  siloatcd  near  the  surface, 
or  if  iho  surrounding  lung-substance  be  atdematous,  tho  phenomena 
denolJDg  solidification  mny  be  more  or  loss  marked,  TJt.,  pcrcuseiob- 
dnlnees,  and  the  broncho-vesicular  or  the  bronchial  respiraUon,  «illl 
perhaps  increaaed  Tocal  resoniince ;  bat,  in  place  of  these  anscul* 
tatory  signs,  the  respiratory  murmur  and  rocsl  resonance  may  b« 
snppreaaed. 

In  infiltrated  cancer,  the  physicsl  signs  of  soliilificntion  are  more 
constant  nnd  more  marked.  The  percussion-sound  is  extremely  doll 
or  flat,  but  the  Tesicular  resonance  over  the  middle  third  is  eometiioes 
replaced  by  a  tympanitic  sound.  The  dulnesa  may  extend  beyond 
the  median  lino  on  the  healthy  side.  The  sense  of  resistanca  ii 
notably  increased.  The  respiration  is  mure  apt  to  be  broDohial, 
either  intense  or  feeble,  but  the  respiratory  sound  may  be  suppressed. 
The  latter  occurs  when  the  calibre  of  the  primary  bronchus  or  '\M 
larger  divisions  is  diminished  by  pressure  of  the  cancerous  dcpout. 
Increased  vocal  resonance  and  bronchophony  are  obdtcrred  in  a  eer- 
tain  proportion  of  cases.  The  hoart-sounds  may  be  (induly  trant- 
mitted.  In  short,  the  physical  signs  dcnoto  solidification  gre*tcror 
less  in  degree  and  extent.  On  iospeetiou,  Battening  or  oontraetion 
of  the  uflcotcd  side  is  apparent,  but  not  the  depreasion  of  the  shoulder 
and  the  »pinal  curvature  which  reiiult  from  chronic  plonriay..  I1i« 
intercostal  depressions  are  somewhat  deepened.  Tlie  ri-«piratory 
movcEoents  are  diminished.  On  palpation,  the  vocal  freiaittu  may 
at  first  be  found  to  be  increased,  and  afterward  Iceaeavd. 

If  softening  nnd  elimination  take  place,  tho  physical  phenomena 
correspond  to  tbc  changes  in  the  physical  conditions  of  tho  affected 
long.  Percussion  elicits  rcsoDancc  which  is  non-vesictilar  in  quality. 
The  sense  of  reKietnnce  is  diminished.  Uucoiia  rales  are  now  more 
or  less  prominent,  and  the  cavernous  signs  may  become  developed. 

On  tJic  healtliy  aide^  in  eases  of  infiltrated  cancer,  and,  also,  of  the 


489 

[.nodulated  form,  if  the  nodules  be  exUnsire  and  limited  to  one  lung, 
tbe  respiratory  murmur  is  abnormally  intense  or  exaggerated. 

B  DiagnoaU. — With  reference  to  tbe  symptoms  and  signti  involved 
ID  tbe  diagnosis,  it  is  important  to  dietinguisb  cancer  of  the  lungs 
from  cancerous  tumors  situated  exterior  to  the  pulmonary  organs, 
generally  developed  in  the  mediastinum,  which  extend  into  ilie  chest, 

I  displacing  the  lung  and  other  organs.     I  shall  notice  the  diagnosis 
of  mediastinal  tumors  under  a  distinct  head.    Intra-lhoracic  canc«r, 
hoir«ver,  may  exist  simultaneously,  hath  vithin  and  exterior  to  the 
lungs,  and  then  the  phenomena  of  both  nill,  of  course,  be  combined. 
Limiting,  at  present,  the  attention  to  cancer  seated  within  the 
tungs,  in  the  vast  majority  of  cases  the  march  of  the  disease  is  ac- 
eompiinied  by  symptoms  denoting  a  grave  pulmonary  malady,  and 
aotne  of  which  possess  diagnostic  significance.    A  constant  symptom 
!•  WBgh,  which  is  at  first  dry,  but  at  length  attended  by  an  ex- 
pectoration moreor  less  abundant,  and  presenting  variable  cbarnctcrs. 
H   Tbe  expectoration  consists,  for  a  time,  and  always  in  part,  of  matter 
H  furnislied  by  the  bronchial  raucous  membrane.  It  assumes  frequently 
H  a  pDruicnt  appearance,  and  is  sometimes  fetid.     lu  ft  cvrtuin  pro- 
^nortion  nf  cit»i>.«,  it  resembles,  according  to  Stokes,  black,  and  accord- 
^Plllg  to  Ilugbe:!!,  red,  curriint  jelly.    This  jclly-ltlce  appearance,  due  to 
fto  intiiniilc  admixture  of  blood  with  the  morbid  products,  is  regarded 
by  the  observers  just  namud  tt»  highly  characteristic  of  the  disease. 
Pare  haemoptysis  occurs  in  a  large  proportion  of  cases  during  th« 
course  of  the  disease ;  according  to  WaUhe,  tbe  ratio  is  seventy* 

(two  per  cent.'  It  a  possible  that  the  microscopical  characters  of 
cancer  may  he  discovered  in  the  sputa.  Tain,  more  or  less  severe,  in 
the  aSected  side,  is  a  pretty  constant  and  persisting  symptom.  The 
pain  differs  in  character  in  different  cases,  being  acute  or  lancinating, 
dull  and  buniing.  This  symptom  is  valuable  with  respect  to  the 
diagnosis.  The  respirations  aro  increased  in  frequency  in  proportion 
to  the  extent  of  solidification  or  destruction,  and  sometimes,  although, 
rarely,  dyspnoea  becomes  a  prominent  symptom,  Dysphagia  is  a 
symptom  noticed  in  some  cases  of  pulmonic  as  well  ae  mediastinal 
cancer.  Tbe  pulse,  for  a  considerable  period  during  the  progress 
of  the  disease,  is  not  notably  increased  in  frequency.     Marked 


I  Thnnnnljtubj-  Wnlihe  embroHd  csMt  of  csncef  of  tfa«  mcdiatticis,  u  woll  at 
'of ItM  lunp. 


_x  1.  ^Hii.    i.'ivii..j^  x  aaa.  sos—r  oT "die  limp  is  a  laim  dif- 
-we-  :»  ~!;=KTC  ^THBom^    JsK  -«»=£  it  s  liniwd  to  muIL  eir- 

^smil—  I«5-r<ttigt.  X  'rnoii  j^o.  wwkI  -explondon,  u  slreadT 

Bm  if  tlie  extent  of  tlw 

Tt-  ^H  ffigiiE  of  solidificuioii, 

of  infiltrated  nncer. 

smnfctirni  vith  the  resnla  of 

■  ■eBniiJJBfa  a  diagnosis.    TTnder 

m  -im  DJiMn  k  ascertained,  not  k 

■E  by  exelndi&g  otlier 

of  hmg,  and  taking 

■  -w^  K  BfDB,  vhicfa  belong 

I  ooIt  be  eonfon&ded 

'xij.     These  affections,  ei- 

.  .^  _.     .    __.  ....     ^_    -^■^—-^  «^   rlrmjr  jinennionitis,   chronic 

T  -—^-r.  _i  -  -.:  _5-:r:  1  sL-^L  "-  T  rrir*!  rirrhosifi  of  the  Inng. 

I-  '-.I  ~-:~-  •    •    -.--■;  ^  -^  --■-*£  h,  lie  differential  disg- 

1l  -  L.Z1  :;.■"  — -—:-  -sj.  iz-  -;j^',-al  s^rns  cf  solidification, 
»-  .  ■  -.  r--  :  1  ■  '.-  ?:~r:r_r  t"  ::i-;  ti^^^  are  eqoallv  present; 
iz  -  - -m -.  _  ir  ■:!..-  i5-.-  ;  :?  Si-  frv:3«=i:  as  camrer  is  rare,  the 
-,-.  --  •-'-  ?  ■■-"  1-  ~  '.  T-^^i  iL-^  '.X7Z-T  affection  for  phthisis. 
X  --  -r  ,-.—-^:l  :  ~--  -~t't=*  i  -ri^T"  characteristic  of  tnber- 
r-^  ~~  -  :c"  -■--'--  ^-  -^  f  :?a^,-^-.  i-.r_  tiKaopiTsiF,  emaciation, 
i.L'.  :.:s;li.  7":t  Z?r:-;-i- t-  ~t?  T-:nai::isg  to  both  signs  and 
f^tT  rs  LT-..  ':»■:■■-.?,  fcri-T^.  I^  ca;;t*r,  the  solidification 
frr.  ---:-'  T:'~-^":~  f  T  1  r-~.£:rt:'-^  x  eTen  a  long  period,  i.e., 
B^-r-rL.  -  -■-li^  »  :1  :t  T:i::r-s.!  c'mjTf :  in  other  irords,  without 
b-.i-.^z-z^z  i-i  :-rav'r:.T_  ir:;;-?;':  ^t  ibe  dcTtlopment  of  mncons 
TL.-.-T  li--;1t  ra":-—:^  s  rr-s  ::tsix?-i  rTiercisssionand  aoscnltation. 
O-  '-1:  ::i.tr  LsiL  t-.:L  ir  i-i-il  az:;-nEi  C'f  rnbercnlons  deposit, 
iLe^  ti^;  ■w:-^i  ':-:  ixj^otei  :;   s-perrene  more  uniformly,  and 


TUB    LUXUS. 


491 


I 
I 


I 
I 
I 


after  tlic  lapse  of  k  uliorlcr  period  ;  and  as  tbe  f«flening  and  elimi- 
DBtion  of  tubercle  go  on,  in  gcncrnl.  more  extensively  as  well  as  more 
npidlj,  time  i<igii8  become  more  strongljr  marked  in  tuberculoaiii 
than  in  the  conrso  of  cancer.  In  the  latter  affection,  the  phenomena 
due  to  the  eolidification.  vh..  dulncss  or  flatness,  with  suppreKsion  of 
respiratory  sound,  or  the  bronchial  respiration,  and  perhaps  bron- 
ehophony,  continue  without  the  addition  of  the  contingent  adventi- 
tious fionnds  or  rales  for  a  longer  time  than  in  phthisis.  In  infiK 
traled  cancer,  the  deposit  being  (extensive,  and  in  the  nmjottty  of 
CMCS  limited  to  one  lung,  the  affection  differs  from  phthisis  in  pre- 
Bcnling  the  xigns  of  soIidiGcation  exclusively  on  one  side,  the  other 
aide  affording  no  evidence  of  disease;  with  a  similar  amount  of 
Inbercle  in  one  lung,  more  or  less  of  the  evidences  of  a  tuberculous 
doposit  in  the  other  lung  would  he  expected.  The  tvo  circuinEtt.tnces 
Just  mentioned  arc  the  strong  points  in  the  differential  litagnosiit  so 
far  as  coneems  physical  signs.  As  regards  symptoms,  the  ex- 
pcctonition  of  matter  r^tsembling  currant  jelly,  which  occurs  in  a 
certain  proportion  of  llie  cases  of  cancer,  is  foreign  to  tbe  veincio- 
logical  history  of  tuberculosis. '  Febrile  movement,  or  marked  ac- 
celeration of  the  pulse,  which,  in  the  majority  of  cases,  chuructcriscs 
the  march  of  phthisis,  does  not  occur  till  late  in  the  progress  of  can- 
cer. Pain  in  the  chest,  exclusive  of  that  attending  the  occasional 
attacks  of  dry,  circumscribed  picuritis,  does  not  belong  to  the  his- 
tory of  phthisis.  The  pleuritic  stitch-pain,  just  referred  to,  is 
readily  recognized,  and  constitutes,  as  has  been  seen,  one  of  the 
characteristic  symptoms  of  tuberculous  disease;  cancer,  on  the 
other  hand,  generally  gives  rise  to  persisting  paJn,  which  becomes 
a  prominent  feature  of  the  disease.  The  dislurhanco  of  the  cir- 
culation is  disproportionately  loss,  as  compared  with  the  pulmonary 
symptoms,  than  in  cases  of  tuberculous  diseases,  the  pulse  frcijucntly 
for  a  considerable  period  remaining  nearly  or  quite  natural.  Ema- 
ciation is  not  so  prominent  a  feature  early  in  the  career  of  tbe  dts- 
ea-se  as  in  the  majority  of  the  eases  of  phthisis.  In  a  certain  pro- 
portion of  cases,  cancer  of  the  lungs  coexists  with  a  cancerous 
deposit  in  some  part  where  its  characters  are  open  to  inspection  or 
manual  examination.  The  existence  of  cancer  elsewhere  than  in 
the  lungs  renders  it  altogether  probable  that  pulmonary  solidifica- 
tion is  cancerous;  and  if,  after  the  extirpation  of  a  cancerous  part, 
pulmonary  symptoms  and  signs  denote  some  grave  affection  of  the 
longs,  the  development  of  cancer  in  these  organs  is  highly  probable. 


492 


mSKASSS    OP   TItE    RESPIRATORT    ORGAXg. 


eiDce  obMrr&tionii  show  that  nnder  tbeae  cireuiostancps  Ibej  m 
apt  to  I>e  invnddl. 

Attention  to  the  Toregoing  poinu  of  distinction,  io  a  Iarg«  pro- 
portion of  CAKcs  enable  tho  practitioner  to  dUcrimtnate  cUnicaDT 
between  the  two  affections. 

Chronic  pncamoniliM  is  as  rare  nn  affection  as  caneer  of  the  \ngL 
It  is  attended  by  contraction  of  the  chest,  hut  in  a  less  d^re«  thai 
infiltrated  cancer.  A  cancerous  depwil  differs  from  tnbercle,  as  hai 
just  been  ceen,  in  undergoing  less  uniformW  nnd  morv  elowlj  tW 
processes  of  softening  and  elimination.  On  the  other  hand,  it  difltrl 
from  chronic  pnenmonitia  in  the  greater  frc<|acncj  with  which  it 
erentoatcs  in  excavation.  In  extensive  cancerous  solidification,  tht 
percnssioD-dulness  sometimes  shows  the  extension  of  the  disease 
lateralljr  beyond  the  median  line ;  this  does  not  occur  in  chronic 
pneumonitiB.  Chronic  pneumonitis  generally  succeeds  the  acate 
form  of  the  disease ;  acnto  pneumonitis  ie  an  antecedent  of  cancer 
only  as  an  accident.  The  lover  lohe  of  the  lung  is  most  prone  to 
be  attacked  nith  inflammation  ;  a  eaneerous  deposit  is  most  apt  to 
take  place  in  the  superior  lohe.  Pure  bxmoptysis,  which  occurs  in 
a  large  proportion  of  oases  of  cancer,  very  rarely,  to  nay  the  least, 
is  n  symptom  of  pneuinonilis;  nor  in  cases  of  the  tatter  aSectioa 
is  the  jelly-like  expectoration  of  cancer  observed.  The  concur- 
rcncc  of  cancerous  deposits  elsewhere  than  in  the  langs  has  tlic 
same  diagnostic  significance  as  in  the  differential  diagnosis  tna 
tuberculosis. 

In  chronic  plcuritiA,  marked  contraction  of  the  chest  follows  the 
absorption  of  a  considerable  portion  of  the  liquid  effu.'tion.  AKiuming 
that  a  case  conies  under  observation  at  this  period  of  the  discaae, 
there  is  a  poHsibility  of  mistaking  it  for  cancer.  But,  in  general,  if 
a  case  have  not  been  observed,  either  from  tho  beginning  or  an  early 
period  in  the  disease,  the  previous  history  will  supply  facts  snSeient, 
in  conjunction  with  present  signs  and  symptoms,  to  render  the  dar- 
acter  of  the  disease  abundantly  clear.  The  distinctive  points,  how- 
ever, are  not  less  available  than  in  tbe  other  affections  which  are 
to  be  excluded  in  arriving  at  the  diagnosis  of  cancer.  The  contrac- 
tion of  the  chest  is  greater  and  more  general  on  tho  affected  side  in 
chronic  pleuritis:  the  shoulder  is  depressed,  the  spine  frequently 
curved  in  a  lateral  direction,  the  intercostal  spaces,  except  at  the 
summit,  narrowed,  and  the  respiratory  tnorcmenta  more  diminished. 
Unless  the  liquid  effiision  be  completely  absorbed,  flatness  and  sb- 


CAjrOKB    OF   THE   LDiraS. 


I 
I 


B«nce  or  respiratory  Hoiind  extend  from  tlir  base  of  thecliest  apmrd 
to  a  certain  hciglil ;  but  it  is  to  bi-  borne  in  mini]  that  pleuritic,  with 
liquid  tlTuHioD,  may  occur  sh  a  complication  of  cancerous  diMcaso. 
The  pulmonary  and  geoeral  symptoms  in  case*  of  simple  plcuritis 
are  not  auflSciently  grave  for  an  amount  of  cancerous  disease  suffi- 
cient to  account  for  tie  physical  signs.  Cough  and  expectoration  aro 
frequently  slight  or  wanting  in  chronic  pleuritis.  The  strength  and 
weight  are  better  preserved.  Uxemoptysis  occurs  but  rarely,  unlcs* 
the  plcuritis  be  complicated  with  tubercle.  The  jelly-like  expectora- 
tion peculiar  to  cancer  is  never  observed. 

Cirrhosis  of  the  lung  with  dilatation  of  the  bronchial  tubes  pre- 
sents, in  connection  with  thoracic  contraction,  this  feature  of  cancer, 
vix.,  persistency  of  the  aignti  of  Kolidificalion.  In  the  differential 
diagnosis  the  existence  of  the  latter  affection  is  cither  determined 
er  disproved  by  the  absonce  or  the  preaence  of  bloody  expecto- 
ration and  pure  hivinopty^ia ;  by  pain  being  either  wanting  or  promi- 
nent ;  by  the  evidence  of  a  grave  affection,  which  belongs  to  the 
history  of  cancer,  derived  from  loss  of  weight  and  strength,  and  the 
physiognomy  indicating  a  malignant  disease,  or,  on  the  other  hand, 
the  deficiency  of  this  evidence,  which,  comparatively  speaking,  dis- 
tinguishes cirrhosis,  and  by  the  exiatence  or  the  non-existence  of  can- 
IcerouB  deposit  in  aituations  accessible  to  direct  examination. 
Absence  of  positive  signs,  if  the  cancerous  deposit  be  in  the  form 
of  small,  disseminated  nodules,  distributed  in  both  lungs.     I)ulneK8 

•  OD  percussion  with  the  auscultatory  signs  of  solidification,  when  the 
nodules  are  sufficient  in  number  and  size,  agglomerated,  nccompanicl 
by  ffidcma,  and  especially  if  limited  to,  or  more  abundant  on,  one 
ude.  In  cancerous  infiltration,  contraction  of  the  chest  over  the 
affected  lung,  and  leeaened  respiratory  movement ;  marked  diminn- 

Ition  or  absence  of  vesicular  resonance  on  percussion,  with  or  without 
the  substitution  of  tympanitic  sonorousnesa,  and  marked  resistance 
of  thoracic  wall ;  bronchial  respiration,  or  suppression  of  respiratory 
sound,  with  or  without  increased  vocal  resonance,  or  bronchophony, 
and  vocal  fr«mitu3  ;  undue  transmission  of  the  heart-aounds.  Af^r 
,      a  time,  mucous  rales,  gurgling  and  other  cavernous  signs ;  the 


BDUMART  OF  TUB   PETSICAL  SIQXS   BBLOKaitIO   TO  CAKCKB  OF   TItB 

LDltOS. 


per- 


494 


DISBASBS   or  TH8   RB8FIRAT0BT    OkOAJTS. 


cussion-rcwiunncc  grewtcr  than  prcrioiut;,  but  tjinpsaitic.     Sop- 
plemenUrv  respiration  on  the  uosfiectcd  side. 


Caxcer  in  tbe  MsousriiniM. 

Intra-tlinriiCTC  cnncvr  exterior  to  tlic  lung«  may  origtnstr  in  tbt 
plenra  or  oKiliikitliiiijii),  forming  one  or  more  tumors  of  gre»lrr  or 
lew  ttize,  displacing  snil  comproMing  tlic  pulmoDsrj  orgMic,  tht 
trnclica  and  bronchi,  tbi'  bcxrt  und  it«  large  Te«SfU,  tbe  oe^ophagM, 
tborncic  duct,  und  nerrc«,  and  giving  rise  to  sjrmptoms  and  ^jpa 
which  distinguish  it  from  a  cancerotu  aScction,  properl/  npniiiig, 
of  the  pulmonarj:  orgitns.  Allliongli  pvrliapo  giricily  more  apptO' 
priatc  to  include  cancvrous  groirtbs  exterior  to  the  longs  in  iLt 
group  of  discuses  affecting  the  pleura,  which  irill  consli(nte  tliit 
subjects  of  the  succeeding  chapter,  it  will  b«  more  convrulent  tai 
useful  to  notice  them  in  the  present  connection  in  order  to  pretcat 
their  diagnostic  trails  in  contrast  with  those  which  belong  to  tit 
same  disease  seated  within  the  pulmonnr;  organs.  And  it  nil 
answer  every  purpose  to  notice  only  cancer  in  the  media«tnins, 
since,  with  certain  quuliGcations  which  will  readily  eugigesi  theo- 
sclves,  the  points  involved  in  the  diagnosis  are  tfae  aame  as  when  tlie 
affection  is  dewlopcd  at  any  other  point  wilbin  the  chest  enterior  to 
the  lungs.  Moreover,  ihe  principles  of  diagnosis  which  relate  lo 
cancer  in  the  mediastinum  will  apply,  with  very  few  modifiealtons, 
to  other  tumors  huring  the  same  seat ;  and,  therefore,  U  will  suffice 
to  consider  the  symptoms  and  signs  belonging  to  the  former,  as  rep- 
resenting intra-thoracic  tumors  generally,  notidng  certain  points 
which  are  distinctive  of  canccrons  disease. 

A  fact  already  stated  is  to  be  borne  to  mind,  nz.,  that  cancer 
exisla  exterior  to,  and  at  the  same  time  within  the  langa,  in  a  ecrtaia 
proportion  of  cases. 

A  cancerous  growth  originating  m  the  mediastinum,  in  pnipor- 
tioD  to  its  magnilnde  and  the  direction  laterally  nhidi  it  takes,  ex- 
tends into  one  or  both  sides  of  the  chest.  It  has  been  oftenrr  ob- 
served to  extend  into  the  right  than  into  the  left  side.  In  some 
cases  it  attains  to  snch  size  aa  to  fill  nearly  the  i-ntlrc  thoracic  span 
on  one  side,  and  nlso  a  eonsiderahle  portion  of  that  on  the  oppostc 
side.     An  example  of  this  kind  was  reported  by  the  late  Prof.  Swett,* 

■  I>lMMOTorihaClMat,pi*g»89& 


CANCBR    IS    THE    MEDIISTINCM. 


4&S 


tha  tumor  weighing  eleren  and  »  half  pounds.     The  tumor  may 
Lext«nd  in  eilher  lateral  t)iri(<:lion  about  ecjually,  compreftaing  both 
lungfl  alike,  niid  giving  rise  to  similar  physical  phenomena  on  both 
■ides  of  the  chcni. 


J^Agtietil  Sign». — Diminution  or  abolition  ofvesiciilar  resonance  on 
sion  extends  from  the  median  line  on  one  or  both  tiido»  over  an 


I  tact  with. 


1  close  1 


fcnyn  within  which  the  tumor  is  either  in  contact  with,  or  in  i 
irotty  to,  the  thoracic  pariote».  The  vi'»ieiilar  resonance,  especially 
at  the  Kiiimnit  of  the  chest  in  front  and  behin<1,  near  the  mediiin  line, 
niBj-  be  replaced  by  a  tympanitic  douud  traii«mitlcd  from  the  tmehca 
and  bronchi.  A  tympanitic  sound  may  niso  bo  found  over  the  middle 
and  lower  parts  of  the  chest,  and  the  nrapboriu  ranety  is  sometimes 
observed ;  the  sources  of  the  latter  niuy  be  the  stomach  or  intcs- 

I tines.  A  marked  degree  of  tympanitic  sound  in  cither  situation 
is  an  exceptional  phenomenon.  As  a  rule,  percussion  over  the 
tumor  elicits  duloess  or  flatness;  nnd  this  dulness  or  flntne»s  being 
dependent  on  the  presence  of  a  solid  mass  which  is  at  least  ntlacbcd 
to  the  point  whence  it  springs,  the  area  over  which  it  extends  re- 
mains nnaltered  or  nearly  so,  in  diflerent  positions  assumed  by  the 
patient.  If  the  tumor  extend,  so  as  to  come  into  contact  with 
the  heart  or  liver,  the  relative  positions  of  the  latter  to  the  tumor 
may  fre(iuently  be  niiccrlained  by  an  alteration  in  the  percut^ion- 
sound.  The  »ense  of  restHtance  felt  by  the  Hnger  employnl  in 
percussing,  or  in  pressure  made  with  reference  to  this  point,  is  nota- 
bly increased. 

AuKCultfttion  may  discover,  strongly  marked,  the  characters  of 

»  bronchial  respiration  at  the  summit  uf  the  cbe^l,  in  front  and  behind, 
extending  more  or  less  over  the  chest;  or  these  characters  may  be 
feebly  manifested;  or,  more  frequently,  the  respiratory  sound 
is  abolished  oVer  a  greater  or  less  portion  of  the  space  in  which 
percussion-dulness  or  flatness  is  observed.  These  variations  de- 
pend on  the  relations  of  the  tumor  to  the  trachea  and  bronchi,  and 
on  the  amount  of  compression  which  may  bo  made  on  these  portions 
of  the  air-paseagcs.  The  bronchial  respiration,  when  prcHent,  may 
be  beard  either  over  the  compressed  lung  at  the  sammit,  or  over  tlic 
tumor,  or  in  both  situations.  Its  limitations,  therefore,  as  well 
aa  those  of  suppressed  respiratory  sound,  do  not  always  corre- 
spond  to  the  space  occupied  by  the  tumor.  Adventitious  souuds, 
or  rates,  arc  present  as  contingent  phenomena,  due  to  coexisting 


4dS 


DISKA9S5    OP    THR    BESPIBATORT    OBOAXS. 


bronchilu,  or,  if  ft  cnncerotu  deponit  within  the  )ung»  bsvc  taken 
plicc,  to  il«  ^ofu-ning  and  elimination.  Tlic  soundd  of  the  Itcirt  m 
imdaly  transmittvil. 

The  rocnl  signs  ari'  vitriftblc.  Tticrc  mny  be  tnnrkcd  tncrcue  of 
thv  Tocnl  resonance  and  broiicliofihony,  or  these  phi^noracna  tnsjbe 
vanting.     Even  pectoriloquy,-  may  be  present. 

Frcsfurc  of  the.  tumor  on  the  aorta  may  occasion  an  arterial  thttQ 
ftnd  bt'llovrs  murniur. 

In?ipcction  and  piilpation  funuHh  importftnt  signs.  Dilstatwn  of 
the  chest  distingaishcs  cancerous  growths  developed  exterior  to  thi 
longs,  after  they  have  attained  a  certain  sixc.  The  dilatntton  i»  eithct 
partial,  or  extends  over  the  whole  of  one  side,  or  nITecta  both  sidcf^ 
according  to  the  size  and  direction  of  the  morbid  growth.  It  mtj 
be  confined  to  the  steninin  and  'costnl  C4irlilagrs  ;  hat,  as  the  rc«ist- 
anoe  is  lc»*  in  a  lateral  direction,  the  tumor  gcncrallj  exiendf  inb) 
the  ohest,  instead  of  producing  a  circumscribed  enlargement  in  tW 
sitimlioiis  jiift  inciiitoned.  The  intercostal  space-s  arc  widened,  ud 
in  some  ca«ca  are  dilated  or  even  bulging,  and  remain  unuffectcd  bj 
the  act  of  inspiration.'  The  heart  may  be  removed  in  variou 
directions  from  its  normal  position ;  in  the  case  already  referred 
to,  reported  by  Swett,  it  was  found  to  the  right  of  the  stemtiB, 
where  its  pulMtttons  had  been  observed  during  life.  If  the  tumor 
extend  to  the  base  of  the  chest,  the  diaphragm  and  the  mibjaorot 
riscero  may  be  depressed.  The  superficial  thoracic  veins  of  tht 
affected  side  may  be  enlarged,  giving  rise  to  a  livid  hue  ud 
(edematous  infiltration.  Fluctuation  is  very  rarely  observed,  bnl 
this  woB  present  in  the  case  reported  by  Svett.  The  voc«l  frcmitnt 
over  the  tumor  is  abolished.  In  proportion  u  the  cheist  is  dilated, 
it«  contraction  with  the  act  of  expiration  U  restrained,  and  tlit 
range  of  expansive  movement  is  correspondingly  lessened. 

Mensuration  shows  an  increase  of  the  size  of  the  cheat,  no  ab- 
normal disparity  in  this  respect  existing  between  the  two  side*  if 
the  dilatation  be  confined  to  one  side,  or  if  the  two  sides  are  uc- 
equally  dilated.  This  disparity  is  ascertained  by  semicircular  mea«> 
nrements,  by  a  comparison  of  the  antero-posterior  diameient,  and 
by  measuring  the  distance  from  the  nipple  to  the  median  line. 

IHaffnotia. — The  compression  and  displacement  of  the  polmonarj 


*  Vidt  COM  reported  bv  Prof.  Sw«tt  (op.  cit.,  p.  SSI},  in  wbicb  bulging  vat  ob- 
MrT«d. 


FtroM. 


497 


[organs,  air-tubes,  vessels,  oeeopbagus,  etc.,  by  a  mediastinal  tumor, 
[give  rise  to  a  rariotv  of  symptoms,  as  veil  aa  sigD&,  whicli  aremeas- 
'urablj  distinctive  when  contrasted  with  cancer  of  the  lungs.     In 
proportion  to  the  extent  to  which  the  lungs,  air-passages,  pulmonary 
artery,  and  reins  are  compressed,  dyspnoea  becomes  a  prominent 
[symptom.     The  suffering  from  want  of  breath,  as  the  tumor  in- 
I  creases  in  size,  may  be  extreme,  rendering  the  recumbent  posture 
insupporlable.     Pressure  on  the  Tenous  trunks  communicating  with 
the  Tcins  of  the  head  and  upper  extremity  induces  congestion  of 
•tbese   parts,   and   consequent   tumefaction,   lividity,  and   oedema. 
When  the  pressure  is  chiefly  on  the  vessels  of  one  side,  the  disten- 
sion of  the  veins,  together  with  the  tumefaction,  lividily  and  oedema, 
is  limited  to  that  aide.     Heaviness  and  somnolency  are  effects  of 
cerebral  engorgement.     Pressure  on  the  oesophagus  may  occasion  an 
obstruction  to  the  passage  of  alimentary  substances,  and  hence  re- 
sults dysphagia  which  is  more  likely  to  be  prominent  as  a  symptom 
;  than  in  cancer  seated  in  the  lungs. 

Diminishing  the  calibre  of  the  nrtcria  innominata  or  the  sub> 
clavian  on  one  side,  the  radial  pulse  of  the  extremity  corresponding 
to  that  side  may  be  perceptibly  Icsa  iu  sIec  and  force  than  that  of 
the  opposite  extremity. 

If  the  important  nerves,  the  par  vagum,  recurrent,  or  the  phrenic, 
he  included  in  the  purtM  compressed,  here  is  another  source  of  dis- 
turbance of  the  Tospinition.  nffccling  the  diaphragmatic  action,  and 
tbo  respiratory  movements  of  the  glottis.  Ilydroiborax,  or  pleuritic, 
leading  sometimes  to  the  formation  of  pus  {empyema),  are  contingent 
aBTections  giving  rise  to  signs  which  denote  liquid  within  the  pleural 
Cftvity.  Pain  in  the  chest  is  more  or  less  persisting  and  severe ; 
cough,  hremoptysis,  and  the  jelly-like  expectoration  referred  to  in 
connection  with  cancer  of  the  lungs,  may  occur  in  the  course  of 
this  affection ;  and  toward  the  close  of  life  anasarca  is  asuslly 
present.  Perforation  of  the  thoracic  walls,  liitig,  cesopliagua,  or 
some  of  the  large  vessels,  is  liable  to  occur,  giving  rise  to  addi> 
tionni  (rains  of  nymptoms,  or  proving  the  immediate  cause  of  a  fatal 
termination. 

Numerous,  diversified,  and  grave  as  are  the  results  just  enume- 
nt<d,  Walshe  states  that  he  bns  seen  them  united  iu  one  and  the 
BUUe  individual. 

DilTerentially,  the  diagnosis  of  mediftsttnal  cancer  involvcfl,  in  the 
first  place,  a  discrimination  from  cancerous  infiltration  of  the  lungs, 

32 


498 


diss; 


)r   TUB    RESPIRAl 


OHSAKB. 


and  th«  wvoral  aflcctions  with  wliicb  the  Utter  ia  liable  to  be  oon- 
founded.  The  HUtinctive  circnmBtances  are  those  which  Imve  rela- 
tion to  (liUtittion  of  the  chest,  and  the  pressure  of  tlio  tumor  on  the 
vesseK  nir-pn»Mges,  nerves,  o-ntophngiis,  heart,  etc.  The  ptienoinena 
due  to  ciilargenentfdiaplacemont,  and  coniprettsion,  arc  rnrcl;r  pres- 
ent, and  never  to  the  eaine  extent,  in  cancer  seatod  in  the  lunirit,  in 
ohronio  pneamoiiitis,  in  tuberculonis  or  in  plenritis  nflor  partial  ab- 
sorption. These  phenomena,  consliluting  a  lar;;e  »hiire  of  the  li«t 
of  Hymptoms  and  signs  jnst  given,  are  cliaractenstic  of  intra-thoractc 
tDinor  exterior  to  the  lungs.  Aforeover,  from  pneumoDitts,  tnlier- 
oulosiH,  ami  chronic  pleuritis,  a  cancorous  tnmor  in  the  mcdiai>tinam 
majr  often  be  diKtinguishcd  bj  (he  occurrence,  in  the  course  of  tho 
disease,  of  certain  of  the  sjioptoms  which  arc  observed  in  a  cancer- 
ous alTection  of  the  lungs,  viz.,  hstmopt^sts,  and  Ihc  curraDt-joIl 
expectoration ;  and  in  this  connection  tho  fact  mnjr  be  again  sUtod 
that  mediastinal  cancer  frequontljr  coexists  with  a  caDflorons 
tJon  of  the  lungs. 

In  the  second  place,  roediaatinal  tumor  is  to  be  d  incriminated  from 
enlargement  of  the  heart,  pericarditis  vriih  large  effusion.  su<l  aortio 
anonrism.  Many  of  the  pbenomeQa  incident  to  lh«  dilatin^r,  com- 
preosin)!,  and  diNplai-ing  elfect.t  of  a  mediastinal  tumor,  which  havo 
boon  enumerate*!,  are  common  to  the  affections  just  named.  Tho 
differential  diagnosis  turns  on  the  presence  or  the  abacnoo  of  th* 
aymptomM  and  signs  distinctive  of  these  affeclions ;  in  other  wor 
in  arriving  at  tlie  conclusion  that  the  phenomena  proceed  frvm 
mediastinal  tumor,  and  not  from  either  of  these  aBbctions,  the  lattor 
are  to  be  excluded.  To  consider  the  negative  points  vrarrunting 
their  exclusion,  would  involve  a  consideration  of  their  positive  diag- 
nostic criteria ;  for  these,  tho  reader  must  be  referred  to  works  wbidk 
treat  of  the  discaaes  of  the  heart  and  arteries. 

In  the  third  place,  the  affections  for  which  there  ia  tiko  tnoit  lia- 
bility- o£  mediastinal  tumor  being  mistaken  are  chronic  plcnritia 
prior  to  retraction  of  the  chest,  and  empyema-  llcrc  w«  have  com- 
bined the  phenomena  due  to  dilatation,  displacement,  and  mora 
or  le«s  compression.  Moreover,  the  fact  is  not  to  be  lost  sight  of, 
that  liquid  effusion  within  the  pleural  sac,  either  purulent  or 
rous,  may  exist  as  a  complication  of  either  mcliaatinal  cancer,  or  : 
cancerous  afl'ection  of  the  lungs.  This  complication  renders  llio 
diagnosia  lesa  intricate  than  might  at  first  be  sappoaed.  The  phe- 
nomena due  to  compression,  via.,  dyapnoea,  tumefiactioD  of  face,  liv- 


tlASTII 


499 


I 


I 


idit;,  swelling  of  the  veins,  dysphagia,  are  not  present  to  the  eame 
extent  in  chronic  pleurltis,  or  empyema,  even  when  the  chest  ia 
largely  dilated,  Iii  a  case  of  mediastinal  tumor  involving  a  con- 
sidei-able  amount  of  dilatation  of  the  cheat,  the  effects  of  pressnre 
on  large  vessels,  the  trachea,  ccsophagus,  and  nerves,  may  be  ex- 
pected to  be  in  a  marked  degree  greater  than  irhen  an  ec]ual  amount 
of  dilatation  is  caused  by  pleuritic  effusion  alone.  This  is  a  capital 
point  of  distinction.  Moreover,  the  distinctive  feature  of  cancer 
pertaining  to  the  expectoration,  viz.,  the  character  Li  tic  jelly-like  ap- 
pearance,  does  not  occur  in  chronic  pleuritis,  nor  in  cmpyenia.  Hence, 
if  this  symptom  be  present,  it  is  diagnostic  of  a  cancerous  affection ; 
and  the  coexistence  of  cancer  in  some  part  where  the  fact  can  be 
ascertained  by  examination,  here,  as  in  other  instances,  is  highly 
lificant.    Physical  exploration  furnishes  certain  diatlnctirc  points. 

e  bronchial  reepiration  and  bronchophony  are  marked  in  cases 
of  chronic  pleuritia  with  large  effusion,  or  of  empyema,  as  exceptions 
to  a  rule ;  whereas,  although  not  uniformly  observed  in  connection 
with  cancer  in  the  mediastinum,  they  are  more  frequently  present, 
and  not  infrequently  strongly  marked.  The  dilatation  of  the  chest 
from  the  distension  of  liquid  is  more  uniform  than  from  an  intra- 
thoracic  tumor.  The  inUrrcostal  deprc»s)ons  are  more  eoiifttaiiLly 
and  ill  a  more  marked  degree  affected  by  distension  from  liijuid. 
It  is  rare  that  bulging  between  the  ribs  occurs  from  the  distension 
of  a  tumor,  whereas,  it  is  the  iisiiiil  effect  of  great  eiilnrgeinent 
from  the  presence  of  liquid.  A  sense  of  fluctuation  is  nn  excep- 
tional sign  in  the  former  case,  and  oocura  more  frequently  in  the 
latter.'  Finally,  it  is  extremely  rare  in  cases  of  chronic  pleuritis 
with  large  effusion,  or  in  empyema,  to  6nd  vesicular  resonance  on 
percussion,  denoting  the  presence  of  pulmonary  substance  below 
the  level  af  the  liquid.  In  cases  of  mediastinal  tumor,  on  the  ether 
hand,  it  will  frequently,  and  perhaps  generally,  he  found  that  the 
physical  evidence  of  lung  containing  air  in  the  air-cells  is  obtained 
in  parts  of  the  cheat  in  which,  if  the  morbid  phenomena  were  due  to 
liqnid  effusion,  the  gravitation  of  the  Suid  would  be  almost  sure  to 
abolish  both  percussion -resonance  and  respiratory  sound. 

The  data  upon  which  a  probable  opinion  that  a  mediastinal  or 

*  Bolging  Bcd  flu(iluslli>a  are  »MWA  not  to  uooar  In  dlUtatlnii  from  the  ]in«(<n<:a 
of  %D  intiD-thomcic  tumor,  but  \n>l)i  wvru  ulnvrTod  ia  •  cane  uf  canovr  in  tlie  me- 
diwilliiuai,  itlrc«^;  rfforrivl  to,  rt^portnd  b;  Swott,  In  which  a  UlQtng  quiintity  of 
U<|ui<l  only  eaUtud  within  tbv  pleural  im. 


IBABE8  OF  THE  BESPIBATOKY   OBGASB. 


ler  intra-thoracic  tamor  is  of  a  cancerous  natiir«,  are  tbe  follow- 
g:  Hsemoptjsis,  and  a  characteristic  jelly-like  expectoration; 
possibly  llie  presence  of  cancerous  matter,  detertoined  microsco- 
pically, in  the  spnta, — tbese  phenomena,  probably  in  the  majority 
of  cases,  iudicating  a  coexisting  deposit  of  cancer  trithin  the  loop; 
the  existence  of  a  cancerous  affection  in  other  parts  of  the  body,  is 
which  the  fact  of  ita  existence  may  be  positively  ascertained. 


CHAPTER    VII. 

ACCTK  PLECBITIfi-CHROinC  PLEURITIS-EMPYBMA— HTDBO. 
TUORAX-rSKmoTUORAX-l'KEUMO-UYDROTHORAS— PLBO- 
KALGIA— DIAPHRAGMATIC  HEltNIA. 

Tub  group  of  diseases  to  which  this  chapter  is  devoted  consists  of 
afTeelion^  which  arc  cither  seated  in  the  pleura,  or,  as  regnrd#  their 
seat  and  sjuiptomntic  phcnouienu,  nre  relnteil  mure  eloKcly  tp  tbis 
than  to  any  other  of  the  structures  entering  into  the  piiluionftr^  or- 
gans. Tliej  form  ao  interesting  and  important  class  of  the  diseases 
of  the  respiratory  system.  As  regards  their  dingno^is,  it  vill  be 
round  that,  without  the  aid  derived  from  physical  exploration,  they 
arc  frequently  delected  with  great  difficulty,  and,  indeed,  in  many 
instances  caonot  be  distinguished  either  from  each  other,  or  from 
certain  of  the  diseast^H  treated  of  in  the  preceding  chapters.  On  the 
other  hand,  by  means  of  physical  signs  in  conjunction  with  sytnptome, 
the  discrimination  i$  in  general  made  with  facility  and  po^^itiveucM. 
I  shall  consider  these  alTections,  respectively,  in  the  order  in  which 
they  are  enumerated  in  the  heading  of  tbis  chapter. 


ACOTB  pLEtlRlTIS. 

In  point  of  frequency  thii^  affection  ranks  third  in  the  list  of  acute 
pulmonary  diseiiitcs,  hroncbilin  and  pneumonitis  taking  precedence 
in  thi«  regard.  It  occurs  either  as  an  independent  or  a  concomitant 
pulmonary  affection.  When  developed  as  a  complication  of  soid« 
other  disease  of  the  lungs,  for  example,  tuberculosis  or  pneumonitis, 
the  inSammation  is  usually  limited  to  a  portion  of  the  pleural  sur- 
face: that  is,  the  picuritis  is  circumscribed.  Its  occurreoce  in 
connection  with  the  diseases  jii.'tt  tiatned  has  been  noticed  in  the 
chapters  deroted  to  tbeir  coDsidcratioD.    ^Vheu  not  thus  consecativo, 


SOS 


DISEASES  OF  THE  HEEPIKATORT    ORGAXR. 


the  influn motion  U  ustmlt j general,  i.  e.  it  cxttnda more  or  1e» ors 
the  entire  pleural  membrane  on  one  side.  To  this  rale,  faovtro', 
there  are  exceptions;  the  iDflammstion  is  somettmrs  limited,  eoih 
stitoting  partial  pleuriaiea  which  are  c«llc<l,  according  to  the  par- 
tions  affected,  costal,  pulmonary,  diaphrngmstic,  mediafltiBal,  aal 
inter-lobar.  Again,  the  pleuritic  inflnmmstion  majr  b«  conSixd.li 
one  flide,  or  it  may  afl'ect  both  ndes.  In  the  rormcr  esse  it  is  tngk, 
and  in  the  latter  douMe  pleuritis.  In  treating  of  the  phjsical  apa 
and  diagnosis  of  the  disease,  reference  will  lie  had,  in  the  6r«t  places 
to  acute  general  pleoritia.  Partial  pleurisies  vill  be  brieflj  notioei 
■after  treating  of  chronic  pleuritic. 

Acute  general  pleuritis  is  divided  hj  some  writers  into  Bennl 
stages.  For  clinical  conrenience,  and  with  especial  reference  to 
phjacal  signs,  it  suffices  to'  recognise  three  different  petiods  is  tk 
progress  of  the  disease.  1st.  The  period  from  the  conuneBoeiMOt 
of  the  inflammation  to  tlie  accumulation  of  an  appreciable  qnantitj 
of  liquid  effusion  within  the  pleural  sac.  This  period  will  comprise 
the  dry  anil  the  ptiuttic  stage  of  some  writers.  2<I.  The  period 
during  which  the  liquid  is  either  sccaioulatiog  or  remains  stationafj. 
This  period  may  bo  culled  iho  Itage  of  effusion  or  of  liquid  accu- 
mulation. 3d.  The  period  when  the  liquid  effusion  is  being  re- 
moved by  absorption.  Perforation  of  the  thoracic  walls,  or  of  the 
lung,  by  which  the  effused  liquid  is  evacuated,  in  the  one  cate 
directly,  and  in  the  other  case  indirectly  through  the  bronchial 
tubes,  is  of  rare  ocourrence,  and  does  not,  therefore,  belong  to  th« 
natural  history  of  the  disease,  as  deduced  from  the  phenomena  oo> 
curring  in  the  large  majority  of  cases. 

The  physical  conditions,  pertaining  to  the  morbid  anatomy,  whiei 
are  represented  by  signs  in  these  tbree  periods,  are  the  following: 
^V«(.  The  presence  of  coagulable  lymph,  either  in  patcbea  rarying 
in  eise  and  more  or  less  nnmeroos;,  or  diffused  over  the  whole  of 
the  inner  surface  of  the  pleural  sac  It  has  been  hypothetically 
assumed  that,  prior  to  the  exudation  of  lymph,  there  is  an  abnoraal 
dryness  of  the  membrane,  which  may  give  rise  to  acoustic  phenoo* 
ena.  jSecotiii.  The  presence  of  liquid,  which  speedily  grBTitatc*  to 
the  bottom  of  the  sac,  comprcfsing  the  lung  and  displacing  it  in  a 
direction  upward  and  backward,  except  it  have  become  fixed  al 
oartai&  points  by  prerions  morbid  adhesions.  The  accumulation 
of  liquid  in  some  cases  is  in  suffiment  quantity  to  expel  by  oompre^ 
•ion  the  air  from  the  lung,  reducing  it  to  a  small  condensed  naas 


ACDTE    PLBURITI0. 


603 


(carnificatioo);  in  some  cases  enlarging  the  size  of  the  ch«t,  do- 
pressing  the  diaphrogm  and  subjacent  organs,  displacing  the  heart, 
and  producing  various  alterations  in  the  relations  of  the  thorucie 
^tparieies.  Third.  The  diminution  and  ultimate  disappearance  of  the 
^"effused  liquid,  accompanied  by  an  expansion  of  the  compressed  lung 
I  which  ma;,  or  may  not,  regain  its  former  volume;  in  the  lattrr 
^Kcue,  contraction  of  the  chest  follows,  with  sometimes  pcriuanent 
^^alterations  in  form,  and,  as  regards  the  relations  of  pnrt.-t,  changes 
the  reverse  of  those  which  have  occurred  at  a  former  stJigc.  The 
H  pleural  surfaces,  in  proportion  as  the  liqnid  effusion  dlminishciS 
H  again  come  into  contact,  roughened  by  a  fibrinous  conting  more  or 
Blws  dense  and  irregular  in  its  distribution.  Finally,  there  is  ad- 
H  liesion  of  the  pleural  surfaces  by  means  of  newly-formed  tissue. 

The  foregoing  list  of  the  physical  conditions  belonging  to  the 
different  stages  of  the  disease  will  apply  equally  to  acute  and  chronic 
pleuritis ;  tlic  cfi'ccts  of  an  abundant  accumulation  of  liquid  on  the 
vails  of  the  chest  nnd  the  intro-tboracic  organs,  arc  generally  much 
more  marked  in  the  latter  variety  of  tho  disoajio. 


I 


Phytical  Siff7t». — As  remarked  by  Valleix,  the  phenomena  be- 
longing to  the  natural  history  of  pleuritio,  notwithotanding  the  fre- 
quency of  the  disease,  have  not  been  studied,  by  means  of  the 
analysis  of  clinioal  records,  to  the  same  extent  as  those  of  some 
other  pulmonary  affections,  more  especially  pnenmotiitis  and  tuhcr- 
Cutuxis.'  Nvvcrthelt-M,  lis  diagnostic  traits,  derived  both  from  I'igns 
and  symptoms,  are  well  OKCcrtained.  With  retppect  to-the  results  of 
physical  exploration,  some  interesting  facts  have  been  contributed 
within  laic  years. 

Proceeding  to  present  the  phenomena  of  the  different  stages  of 
tltis  affection,  as  furnished  by  the  several  methods  of  exploration, 
ia  the  order  in  which  the  latter  were  taken  up  in  the  first  part  of 
this  work,  the  signs  obtained  by  percussion  are  to  be  first  noticed. 
Prior  to  the  accumulation  of  liquid  in  sufScient  quantity  to  gravi- 
tate to  the  bottom  of  the  chest  and  occupy  a  certain  amount  of 
space  to  the  exclusion  of  the  lung,  the  resonance  on  percussion 
bay  not  be  in  a  marked  degree  altered.     There  is  usually  moder- 


■  Tliii  (lUiingutshiMl  clintcnl  ubserm'  nnd  autlioT,  at  the  liroo  of  tiLi  4i>alh  wM 
liapMpnriiiff  a  (lopor  on  the  rotulti  or  pcrcuuioa  in  pleuriijr.    (JrcAimt 
fitMidMint.) 


so* 


DIEBAEXS    or   TVS    KISriftATOBT    OBOaXS. 


st«  or  iliglit  dhninatjoo  of  nsounoe,  attrilntablc  to  mtctsI  cutas, 
ns^  \tt*catd  eipsnsion  of  the  IsBg  on  leeoaat  of  th«  pua  itteal- 
ing  the  inspiniorj  act;  the  exwUtioa  <tf  Ijrnph  on  the  pleai) 
Borbccs,  wid,  poesSiljr,  u  eoeieadefl  by  WoiUex  mod  Iliru,  tW 
pnaeoce,  during  this  BUge,  of  «  thin  etrstiun  of  liquid  difutd 
ever  the  lung.  Tlie  tatt«r,  which  >9  called  laminar,  in  dutiBcn* 
from  ffraritatiny  eSiuion,  ia  qD«stionabl»;  and  that  the  lesMM4 
expansion  of  the  lung  a  the  chief  cause  of  the  slight  dMlacai, 
nay  be  shown  bj  ibc  fact  that  a  deep  ittspiratioo  (if  the  pttini 
wit)  disregard  the  pain  which  instinctivdj  leads  him  to  repn* 
the  moveiB4:nts  of  the  affrctrd  slilc),  gotoetime*  reMerc*  the  normtl 
retonaocc.  The  diminution  of  resonance  extrads  orer  tli«wbeW«r 
the  greater  part  of  the  affected  siilc.  During  this  stage  espcctsDj, 
and  frequenllj  during  the  vubscqaent  stagvc,  percussioB,  uilm 
lightly  performed,  u  painful,  owing  to  the  soreness  of  tht  ebe«t. 

The  effoHton  of  a  quantity  of  liquid  sufficient  to  dii^laee  sad 
rievate  tbv  lung  to  a  greater  or  li-fs  extent,  gcnrrmllj  take*  placi 
with  sucli  rnpi<lity  that  in  a  large  proportton  of  cb»c!  the  opportuaitj 
of  examining  the  chest  during  the  first  period  of  the  disease  is  Wt 
ofTi-red.  It  very  rarely  happens  that  hofptta)  pntients  come  vndtr 
obticrration  before  the  disease  has  adranced  to  the  second  period. 
The  stage  of  liquid  sccumnUrion  may  superreDe  eveii  in  a  few  hows 
after  the  date  of  the  attacit,  and  it  is  seldom  delayed  tieyuuil  ibt 
third  or  fourth  day. 

When  tbe  liquid  aceamslates  at  the  bottom  of  the  pleural  mc, 
elevating  the  lung,  the  percussion-resonance  is  abolbbed  from  the 
base  of  the  chest  upward  over  a  space  corresponding  to  the  amuiial 
of  effusion ;  there  is  Balnesa  on  pereuseiion  if  a  gastric  or  intestiaat  _ 
tympanitic  sound  be  not  transmitted  from  below,  and,  under  'M^^l 
circumstances,  tbe  Utter  rarely  occurs  in  a  isarked  degree.     Ah^^ 
lilion  of  vesicular  resonance  is  invariable,  and  ftatoess  is  the  rakk 
Tbe  elasticity  of  the  thoracic  vails  ia  notably  dimiDished.  and  the 
senxe  of  resistance  iBcreued  below  tbe  line  indicating  the  uppCT 
boundiiry  of  the  Satness. 

If  the  quantity  of  effusion  be  small,  atthoogfa  sufficient  to  ele- 
vate the  lung  to  some  extent,  the  evidence  of  its  presence  afforded 
by  percussion  while  the  patient  is  in  one  position  only,  may  be 
iueomplete,  owing  to  the  normal  line  of  flatness  being  variable  in 
different  peroons,  aod  on  the  led  «ide  in  the  nme  person  at  different 
periods.     The  results  of  percussion  io  differeot  positions  will  often, 


AOVTB   PtBUniTIS. 


£05 


^ 


if  not  gtnorftllj",  in  fiocli  a  cnse,  establish  the  presence  of  liquid. 
Having  Bsccrtaincd  snd  innrkpd  the  point  at  vliicli  the  reso- 
nance is  lost  on  tW  posterior  eiirfnco  of  the  chest  while  the  pa- 
"tieDt  }6  \a  n  sitting  poHturv,  let  liim  ihirii  V\c  upon  hi*  fitoe;  wait- 
ing »  moment  for  the  liquid  to  gravitate  to  th«  anterior  portion  of 
ihi'  ttac,  pcrcui>»ion  inaj  now  elicit  resonance  below  the  line  in- 
dicating its  lower  boundary  when  the  body  wait  id  a  vertical  po- 
sition. It  is  seldom  that  the  quantity  of  liquid  is  so  smal)  aa  to 
leave  room  for  doubt  whether  the  situation  of  the  line  of  Hutness  be 
sbnornud. 

Extending  upward  from  the  ba«o  orer  a  third,  a  half,  or  two- 
thirds  of  the  chest  on  the  nlToclcd  side,  the  line  of  flatness,  de- 
fined without  difficulty  by  peroiiMivn,  marks  the  level  of  the  liquid. 
Thia  line,  as  a  rule,  over  the  anterior  ami  latcntl  aspect  jof  the 
chest,  is  horizontal,  the  patient  silting.  Hxcepti»n»  to  this  rule 
exist  when  ■  portion  of  the  lung  ia  fixed  below  the  level  of  the  liquid 
by  previous  morbid  adhesions.  For  example,  in  a  ease  recently 
under  observation,  in  which  the  evidence  of  liquid  in  the  left  pleural 
cavity  was  unequivocal,  the  lino  of  flalnciss  extended  hurizontallf 
through  the  nipple,  laterally  iind  poeitenorly,  U>  wilbin  two  or  three 
inches  of  the  spinal  column.  Prom  this  point  percussion  elicited 
a  vesicular  resonance  for  several  inches  below  a  continuation  of  the 
horinontsl  line,  showing  that,  at  its  inferior  posterior  extremity,  the 
lung  wa.<t  held  down  by  an  attachment  which  was  sufficient  to  resist 
the  upward  pressure  of  the  liquid. 

Variation  in  the  line  of  flatness  with  different  positions  of  the 
,W^enti  in  a  proportion  of  cases  larger  than  is  to  be  inferred  frum 
tht  opinions  expressed  by  most  writers,  is  available  as  a  teal  that 
the  flatneas  is  due  to  the  presence  of  liquid,  provided  the  cheat  be 
but  partially  filled  with  the  effusion.  It  is  not  available  when  the 
pleural  surfaces  are  adherent  above  the  level  of  the  flnid,  nor 
vheD  Uic  liquid  is  sufficient  to  compreEs  the  lung  into  a  BoUd 
DIMS.  In  the  case  just  referred  to,  in  which  the  inferior  posterior 
extremity  of  the  lung  was  fixed  at  the  base  of  the  chest,  the  evidence 
of  the  presence  of  li(iuid  was  afforded  by  percussion  over  the  sub* 
merged  portion  of  the  lower  lobe.  When  the  patient  inclined  far 
forward,  or  lay  u^ton  lite  face,  the  resonance  became  notably 
greater  than  when  the  position  of  the  body  was  vertical,  showing 
that  the  portion  of  lung  was  not  united  to  the  thoracic  wall  by 
close,  uniform  adhesions,  bat  by  bridles  or  bands  of  false  membrane. 


506 


DI3BASKS  OF  TDK    RKSPIRATORT  OHQAJIS. 


TIic  direction  nbich  the  line  of  HatncM  »  Tound  to  pame  vhcn 
the  patient  is  silting  or  HtnniliDg,  Kcrvce  to  dietiDguiith  k  graritating 
effiuion  fmm  the  soliOilivattDn  of  the  lower  lob«  in  lobar  pneatBO> 
nitit).  In  the  Inttcr  case,  m  stittctl  in  the  chapter  on  pncumoniliii, 
proTidd  the  intlnmmRtorj  exuihilion  be  limited  to  s  lobe,  and  extend 
OTor  the  whole  lnW,  tlio  situstion  of  the  interlobnr  fiMarc,  crowing 
ihe  chcHt  oblic[uelj'  from  the  fourth  or  fifth  cnrtilagca  to  the  spinul 
extrvinity  of  the  spinous  ridge  of  the  seapula,  ibbj  be  delimited  by 
»n  abrupt  chung«  iu  the  percuf(Hioii-«onnd ;  iind  tbio  Itoo  i«  found 
not  to  vary  willi  the  different  positions  of  the  patient.  It  could 
onlj  bo  bjr.a  coincidence  not  fitllinf;  within  the  nngo  of  prubn- 
bilitiTi  that  A  collection  of  li<(ui<l  «houM  hiippcn  to  be  confini-d  bj 
pleuritic  adhesions  witliin  a  space  bounded  exactly  b;  the  interlobar 
Gsflur*. 

The  toss  of  olnslioitjr  and  sense  of  resistance  on  pereauion  art 
greater  in  proportion  aa  the  effusion  is  abundant,  being  stroDgl/ 
marked  when  the  qimntilj  is  aulTtcicnl  to  produce  coiuidembloim- 
largement  of  the  chest. 

The  loMH  of  resonance  is  usually  more  complete  below  the  level  of 
a  considiTiible  fjiiiiniity  of  li<iuid,  than  over  lung  solidificil  hy  in- 
flitmmator;  or  other  vxudation.  In  the  former  case  therv  is  6at- 
n«<s;  in  the  latter,  more  or  less  dnlnese,  the  prcseneo  of  air 
within  the  bronchtnl  tubes  and  some  of  the  celhi  yielding  a  cer^ 
tain  amount  of  resonance,  which,  under  these  circnmstances,  is  not 
vesicular  but  tympanitic  in  qnality.  Perfect  flatness,  therefor^ 
•Ithough  not  concluKiTe  eridence  of  the  presence  of  liquid,  for  it 
may  be  caused  by  an  intra-tlioracic  tumor,  and  occasionally  by 
eonaolidatioo  of  lung,  warrants  a  strong  presumption  that  elfusioa 
exists ;  and  this  presumption  t8  rendered  still  stronger  bj  the  flat- 
ness being  found  to  extend  from  the  base  of  the  chest  upward,  the 
line  indicating  its  upper  limits  being  well  defined  and  pursuing  a 
direction,  if  the  body  be  in  a  vertical  position,  extending  horizon- 
tally, or  nearly  so,  sround  the  affected  side.' 

In  cases  in  which  the  (quantity  of  liquid  is  large,  distending  tl 
chest  and  compressing  the  lung  into  a  solid  mass,  either  flaiac 


■  It  U  aUt»d  (TralU  da  DiafcuMtlc,  etc.,  psr  l«  Doct«ar  V.  A.  Bacte),  thu 
wlinn  n  ccHain  qiionlitf  of  liquid  U  cotiuiiioil  trllliln  lb«  pleural  »i-,  and  lliit 
pl«iiral  mirfaccf  nro  free  ttom  ndlmions  the  body  b«il>{;  in  a  vcrllnl  ]>>nUlon, 
tho  larcl  u  not  exacilj  borlaonta},  tltu  fluid  rUlttg  »ocu«wlut  higLcr  Iwhind  ttua 
In  ttoal. 


ACOTB 


507 


I 
I 


I 

I 


t 


exists  aniTDTCnily  over  the  affvotcd  «ide,  or,  tt  all  events,  there  is 
complote  loiw  of  vwiculor  rcsonuncc.  The  flatness  may  not  be 
vonfinpii  to  tho  affected  side;  the  Dccumiilnlion.of  liquid,  when 
large,  produces  a  lateral  displacement  of  the  niedia»tinuin,  and  the 
dislcnded  pleural  wic  may  encroach  on  the  opposite  side,  giving  ri»e 
to  dulness  on  percussion,  sumotimvd  extending  from  half  an  inch  to 
•D  inch  beyond  tho  stcntom.  But  when  the  effusion  is  lens  abun- 
dant, the  fluid  rising  to  within  a  third,  a  half,  or  two-t.hirdii  of  the 
distance  from  the  base  to  the  top  of  the  che^t,  pc-rcusaion  over  the 
long,  above  the  level  of  tfao  liquid,  elicits  a  resonance  greater  than 
in  a  corresponding  eituatton  on  the  opposite  side,  and  the  resonance 
is  vesiculo-tympauitic.  This  fact  had  attracted,  iu  occnHional  in- 
stances, the  attention  of  observers,  but  the  freqncncy  of  its  occur- 
rence has  only  of  late  been  ascertained.  The  resonance  above  the 
level  of  the  liquid  is  in  some  cases  so  intense,  and  the  tympanitic 
quality  BO  marked,  as  to  appear  to  denote  air  in  the  pleural  caiity, 
or  pneutno-tborax.  A  probable  explanation  is  the  same  as  when  a 
similar  resonance  exists  over  an  upper  lobe,  the  lower  lubo  of  the 
same  lung  being  solidified  in  pneumonitis,  viz.,  the  permanent  ex- 
pansion of  llio  cbesl  over  the  affected  side  involves  dilatation  of  the 
air-cells  which  receive  air.  Exaggerated  or  vesicnlo-tyoipanilic 
resonance  is  less  marked  or  wanting  after  tlie  chest  has  been  tilled 
with  liquid  on  one  side,  and  absorption  of  more  or  less  of  the  liquid 
has  taken  place.  The  presence  of  lymph  on  the  pleural  surfaces, 
under  thcite  circmnalunccR,  may  cause  more  or  le^  dulncsa  abovo 
the  level  of  the  liquid. 

The  cracked-metal  variety  of  tympanitic  resonance  has  been 
observed  by  Stokes,  Wulshe,  Roger,  and  Bouillaud,  at  the  summit 
of  the  chest  in  cases  of  large  effusion  within  tlic  plenral  eac,  and 
several  examples  have  fallen  under  my  obsenalion. 

During  the  progress  of  the  removal  of  the  liquid  by  absorption, 
the  area  of  rosoiiariee  progressively  increases:,  extending  from 
above  downward  in  proportion  as  the  level  of  tfae  fluid  is  lowered. 
Dulncss,  however,  as  compared  with  the  healthy  side,  below  the 
height  to  which  the  liquid  has  extended,  persists  for  an  indefinite 
period;  and,  owing  to  the  slowness  with  which  absorption  usu- 
ally goes  on  after  tbe  quantity  of  liquid  has  been  considerably 
reduced,  flatness  may  persist  for  a  long  time  at  the  base  of  the 
eb«st. 

The  exaggerated  or  resiculo-tympanitio  reaonancc  above  the  level 


MS 


DIFS19BS  or  THE  KSSmATOBT  OaOAVg. 


of  the  liqntd,  were  ibe  cxmaiitimtiMi  fimited  to  tbe  Mmiut  of  lb 
^est,  might  lew),  vitbovt  cur,  t«  tbe  error  qf  cappgsbg  Uut  W- 
a«9s  existed  on  tbe  besltbj  Ei4«.  Hu  error,  w  kv  been  bwmfat 
poinied  out,  nuiy  sIwkvs  b«  sreiiicd  bj  attantMB  to  tbe  piteb  aJ 
qmlitjr  of  tbe  rooBuc*  on  tbt  trv  odes.* 

Tbe  ili«pl»oempDt  of  intrs-tboracic  parts,  srisa^  on  the  one  hskd, 
from  tbe  prepare  of  m  Urge  qttuititT  of  effasoo,  aitd,  on  ibe  olW 
bui<l,  from  the  »octioD-foTce  dndopcd  by  tbe  abeorptioo  of  dn 
liqoid,  viU  be  tnetiuoned  prcMntljr.  ia  eaanvetloa  witfa  ptlpatioa. 
As  I  bare  referred,  bowerer,  alrcadv  to  tbe  Utorml  £qilaceant  rf 
tbe  BMdiiKiaMia,  it  bbjt  be  added  tbat,  after  abeorptiott.  a  rcT«m 
dit^aeeiBeat  U  Gable  to  take  place,  and  tbe  reeoaaaee  dae  k 
tbe  eneroairhmeot  of  tbe  lasg  of  tbe  bcaltbj  ade  mar  be  i^parent 
ercn  bejoad  tbe  stereoa  oa  tbe  »de  ia  «bieb  tbe  i  iWmitm  bu  a- 
ieled. 

Aueoltatioo  fimiibM  nmlts  sbidb,  ia  a  porithe  aad  aegathc 
poist  of  new,  are  of  great  uaportaaee  ia  tb*  tfayosU  of  pfa'aiitk 
7b«  reapiratarj  toaad  is  Bort  or  leM  vaafccDed  prior  to  tbe  au^ 
»f  Byad  aeea»alati— .  Ia  qaaSt^  aod  pi«^  tbe  napaUocr  eoasd 
ia  B«t  BsteriallT  chiapil ;  tbe  latniitT  is  alooe  altered — a  radt 
cUe«7  nf  tbe  tertraiaad  nipaairiia  «f  tbe  nda  aSecied.  Tb 
m  fiaqaeady  ntamptai  er  jntaa^  vaiBg  *•  a  «aai  •( 
■tT  ia  dke  reapiraiarj  BMcaeaa,  aa  eCwc  of  tbe  acat* 
paiaiMidnttaibBatiCe. 

Dw^tfcepcriadef  rfbMM,  AeeftoH  of  ibe  aeeM 
B^id,  as  rcgat^  tbe  tcspiratocT  so^kd.  are  man  or  Ie«  Bvitd, 
batvaiTag  ia  dAieac  parta  af  tbe  affiitat  «de;  aed  tbepb»- 

•r  lasd  pariritiag  to  tbe  tittoM  of  tbe  Aesi.  itn^TJag  let  a 
aS^  degree  at  sn^rBiaiw  ef  tbe  laafr  tba  re^nalaod  is  ciis|l7 
■or*  er  kas  aiabtatiJ  Xi;  b««M«.  tbe  <|«wtt7  af  fiqoid  b 
tiairiletillr  or  brge^  tKag  sasbrif  or  t«o-lbitd>  af  tbe  dert, 
tbeiwdM  ef  laiiialniiiM  pnecbed  aben  aad  bda*  tbe  le«d  af 
tha  Md,  an  k  snAias  eatrast  vA  aaeb  oAer.     Over  de 

tin  is  bwiha  iiakalii  or  bnacbid 
to  tbe  dt^ea  ef  eialiian'ja  of  tbe  p-Ttinaij  sine- 

Bekwtbe  baerf 
Bqaai,tba 


fbbPteti, 


ux. 


ACCTlt   PLBtRITTS. 


[torj  soand  is  frequently  sappressed.'  The  loss  of  sound,  passing 
the  stethoscope  from  above  downward,  is  often  abrupt,  denoting, 
'  like  the  sudden  loss  of  resonance  on  percnseion,  the  height  to  which 
the  li^iuid  ni^cenda  in  the  chest.  Tliia  is  the  rule,  as  respects  the 
ree]Hratorj  phenomena  above  and  beiow  the  liquid  effusion,  in  cases 
in  which  the  latter  is  more  or  less  abundant.  But  there  are  impor- 
tant exceptions  to  this  rule.  In  some  cases  in  which  a  loud  bronchial 
respiration  is  heard  over  the  condensed  lung,  this  sign  is  propagated 
below  the  level  of  the  litiuid,  and  may  extend  over  the  entire  side. 
This  fact  I  huve  repeatedly  noted  in  cases  in  which  a  large  amount 
of  effusion  existed,  producing  considerable  enlargement  of  the  af- 
fected side.  A  welUmarIcc<]  bronchial  restpirntion  diffused  over  the 
entire  side  cliaractcriioa  a  certain  proportion  of  the  cases  of  plcuritia 
with  large  effumn.  The  number  of  instances  in  the  adult  is  not 
suGGcient  to  render  them  other  than  exceptions  to  a  general  rule. 
In  early  life,  the  ratio  is  larger.  Aocording  to  Swctt,  a  bronchia) 
respiration  more  or  less  extensive  ia  the  rule,  not  the  exception,  in 
pleoritis  affecting  young  children. 

In  general,  when  a  bronchial  respiration  is  diffused  over  the  aide 
in  cases  of  abundant  or  lar^e  effusion,  certain  points  of  difference 
pertain  to  the  *ign  as  heard  above  and  bolow  the  level  of  the  liquid. 
Over  the  condcni^od  lung  it  in  more  intense  and  conveys  the  idea  of 
proximity  to  the  ear;  over  the  liquid  it  is  more  fvobic,  and  seema 
to  be  transmitted  from  a  distance. 

When  the  effusion  is  very  copious,  &lliog  and  dilating  the  affected 

side,  and  compressing  the  lung  into  a  smalt,  solid  mass,  the  respira* 

tory  sound,  in  the  adult,  at  least,  is  usually  suppressed  over  the 

greater  portion  of  the  chest.     A  bronchial  respiration,  either  feeble 

or  more  or  less  developed,  under  these  circumstances,  may,  however, 

■  be  detected  at  the  summit  of  the  chest,  sometimes  below  the  clavicle, 

Lbnt  more  frequently  behind,  above  the  spinous  ridge  of  the  scapula, 

^Baad  more  especially  in  the  upper  portion  of  the  interscapular  rcgloo. 

'  >  Th*  Rounclii  nf  the  litmrt  am  trnniiroittnd  through  the  mnu  of  Ilijiild.  Ta 
CMM  ia  whic^ti  th(>  rigbi  tiilL-  is  I11Ii.h1  with  fluid,  the  hi-art^uundB  aru  uauilljr 
beard  with  dUlincIncM.  Aiiipultalionof  the  hunrt,  ■>•  oni-  of  the  mfniii  of  wccr- 
tainlng  the  Jl-iplnc^m'UiW  of  Ihlt  orjiftn,  will  hn  iiotlroil  pn-ii-iiily  in  oimum-liun 
■with  pBlpRtlon-  Tho  r*»piriitory  louiid  mnj-  be  bronchinl  wiihin  a  limited  tpncQ 
at  or  Dear  tbs  Itvcl  uf  the  liquid;  hroncbo-vMlcuIar  a  titUu  lilghw,  and  lujruuU 
Tcaleular  at  tho  *unimit. 


SIO 


DI6BAS88  OP  tnS   KBSrikATOBT  OBOIXS. 


It  U  nrel;  altogolhur  wanting  in  one  or  more  of  tlieaft 
From  tbe  eummit  it  m^y  extend,  villi  diminUhed  inieiMUj, 
Meniiig  to  b«  more  diKtaot,  oTcr  »  viriiiblc  «ren. 

In  »  publieatiOD  by  Monnervt  itnd  Bsrtfacx,  of  Parii,*  it 
■toted  that  tbe  respiration  over  the  condensed  lung  in  plvtintii 
•Bsnae  tbe  cbaraetera  of  the  cavcmoog  and  crcn  the  wnpbi 
ikodificstMos.  As  described  by  these  writers  in  the  esses  reported 
ij  tWa,  I  U  mablc  to  pcrn-ivc  any  evidence  of  other  iban  tntenn 
!■  Will  ill  mpiration ;  the  intensity,  in  fact,  appears  to  have  brea 
Mandctfd  by  tbem  as  proof  of  its  carcrnous  character.  But  a 
CftTcnMB  resfuration  is  by  no  means  u1«'ay»  aif  intrn»«  as  a  loud 
broocUal  reaptration ;  the  intensity  is  hut  un  incidental  clement 
gf  botb.  That  the  two  are  frequently  confounded  even  by  ax- 
fMwaeed  anscaltators,  I  am  folly  persuaded.  If  tbe  distinciil^ri 
daneters  ef  «aeh,  as  they  have  been  poinlod  out  iu  Part  I,  aii^V 
kbo  IB  the  chapter  ott  Pulmonary  Tuberculosis,  are  correct,  it  is  in- 
poaaiUc  for  a  cavernous  respiratory  sound  to  be  developed  in  con- 
Beetion  with  solidification  of  lung.  It  is  proper,  howerer,  to  add, 
that  the  occurrence  of  carernoits  mpiration  in  some  cases  of  plean- 
tis  without  excavations,  is  admitted  by  Barth  and  Vaileix. 

In  the  in.4ianc«3  referred  to  in  the  preceding  remarks,  I 
pofe  that  the  bronchial  rcnpiralioD  was  mistaken  for  the  cavemoi 
But  a  mistake  may  arise,  if,  in  eoaacction  with  a  ccruin  anoral 
of  liquid  effusion,  tbe  re.'>pirntion  (as  may  occur)  is  nritbcr  bronchcil 
nor  broncho-vesieulnr,  but  intensely  rencnlar,  or  in  other  word*, 
highly  exaggerated.  The  luttcr  effect  I  snppoM  to  be  very  rarely 
produced  on  tho  side  affected  in  single  pleuriiis,  bat  I  have  already 
referred  to  it  as  •  possible  occurrence.    I  hsTe  observed  this 


'  HM,  Bsriti  ani]  Rog«rfuun(l  thobroDchial  tnpiratioBatiuiit  in  IT  nf  2>i( 
«f  ptvnritU,  MilectKd  inducriinlnatolf ,  m  quulwl  Id  Part  I  of  ttib  work.  Thr  ' 
P«rl«aoo  or  olb«n  gou  tu  ihow  Uiat  it  i«  diseorwmblf  at  Uic  aiiBiiutt  of  thr  dial 
in  a  Inrger  proportion  of  ctuxa  than  ihia  ;  anil  lli«  latter  acrord*  witli  my  own 
eipcrif-ncu.  Vall«ii  ■u^Kotfl  that  th«  di>)i«riiy  bctwmi  tbe  mnilt*  oliuiiiedbj 
Banb  and  Bogor,  aad  oth**-  obHTivn,  mav  bo  ntfUiati  by  ttw  tonaet  •tadjiof 
tbe  cA<N>t  of  natural  or  tranquil  mpiratiuii,  and  the  lalt«r  caoiinf  tbo  padoan  ax. 
amtiwl  to  brcatho  with  quicknos  and  fnrcc.  Tb*  iaSoMioo  of  forcMl  broatbliv 
in  derulopfnK  and  incrtaiing  the  inutuBity  of  the  brondiial  ■*  «f  the  tMrnal  r^ 
aplratory  lound,  tt  well  known  lo  priwtif^al  autciillalon. 

>  Art^hivM  ObafctalM  de  Mt4ecin«,  Hare,  1603.     VUe,  also,  TalUix,  cp,  < 

vol.  i,  p.  no. 


AOUTB    PI.SCniTIB. 


511 


I 


I 


to  he  marked  in  a  case  of  double  pleuritis,  to  vhich  nlluaiou  hax  been 
kiready  made  in  treating  of  cavernoos  respiration  in  Part  I. 

A  patient  yas  admitted  into  hospital  apparently  in  the-  la^t  Htagc 
if  pulmonar;  tuberculosis,  and  died  &  few  days  after  1ii«  admiMion. 
A  single  exploration  of  the  cheat  only  was  raai)e>  which,  on  the  p^^- 
Bumption  of  the  case  being  one  of  advanced  tuberculosia,  was  limited 
to  the  summit  of  the  chest,  and,  on  account  of  the  great  wenkne-S8 
of  the  patient,  was  con6ned  to  the  anterior  surface.  The  superior 
costal  type  of  breathing  was  obserred  to  be  remarkably  predomi- 
nant, the  patient  being  of  the  male  sex.  An  intense  resonnncc  on 
percussion  with  tympanitic  quality  esisted  at  the  summit.  The  re- 
epiratory  sounds  were  loud,  the  inspiration  low  in  pitch,  and  followed 
by  an  expiration  shorter,  less  intense,  and  lower  than  the  sound  of 
inspiration.  Moreover,  at  the  comnienccnienl  of  the  inspiratory  act, 
tlie  sound  appeared  to  present  a  flight  amphoric  intonation.  These 
were  the  chnructors  on  both  mU-tt,  nnrl  upon  them,  without  an  elabo- 
rate exnmiiiation,  a«  already  iitated,  was  predicated  the  opinion  that 
the  respiration  was  cavcrnouit.  At  the  aniop»y  I  expected  to  find 
large  excavations  nt  the  apex  of  both  lungs  ;  but  instead  of  this, 
there  was  double  plcnritis.  The  chest  on  both  sides  was  about  two- 
tbirds  filled  with  liquid,  the  pleural  surfaocs  being  firmly  adherent 
above  the  level  of  the  fluid.  A  vesicular  murmur,  thus,  highly  ex- 
aggerated from  the  fact  that  the  upper  portion  of  the  lung  on  each 
ude  was  alone  available  for  roi-pinvtion,  and,  from  tho  great  develop- 
ment of  the  superior  costal  type  of  breathing,  presenting  certain  of 
the  characters  of  the  cavernous  respiration,  was  mistakon  for  the 
latter  in  a  case  in  which  the  general  aspect  suggested  only  the  idea 
of  advanced  tuberculosis.  The  error  of  ohserration  was  of  coarse 
due  to  carelessness  in  physical  cxplorstion,  and  the  lesson  to  be  en- 
forced by  it  is  too  obvious  to  require  comment.  The  case  illus- 
trated the  law  laid  down  by  Louis,  that  double  picurilis  generally 
iDToIvea  the  existence  of  tuberculosis :  for,  although  excavations  were 
wanting,  small  tuberculous  deposits,  not  exceeding  the  sine  of  a 
Braall  pea,  which  hud  not  advanced  to  softening,  wore  found  in  both 
lungs.' 

During  the  period  of  absorption,  tho  expansion  of  the  lung  taking 


■  I  rtliiin  tlic  ■Mount  at  tbU  cnte  in  the  praent  edition ;  but,  with  an  apprvol- 
'ation  of  thii  vi>icu!ur  (|ualilj  of  lb«  r»[iiriilory  murmur,  an  •laggeratod  ibould 
BUTcr  tw  miilnkvu  for  tlie  cavcruuiu  rupiiSLiou. 


VIB8A8BS  OF  TBS  BESPEBATOHT  OBOXKS. 


place  in  proportion  >9  t)io  coropreftsing  agent  is  rcmOTcd,  the  bmi- 
cbinl  rc^ptratioii,  iT  it  have  existed,  disappears,  ^nng  place  lo  iW 
brouoho-vc»icular,  wliiclt  graduallj  aasoiBes  more  and  more  of  lfc« 
TCMcular  quality.  The  resptralion,  as  abHorption  gOM  on,  cttW 
becomes  audible,  or  ri>siiinc!i  il<«  normal  characU-rs,  progrcsnrd? 
frMD  the  summit  doirnwurd.  Absorption,  after  the  liquid  ii  n- 
daced  to  a  nmall  quimtity,  taking  place  frcqaentl^  rerjr  »]o«1;, 
absence  of  respiration,  with  diilness  or  Satncsa  on  pcrcuxxion,  ofia 
continiMifi  for  a  long  time  at  the  base  of  the  chost.  Peebleuesa  of 
th«  respiratory  murmur  over  tbe  whole  side  charactcriiea  the  re- 
newal of  the  fanctiou  of  the  compresMd  lung;  this  continues  for 
weeks,  or  even  mouths.  The  permanent  eHtrcts  following  recowij 
from  pleuritis  with  large  effusion  will  be  noticed  under  a  i£sii&ct 
head  in  connection  with  the  cbronio  furictj  of  thv  disease. 

Finully,  on  the  unaflectfd  Hide  during  tlic  three  perioihi  of  tfe 
disease,  but  mpociallj'  during  the  stage  of  liquid  avc  urn  illation,  the 
tntensitj  of  the  respiratory  murmur  is  abnormally  increased,  consti- 
tuting cxHggcraled  ur  supplcmentsry  respiration. 

Of  adveoiitiouB  auscultatory  eoonds,  the  bronchial  rale«  areocca- 
aionally  heard  in  cases  of  pleuritis.  Their  occnrrenoe  is  porely  aca- 
dental.  Bronchitis  coexists  with  pleuritic  inflammation  oiilr  ai  a 
accidenul  coincidence.  The  inflammation  docs  not  extend  to  the 
parenchyma  of  the  lungs,  and,  conscqucDtly,  the  crepitant  rale 
does  not  belong  to  the  clinical  history  of  the  disease  Adm- 
titious  Mouuds,  however,  may  be  dereloped  within  the  pleural  sac, 
which  are  highly  significant ;  I  refer  to  attrition  or  friction  sooods. 
If  patients  come  under  observation  in  the  first  period,  or  before  much 
liquid  accumulation  has  taken  place,  a  graiing  or  nibbing  emtsd 
may  sometimes  be  detected  over  the  lower  part  qf  the  anterior  or 
lateral  surface,  and  exceptionally,  during  this  period,  it  is  audible 
over  the  greater  part  of  the  afTeeled  side.  The  pro4luctiou  of  tlw 
sound  at  this  stage  is  due,  in  most  cases,  to  the  de|>o»tt  of  lynph 
on  the  pleural  surfaces.  It  is  possible  that  the  increased  rascolariiy 
of  the  superficies  of  the  lung,  togt^thcr  with  the  absence  of  the  nswtl 
exbalatJOD  lubricating  the  picuro,  may  be  admiuate  to  pnxltKe  it. 
Walshc  gives  an  instance  in  which  a  tond  rubbing  sound  was  beard 
over  the  whole  side,  and  after  death,  which  occurred  Mxteen  dajs 
from  the  time  when  this  sign  was  noted,  the  pleural  surface  wa* 
found  to  be  entirely  free  from  lymph  except  o^-er  *  spot  of  the  site 


ACUTE    PLEURITIS. 


513 


Fof  lialf  n  crown.  The  sound  is  hcurd  in  s  corlain  proportion  only 
tof  thv  CMC*  irliich  arc  cxaniincil  antvricr  to  tho  Htngo  of  effusion. 
tShe  rcatrBincd  movcmentH  of  tbc  nffcclcd  tsiic  from  pain  arc  some- 
Itimra  innnflicieot  for  iw  production,  »nd  then  it  tntty  be  developed 
thy  inducing  t)ie  patient  to  disregard  tbc  pain  and  expand  the  side 
linorc  futlj.  It  would  perhaps  be  detected  at  this  period  oftcner 
[tban  it  i».  were  tbe  side  to  be  more  frequently  examined  than  is 
Fusuii),  nnd  the  explorations  made  with  care  over  every  point ;  for 
Itbc  sign  is  frequently  intermittent,  and  may  be  confined  to  a  email 

After  the  accumiiUtion  ofliqmd,  and  daring  ibe  stage  of  effusion, 
B  fiction-sound  is  rarely  discovered.  In  exceptional  instances,  it  is 
observed,  In  this  period,  over  the  compressed  lung.     According  to 

IWalshc,  it  moy  occasionally  be  developed  on  the  back  by  making  the 
patient  lie  on  the  face  for  a  tittle  while.  It  has  been  observed,  al^o, 
over  «  considerable  area,  even  when  the  quantity  of  liquid  is  quite 
large.  In  the  latter  case  the  lung,  having  become  attuchwl,  by  means 
of  bands  or  bridles  of  false  membrane,  to  the  thoracic  walls,  rc«i«t8 
the  pressure  of  the  Suid,  and  the  pleural  Burfa«ea  come  into  contact 
over  a  certain  space,  notwithstanding  the  amount  of  effusion. 
_  It  is  during  the  third  period,  or  the  stage  of  absorption,  that  fric- 
I  tion-sounds  are  tiioal  apt  to  occur  iu  pleurltis.  The  pleural  surfaces, 
having  been  separated  by  the  presence  of  liquid,  are  again  broiigbt 

•  into  contact,  and  iire  more  or  less  coated  with  duise  lymph.  Ii  is 
only  during  this  aiage  thnl  the  rougher  sounds,  called  ra*pm^  or 
grating,  are  produced.     They  may  have  this  character,  or,  in  lh« 

•  third  stage,  as  in  the  first,  only  the  rulihing  and  grazing  varieties 
may  be  developed.  They  are  sometimes  loud  and  strong,  occasion- 
ally heard  at  u  distance,  attracting  the  patient's  notice,  and  accom- 
panied by  a  vibratory  motion  of  the  parietes  perceptible  to  the  touch. 
Their  duration  is  variable.     They  may  last  for  a  very  brief  period, 

Iaod,  on  the  other  hand,  they  may  continue  for  months. 
Friction-sounds  by  no  means  constantly  attend  the  stage  of  ah- 
torption.  The  adhesion  of  the  pleural  surfaces,  which  quickly  en- 
«ac8,  prevents  their  occurrence.  They  would  probably  be  more 
frequently  discovered  than  ihey  are,  if  repeated  examinations  were 
made  for  that  object;  but  at  this  period  of  the  disease  they  are 
generally  unimportant  as  regards  tbe  diagnosis,  which  has  been  al- 
ready made,  and  they  are  generally  sought  for  merely  as  a  matter  of 

33 


514 


DtSKASKS-OF  THE   ilESPlBATOKT   OBGAXS. 


curiosity,'  As  evidpnce,  howuvcr,  that  the  pleurmi  $arfac«s  m  •{)» 
in  contact,  the  fiigQ  is  not  altogether  nnimportaot  at  this  stage  of 
lh«  disease.  Its  occarrcnec  iiubM^qucnt  to  liquid  accomalation  ii,tf 
coarse,  a  proof  of  progress  baring  been  mado  in  sbsorptjcm;  W 
this  point  is  gcDeralljr  cJisily  iwttlcd  hy  other  eigos  whidi  are  mm 
uuiformly  available. 

In  conclueioB,  friction-sounds  arc  clitcfljr  important,  in  a  diagnwtk 
point  of  view,  when  they  arc  discorcrcd  cnrly  in  plcuritU,  tccai 
it  is  onljr  at  this  period  that  the  discrimination  of  ibc  diaesse^  wt  s 
general  remark,  is  attended  with  anv  difGculijr.  AVlico  thejsrt 
heard  at  the  middle  or  inferior  portion  of  the  che«t,  or  are  fooad  to 
extend  over  the  whole  side,  they  are  almost  pathognomonic  Taken 
io  eooneclion  with  symptoms  indicating  pleuritic  inflammation,  thor 
presence  estahlisbea  the  diagnosis.  In  a  ncgatiTo  point  of  vinr. 
howercr,  they  are  of  not  much  importance:  that  i«,  their  abwacs 
b  Dot  evidence  that  plouritis  docs  not  exist,  owing  to  the  want  •( 
eoBataiHjj  in  their  association  with  the  ilisenec. 

For  the  cbaraoters  distinguishing  friction-sounds,  and  bj  wUdi 
they  are  to  be  recognixcd  clinically,  as  well  as  for  other  practietl 
confliderations  conDccted  with  their  production,  the  reader  is  refer 
red  to  that  portion  of  the  chapter,  in  Part  I,  on  Auscullaiion  to 
PiMAse,  which' is  devoted  to  this  subject.*  The  liability  of  roiatak- 
ing  a  friction-sound  for  a  crepitant  rale  is  to  be  borne  in  mind,  ainoe, 
practically,  it  might  lead  to  the  error  of  confounding  plearitia  with 
pneumonitis.  The  occasional  occurrence  of  a  pleural  friction^wad 
produced  by  the  heart,  exclusive  of  any  disease  of  the  latter  or^sa, 
is  an  item  among  the  curiosities  of  clinical  experience,  which  u  to 
lie  recollected.  The  movements  of  the  heart  sometimes  cause  a 
rubbing  of  the  adjacent  pleural  surfaces  sufficient  to  give  rise  to  a 
sound.  Its  dii>conneclion  from  oib«r  evidences  of  pericarditis,  and 
association  with  the  other  cvidcuocs  of  pleuritis,  will  preveut  ais- 
t«kes. 

The  results  of  auscultation  of  the  voice  are  to  be  taken  into  ac- 
count in  the  diagnosis  of  pleuritis.  The  results  before  the  stag*  of 
effusion,  if  not  altogether  negative,  are  not  sufficiently  marked  to 


'  Boalllaud  profa»i«  to  dueo*«r  frictioo-'iODnd*.  aliiuMl  iararUblj  aUtr  i^ 
iuq>lion,  io  awna  vl  pluurit!«  (Vsllwli,  i>p.  du).  TfaU  nuj-  b*  explkioad  on  ika 
luppotltioa  that  ho  i*  accuitMnod  to  take  grmter  p«Uu  Uiaa  oUien  ia  i 
Ibr  tliMn. 

■  riifapsgeSSS. 


ACVTB    PLEU8ITIS. 


[posseKs  diagnostic  importance.    Tlicj:  arc  rnriiiblc  nncr  sn  uccmnula- 

tion  of  liquid  has  tutcvn  place,  but  tlicy  ure  frtrijiientlj'  useful  in  cud- 

Inning  the  evidence  derived  from  otlier  *ign».  Over  ihc  comprc«»ed 

ing  t)ie  resonance  of  tlie  loud  nnd  whispcrfd  voice  miij  be  abnorm- 

allv  exaggerated;  well-marked  brouchoplionj  is  sometimcB  observed, 

*and  (he  occasional  occurrence  of  pcctoriloriuy,  under  these  circum- 
■tances,  is  sufficiently  eatiiblished.  These  vocal  phenomena  ma;  all 
be  absent,  and  arc  present  in  different  cusc;  with  greater  or  losa  in- 
I tensity  or  prominence.  They  are  more  marked  if,  in  connection 
with  pleuritic  effusion,  the  lung  be  solidified,  not  by  compression 
only,  but  by  inflammatory  consolidation  or  a  tuberculous  deposit. 
■When  strongly  marked,  they  afford  presumptive,  bnt  not  positive,  evi- 
4ence  of  solidification  in  addition  to  the  condensation  due  to  the 
pressure  of  liquid  effusion.  A  moderate  increase  of  resonance  is 
l>otti>r  ascertained  if  it  be  on  the  left  side,  owing  to  the  normally 
greater  vocal  resonance  on  the  right  side.    This  remark  is  applicable, 

I  of  course,  to  exaggerated  vocal  resonance  only,  not  to  bronchophony 
■nd  pectoriloquy. 
Thetie  vocal  signs  are  generally  limited  to  the  summit  of  the  chest, 
ud  confined  to  an  area  circumscribed  in  proportion  to  the  space 
Occupied  by  the  compressed  lung.  They  are  often  limited  to  the 
ecapula  and  the  interscapular  region  behind,  ovring  to  the  usual 
situation  of  the  compressed  lung  in  cases  of  large  effusion. 
Over  the  space  occupied  by  liquid,  the  vocal  signs  which  have  been 
nsmcd  arc  usually  wanting.  A  contrast  as  regards  vocal  resonance 
between  the  upper  and  lower  portion  of  the  affected  Mde,  when  ro8* 
onance  on  percussion  ta  at  the  same  time  aheient  below,  and  mor« 

I  or  less  marked  above,  is  pretty  conclusive  evidence  of  the  presence 
of  liquid;  for,  if  the  fistne.is  at  the  inferior  portion  of  the  chest 
proceeded  from  solidification  of  lung,  the  vocal  resonance  would  be 
expected  to  be  more  marked  than  at  the  superior  portion  of  the 
chest  where  resonance  is  eliciled  by  percussion. 
■  In  like  manner,  a  contrast  between  tiie  two  aides  inferiorlj,  con- 
sisiiug  in  the  presence  of  vocal  resonance  on  the  healthy  side  and 
it«  absence  on  the  affected  side,  affords  strong  proof  of  effusion. 

^He^e  the  allowance  for  a  normal  disparity  between  the  two  sides,  is 
A*  reverse  of  that  to  be  made  when  it  is  a  matter  of  question  as  to 
Wlidifimtion  of  lung  at  the  summit.  If  the  flatness  on  percussion 
be  on  the  right  side,  and  the  greater  vocal  rcsonauco  on  tlie  left 


616 


DISSAEIS  OF  Till!    KESPIRiTORT   ORaANS. 


Bid«,  the  proof  of  effosioD  in  tlie  right  pleura  is  stronger  than  it 
VDuH  he  were  tlic  left  Hide  the  one  alTocted. 

An»cnlt«tion  furnisbca  a  vocal  elgn  which  was  deemed  by  Laenneo 
pathognomonic  of  pleuritic  effusion,  and  is  still  considered  as  highljr 
significant,  I  refer  to  the  sign  called  JEgophon^.  A  singular  dis- 
crepancj  of  opinion  exists  among  different  ol>s«rrers  as  regards  thA 
frequeiicy  with  which  this  sign  is  diseorerable  in  plenrttis,  the  ex- 
tent of  its  diffusion,  and  its  diagnostic  importance,  lliis  discrep- 
ancy Tanj,  perhapa,  in  part  be  accounted  for  on  the  Bupposition  that 
tiie  term  legophony  is  used  by  some  in  a  more  comprebensivd  sense 
than  by  othera.  It  may  be  applied  to  slight  modifications  of  the 
transmitted  voice>  or  it  may  be  restricted  to  instances  in  which  the 
tremuloasness  or  bleating  and  acuteness  are  sufliciently  distinct  to 
constitute  at  least  some  approach  to  the  cry  of  the  goat,  or  other 
sounds  to  which  it  has  been  compared.  Without  dwelling  on  the 
subject  here,  the  reader  is  referred  to  the  remarks  onder  this  head 
contained  in  the  chapter  on  Auscultation  in  Disease,  in  Part  I.' 
Suffice  it  to  add  that  not  infreiiuently  at  or  near  the  level  of  liquid, 
within  a  limited  space,  the  voice  is  high  in  pilch  and  appears  to 
eoiae  from  a  distance,  without  the  trenniloii»nc»s  or  bleating  char- 
acter which  distinguishes  tegophony.  This  is  simply  a  modification 
of  bronchophony,  and  it  is  often  associated  with  bronchial  or  broncho- 
vCHiouIar  respiration. 

Inspection  and  mensuration  furnish  striking  and  valuable  signs 
in  pleuritis.  Under  the  inflaence  of  pain  the  movements  of  tlie 
KlTccted  side  are  so  far  restrained  by  the  wilt  as  to  give  rise  to  a 
perceptible  diminution  in  expansion  by  the  inspiratory  act,  and.  on 
measureinenl,  the  site,  as  also  the  range  of  motion,  may  be  found 
slightly  reduced  during  the  first  period.  The  voluntary  restraint 
of  motion  is  especially  apparent  in  the  act  of  coughing.  These  ap- 
pearances give  place  to  others  more  marked  and  distinctive  in  the 
second  stage.  The  lower  part  of  the  affected  side,  in  proportion  to 
tlio  amount  of  liquid,  becomes  dilated,  and  the  inferior  cost.il  mov^ 
ments  with  re-ipiration,  are  lessened  or  arrested.  The  intercostal 
spaces  exhibit  lees  depression,  and  are  not  so  deeply  indented  in  tbe 
inspiratory  act,  as  on  the  opposite  side. 

Accumulating  in  still  larger  quantity,  the  1ii]uid  meets  witli  more 
reelstance  from  the  condensed  lung  than  from  tbe  thoracic  pari«iea> 


>  rt<bpi«a3l7. 


AOVTB    PLB(7RITIS. 


617 


an<l  Iho  letter  aeconlioglj  yield  to  tlie  diUting  force.  The  affected 
Bide  becomes  conxpicuouMly  enlurgod,  nnd  its  rango  of  motion  in  nn- 
piration  proportioniilly  limited.  It  is  dilated  frptjui-ntlj  to  the  fullest 
extent  of  voluntary  expansion,  and  even  beyond  this  limit,  nnd 
bcDce  mnains  motionless,  while  the  movements  of  the  opposite  sido 
hm  sapplementarily  increased.  The  intorcostnl  depressions  nro 
novf  abolished,  and  a  alight  convexity  between  the  ribs  is  in  some 
cases  apparent.  Over  the  lower  and  the  middle  .portion  of  the 
side  ihe  ribs  are  abnormally  separated,  while  at  the  summit  they 
conrerge  more  than  is  natural.  The  obliquity  in  the  direction  of 
the  ribs  is  diminished.  Approaching  to  a  horizontal  line,  their 
angular  union  with  the  oailal  cartilages  is  no  longer  obvious. 
Meiisnremoiit  of  the  Memicircular  oirounifcrence,  of  the  vortical  dis- 
tance from  the  base  to  the  summit,  and,  by  means  of  callipers,  of  the 
«itero-po»tcrior  iltnm<.'t<<r,  shous  an  increase  of  sine  in  all  directions. 
The  nipple  is  somewhat  elevated,  and  is  removed  at  n  greater  dis- 
tance  than  on  the  opposite  side  from  the  median  line.  On  a  pos* 
terior  view,  a  msrkcd  contrast  i«  observed  between  the  two  sides  in 
the  clovatiuD  of  the  scapula  with  the  act  of  inspiration.  These  are 
the  phenomena,  detormincd  by  inapectiou  and  meueuratiou,  which 
denote  a  very  large  aecumulation  of  liquid  within  the  pleural  cavity. 
Oecasionally  presented  in  acute  picurilis,  thoy  are  much  oftener 
observed  in  the  chronic  form  of  the  disease. 

In  the  progress  of  the  absorption  of  the  effused  fluid,  a  series  of 
changes  take  place,  the  reverse  of  those  which  characleriEc  the  pro- 
gressive accumulation  of  fluid.  The  enlargement  decreases;  the 
bulging  intercostal  spaces  become  flattened;  the  divergence  of  the 
lower  ribs  diminishes,  and  they  assume  a  more  oblique  direction; 
the  nipple  falls,  and  its  distance  from  the  median  lino  is  lessened; 
tome  degree  of  expansive  movement  is  perceptible,  talcing  place 
more  slowly  thun  on  the  opposite  side,  and  depression  of  the  side  at 
the  summit  is  apparent.  With  these  changes  the  affected  side  may 
be  slil)  nearly  (ilie'I  with  liquid.  Finally,  when  absorption  of  the 
whole  or  a  greater  part  of  the  liquid  is  effected,  the  alteralions  in 
eisc,  motions,  and  relations  of  the  different  parts  are  ntill  more 
marked.  Tlic  side  becomes  contracted  in  every  direction.  It  is 
obvious  to  tbe  eye  at  the  lower,  as  well  as  at  the  upper  part,  when 
the  chest  is  examined  either  behind  or  in  front.  Mensuration  with 
tbe  inelu«tie  tape,  or  with  callipers,  shows  this  to  be  tbe  case.  Lateral 
curvature  of  the  spine  is  apt  to  occur,  tbe  concavity  looking  toward 


S18 


DI8BA3ES  OF  THE   BE8PIRAT0BT  OBQASS. 


tb?  nflcctci  Biilc.  T}io  ihouMrr  (vith  occasional  «xc«ptioi»)  b  it- 
pr«g»«<];  the  inU-rMaptilar  vpnco  i«  DKirowed:  the  lower  aogleof  tb 
acapnia  projects  from  the  thoracic  wall;  the  lower  ribs  appronaale 
more  than  o&  the  opposite  side ;  the  oipple  falls  below  the  level  of 
its  fellow,  and  is  nearer  the  mediaD  line ;  the  ranjre  of  motion  in  tke 
acts  of  respiration  is  greater  than  before,  but  still  limited  on  coiih 
parisoD  with  the  healthy  ade.  These  changes,  alwan  8(icoe«dnii| 
chronic  plcuritU  with  large  cffution.  hut  not  to  constant  after  tL« 
ftcule  rnricty,  in  amount  bear  a  certain  proportion  to  the  extent  to 
which  the  side  has  been  previoasly  expanded,  or,  in  other  wonls.  to 
the  <{uantity  of  liqaid  effusion  which  has  existed.  They  arc,  hev* 
ever,  also  dependent  on  the  condition  of  the  compressed  long  as  re- 
gards its  ability  to  become  expanded  as  the  pressure  'u  reiboved; 
and  since  this  condition  is  affected  bv  other  circamstances  thai 

w 

»imple  condensation,  vis.,  by  the  adhesion  of  the  pleural  eerficet^ 
and  the  thi'tkness  and  density  of  the  lymph  deposited  upon  it,  Ike 
contraction  of  the  aide  resulting  from  pleurilis  will  differ  in  difo^ 
ent  cases  in  which  the  quantity  of  effused  liquid  was  about  the  nac. 

Contraction  of  the  affected  side  will  be  likely  either  to  be  wntl- 
ing  entirely,  or  to  b«  lee«  marked  and  Iwi  pervistiBg  in  proporiiv 
M  the  effusion  and  \tt  rcmoral  by  abMrption  have  been  rapid.  P«( 
tikis  reasca,  assuming  an  equal  amount  of  accumulation,  tbc  chac^ 
first  mentioned  ehamcterise  chronic  rather  than  acute  plcuritis.  Bnl 
tbey  are  more  apt  to  follow  chronic  plcuritis  for  another  reasoo.  vil, 
tbe  quantity  of  liquid  effitiieii  U  usually  much  greater  in  this  variety 
of  the  disease.  Tli«  rapidity  with  which  absorption  go«s  on  in  acnle, 
as  well  as  in  chronic. pleuritis,  varies  much  in  different  cm!M.-«.  It  a 
not  uncommoa  to  observe  a  very  great  reduction  within  n  few  days 
or  even  hours ;  but  after  the  qoanlity  is  reduced  to  a  certain  pMSt, 
the  removal  is  always  effected  more  slowly.  The  »ide  may  be  ob- 
Tiously  depressed  at  the  summit  or  middle  third,  vbcn  it  is  still 
enlarged  at  the  lower  part,  as  shown  by  meitMiration.  An  regards 
permanent  effects  «i  the  chest,  there  moy  not  be  any  obrions  ili»- 
parity  after  the  Upse  of  weeks  or  months  snc««ediiig  on  attack  of 
the  acute  form,  even  when  the  quantity  of  liqaid  effanon  was  con- 
uderable,  and  a  certain  amount  of  eontnctim  was  evident  imnitdi- 
atciv  after  recovery.  It  i«  otherwise,  however,  with  cases  of  chronic 
pleurili*,  and  I  shall  refer  to  this  p«unt  under  the  head  of  the  latter. 

Sxaminations  of  the  chest  by  inspection  and  nwBffnralioD,  in  cases 
of  pleuritis,  are  not  only  useful  in  order  to  ascertain  the  ezistenee 


^OUIB   PLIDftTTIS. 


619 


For  non-esisteoco  of  either  dilatation  or  contraction,  but  that  the 
[progress  of  the  disease  may  he  watched  from  day  to  day,  an  rogardsL, 
fin  the  first  place,  the  increase  in  the  accumulation  of  liquid,  an>)  in 
I  the  second  place,  its  decrease  by  absorption.     In  cases  in  which  the 

affected  side  is  filled  with  fluid  and  the  thoracic  walls  expanded,  per- 
I  eussion  and  auscultation  do  not  afford  the  meatia  of  determining 
!  from  day  to  day  variations  in  the  qnanlity  of  effuition.     luspcctioo 

and  niciijiunilioii  arc  availiiblc  for  this  object,  and  the  results  may 

I  be  important  in  determining  the  pnictitioner  either  to  continue  or 
to  change  his  iherapcntical  measures. 
Much  information  is  frequently  derived  from  the  employment  of 
palpation  in  eases  of  pleurisy.  In  the  first  period  it  furnishes  evi* 
Idcnce  of  tenderness  to  the  touch,  nnd  also  thul  the  soreness  is  not 
in  the  integument  but  in  the  iutrn>thoracio  structures.  Tlie  pain 
produced  hy  manual  examination  of  the  affected  side  is  not  super- 
ficial and  oecAsioned  hy  mere  contact  of  the  hand,  as  in  some  in- 
stances of  hypencstbosia  of  the  surface,  but  is  more  deeply  seated 
and  proportionate  to  the  degree  of  pressure  mmle. 
N  But  it  is  more  especially  during  the  second  and  the  third  period  that 

H  this  method  of  exploration  furnishes  useful  facts.     The  effect  of  no 
~  acouinulation  of  a  considerable  quantity  of  liquid  is  usually  to  abolish 

»the  normal  vocal  fremitus  on  the  affected  side  over  a  space  corres- 
ponding to  that  occupied  hy  the  efi'uaion ;  and  in  some  instances, 
the  fremitus  is  increased  over  the  condensed  King  above  the  level  of 

Iihe  liquid.  Marked  diminution  or  suppreesiou  of  the  normal  vocal 
fremitus  may  tbus  constitute  a  physical  sign  of  liquid  effusion,  the 
more  significant,  because  over  consolidated  lung  the  fremitus  ia 
frequently  exaggerated.  It  is  obvious  that  to  become  a  sign  of 
effusion,  absence  of  fremitus  must  be  associated  with  other  signs; 
and  it  is  to  be  borne  in  mind  that  in  healthy  persons  the  normal 
fremitus  is  greater  on  the  right  than  on  the  left  side.  If  flatness 
on  percussion  at  the  lower  part  of  the  cbest  coexist  with  absence  of 
fremitus,  while  on  the  opposite  side  there  exists  resonance  wttb  n 
fremitus  more  or  \crs  marked,  ihe  evidence  is  strong  that  the  flatness 
is  due  (o  effu.->ed  fluid  rnlher  than  solidified  lung.  And  inasmuch  as 
H  in  some  persons  a  fremitus  exists  naturally  on  the  right  side  and  not 
on  the  left,  the  evidence  is  stronger  when  the  effusion  is  into  the 
right  pleural  sac ;  in  other  wonts,  flatness  on  percussion,  with  absence 
of  fremitus,  indicates  effusion  more  positively  on  tbe  right  than  on 
tlie  left  side,  making  due  allowance  for  the  fact  that  lliis  combinn- 


520 


DISBA8B8  OF  THE   BBSPIRATORT  OROANS. 


tion  of  signs  ma;  be  produced  by  the  enerottcliineiit  of  on  enlarged 
hv«r  on  the  tltoracio  apace.  A  chnngc  u  regards  fremitos,  wttli  » 
ob«Dg«  in  Uic  pottition  of  tbo  body,  uflbrds  striking  evidence  of  th« 
presence  of  liqiiid.  If  with  flatness  on  pereosuon  extending  trooi 
tbe  bn«o  more  or  letu  upward,  fn-iDitim  he  wanting  while  the  pxli«nt 
U  sitting,  but  be  pr««cnt  when  the  body  is  inclined  forward,  ihe^ 
proof  of  l>c|nid  cffuition  it  ahnost  coniplcto. 

Piilpation  fiirnishcH  Htil)  other  facts.  By  this  method  bctt«r' 
than  by  inspection  Are  al^crluinod  the  moAl  imporunt  of  the  dia- 
pUc«atent8  of  lotra-thorncic  parts  which  uke  place  in  tbe  second 
ami  tlie  third  period  of  pleuritix  with  large  effusion.  An  aceumuUtion 
of  liijuid  in  the  loft  pleural  sac  removes  the  heart  from  it4  nonnal 
nitualion.  TLiit  may  oceur,  and  to  a  great  extent,  before  the  thoracM 
parictva  becomo  dilated.  Occasionally  the  heart  is  pushed  downward 
in  a  direction  toward  the  epigitstrium,  bat  in  the  great  majority  of 
inetanceB  it  is  carried  upward  and  outward  in  a  diagonal  line  extend- 
ing from  the  priecordia  to  the  right  slinuMer.  It  is  found,  us  the 
fluid  accumulates,  to  he  situated  beneath  the  Sternum,  and  at  length 
its  pulsations  may  be  felt  and  fre((uent1y  seen  on  the  right  side,  and 
sometimes  beyond  tbe  nipple.'  If,  on  the  other  band,  the  ell'ueiocibv 
within  the  right  pleural  sac,  and  the  accumulation  be  large,  tlic  heart 
is  displaced  in  a  direction  upward  and  outward  toward  the  left  axilU. 
If  the  impulse  of  the  dislocated  heart  can  neither  be  seen  Dor  f«]t| 
which  is  rarely  the  case  except  when  it  is  beneath  the  sternum,  the 
Bounds  of  the  organ,  as  determined  by  auscultation,  muat  be  the 
guide  to  its  abnormal  situulion.  Its  return  to  the  prsecordia  is  evt* 
denee  of  the  progress  made  in  the  absorption  of  the  effused  fluid. 
In  Miue  instances  it  has  been  observed  to  regain  ita  normal  situation 
in  the  course  of  a  few  days  or  even  hours,  showing  very  rapid 
diminution  in  the  quantity  of  effusion.  It  does  not,  however,  always 
rolurn  to  its  normal  situation  when  the  force  which  in  the  lin>t  in- 
stance pushed  it  out  of  place  i»  do  longer  oi>eratJve.  It  may  be 
detained  in  tis  abnormal  position  by  morbid  attnchuicnis ;  and  it  is 
•  curious  fact  that  the  suction>force  developed  by  Uic  absorptioa  of 
tlio  effused  liquid  may  prove  an  active  cause  of  displacement.     ]n 


■  fAtCurntion  oTtlicliiuirl-^ouDtU,  CTHi  witb  lh«Kr««(«i  Kn»untor4wiibo«iBeal, 
ia  vsr;  TRrolv  obwrt'od.    A  bellow*'  toaad  !«  orculoiia)!;  doTflopvd,  whkli  dia- 
appoan  wlmn  lli«  koriretuiuMlu  noruiBliUukttoa.  Thovsiitcaceof  a  Diirmor, 
unilflr  tbi'iocircuimutuocs,  tber*fi>ro,  ii  rml  jn  mf  nf  (■iilliii  lllnan,  itiia  milild 
iug  aiuDiiila. 


AOOTB  PLBURITIB. 


521 


cases  of  copious  effusion  vithin  the  right  pleura,  after  ahsorptioDf 
the  heart  may  be  drawn  into  the  right  side ;  and  Hubaequent  to  the 

^.    removal  of  an  effusion  in  the  left  pleura  sufScient  to  di^'plnce  the 

B  heart  to  the  right,  it  may  at  length  occupy  a  po&iiion  to  the  left  of 

H  the  pnecordia. 

H       Displacement  of  the  diaphragm  is  another  of  the  mechanical  effectfl 

B  of  s  large  effusion.  This,  according  to  the  observations  of  Stokes, 
may  take  place  suddenly,  so  that  the  fluid  finding  additional  space 
in  this  direction,  the  semicircular  circnmference  of  the  affected  side 
may  possibly  be  diminished,  and  the  line  of  percussion-flatness  on  the 

B  ebmt  lowered,  although  the  ([uantity  of  liijuid  is  increasing.  The 
depression  of  the  diaphragm  of  c<>ur.4e  carries  downward  the  aubja- 
cent  organs.     On  the  right  side  lhi»  i»  evidenced  by  tlie  lower  sitaa- 

^k  tion  of  the  liver.  Under  these  circumstances,  owing  to  the  convexity 
of  its  upper  surface  and  the  convexity  of  the  depressed  diaphragm, 
a  sulcus  or  furrow  is  somctinii's  npparent  hetwe«'n  the  lower  margin 

^P  of  the  chest  and  the  point  at  which  the  anterior  surface  of  the  liver 
projects  against  the  abdominal  walls.     Again,  after  absorption,  the 

•  diaphragm  is  drawn  upward  with  the  subjacent  organs  above  the  poiat 
at  which  it  rises  normally  within 'the  chest;  and  the  liver  on  the 
right  side,  or  the  stomach  and  spleen  on  the  left  side,  are  found  to 

Isscend  higher  than  in  health.  The  latter  changes,  however,  are  as- 
certained by  percussion  rather  than  by  palpation,  and  the  same 
remark  is  applicable  to  lateral  displacement  oE  the  mediastinum,  to 
which  reference  has  been  already  made  under  the  head  of  Percussion. 
Owing' to  the  abolition  of  the  iaicrcontal  depressions  during  the 
stage  of  effusion,  the  affected  side  offers  to  the  touch,  as  well  as  to 
the  eye,  an  unnaturally  regular  and  smooth  surface,  which  is  after- 
ward lost  when  contraction  of  the  chest  litkes  place ;  and,  finally,  in 
•ODio  instances,  the  presence  of  liijiiid  in  the  pleural  sue  may  be 
made  to  give  rise  to  a  scnso  of  fluctuation  uppreciaMv  by  palpation. 
Tbift  may  be  discovered  occaslonttlly  by  applying  the  left  hand  over 
the  affected  side  at  the  base,  »nil  percussing  the  ribs  with  the  pulpy 
portion  of  the  fingers  of  the  right  huml.  In  thin  persons,  peripheric 
fluctuation,  as  it  is  called,  is  oftenor  available.  If  a  finger  be  ap- 
plied over  an  intercostal  space,  and  a  light,  quick  percussion-stroke 
be  made  at  a  short  distance  >o  the  same  space,  the  peculiar  shock 
significant  of  the  presence  of  fluid  may  be  appreciable. 


Ifiagnoeii. — Certain  of  the  symptoms  of  acute  pleuritis  are  some- 


S8S 


vibhabbs  of  thr  rbspikatobt  onoAVt. 


v]iat  (listinctiTe.  Pain  ia  osualljr  a  prominent  symptom  during  the 
firat  period.  It  19  sharp,  lancinating  in  character,  felt  gencrallj 
with  the  act  of  inspiration,  and  its  eereriiy  increasing  with  tb 
progreas  of  the  act,  renders  thia  act  interrupted,  and  shortens  m 
duratioit.  In  theR«  respects,  honerer,  it  does  not  differ  from  ilie 
puin  in  pleuralj^a.  It  is  referred  oftcnest  to  the  lower  part  of  tlte 
affcctcl  *i(ielat«nllv  and  in  front;  somelimeit  it  extends  to  tliehack 
or  over  the  whole  side,  and  occasionally  it  is  felt  exclnsivelv  00  iht 
opposite  side  or  in  the  abdomen.  It  diminishes  as  effasioa  !ak«* 
place,  and  at  length  ceases  to  he  prominent  or  disappears.  The 
rc«pir:ilions  arc  mnltiplied,  at  iir»l  hj  way  of  compensation  for  their 
incompleteness  in  consequence  of  pain,  and  aftertrar<l  from  the  tn- 
tcrruplion  of  the  fiiiiclion  of  the  lung  oa  tlic  affected  side  doe  to  itt 
compression.  Dyspntea  occun  in  only  a  small  proportion  of  nsM^ 
and  these  cusca  are  clinrnctenzc<l  by  rapid  and  copioita  cffasioa. 
Cough  is  aometimcs,  but  rarely,  ahnent.  It  is  iisoally  dry,  ciciltd 
spasmodically,  and  partially  suppressed  to  avoid  tlie  pain  wliidi  it 
occasions.  The  significance  formerly  attached  to  position  «ir  ob- 
cubitut,  at  different  stages  of  the  disease,  ia  in  a  great  measare  ■£>■ 
proved. 

With  an  adequate  knowledge  of  the  physical  signs  which  bel' 
to  acute  piciiritis,  the  diagnosis,  in  the  great  majority  of 
is  sufRcicntly  easy.  It  presents  difficulties  only  to  those  wb 
not  qualify  themselves  to  employ  physical  exploration.  By  thoK 
who  rely  exclusively  on  the  diagnostic  symptoms,  it  is  not  infre- 
quently confounded  with  pleurodynia,  intcreostal  neuralgia,  aed 
pneumonitis.  Instance*  illnstrating  these  errors  of  diagnosis  hare 
repcttleitly  fallen  under  my  observation.  It  will  snfficc  to  point  onl 
the  more  imporunt  of  the  circumstances  inrolvml  Jn  the  differentia] 
diagnosis  from  the  affections  just  named,  commending  to  the  stodeol 
the  study  of  the  physical  signa  of  the  disease  nnUl  they  become  per- 
fectly familiar. 

In  pleurodynia  and  intercostal  neuralgia,  the  physical  phenometia 
which  attend  ihemarchof  acute  pleurit is  are  wanting,  and  the  absence 
of  these  phenomena  warrants  the  exclusion  of  pleuritic  inflamtna* 
tion.  In  a  purely  neuralgic  or  rheumatic  affection,  however,  dirain* 
ished  expansion  of  (he  affected  side,  with  slight  rdlaeiion  in  «ie, 
feebleness  of  the  respiratory  murmur,  and,  perhaps,  relative  ilo1oe6S| 
may  be  present,  tbcjsc  results  being  due  cxclnsircly  to  the  restrained 


1M 

bolH 


AOCTB    FLBtritlTIS. 


J>SS 


I  moTenKMits  from  pnin.     Tb<;  affected  side  may  also  b«  more  cx- 
qiikilcly  tomk-r  on  prc8i<urc  ttiitn  when  plvurittc  Jnflsmmntinn  oxii^ts. 

I  Guided  alone  by  tbc  rcBulu  of  exploration,  for  n  brief  period  nft«r 
tiie  sttock,  th«  diHcriminntton  mnj  involro  donbt.  The  oxistenco 
of  mnrlted  febrile  movement  is  an  important  point  at  this  period. 
Symptomatic  fever  conalitntly  «ccoaipnnies  acute  inflammation  of 
tlic  pU'urn,  nhcreos  it  attonds  pleurodynia  nnd  intercostal  neuralgia 
only  ax  s  coincidoncc.  If  u  friction-*ound  bo  discovered  which  wo 
«re  tiatisGcd  is  pleural,  it  renders  the  diagnosis  quite  positive.     But 

»tbe  constancy  of  this  sign  cannot  he  relied  upon,  and,  indcf^,  it  la 
rarely  discovered  in  the  early  stage  of  plcuritis.  Its  absence,  there- 
fore, is  not  proof  that  a  doubtful  affection  is  either  neuralgic  or 
rbeomatic. 

But  the  occasion  for  hesitancy  uanally  exists  for  a  brief  period 
only.  The  occurrence  of  serous  effiL^iion,  if  the  diaeasc  be  acuta 
plearitis,  gives  rise  to  positive  signs  which  rentier  certain  the  prea* 
enee  of  something  more  than  a  neuralgic  affection  or  an  attack  of 

IrheuntatiBm  seated  in  the  thoracic  walls.     And,  on  ibe  other  hand, 
the  abfience  of  the  physical  evidence  of  effusion  authorizes  an  exclu- 
Bion  of  acute  picuritts.     A  fact,  however,  observed  by  Louis  and 
others,  is  important  to  be  borne  in  mind,  viz.,  an  attack  of  Kcute 
plcuritis  is  occasionally  preceded  by  a  neuralgic  afll'Clion  of  the  side 
in  which  the  inflammation  becomes  afterwards  developed.     Two  in- 
stances illustrating  tbi^  fnct  have  eomc  under  my  observation,  in 
which  the  patients  experienced   acute  painit  in  the  side,  withonC 
febrile  movement,  or  any  of  the  physical  itigns  of  pleuritic  inRamma- 
tion,  for  several  days  before  an  attack  of  the  latter  which  was  sig- 
^  oalised  by  a  chill,  increased  pain,  and  febrile  movement, 
^f      In  the  differential  diagnosis  from  acute  pneumonitis,  we  have  to 
distinguish  between  the  physical  signs  belonging  respectively  to  this 
affection  and  to  acute  pleuritis.     In  pneumonitis  there  occurs,  often 
within  ft  short  space  of  time,  marked  dulness  on  percussion  over  a 
certain  portion  of  the  affected  side.     If  the  upper  lobe  be  first  in- 
fiamed,  the  dulness  will  be  found  at  the  summit  and  on  the  anterior 
1      surface,  while  the  posterior  surface  below  the  scapula  is  resonant  on 
^P  perenssion ;  the  reverse  obtains  in  acute  pleuritis  after  effusion  has 
taken  place.    But  in  the  majority  of  instances,  pneumonic  inflnmm^ 
.  tion  attacks  tho  lower  lobe,  and  in  the  lobar  form  invades  the  entire 
[lobe;  the  dulness  will  then  be  found  to  be  bounded  on  the  ehest 
'by  a  line  pnrsutng  the  direction  of  the  interlobar  6si(»re,  and  not 


VISlASBS  OP  THE  RBSPIKAIOBT   OBOAKB. 

'  «Ttk  tke  ehufe  oT  position  of  the  pfttient,  the  latter  hcing 
tfUim  pnponion  of  the  cases  of  plenritis  with  cSt- 
1 B  yleiiliJ  geaerally  tecnnmUteti  rapidly,  udtlu 
ik  foand  to  extend  otct  a  largerportionof  dkt 
li^m  CMBi  ef  y maonitis.    In  certAia  easea  of  pMi> 
I  aa^  AfcatBC  la^  najr  become  solidified ;  bat  in  thca 
b  Ue  ■  fnt  attacked,  and  at  a  subsetjueot  period  the 
m  iMCriilttr  fissare.  and  invades  tlie  oi^ 
VaA  !■■■  «•  wmdtK  ebMrnuon  from  the  begiDDiD^.  the 
:  «f  ■■*  MOfM  liy  tke  extodioB  of  dulnen  orer  the  cheat 
•  froM  acBle  pleoritis. 
I  pataca  are  aet  teaa  diftinctive.    The  present*  «f 
a  cawMetaUe  qoaatitj  of  liqaid  ta  the  pleural  cavity  gives  tise  la 
fclawi  oa  parcoirion.     Soli£Scmb«a  af  Imig  produces,  in  geneial, 
oalj  dalBCM,  and,  in  a  certata  piopactiaa  of  instances,  the  vesiealv 
ti  replaced  by  tympanitic  reaosaaee  sore  or  ten  narked.     The  dot- 
acta  from  Holidificd  lung  is  acoompaiued,  gei>erally,  by  a  well-tnarfcel 
bronchial  nwpiralion,  frequently  inteiuc  and  appearing  to  b«  dertt- 
oped  near  the  ear ;  the  flatness  from  the  accuinuiiition  of  lii|uid  ii 
nsualiy  associntcd  wilh  »uppressioi»  of  reaptnlory  wand,  or,  a  broa- 
chial  rcHpirntion,  if  it  be  dincorered,  is  soapsratively  feeble  and  dis- 
tant in  the  great  majority  of  ca.sc8.    laenaaed  vocal  resonance,  biw- 
chophony,  and  occasionally  pectoriloquy,  are  signs  belonging  tosotifi- 
Ecation  ;  their  absence  is  the  rule  over  liquid  effusion.     JEgoptumj 
is  occasionally  heard  over  the  latter,  and  rarely  over   th«  fonsar. 
Yocal  fremitus  ts  often  exaggerated  by  solidification,  and  it  is  di- 
minished or  abolished  by  the  presence  of  liquid. 

An  accumulatiou  of  a  large  quantity  of  liquid  in  tbc  plcnral  cavity 
produces  considernble  or  great  enlargement  of  the  affected  side,  and 
eflacee  the  intercostal  depressions.  In  pneumonitis  the  cnlai^ 
ment  is  slight,  and  the  intercostal  depressions  remain.  Di«pbe» 
ments  of  the  heart,  diaphragm,  and  mediastinum,  are  market)  cffcca 
of  copious  liquid  effusion,  and  they  occur  hut  to  a  slight  extent  ai 
results  of  solidification. 

Moreover,  a  symptom  and  a  sign  almost  pathognomonic  of  acute 
pneumonitis  are  wanting  in  acute  pleuritis,  vi^,  the  rusty  expecto- 
ration and  the  crepitant  rale. 

Exceptional  variations  from  general  rales  as  regards  the  phyncal 
signs  belonging  to  the  two  diseases  jost  contrasted,  can  alone  CM: 
Btitute  sufficient  ground  for  hesitation  in  making  the  differential  di- 


loais.    For  extmple,  in  some  cases  of  plcaritis  vitb  large  efTusion, 

.  broRcliial  respiration  is  found  to  pervade  ihfl  whole  of  the  affcclcil 

tside;  and,  on  ihc  other  hand,  in  nome  caaea  of  solid! flea tioti  from 

F pneumonitis,  absence  of  respiratory  Hound  is  equally  extoiisirft.    AU 

t«Dtion,  lioffcvcr,  to  other  points  of  contrast,  in  all  such  instance*, 

vill  develop  atopic  data  for  the  discrimination. 


SCHUAftr  OF  FHTBICU.  SIOKS  BBIOMOINO  TO  ACUTE  FLBUItlTIS. 

Vint  Period,  vii.,  prior  to  Aceumulation  of  Liiptid. — Moderate  or 
'rtighl  diminution  of  vesicular  resonance,  or  dulnesB  on  percussion. 
Feebl«  and  interrupted  respirutory  murmur.  No  alteration  in  vocal 
resonance  or  fremitus.  Diminished  expansibility  of  tbe  affected 
Bide.  Tenderness  on  pressure.  Occasionally  a  grazing  or  rubbing 
&ictioD-»oun(I. 


Stctmd  Period,  or  Stage  of  Aecumutaiion  <^  Ztqaid. — ^FlatBMB 
'i  on  percussion  from  the  base  of  the  chest,  extending  upward,  mon  or 
leu,  orer  tlie  affected  sidp,  and  the  upper  limit  in  front  generally 
following  a  boriKontal  line ;  diminished  elasticity  of  thoracic  parietcs, 
and  sense  of  resi!<tanco  notably  Increased.  The  rceonance  above 
tlie  level  of  the  liquid  frequently  exceeding  in  intensity  the  sound 
on  the  opposite  side,  and  vesiculo-tympanitic  in  character.  Am- 
phoric resonance  at  the  summit,  sometimes  strongly  marked,  and 
occasionally  the  cracked-metal  vorioty.  The  limits  of  flatness,  in  s 
certain  proportion  of  cases,  found  to  vary  when  the  patient  assumes 
different  positions.  The  flatness  sometimes  found  to  extend,  in  front, 
on  the  opposite  side,  even  beyond  the  sternum,  in  conseqtience  of 
lateral  displacement  of  the  mediastinum.  Respiration  often  Bup- 
presfiHl  below  the  level  of  the  liquid  effusion ;  broncho-vesicular,  or 
the  bronchial  respiration  over  the  compressed  lung.  A  bronchia) 
respiration  sometimes  diffused  over  the  clicsl,  but  usually  feeble  and 
distant,  except  at  the  summit ;  in  the  latter  situation  generally  dis- 
coverable either  in  front  or  behind,  oftencr  tlie  latter,  varying  in 
different  cases  us  respects  intensity  and  the  area  over  which  it  is 
heard.  Friction-sounds  occasionally  heard  in  this  stage.  Increased 
vocal  resonance,  exaggerated  bronchial  whisper,  sometimes  broncho- 
phony, and,  OB  a  rare  phenomenon,  pectoriloquy,  discovered  at  the 
summit  of  the  chest  on  the  affected  side.     All  these  vocal  signs  may 


fi26  DISBA8B8  OF  THB  RS8FIBAT0KT  0BQA5& 

be  kbacDt  at  the  sammit,  and  they  are  ill  absent,  u  a  mtr,  otct  tb; 
portion  of  the  etdo  occupied  bj  the  liquid,     ^gophony  present  m  t 
certain  proportion  of  caws  at  a  particular  and  usually  a  tramiat 
period  in  this  suge ;  generally,  when  present,  limited  to  the  neigfc- 
borhood  of  the  inferior  angle  of  the  scapula  behind,  and  to  a  tont 
Gxicniling  from  this  point  to  the  anterior  part  of  the  cheit,  b«t  a 
some  iosUncc«  diffused  over  the  irbole  side.     Dilatation  of  the  af- 
fected side,  commencing  below  and  extendbg,  in  some  cas«s,  over  tht 
entire  side ;  the  intercostal  depressions  effaced,  and   varioas  altc^ 
aliens  in  the  relations  of  the  parts  composing  tbe  thoracic  parieUs. 
Dislocation  of  the  heart,  and  deprefision  of  the  di^hr»ga>  with  eab- 
jaccnt  organs,  from  tbe  pressure  of  tbe  Suid.     Uaiiataral  regnlaritj 
and  smoothncas  of  the  surface  of  the  affected  nd«.     Flnctuatioa  per 
ceptible  to  the  eye  and  to  the  toach  in  some  instances.     Compart- 
tire  immobility  of  the  affected  side.     AboUtioD  of  vocal  freodtai 
belov  tbe  level  of  tbe  liquid.     Increased  respiratory  movements  taH 
exaggerated  ve^cular  marmur  on  tbe  besllby  side. 

Third  Period,  or  Suifft  of  Ahtorption.'—^esonfijice  on  percusson 
developed  first  at  the  summit  and  gradually  extending  dovnwaid, 
but,  relatively  to  the  opposite  «ide,  peraiating  dulnetta.  Flataos 
continuing  at  the  base.  Re.''piratioo  feeble  and  broncbo-vemcular, 
progressively  extending  fruui  above  downtiard,  and  gradually  awaa- 
ing  the  normal  vesicular  olinractcr.  Supprf»3ion  at  llie  lower  pan  of 
the  affected  side.  Vocal  resonance  and  fremitus  absent  at  tbe  loan 
part  of  the  affected  side,  and  either  wanting  or  more  or  less  marked 
above,  ^gopbony  sometimes  discovered  in  this  suge.  DeprcMiaii 
at  the  summit  of  the  chest,  and  afterward  frequently,  if  tbe  vffuflMi 
have  been  large,  marked  contraction  of  the  whole  aide,  with  changts 
in  relations  of  the  different  parts  compoeing  the  thoracic  parieteit 
the  reverse  of  those  wliicb  previously  czistcl  indicating  dilatatioiL 
Irregularity  of  the  surface  of  the  affected  side.  Limited  exjUBaon 
movements.  Friction-sounds  much  ofteaor  discovered  in  this  stafi 
than  in  the  first  or  second,  and  in  this  stage  ft«t)nently  gruing  or 
rasping;  accompanied  sometimes  by  tactile Jremitua,  I}isplaceiaeBt 
of  tbe  heart  from  the  previous  pressure  of  tbe  liquid,  or  taking  plaoe 
aa  an  effect  of  absorption.  Abnormal  elevation  of  tbe  diaphragn 
and  subjacent  organs,  after  very  large  effusion,  and  lateral  disp]ao» 
mcnt  of  the  mediastinum  toward  tbe  affected  ndc^ 


CHHOXIC    PLKURITIS. 


527 


Chro:«io  Pleubitis. 


Chronic  pk-uritis  with  copious  scrouo  cffti^ion  is  entitled,  clinically, 
to  be  considered  as  an  afTection  distinct  from  acute  inflainmatioa  of 
the  pleur*,  since  it  rarely  follows  or  ia  preceded  by  the  latt«r ;  in 
the  majority  of  cases  the  inflammation  ia  eubacute  from  the  Kr»t. 
The  anatomical  conditions,  however,  as  far  as  concerns  their  rela- 
tions to  physical  signs,  are  essentially  the  same  as  in  acute  pleuritis 
after  sn  nccuinulutioii  of  liquid  bail  taken  placv.  The  chief  point 
of  difference  relates  to  tho  quantity  of  effusion.  In  chronic  pleu- 
ritis with  copious  efrusicn,  the  quantity  commonly  attuins  to  wi 
amount  which  is  only  occnjiioiiuny  ohsorved  in  the  ncutc  variety. 
The  clinical  history  of  the  former  is  therefore  characterixed  by  tho 
phenomena  to  which  a  large  nccnraiilation  gives  rise.  When  cases 
of  chronic  pleuriiis  present  themselves  to  the  physician,  tlicy  ex- 
hibit one  or  two  phases  of  the  nfl'ectiun ;  and  it  sufScos  fur  practical 
convenience  to  consider  each  phase  as  a  distinct  period  or  stage. 
The  two  periods  or  stages  correspond  to  the  second  and  third  of 
acnle  pleuritia.  The  first  period  or  stage  of  the  latter  is,  in  fact, 
wanting  in  chronic  piciiritis.  The  first  period,  or  stage,  will,  then, 
eoiitinno  SO  long  as  the  liquid  in  the  pleural  sac  is  accumulating,  or 
remains  stationary.  This  may  he  termed  the  stage  of  accumulation. 
The  second  period  or  stage  extends  from  the  lime  when  the  liquid 
begins  to  diminish,  till  it^  removal  is  effected;  and  this  may  be  called 
the  stage  of  absorption.  The  first  period  is  frequently  of  brief  du- 
ration, hut  it  varies  in  this  respect  considerably  in  different  cases. 
The  second  period  is  usually  much  longer,  being  rarely  limited  to  a 
few  wwks,  and  often  embracing  many  months. 

It  was  reinarlte*!  by  l)r.  Hope,  of  chronic  pleuritis,  that  "  there 
b  no  class  of  affections  more  habitually  overlooked  by  the  bulk  of 
the  profession  than  this;"  and  the  previous  histories  in  the  cases 
that  have  fallen  under  my  observation  have  afforded  evidences  of  tho 
correctness  of  the  remark.'  This  fact  renders  the  diagnosis  a  sub- 
ject of  importance.  The  fact,  howover,  is  significant,  not  of  in- 
trinsic difficulties  in  the  way  of  discriminating  the  disease,  but  of 
the  extent  to  which  physical  oxplorntion  of  the  chest  is  neglected. 
Afl  regards  physical  signs  and  tho  points  involved  in  the  diagnosis, 

'  llrf^  Clinical  Report  «a  Chronic  PlourUj,  bued  on  nn  »nali(«U  uf  furlj- 
seven  cm«*,  recordvcl  by  tb«  author.    1S&8. 


6S8 


DISBABS8  OF  THl   RBBPIRATOBT   0R0AK8. 


Hkj  have,  for  the  ino»t  part,  b««R  iMnbraocd  in  Uic  e«ns>dentkni  of 
acute  plcnritts.  Iiiajtmiich,  however,  m  fnmilinrity  wttli  tbe  phe- 
nomena. Bttaiiictl  hy  exploration  and  their  combinations  is  oalj  n 
be  acquired  bj  repetition,  n  recapitulation  of  thew  signs  and  tlu 
diagnostJc  ptMitta  in  tho  present  cooncction  will  not  be  disadvaatv 
geiHia  to  tbe  Mudeot, 


J 


Phytical  Signs. — A  patient  with  chronie  plcuritis,  who 
under  obscrrution  while  the  serous  effuHioQ  is  either  acconiaUtitig  tr 
romaina  stationary  at  the  highest  point  of  aceamalatioD,  wilt  be 
found,  in  tho  great  majority  of  cases,  t«  present  the  physical  eti- 
denc«  of  a  sufficient  quantity  of  liquid  in  tbe  pleural  sac  to  fill  the 
affected  side,  compressing  the  lung  into  a  small  space;  and,  fre- 
quently,  the  phenomcoa  incident  to  enlargement  and  displacvoeiit 
of  other  intra-tboracic  organs  are  superadded. 

Tho  percussion-sound  is  flat  from  the  base  of  the  chest  Dpnid 
over  tbe  whole  or  greater  part  of  tho  aSectcd  side.  A  tympaniiie 
resonance  may  be  discovered  at  the  eummit,  with  perhaps  an  am- 
phoric intonation.  The  want  of  elasticity  of  the  thoracic  p«rietH 
and  sense  of  resistance  felt  in  percussing  are  marked. 

In  the  majority  of  caseK,  at  least  in  adults,  all  respiratory 
is  suppressed  over  the  greater  part,  and  sometimes  orer  tho 
of  the  affected  side.  In  a  small  proportion  of  instances,  in  adalts.t 
bronchial  respiration  may  be  perceired  more  or  less  difTused.  It  'a 
feeble,  and  conveys  the  Impression  of  distance,  except  at  the  nunmit. 
In  the  infra-olavicular  region,  in  a  certain  proportion  of  caaet,  in 
the  upper  scapular  region,  in  a  larger  proportion  of  cases,  and  intha 
interscapular  region  in  most  cases,  a  bronchial  respiration  may  bt 
disoovered,  more  or  less  intense,  and  seemingly  near  the  ear.  It 
very  rarely,  in  either  of  these  situations,  has  that  intensity  wfakk 
belongs  frequently  to  the  branchial  respiration  due  to  lung  6oli£- 
fied  by  tuberculous,  or  still  more  by  inflammatory  deposit.  On  tbe 
healthy  side,  the  respiratory  murmur  is  intensifled  bat  Tesienlu, 
distinguished  as  exaggerated,  puerile,  supptementary,  or  hype^ 
vestciilar.  Increased  vocal  resonance,  exaggerated  bronchial  whisper, 
and  sometimes  bronchophony,  with  the  load  and  whispered  votct, 
may  be  found  on  the  affected  side  in  the  interscapular  space,  and 
less  frequently  in  the  upper  scapular  and  the  infra-clancular  rfr 
gioD.  Elsewhere  than  at  the  summit,  these  vocal  signs  are  wandiij. 
^gopbony  is  an  event  of  rare  occurrence. 


CHROXIC    PLB0RITI8. 


SS9 


I 

I 


Tnfpcction  diflcovcre  comparative  or  positive  iiiiiiio1>iliij  of  the 
nde  sficctod;  itD<I  on  the  opposite  «i(Io  the  respiratory  movemeotfl 
c  manifcetl;  incn-uscd.     The  iiffvcted  side  mnr  remain  quite  mo- 
ionlriu  CTCQ  when  the  respirations  are  forced,  or  there  may  be  a 
ilight  ami  tardy  elevation  of  the  ribs.     In  proportion  as  the  side  is 
'liiit  little  alfeetcd  hy  foreed  respiration,  it  is  uf^ually  enlarged  in  size. 
t  may  be  distended  to  quite  or  even  beyond  the  extreme  limit  of  a 
oIuDtsry  expafi!>ion.     The  ribs  are  raised,  and  they  approach  to  a 
orizontal  dirc<!tion.    The  lower  ribs  diverge  and  the  upper  converge, 
'be  intCTcovtal  deproi«.«ion8  arc  effaced,  and  there  may  be  bulging 
between  the  rib*.     The  nipple  i*  raised,  and  removed  to  a  greater 
distance  from  the  median  line  than  that  on  the  opposite  side.    The 
side  presents  an  unnaturally  regular  and  smooth  appearance.    Slight 
ocdematous  infiltration  beneath  the  integument  of  the  affected  side 
U  sometimes  observed.     Semicircular  measurements  with  the  in- 
clastic  tape,  applied  just  below  the  nipple  and  the  lower  angle  of 
ithe  scapula,  show  an  increase  of  size,  varying,  not  only  in  different 
cases,  bnt  at  different  periods  of  this  stage,  the  maximum  being 
bont  two  inches.     Diametrical  mensuration  with  callipers  will  also 
show  enlargement  between  different  points. 

Palpation,  in  conjunction  with  percussion  and  inapectioD,  shows 
displacement  of  movable  parta  within  the  cheat,  in  addition  to  tbe 
oompre»sion  and  elevation  of  the  pulmonary  organs.     The  heart,  if 

tthe  left  .Hide  he  affected,  is  pushed  to  the  right,  carried  beneath  the 
SternniD,  and  frequently  transferrt^d  to  the  right  itide,  being  found 
to  pulsate  somctinie:^  even  beyond  the  nipple;  if  the  effusion  be  in 
the  right  side,  it  ie  elevated  and  carried  in  a  diagonal  direction  to 
the  left.  The  mediastinum  is  displaced  laterally,  and  flatness  on 
percussion  is  sometimes  discovered  not  only  over  the  sternum,  bnt 
for  a  distance  beyond  on  the  opposite  »iAe  ;  the  dislocation  of  the 
heart  will,  of  course,  give  rise  to  dulnesa  over  its  new  situation. 
Depression  of  tho  diaphragm,  with  the  viscera  in  contact  with  ita  in- 
ferior surface,  occasions  on  the  left  side  extension  downward  of  flat- 
nets  from  the  presence  of  liquid ;  and  on  the  right  side  hepatic  flab- 
Bess  to  an  abnurnial  extent  below  the  ribs,  a  tumor-like  projection 
B  CBDsed  by  the  anterior  surface  of  the  liver,  and  a  sulcus  above  due 
^  to  iho  oonvcxity  of  its  uppt^r  fiurface.  This  sulcus,  as  remarked  by 
Stokes,  may  after  a  time  be  Inst,  before  absorption  takes  place,  in 
consequence  of  the  convexity  of  the  liver  being  dioiinished  by 
pressure. 

U 


580 


DISKA8B8  OF  TDB  RESriKATORT  OBOitlTB. 


Flucluation  in  the  mtcroo«l&I  spaces  may  sometimes  be  disco* end. 

The  Tf>cal  fremitus  nsturnl  to  tlio  afiecteil  eide  is  abolished. 

During  the  second  period,  (he  physical  signs  trill  preaeiBt,  ttnfr 
ccssive  explorations,  repented  at  intervals  of  some  dnntioo,  miv 
tiona  in  degree  rsther  than  in  kind,  according  to  the  rapidity  «nk 
vhich  the  effused  fluid  is  removed.     The  change  maj  consist  in  a 
gradual  retnm  to  the  Donoal  comlitton  as  respects  the  sise,  m^ 
hility,  uid  relations  of  the  different  anatomical  parts,  inierul  tti 
external,  of  the  affected  side.     But  it  is  verj  rarely  the  case  that  a 
normal  condition  is  recorered,  and  the  natural  symmetry  of  the  AnA 
left  unimpaired.     As  the  quantity  of  liquid  diminishes,  the  enlu^ 
ment  of  the  vide  decreases,  and,  at  length,  the  site  falls  within  its 
natural  dimensions.     Depression  of  the  upper  thJnl  in  front  is  fint 
oboerred.  This  frequently  takes  place  while  the  semicircular  meassi*- 
ment  still  shows  enlargement.     Anally,  contraction  tuuTeiaaUy  ff 
th«  affected  side  is  a  uniform  result  when  the  liquid  is  eoiiq>teldy 
absorbed  or  reduced  to  a  small  quantity.     The  various  pbciHmat, 
ascertained  by  inspection,  which  are  incident  to  eonirxctioQ  of  ihe 
ehest  after  the  removal  of  pleuritic  effiision,  in  general  tenu,  an 
ihe  reverse  of  those  which  charaeteriie  dilatation.       They  ban 
already  been  mentioned  in  connection  with  acute  pleariti*,  and  ^Mf 
again  be  reproduced  under  the  head  of  the   Retrospective  DnP 
nusis  of  Chronic  I'leuritls:  they  need  not,  therefore,  be  here  ow- 
mermted. 

But  before  marked  contraction  of  the  chest  takes  plaoe,  tbe  di»- 
placed  intra-tboracic  organs,  especially  tbe  he«rt,  rclrogrsd*  tovaid 
their  normal  situations.  And  as  regards  the  final  dtspociMa  af 
these  organs,  certain  changes  are  liable  to  snceeed  chronic  plnrifi^ 
which  have  been  already  noticed,  inasmuch  aa  they  occasiooally 
follow  the  acute  variety  of  the  disease;  these  abo  will  Iw  recapita. 
laled  presently. 

Percu38ton>resonanc«,  in  proportion  a»  the  compressed  lung  under- 
goes  expansion,  beeonea  developed  at  th«  app«r  part  of  the  chert, 
and  extendi  downward.  Tbe  affected  side  over  the  ap»e«  oeeapM 
by  tbe  expanded  lung,  however,  in  most  instaaccs,  yields  a  dull  somd 
as  compared  with  tbe  r«9onanee  of  the  healthy  side;  and  if  lbs  Ksa- 
nance  be  marke'l.  a»  is  sometimes  the  casa.  It  is  TKicnlo-tynpaattie  n 
qgality.  The  respiratory  sound  beoomes  defefeped,  extending  losw 
and  lower,  bat  it  is  relatively  feeble,  and  for  saae  time  may  hava  a 
broncho-vesicular  character.    Tbe  vocal  rescmaneciaay  begreattfor 


CHBOHIO   PLBUSITIB. 


SSI 


Tcse  thftn  on  the  licalthy  side  The  same  is  trne  of  vocal  fremitus. 
Friction-MuantU  nre  froqtietitly  discoTerod  during  thia  stage.  They 
ar«  to  bo  sought  for  ovor  tbv  middle  and  lower  third  in  front,  lalC' 
i«Uy,  and  behind.  Thejr  arc  often  rough  and  loud.  I  have  knovn 
several  inj^tances  in  which  tliej  attracted  the  attention  of  th«  |)a- 
ticDtH.  They  I7IRV  be  acooiiiimnied  by  tactile  fremitus.  They 
persist  in  some  instances  for  a  long  period ;  I  have  noted  their  ex- 
istence in  a  caso  ten  months  after  the  date  of  the  commencement  of 
the  di^ensc. 

Agophony  is  sometimes  discovered  during  the  progress  of  absorp- 
tion. 

The  period  oconpicd  by  the  progressive  changes  indiealing  th« 
dimbution  and  removal  of  the  liquid  effusion  in  chronic  plcurilts,  as 
^ready  stated,  is  variable,  but  in  most  cases  it  extends  over  several 
months. 


IHagnom. — So  far  as  the  symptomatology  of  the  disease  U  con- 
cerned, irrespective  of  the  physical  signs,  chronic  plcuritis  is  often 
remarkably  latent.  Excluding  the  small  proportion  of  cases  in  which 
it  is  preceded  by  acute  pleurilis,  the  developiDcnt  of  the  affection  is 
very  rarely  attended  by  severe  prun,  and  frequently  this  symptom  is 
entirely  wanting.  In  obtaining  the  previous  history,  the  fact  of 
pain  having  existed  would  often  cscapo  notice  without  careful  in* 
quiry,  the  attention  of  the  pntient  having  been  at  the  time  scarcely 
attracted  to  it,  and  its  occurrence  being  forgotten.  When  cases  come 
ijn<ler  observation  after  the  disease  bus  existed  for  several  weeks, 
sbsencc  of  pain  is  the  rule.  Cough  and  expectoration  are  sometimes 
wanting,  and  are  rarely  prominent.  As  a  rule,  these  symptoms  do 
not  prwwde  the  development  of  chronic  plcuritis  except  they  depend 
00  antecedent  pulmonary  tuberculosis.  When  cough  is  present,  it  is 
generally  either  dry  or  accompanied  by  a  email  expectoration  which 
consists  of  mucus  more  or  less  modified.  The  sudden  occurrence  of 
a  copious  sero.atbuminous  or  puruloid  expectoration,  continuing  for 
a  greater  or  less  period,  indicates  ulcerativi;  perforation  of  the  pleura, 
commencing  within  the  snc,  and  establishing  a  communication  with 
the  bronchial  tubes.  This  accidental  event  give«  rise  to  pneumo- 
hydrotborax.  The  respirations  are  asnally  increased  in  fri'quency, 
bat  to  this  rule  there  arc  exceptions,  even  when  the  accumulation  of 
liquid  is  sufficient  to  remove  the  heart  to  the  right  of  the  sternum. 
The  increase  in  frequency  is  rarely  great  while  patients  are  tranquil. 


682  DtBEABBS   OF  THB   SE8PIBAT0RT  OBQAVS. 

Exercise  or  the  ase  of  the  voice  in  conversation  furnishes  the  evi- 
dence of  vant  of  breath.  Under  these  circumstances  dyspnoea,  with 
lividit;  of  the  prolabia,  may  be  produced,  which  is  rarely  observed 
while  patients  are  at  rest.  The  palse  in  the  majority  of  cases  is  more 
or  less  accelerated,  ranging  from  80  to  120  per  minute ;  but  I  have 
observed  it  to  be  even  below  the  normal  average,  viz.,  64  per  minute. 
Sweating  frequently  occurs  at  night,  not  uniformly  preceded  by  a 
febrile  paroxysm  or  exacerbation.  Chills  or  chilly  sensations  from 
time  to  time  are  apt  to  occur,  even  when  the  disease  is  simple,  i.  e., 
not  complicated  with  tuberculosis,  and  also  when  the  liquid  contained 
in  the  chest  is  not  purulent.  The  digestive  functions  may  be  more 
or  less  disordered,  but  in  some  instances  the  appetite  is  good,  and 
the  ingestion  of  food  occasions  no  disturbance  during  the  whole 
progress  of  the  disease.  Pallor  of  the  countenance  is  marked  in 
some  cases,  but  in  others  the  aspect  is  not  notably  morbid,  although 
the  chest  be  filled  with  liqnid  effusion.  In  a  large  proportion  of 
cases,  if  the  disease  be  uncomplicated,  the  progress  of  the  afft'ction 
is  not  attended  by  great  loss  of  weight  or  emaciation.  The  strength 
is  sometimes  preserved  in  an  astonishing  degree.  I  have  known 
instances  in  which  the  disease  was  allowed  to  pursue  its  course  with- 
out receiving  any  medical  treatment,  the  patients  prosecuting,  most 
of  the  time,  laborious  occupations.  Tlie  diagnosis  in  these  cases  was, 
of  course,  made  retrospectively.  It  is  not  uncommon  for  cases  to 
come  under  observation  when  the  disease  has  existed  for  several 
weeks  or  even  months  without  any  previous  application  having  been 
made  for  medical  aid,  little  or  no  inconvenience  having  been  expe- 
rienced except  from  want  of  breath  in  active  exercise.  Employments 
involving  violent  exertions,  such  as  chopping  and  sawing  wood, 
stonecutting,  the  duties  of  a  housemaid  of  all  work,  and  active 
participation  in  the  rough  outdoor  sports  of  youth,  have  been  con- 
tinued in  cases  that  have  fallen  under  my  notice,  when  the  cheat 
was  filled  with  liquid  which,  under  these  circumstances,  has  pro- 
gressively diminished  by  absorption.' 

Tlie  symptoms  of  chronic  pleuritis  embracing  so  little  that  is  dis- 
tinctive, the  disease  is  not  only  confounded  with  other  pulmonary 
affections,  especially  phthisis,  by  those  who  do  not  avail  themselves  of 

■  Tho  rate  of  morlalit;  from  uncomplicated  chronic  pleuriey  in  my  experienc« 
i«  about  17  per  cent. 


cnnoitic  PLBimiTiB. 


588 


I 


pbjeicnl  exploration,  but  frequently  eren  the  exUteoce  of  s  pulino- 
ti»r_T  nffccliofi  is  not  suspected.  Latent  intermittent  fever,  bilioua 
fever,  (IjTEpcpHia,  general  debility,  diseaee  of  beart,  and  ibe  ideal 
sffection  culled  "  liver  complaint,"  are  the  maladies  under  which 
patients  have  been  supposed  to  labor  in  coses  that  hare  fallen  under 
toy  obeeri'ation. 

To  determine  the  existence  of  the  disease  with  the  aid  of  physical 
signs  is  g;enerally  one  of  the  easiest  problems  in  diagnosis.  I  bare, 
however,  known  the  phenomena  to  be  atlribiiti^d  to  hepatization  of 
lung  by  those  who  bad  given  »»inc  nttenlion  to  the  expbiration  of 
the  chest.  Ciroamstanccs  pertaining  to  the  physical  signs  Htifhoe 
for  the  discnminatioii  between  the  presence  of  an  abundant  effu- 
sion and  the  solidilicalion  from  pneumonitis.  The  points  involved 
in  this  discriminntion  bnvo  already  been  presented  in  connection 
with  acute  plotiritis,  and  n«ed  not  be  rccnpitiilated.  But  in  view  of 
the  previous  himory,  when  flatness  is  found  to  extend  more  or  Ie«8 
ever  the  chest,  pneumonitis  is  almost  excluded  by  the  law  of  prob- 
abilities alone.  Antecedent  acute  inflnmmntion  of  the  pulnioriary 
parenchyma  would  he  evidenced,  in  the  x'act  majority  of  instances, 
by  rational  symptoms  having  occurred  which  do  not  accompany  the 
development  of  chronic  pleuritis,  viz.,  pain,  rusty  expectoration, 
febrile  movement,  and  coDBnement  to  the  bed  for  a  cvrtuin  period. 
But,  irrespective  of  this  point,  the  existence  of  chronic  pneuraoniliH, 
cither  M  a  sequel  of  the  acute  form  of  the  disease  or  as  a  primary 
affection,  is  exceedingly  improbable. 

The  iiScctions  which  may  give  rise  to  phenomena  closely  analo- 
gous to  those  belonging  to  chronic  plcnritis,  are  infiltrated  cancer 
of  lung  and  meditislinnl  tumor.  These  affections  are  much  lees 
frequent  in  their  occurrence  than  chronic  pleuritis,  and  the  liability, 
therefore,  to  error,  in  in  attributing  their  phenomena  to  the  latter 
ftffection ;  in  other  words,  to  suppose  that  chronic  pleuritis  exists, 
when  th*y  arc  present.  The  liability  to  this  error  is  somewhat  in- 
creased by  the  fact  that  in  both  these  affections  pleuritic  effusion  is 
apt  to  occur.  Infiltrated  cancer  of  the  lung  produces  contraction 
of  the  affected  ^idc  of  the  cheat.  Mediastinal  tumor,  on  the  other 
hand,  may  lead  to  dilatation.  In  the  first  instance,  the  disease  may 
be  raiiitalcen  for  pleuritis,  advanced  to  the  second  period,  or  the  stage 
of  absorption.  In  the  second  instance,  pleuritis  in  the  first  period, 
or  Nlago  of  liquid  avcumulation,  may  be  supposed  to  exist.     The 


&34 


DI8BA8IS  or  TIIK    BESPIRaI 


OROANil. 


point*  inrolrcil  in  the  differential  diagnosis  from  these  affections 
have  been  already  noticed,  in  the  precedinj;  chapter,  in  treating 
of  Cancer  of  (he  Lungs,  and  Cancer  in  the  Mo<liastinum.  A  brief 
reference  to  them  will  be  all  that  is  requisite  in  this  place. 

A  cancerous  affeotion  of  the  lung  or  mediastinum  (and  it  na^ 
coexist  ill  the  two  situations)  ia  more  uniformly  aocompanied  b^ 
oough  and  expectomtiun  ttian  chronic  pleuritis.  The  expeclorattOD 
is  more  ubnndant,  it  Woomiys  purulent,  and  it  is  frequently  characier- 
istic,  resembling  red  or  black  currant  jelly.  Ummoptysis  is  an 
event  of  frequent  ocourrenoe.  Pain  is  a  more  prominent  and  per* 
eititing  symptom.  The  puW,  on  the  contrary,  is  less  commonly 
accelerated  until  the  aff<,<ctiuu  U  quite  advance)].  The  oontraetiOD 
of  the  chi!«t,  produced  by  the  absorption  of  the  liquid  effiuiion  in 
chronic  pleuritic,  is  tiitimlly  greater  than  in  caws  of  inlilimtcd 
cancer.  In  the  latter  ulfection,  tbe  lots  of  strength,  piuaciation, 
and  pallor,  denote  >t  graver  malady  tlian  uncoDiplicutcd  ohronio 
pleuritis. 

Cancer  in  the  mediastinum  frequently  extends  more  or  less  into 
both  sides  of  the  cliuifl ;  giving  n»c,  of  course,  to  fintness  on  percus- 
sion and  other  physical  phcDOucnD,  not  limited  to  one  aide,  ■*  in 
cases  of  chronic  plearitis,  ERiiccmciit  of  the  inlcrcoslal  deprw- 
eione,  and  even  a  sense  of  fluctuution,  muy  be  produced  by  the  pre*- 
snre  of  a  tumor,  but  only  in  rare  instances,  whereas  tho  first  of  these 
effects  is  common  when  the  side  is  dilated  by  the  presence  of  liquid. 
The  dilatation  from  a  cancerous  or  other  tumor  is  often  partial  or 
circumscribed,  irregular,  and  extends  from  above  downward ;  while  in 
the  stage  of  aecnmulution.  in  chronic  pleurits,  it  becomes  general,  ex> 
tending  from  bt^low  upward,  and  the  enlargement  is  more  regular. 
Dyspnoea  ts  a  more  constant  and  prominent  symptom  in  casoe  in 
nhich  a  tumor  exists  of  suflicient  eiio  to  occjisJun  u  considerable 
dilatation  of  the  chest.  In  both  affections,  the  heart  and  dinphragm, 
as  well  as  the  lung,  are  subject  to  displacement.  But  when  tliis 
occurs  from  tho  pressure  of  n  tumor,  certain  symptoms  are  fre- 
quently superadded  to  those  incident  to  an  equal  amount  of  dia- 
plauement  from  tbe  accumulation  of  liquid;  vin.,  oedema  of  tlie  faoCt 
lividily,  swelling  of  the  veins,  dysphagia,  ■*  well  as  marked  dj 
DIM.  These  symptoms  are  due  to  prmnuro  on  tho  air-lubcA,  In 
vessels,  nerves,  and  oBsophagus;  on  the  other  band  liquid  accumnli 
lion  in  tbe  pleural  sac,  however  large,  never  producca  an  amount  of 
pressure  on  these  ports,  equal  to  that  which  results  from  a  Ur 


535 


ledlastinal  tumor.  The  symptoms,  therefore,  ju«t  niim«il,  «rc  di«- 
tinctive  of  the  latter. 

Revertiog  to  physical  signs,  in  cancer  of  the  lungH  or  in  the  me- 
diastinum, the  bronchial  respiration  anil  increased  rocal  resonance, 

bronchophony,  nre  often  fouml  over  the  pnrtsi  of  the  chest  in  which 
ig  either  liulne**  or  fl»tne>iti  on  percnssion.  Those  auscultatory 
arc  eminently  iliMiuclive  of  pulmonary  solidiGcation.  On  the 
other  hand,  in  chronic  ptcuritia,  aht>cnffc  of  respiratory  murmur  and 
ftWiitiou  of  rocal  rvsonanec,  hclow  the  level  of  the  liquid,  is  the 
rule,  the  reverse  occurring  in  only  excopiional  inatanoea.  Abeence 
of  respiratory  anil  vocnl  »ound,  with  flHtneitt>  on  percuitiiioD,  is  a  com- 
bination of  «igi)8  eminently  distinctive  of  the  presence  of  liquid- 
Vocal  fremitus  may  he  pr(.-8orvcd  or  increased  in  eases  of  cancerous 
infiltration  or  tumor;  it  im  uniformly  nolshly  dtminifibcd  ornholii<hed 
ImjIow  the  level  of  the  liquid,  in  chronic  pleuritic.  In  the  former  af- 
fections, we  may  expect  often  to  find  vesicular  resonance  oil  ptircus- 
BJon,  at  or  near  the  base  of  the  chest,  below  the  limit  of  dulness  or 
flatness.  In  chronic  pleuritis,  in  nil  save  some  tltv  rare  instiincej^ 
we  find  flutnoes  from  the  base  of  the  chest  extending  more  or  Icjsa 
upward. 

The  distinctive  circamatanoes  involved  m  the  diffbrential  diagnosis 
of  chronic  pleuritis  from  oanoer  in  the  mediasliuum  are  applicable, 
ID  a  great  measure,  to  tlie  discrimination  in  caaes  of  intra- thoracic 
tumor  arising  from  any  other  part  exterior  to  the  lungs. 


RETROSPBCTIVB    DIAaNOSlS   OF  CHRONIC    PLUtFKITtS. 


Cases  not  infrequently  are  presented  in  practice  in  which  it  is 
important  to  determine,  from  an  examination  of  the  chest,  whether 
chronic  pleuritis  have  existed  at  some  former  period.  A  sense  of 
weakness  in  the  chest,  and  some  deficiency  of  breath  on  active  ex* 
ereise,  are  apt  to  remain  for  a  long  time  after  recovery,  that  i», 
after  the  liquid  effusion  is  completely  absorbed,  and  there  are  no 
other  symptoms  which  denote  any  pulmonary  alfection.  hisiunces 
of  this  description  have  come  under  my  observation,  in  which  pa- 
tients had  experienced  the  di<K^ase  several  years  before,  its  character, 
perhaps,  at  the  time,  not  having  been  determined.  lo  other  cases 
there  are  present  symptoms  which  may  be  due  to  Numc  existing 
afiectioD  of  the  lungs,  and  in  endeavoring  lo  ascertain  its  nature, 
the  permanent  changes  which  have  resulted  from  tlie  pleuritis  iDutt 


S36 


DISBASKB   or  TtlR   BK6PIRAT0RT  OECAIIS. 


be  uken  into  socount.     Chronic  pleurititi  may  k-ad  to  oerUia  cw- 
sccuttve  ftlTectiona.     Dilatation  of  the  bronchial  tubes  b&s  ben  ob- 
•orved  to  folloir.     Emphytiema  mar  b«  a  result.     It  has  be«iiM^ 
posed  to  increase  tb«  liability  to  pulmonary  taberctitosis.     SlatittM* 
show  tb«  Utter  opinion  to  be  incorrect;'  but  phthisis,  of  eooTse,Bsp«- 
renes  in  some  instances,  and  it  is  not  infrequently  an  importnt 
problem  to  solve,  in  individual  cases,  whether  this  be  so  or  not;  i 
problem  which,  as  has  been  seen  already,  t»  rendered  more  diAcnlt 
by  the  chaiigos  consequent  on   llie  nbMrption  of  a  Inrgr  pldtridt 
elTusion.     The  retnMpectivo  diagnosis  of  chronic  pU-aritia,  therefon, 
\s  a  subject  which  appecra  to  ne  deMrring  of  wparute  oonsideratiou. 
Tlie  diagnosis  is  made  rctroapectivcly  by  means  of  the  resoote  m 
permaDeot  effects  of  the  di»caM.     Thcw  are  eesentinlly  the  pmi. 
mate  eBecia  which  do  not  enliroly  disappear  for  ao  ind<^finite  petiol, 
or  eren  during  the  rcmaindor  of  life,  and  they  hare  already  been  id- 
verted  to.     They  connst  in  contraction  of  the  chest,  altcrstiow 
in  the  rtrlatioriN  of  diflcrent  anatomicnl  parts  on  the  exterior  of  the 
thoracic  parietes,  displacement,  in  soma  instance*,  of  intra-tbontit 
organ&i  and  a  disparity  between  the  two  sides  in  au:<cullatory  and 
p<>  re  ti^  ion -sounds — in  Khorl,  disturbance  of  the  tinlural  symraelryff 
the  two  sides  of  the  chest,  as  respects  the  results  furnished  by  tW 
d ilTcr en t  methods  of  physical  examination.    This  distarbaoce  of  tjwr 
metry,  presenting  cbarnclcrs  which,  collectively,  are  highly  sigoifi- 
cnnt  of  the  pre>cxistcnee  of  chronic  pleurilis,  justify  a  retroepectiT* 
diagnosis.     For  whnt  length  of  time  after  recovery  is  this  diaglMM 
practicable  ?    This  will  of  coursei  depend  on  the  persistency  of  the 
Ghafacter!ijui>l  referrcit  to.     The  period  doubtless  varies  in  differeat 
oases.     The  changes  immediately  succeeding  the  disease  gradually 
diminish,  and  examinations  repeated  at  long  intervals  show  progret- 
sive  advancement  toward  restoration  of  the  natoral  sytumetry.  Mnrfi 
will  depend  on  the  extent  of  the  proximate  effects.     The  age  of  the 
patient  will  also  affect  the  final  condition.     In  proportion  to  youths 
other  things  being  equal,  will  be  the  oltimate  approximation  to  ths 
normal  symmetry.     But  in  many,  if  not  most  instances,  charaeten 
sufficient  for  a  retrospective  diagnosis  remain  during  life.     I  have 
notes  of  examinations  made  many  years  after  recovery,  the  trace* 
of  the  disease  being  strongly  marked.     The  brief  aceount  which  I 


1  Fu/<  "  Practical  OtuoTvalliina  nn  OH*ln  Dtfimu*  or  ih«  ChMI,  «te.  Bv 
Pey^a  BtakUton,  M.D."  Am.  Ed.  1848.  Abo,  ■■Clioiol  B«port  oa  Chroak 
FUwiaj,"  bf  author. 


CnnOXIO  PLRTIItTTTS. 


687 


I 
I 


I 


AM  give  of  the  remoto  cfTrcU  on  wliinh  the  retroopoctive  ^ingnoflis 
is  to  be  b&soJ,  will  be  derived  from  the  notes  of  fifteen  exaniinnlions 
of  different  pulicnlit,  mnHe  at  pcriodf*  varying  from  ten  months  to 
ten  ycnrs  from  the  iJate  of  the  utinck.  In  h11  tliew  oa»e»  recovery 
hni  tukcn  place,  and  the  patients  (all  of  them  a<lii!ts),  so  far  a3 
could  be  judged  from  the  symptoms  aud  tigns,  vrcre  free  from  any 
existing  pulmonary  disease.' 

Of  fourteen  cases  in  which  either  the  existence  or  noii -exigence 
of  diminished  width  of  the  chest  was  noted,  it  had  occurred  in  nil 
Mvo  two,  and  in  these  two  instances  there  wan  finltening  of  the 
summit.  In  one  case,  at  the  summit  of  the  affected  side,  instead 
of  depression,  there  was  greater  comparatire  fulness;  and  this, 
coexisting  with  a  vesiculo-tympanitie  percuss! on -rcsonnncc,  and 
fechleneea  of  the  renptrntory  murmur,  showed  that  emphysema  had 
become  developed  in  that  situation.  In  the  two  instances  in  which 
diminished  width  was  not  apparent,  the  examinations  were  made 
in  one  ten  months,  and  in  the  other  three  years  from  tbc  date  of 
the  disease.  The  relative  measurements  of  the  semi-circumference 
of  the  two  sides  were  noted  in  six  cases.  In  these  cases  the  con- 
traction varied  fiom  half  ati  inch  to  one  and  a  half  inches,  always 
allowing  for  the  right  side  half  an  inch  n*  a  normal  disparity.  The 
comparative  contraction  of  the  affected  side  after  pleuritic  in  partly 
absolute  and  in  part  relative,  the  opposite  side  augmenting  in  sise 
from  tbc  hypertrophy  of  lung  resulting  from  the  supplementary  in« 
crease  of  the  respiratory  movements.  The  disparity  between  the 
two  sides,  immediately  following  absorption,  gradually  becomes 
less,  especiiilly  if  the  patient  be  young.  For  example,  io  a  case 
attended  with  large  effusion,  removing  the  heart  to  the  right  of 
the  sternum  (the  left  side  being  affected),  the  contraction  after  re- 
covery was  strongly  marked  ;  in  the  space  of  four  years,  the  con- 
tracted side  had  expanded  so  as  to  leave  but  a  slight  apparent  differ- 
ence. A  similar  change,  after  the  lapse  of  two  years,  I  have  noted 
in  another  ctise.     In  both  instances  the  patients  were  young. 

Of  fourteen  cases  the  shoulder  was  depressed  in  all  but  three.  In 
one  instance  it  was  .slightly  elevated  on  the  affc-cted  side. 

Of  live  cases  in  which  the  vertical  position  of  the  nipple  was 
noted,  it  was  lowered  in  four  and  raised  in  one.  Id  one  instance  it 
waa  an  inch  lower  than  its  fellow. 


)  Two  CMU  tro  to  Im  4:xe»ptod  from  Ihl*  tlstomoat;  in  one,  dllhtatlon  of  ibo 
brODvliial  lubv),  »ii4  ia  tbv  otim,  parlUI  eiDphj'Kiaa  bvlng  luppOMd  to  oxltL 


538 


DI8BASB8  OF  TDB  KBSPIKATOaT  OBOAFS. 


Its  disUnce  from  ihc  median  line  was  noted  !q  three  eases,  wA  a 
«1I  it  was  nearer,  the  different  rarying  from  a  quarter  of  an  oA 
to  an  inch. 

The  distance  between  ibe  lower  ribs  was  compared  on  the  vn 
sides  in  three  cases,  and  in  all  it  was  diminished  on  the  affected  nd& 
In  one  instance  the  nhx  approximated  so  b»  almost  to  overlap,  h 
this  cn»c  there  existed  a  deep  depression  on  the  inferior  anterior 
»iirlac«  of  tbo  chest.  In  two  instances  the  npper  ribs  were  eo» 
jiared  in  this  respect,  and  found  to  he  divergent  on  the  aBected  ait. 

In  nine  cases  the  comparative  width  of  the  interscapular  spaces 
was  not«d,  and  in  eight  it  was  lessened  on  the  affected  nde.  In  om 
instance  it  was  one-half  less  on  that  side  than  on  the  other.  The 
difference  vaa  in  no  case  leas  than  one  and  a  quarter  inch**,  b 
the  single  excepted  instance  in  which  the  width  was  greater  on  tin 
a&'ccte<l  side,  ihia  wan  evidently  owing  to  the  existence  of  ^aal 
coTvature,  the  eoovexit;  looking  to  the  opposite  side-  Projectiua  of 
the  loner  angle  of  the  scnpnia  existed  in  all  the  c«»c8  in  which  the 
fncis  with  renpcct  to  this  point  were  noted,  vix.,  in  four;  the  sagw 
statement  will  appi;  to  lowering  of  the  scapula,  which  was  noted  it 
four  cases. 

Of  foarteon  cases  in  which  the  results  of  a  comparison  of  the 
breuthing  movements  on  ths  two  sides  wore  uotvd,  in  rH  save  one 
they  were  more  or  less  diminished  on  the  affected  side.  This  com- 
paratiTe  diminution  was  eridently  in  a  measure  due  to  ma  exagger- 
ated expanaibilitv  on  the  opposite  side. 

Dulness  on  percussion,  as  compared  with  the  resonance  on  the 
ude  not  affected,  existed  in  every  instance  in  which  information  rel- 
ative to  this  point  was  holed,  viz.,  in  thirteen  oases. 

Grcftt  clearness  of  the  pcrctissioo-resonaooe  was  aniformly  ob- 
served on  the  opposite  side,  anil  this  contributed  to  r«oder  the  coa- 
tnuit  between  the  two  sides  more  striking. 
-Feebleness  of  the  respiratory  sound  over  the  whole  of  the  affected 
side  existed  in  eleven  of  thirteen  cases.  This  was  rendered  more 
narked  by  an  unusual  intensity  of  the  vesicular  murmur  on  the  oppo- 
site side.  In  one  of  the  two  excepted  cases,  bronchial  respiratiw 
on  the  affected  side  behind,  below  the  scapula,  existed,  in  conjoao- 
tion  with  marked  bronchophony,  the  respiration  being  broncbo-Tesio* 
niar,  and  the  vocal  resonance  comparatively  feeble  over  the  scapola. 
This  combination  of  signs  rendered  the  existence  of  dilatation  tX 
the  bronchial- tubes  probable.     In  the  other  case,  bronchial  respin- 


CBBOSIC  PLRTTRITIS. 


Si& 


I 


I 


tion  and  bronchoplionj  exiHted  io  the  intemcapulnr  space  on  the  af- 
fected side.  The  reiipiration  yiu*  inicrruplod  on  the  aSieot«d  sid«, 
at  the  »ummit,  in  oiiv  in^tnncc.  In  fivv  cwv»  tho  respiralor;  sound 
presented  certain  of  the  characters  of  the  bronelio-veiiioiilnr  rcspi- 
raliou,  coii^tnting  cither  in  diminished  vesiculur  quality,  with  etc* 
Tnlion  of  pitch,  of  the  iDspiration,  or  a  prolonged  high  expiration. 
The  akHencc  of  ttiefto  characters  in  the  other  cases  i»  itut  always 
staU-d. 

Thv  results  of  a  compariMn  as  respects  vocal  resonance  arc  giren 
io  lei)  instances.  In  six  of  these  cases  the  rcsonstic*'  was  gn-ater  on 
the  aflfeeted  side;  but  of  these  six  cases,  tn  three  the  right  siilv  vas 
the  ouc  aSfcutcd.  On  thu  other  hand,  the  four  cases  in  which  the 
vocal  resonance  ivns  not  greater  on  the  affected  side,  included  two 
in  vhich  thv  left  side  was  the  one  affected. 

Of  six  cases  in  which  the  vocal  fremitus  on  the  two  sides  vas 
compared,  in  fi>iir  it  was  greater  on  the  affected  side,  and  in  three  of 
tbese  four  instances  the  left  side  was  the  one  affected. 

Tlie  situation  of  the  apex  impulse  of  the  hr^art  wiis  noted  in  seven 
CMes.  It  was  normal  in  thri-e  instances.  In  the  remnitiin^  four 
instances  thv  facts  were  as  follows :  in  two  cases  an  impulse  was 
perceptible  between  the  third  and  fourth,  and  also  between  the 
fourth  and  6ftb  ribs.  In  one  of  these  inManccs  it  was  not«d  that 
the  movements  in  these  two  situations  were  in  ahernatioo  ("fiMn 
undulatorj^").  In  both  the  left  side  was  the  one  affected.  Id  one 
instance  the  impulse  was  on  a  line  with  the  nipple,  and  one  and  a 
lialf  inched  below  it.  In  the  other  case  a  diffused  pulsation  was  ap- 
parent over  an  area  three  inches  in  diameter,  situated  above  the 
sipple.     In  the  two  last  instances  the  left  side  was  the  one  affected. 

Curvature  of  the  spine  was  noted  in  four  of  Bcven  cases.  In 
three  instances  ilie  curvature  w.as  lateral,  and  in  one  instance  in  an 
anterior  direction,  causing  the  patient  to  assume  a  stooping  gait. 

The  foregoing  results  are  not  given  as  embracing  data  suCBcient 
for  determining  the  numerical  ratio  in  which  the  several  changes 
respectively  occur.  TbiH  would  be  an  interesting  object  of  tntjuiry, 
and  I  regret  that  I  biive  not  availed  myself  of  the  opportunities 
that  have  been  presented,  to  accumulate  materiaU  for  au  analysis 
with  reference  to  it.  In  the  few  cases  analyzed,  it  will  he  obiicrved 
that  pains  were  taken  to  note  facts  respecting  all  the  points  in  a 
small  proportion  only,  the  attention,  in  most  instances,  being  limited 
to  obvious  contraction,  a  comparison  of  the  expansibility,  the  per- 


540 


DISEASES  OF  THE  BBSPIBATOBT  OBOAX8. 


COSMOS  souni],  nntl  llic  inlrnsitj  of  the  rcRpintory  nmnniir.  Tht 
rccults,  howi^vcr,  nro  nilcquntc  to  »boir  the  gron^  of  charsctenbj 
mcaii»  (if  which  th«  rctrojiiM-ctivc  dlngnosin  is  to  be  mnde,  for  muj 
monlh.4  or  years  »fler  recovery  from  ohrouic  pleurisy.  Thia  is  tbt 
only  piirp^M;  (  haw  hud  in  view,  niiij  these  cbiraeter*  an  rempii- 
uUled,  ill  the  summnry  which  follon. 


eVUUAKT   OP  CHARACTBR<1   INVOI.VKD   IN   TUB    EKTROSPBCTITI 
DIAGNOSIS   or   CHRONIC    FLRUBtSY. 


Diminished  width  of  (he  chest,  apparent  on  inspection  io  the  jmt 
mnjority  of  o:i!i<.'9.  Depression,  or  flattening  at  the  summit  of  the 
affected  itlde,  ahiiost  inrarinbly  oWcrred;  but  ocasionally  enlarge- 
ment, vrliich  probably  denotes  iibnorroal  dilalattan  of  the  atr-cella,  er 
emphyaeinn.  The  n^ductton  in  sisc  al«o  shown  by  tnenanratiea. 
The  shoulder  gt^ner&Ily  dcpresMcd ;  but  in  some  ioilancc*  thia  is  Mt 
apparent,  and  it  may  be  even  raided  aborc  the  level  of  that  on  the 
opposite  »dc.  The  nipple  nsually  dcprc»(od,  but  not  inrarinbly,  and 
nearer  tlie  median  line.  The  lower  ribs  contergiog.  sometRMf 
almoHt  overlapping;  the  upper  ribs  diverging.  The  distance  froa 
the  posterior  margin  of  the  scapula  to  the  spinal  column  leeeeocd, 
often  in  a  notable  degree,  an  exception  to  this  rule  obtaining,  ia 
some  instances,  when  lateral  cnrralure  of  the  spine  takes  plncei,  the 
concavity  looking  toward  the  affected  side.  Projection  of  the  lower 
portion  of  the  scapula,  occurring  in  a  certain  proportion  of  instance*, 
and,  also,  depression  of  the  inferior  angle  below  the  level  of  that  on 
the  opposite  side.  The  respiratory  movements  almost  uniformly 
diminil^hed  in  a  degree  more  or  less  marked,  the  expansibility  on  the 
opposite  side  being,  at  the  same  time,  exaggerated.  Cowparattfe 
dulness  on  percussion,  the  contrast  rendered  more  striking  by  tW 
great  clearness  of  the  percussion-resonance  on  the  opposite  side.  A 
vesic u I o> tympanitic  resonance  at  the  summit,  conjoined  with  enlorgt- 
tnent,  denoting  the  supervention  of  emphys*nia,  Feeblene«s  of  res- 
piratory sound  over  the  entire  side,  with  few  exceptions :  and  on  ihs 
opposite  side,  an  unusually  intense  vesicular  murmur.  A  broncfakl 
respiration  sometimes  observed  in  tJie  interscapular  space,  and  in 
other  parts  of  the  affected  side;  in  the  latter,  especially  if  associ- 
ated with  bronchophony,  thcao  signs  perhaps  denoting  dilatation  of 
the  bronchial  lubes.    Tb«  respiration,  in  a  certain  proportion  of 


XMPTBUA. 


541 


Emptgma. 


eases.  broncho-TesicuUr.    The  vocal  resonance  sometimes  increased, 

tbut  not  uniforinly.     The  same  sUtement  applicable  to  vocal  frem- 
iltis.      Curvature  of  the  spine  in  some  cases,  the  inclinatioD  lat- 
eral, and  the  concsrit;  toward  the  affected  side.    The  position  of 
the  heart  frequently  normal,  bni  in  some  instances  displacement  of 
this  organ,  it  being  found  to  the  left  of  its  natural  position  and 
■  elevated,  if  rhe  pleuritis  be  seated  in  the  left  side.* 
H      It  will  be  borne  in  mind  ibat  this  summary  embraces  characters 
Hobscrved  in  persons  after  complete  recovery  from  chronic  pleuritis, 
H  »nd  presumed  to  he  entirely  free  from  any  existing  pulmonary  dis- 
ease, excepting,  in  some  instances,  emphysema  and  dilatation  of  the 
I  bronchial  tubes. 
When  the  liquid  contents  of  the  pleura  are  pnrulcnt,  the  affection 
is  geneniliy  called  empyema;  a  better  term,  used  by  some  writers, 
is  jfyothoras ;  a  still  better  tenn  is  tuppurative  pUurt'lit.    Empyema 
w,  in  fact,  only  a  variety  of  ploHriiis;  but  in  view  of  certain  patho- 
logical pcculiaritii«,  there  U  a  propriety  id  considering  it  as  a  distinct 
form  of  the  disease.    InHummution,  either  acute  or  chronic,  in  this,  as 
in  oiher  situations,  evince*  in  some  instances,  a  peculiar  tendency  to 
the  formation  of  pus.    This  tendency  is  independent  of  the  intensity, 

I  nor  does  it  depend  on  the  duration  of  the  inflammation  or  the  amount 
of  e6'uscd  products.  The  symptoms  denoting  a  high  grade  of  inflam- 
matory action  may  be  equally  absent  when  the  chest  is  Blled  with 
'purulent  matter,  as  in  ordinary  cases  of  chronic  pleuritis;  and  death 
may  occur  with  an  nccumulation  of  pleuritic  effusion  of  long  standing 
when  the  chest  contains  only  serum  and  lymph.  Empyema,  there- 
fore,  seems  to  be  n.  form  of  pleuritic  inflammation  differing  from 

•  ordinary  pleuritis,  ab  initio,  in  a  tendency  to  the  formation  of  piw. 
Clinically,  however,  it  ia  by  no  means  easy  to  distinguish  empyema 
from  ordinary  chronic  pleuritis,  and,  indeed,  a  positive  dtitcrimina- 
tion  by  means  of  the  symptoms  und  signs  is  impracticable.  The 
physical  phenomena  tn  both  arc  equally  those  which  are  due  to  an 
I  accumulation  of  liquid.  There  are  none  which  are  distinciire  of 
i  the  character  of  the  liquid.     Bulging  between  the  ribs,  which  has 


1  Th«  llabllilf  of  Ibe  h«ut  to  bo  pnnu&nontlj  drawn  toward  tbe  rlgbl  *ld« 
Fkfter  pl«uiitu  affooting  tlist  lidc,  hw  been  slread;  adverted  to. 


&42  DI8BA8SB  OF  THB  BS8PIRAT0KT  OEGANS. 

been  sapposed  to  indicate  the  presence  of  pas  rather  than  serous 
effusion,  depends  on  the  quantity  of  liquid,  together  nith  a  condition 
of  the  intercostal  spaces  which  causes  them  to  yield  to  pressure, 
and  ie  significant  aliite  of  both  varieties.  The  occurrence  of  hectic 
paroxysms,  of  more  marked  and  persisting  febrile  movement,  or 
greater  gravity  of  the  local  and  general  symptoms,  cannot  be 
relied  upon.  I  have  known  the  fact  of  an  enormous  accumulation 
of  liquid,  which  was  found  to  be  purulent,  to  be  discovered  accident- 
ally only  a  few  days  before  death.  Cases  of  empyema,  as  well  as 
of  ordinary  chronic  pleuritis,  are  liable  to  he  overlooked,  patients 
being  able  to  go  about,  and  supposed  to  labor  only  under  general 
debility,  or  some  malady  not  seated  in  the  chest.  Several  such  in- 
stances have  fallen  under  my  notice. 

Assuming  it  to  be  determined  that  the  pleural  sac  is  more  or  less 
filled  with  liquid,  a  point  which,  as  has  been  seen,  by  means  of 
physical  exploration,  may  be  settled  with  promptness  and  certainty, 
it  is  highly  desirable,  with  reference  to  the  prognosis  and  the  man- 
agement, to  decide,  if  possible,  whether  the  liquid  be  purulent  or 
not.  A  rational  conclusion  may  be  formed  with  considerable  confi- 
dence if,  the  quantity  of  liquid  being  large,  it  remains  stationary, 
and  more  especially,  if  it  continue  to  increase,  in  spite  of  judicious 
therapeutical  measures  to  promote  its  diminution  by  absorption. 
In  the  great  majority  of  cases  of  ordinary  chronic  pleuritis  these 
measures  are,  to  a  greater  or  leas  extent,  successful :  the  amount 
of  fluid  is  reduced,  although,  after  a  time,  its  farther  reduction  may 
not  be  efTectod.  A  purulent  fluid  being  with  great  difficulty  ab- 
sorbed, it  la  much  more  likely  to  remain  undiminished  or  to  increase. 
As  regards  the  relative  quantity  of  liquid  at  difi'erent  periods,  this 
can  of  course  be  ascertained  with  precision  by  repeated  explorations. 

But  although  the  physical  signs  and  symptoms  are  not  adequate 
to  aff'ord  positive  information  as  to  the  character  of  the  liquid  con- 
tained in  the  pleura,  this  point  may  bo  settled  readily  and  demon- 
stratively by  a  method  involving  little  or  no  difficulty  or  danger.  I 
refer  to  the  use  of  the  exploring  canula.  The  cases  reported  within 
the  past  few  years  by  Dr.  Bowditch,  of  Boston,  and  others,  in  which 
paracenteeis  tlioraeia  was  performed  after  the  plan  proposed  by  Dr. 
Morrill  Wyman,  of  Cambridge,  Maaa.,' show  that  the  operation  may 

'  Viilf  Am.  Jour,  of  Med.  Sciences,  April,  1852.  The  method  reforred  to  con- 
tiste  in  uijiiig  a  small  canula,  which  ie  attuclied  by  a  Sexible  tuba  to  a  giiction- 
pump,  DO  coiislruuled  that  the  fluid  may  be  removed  from  the  cheat  Ihrougli  llie 


BMPTKMA. 


643 


be  rcsortei]  to  wiUi  H%M||flil|faj|j[.  in  order  to  determine  the  nature 
of  th*!  liquid  contciita  el'ww  MRSt. 

Prof.  T.  0.  Tliomxft,  of  tliiti  city,  has  designed  a  rerv  simple  in- 
strumNit  fur  removing  from  within  the  chi»l  a  sufficient  <]uantity 
of  liquid  to  determine  its  character.  The  instrument  conNiftUi  of  a 
email  glass  tube  and  bulb,  connected  at  one  end  nilh  a  small  India- 
rubber  bag,  and  at  the  other  end  with  a  flexible  tube,  which  may  be 
attached  to  an  extremely  small  exploring  trocar  and  cauulu.  Af- 
ter  {lerforating  the  cbest  and  introducing  the  trocar,  the  cauuin  i« 
attached  to  the  flexible  tube,  and  the  Huction^force  which  fo1lovt»  com- 
pression of  the  India-rubber  hag  Alls  the  g1ii»a  bulb  with  Uiu  liquid. 

It  i»  chiefly  in  eases  of  empyema  that  the  contvntti  of  the  pleural 
nc  are  discharged  spontaneously,  hy  menns  of  ulceration  and  a  6a- 
tuloui  communication,  either  directly  tlirough  the  Iboracie  piirictcs, 
or  indirectly  through  some  natunil  outlet.  The  cvucuittion  may 
toke  place  through  the  bronchial  tube^,  which  occurs  next  in  fre- 
quency to  perforation  of  the  walls  of  the  chest.  It  hiw  becu  known 
10  take  place  into  the  alimentary  canal.  The  sudden  occurrence  of 
a  copious  purulent  expectoration,  when  the  chest  ia  known  to  con- 
tain liquid,  \«  evidence  that  ulceration  has  ensued,  commonctng  from 
■within  the  pleural  sac;  but  the  phenomena  arising  from  the  prea- 
ence  of  air  and  lit^uid  in  the  cavity  of  the  pleura  are  speedily  super* 
added — the  affection,  in  short,  becomes  pncurao'hydrothorax. 

When  perforation  of  the  thoracic  parietes  occurs,  the  purulent 
fluid  collecting  beneath  the  uitegument  forms  a  fluctuating  tumor, 
evidently  situated  exterior  to  the  parietes  of  the  chest.  If  the 
pre-existence  of  an  accumulation  of  liquid  have  not  been  ascertained, 
this  tumor  may  be  regarded  as  simply  an  abscess,  not  communica- 
ting with  the  interior  of  the  chesL  I  have  known  this  mistake  to 
be  committed  by  those  who  were  not  accustomed  to  employ  physical 
exploration.  The  coexistence  of  the  physical  signs  of  a  large  accu- 
mulation of  liquid  in  the  pleural  sac,  rcndoni  the  connection  of  the 
subcutaneous  collection  with  empyema  altogether  probable.  But 
this  connection  may  be  established  by  compression  of  the  tumor. 
If  it  be  simply  an  abscess  beneath  the  integument,  it  is  irrcilueihlc 
by  pressure ;  but  if  the  fluid  be  derived  from  the  chest  through  n 


CMiiila,  »nil  dlxchargod  from  thn  jiump  through  another  •[>erlUTa.  For  a  nlniplor 
m«tboij,  hj  uiing  D>vid*on'*  Sjrioge,  «id«  PrmciplM  snd  Practice  of  Medidna, 
bf  th*  Buihor. 


M4 


DI8BA&ES   OF  TIIK    RKKPIR  ATORT  OROAXS. 


perforation,  it  may  bo  diminished  or  made  to  disappear,  by  fuTciBg 
its  contents  into  iJie  tlioracic  cavity.  Again,  a  tumor  eontttioing 
a  fluid  whicli  communicates  freely  vitL  liquid  in  the  cbe«t,  will 
be  obwrred  to  rise  and  fall  with  the  successive  sets  of  iiupin- 
tion  and  expinlion.  Moreover,  un  abbess  developed  exterior  M 
the  chest  would  involve,  geucrally  nt  least,  acute  inSaoiaatioa, 
sccvmpimicd  by  pain,  swelling,  hesl,  and  redness,  prior  to  floctm- 
tion.  Tliese  local  phenomena  do  not  precede  the  appearance  of  a 
fluctuating  tumor  due  lo  pciforatioQ  in  the  course  of  empjeno. 
If  the  tomor  be  opened,  under  the  erroneous  impression  that  k  it 
DOtbing  more  than  a  subonlaneous  abscess,  the  great  abunduoe 
of  the  purulent  discharge  will  lead  to  a  discovery  of  the  error. 

A  fluctuating  tumor  beneath  the  integoment,  due  to  pcrforatioa 
in  empyema,  is  sometimes  found  to  pulsate  syncbronotisly  with  the 
beating  of  the  heart.  This  may,  at  first,  excite  a  suspicion  of  u>eii- 
rism.  The  tumor  is  too  rapidly  developed,  its  Hcjuid  conivnt*  arr 
too  superficially  situated,  and  the  fluctuation  loo  marked  and  exic»- 
sive,  to  be  aneurisuial.  The  positive  signs  of  aneurism  are  wantinj, 
viz.,  the  bellows*  murmur  and  thrill;  and  the  phyiiicn]  signs  of  an 
abundant  accumulation  of  liquid  in  the  client  remove  all  doubt  as  lo 
its  chnrncter. 

A  pulsation  is  occasionally  observed  more  or  lees  difliised  over  the 
affected  side,  in  cases  of  empyema  in  which  the  liquid  is  retained 
within  the  pleural  sac.  This  gives  rise  to  a  variety  of  the  di 
which  has  been  called  puUalitij  empyema.  An  instance  ha*  fi 
under  my  observation,  in  which  the  shock  communicated  t«  the  waUl 
of  the  aflcctcd  side  led  the  attending  physician  to  suppose  that  the 
cose  was  one  of  disease  of  the  heart.'  Moderate  hypertrophy  of  the 
left  ventricle  actually  existed,  as  ascertained  after  death.  The  cir- 
cumstances, io  such  cases,  which  anthotize  the  exclusion  of  anea- 
rism  are  the  absence  of  its  positive  signn  furnished  by  auscult«liaa 
and  palpation,  vis.,  the  bellows'  murmur  and  thrill,  together  with 
the  absence  of  the  symptoms  due  to  the  prca^ure  of  an  intra-tborwo 
tumor  on  the  vciihcU,  nerves,  oesophagus,  and  air-paecages— symp- 
toms not  helougiug  to  the  clinical  history  of  liquid  scctimulation  in 
the  pleura,  however  large.  Taken  in  connection  with  these  n^alive 
points,  the  physical  signs  of  a  large  quantity  of  lii^uid  in  the  cheM 
establishes  the  diagnosis. 

>  CUa.  Beport  oa  Chronic  Pleuritic,  p.  4T. 


CrRCCHf^cRiBED  Plkuritis,  witb  Liqutd  Efpc6io:f. 

Circum8crib«d  inflatniniition  of  the  pleura,  either  vilhout  much 
liqutd  efliiflion,  cnlled  dry  plcaritis,  or  the  elTuHion  not  confined  within 
the  limits  over  which  the  tntlaniinstion  extends,  occurs  u  a  compli* 
cation  of  other  pulmonnry  uffL-ctioDS,  and  has  ulrendy  heen  noticed 
in  connection  with  pneumonitis  and  pulmon&rj  lubercnlosis.  Bat 
plenritis  may  be  partial  or  circumscribed,  iind  uccompiknied  by  more 
or  less  efTusion  of  liquid,  which  is  not  diffused,  but  which  not  gra?- 
itsting  to  llie  bottom  of  the  asc,  is  retained  by  iidhesions  at  the 
borders  of  the  area  of  the  inflatntnation.  Under  these  circumEtancea, 
the  fluid  is,  aa  it  were,  encysted,  occnpjing  between  the  pleural  ear- 
faoes  A  circumscribed  space  varying  in  size  and  in  situation.  la 
some  instances  there  exist  several  distinct  collections  of  liquid,  con- 
stituting, if  the  fluid  be  purulent,  what  has  been  denominated  muHi' 
loffvlar  emp^etna.  The  latter  variety,  as  well  as  that  in  which  the 
affeotion  is  untloeidar,  occurs  in  persons  who  have  previously  had 
general  plenritis,  followed  by  agglatinalion  more  or  less  extensive, 
of  the  pleural  surfaces,  but  leaving  one  or  more  spaces  in  which  the 
surfaecs  do  not  adhere.  Subsequent  attacks  of  inflammaljou  lim- 
itcil  to  tlic  non-uggliitinatcd  portions  of  the  membrane  constitute 
circumscribed  pleuritiii,  the  cfTuKiou  being  confined  wilhin  the  boun- 
daries of  the  space  or  spaces  in  which  the  surfaces  are  free. 

Tlie«e  local  collections  of  liquid  may  occur  in  ditfi^rent  situations. 
They  may  be  seated  between  the  diaphragm  and  the  huso  of  the 
lung,  or  at  any  point  between  the  costal  and  pulmonary  portions  of 
the  pleura  on  the  anterior,  posterior,  or  lateral  surface,  and  they 
have  been  known  to  take  place  between  the  lobes,  the  latter  having 
become  adherent  at  the  margins  of  the  interlobar  Gssure.  Ciroum. 
scribed  inltamntation,  in  these  different  situations  respectively,  is 
distinguished  as  costo-pulmonary,  diaphragmatic,  and  interlobar 
plcuritis. 

If  acute  inSammalion  be  seated  in  the  diaphragmatic  pleura,  cer- 
tain symptoms  are  pointed  out  as  somewhat  distinctive,  viz.,  severity 
of  pain,  forward  inclination  of  the  body,  cough  remarkably  paroxya- 
nal,  predominance  of  the  superior  costal  type  of  breathing,  hiccough, 
nausea,  and  vomiting,  jaundice  if  the  right  side  be  aSeoted,  aod 

35 


546 


DI8SASB8    0?    THE    RBSPtRJtTORT    OROAKS. 


BometimM  the  mits  lardontciu.^  It  may  hfi  doubted  if  these  ajap- 
toms  posses*  tnncfa  ilia^nostic  value.  Tbev  «re,  howerer,  voiikyof 
being  borne  in  mitx),  the  more  because  the  existence  of  a  drcns- 
Bcrlbeil  coUeetion  of  fluid  betwcon  the  diaphragm  and  the  lue  of 
the  lungs  is  delected  hj  means  of  physical  signs  with  much  grcaUr 
difficult;  than  in  other  aituutiona.  In  fact,  when  an  accumulation 
exists  in  this  part  of  the  chest,  if  small  or  moderate  in  amount,  a 
positive  diagniHis  is  bardi;  attainable,  Eten  with  the  adfantage 
of  the  occtirrcnce  of  perforation  of  the  long  and  the  duKharge 
throngh  the  hronebtal  tubes  of  purulent  matter,  assuming  that 
tuberculosis  and  pulmonary  abscess  are  excluiled  by  the  negatire 
results  of  physical  exploration,  it  may  be  difficult  to  determiw 
whether  the  collection  of  pus  have  taken  place  above  the  diaphragm 
or  in  B  subjacent  organ.  The  following  case,  which  came  under  mj 
observation  sereral  years  ago,  will  serve  to  illustrate  this  diffiealty: 
A  puiicni  entered  hospital  with  a  copious  expectoration,  apparently 
of  pure  pus,  which  had  existed  for  some  time.  Ten  ounces  were  ex- 
pectorated in  the  space  of  twenty-four  hours.  lie  wia  not  mtuk 
emaciated ;  the  pulse  wks  12 ;  the  respirations  were  24 ;  moderate 
diarrhoea  existed,  sod  it  was  reported  that  the  dejections  sometiiiiee 
contained  puiK  bat  the  latter  point  was  not  Mti]<fuctorily  aseeTtained. 
Physical  exploration  funii^bed  the  following  results :  £maciatiia 
not  sufficient  to  render  the  outline  of  the  ribs  vitiblc  Good  pereos- 
s  ion -resonance  at  the  SrUiDmit  of  the  chest  on  both  sides.  Flatnesi 
on  the  right  side  from  the  base  to  the  fourth  rib  in  front.  Behia^— 
jD  the  interscapular  space,  resonance  good  on  both  sides.  Flatne^^l 
below  the  inferior  angle  and  orer  the  lower  part  of  the  right  scapula. 
Tenderness  on  pre«sure  at  the  lower  part  of  the  right  aide,  extend- 
ing below  the  boundary  of  the  chest.  Respiration  on  the  left  side 
exaggerated;  on  the  right  side,  above  the  fourth  rib  feeble  bat 
resicular;  below  the  fourth  rib  absence  of  respiratory  murmar,  and 
a  distinct,  but  not  loud  friction-«onnd  with  both  respiratory  acts. 
Behind,  on  the  right  aide  respiration  feeble,  bronchial,  and  accom- 
panied  by  a  fine  mneous  or  sub-crepitant  rale.  Bronchophony  at  the 
angle  of  the  scapula. 

After  the  death  of  this  patient,  it  was  ascertained  that  a  pleuritic 
abscess,  as  it  may  be  called,  was  situated  at  the  lower  part  of  the 
right  side  of  the  chest.     Circumscribed  infiammatioD,  the  plental 

*  Wtiih*,  op.  tit. 


iciRCUIlBORIBED    PLBCRITIS,  WITH    LIQUID   BPFUSIOX.   647 


I 
I 


I 


» 


surfaces  being  free,  existed  over  a  strip  fire  or  six  incheB  in  vidtb, 
M  the  base  of  the  cbeet,  extending  from  the  lower  psrt  of  the  ster- 
num <)uite  around  the  right  side.  Above  this  strip  the  pleural  sur- 
faces  were  agglutinatod.  The  lower  lobe  of  the  right  lung  was  so- 
lidifits);  othervi»e  the  pulmonary  organs  vere  free  from  disease. 

The  silumtion  of  llio  circumscribed  empyema,  in  this  case,  accorded 
with  thephveical  signs;  yet,  in  view  of  all  circumstances,  and  baiano* 
ing  probabilities,  there  being  no  evidence  that  genera)  chronic  plea- 
ritiit  or  einprema  hnd  exiitti'd,  hepatic  abscess,  eracuating  through 
the  lungs,  bad  been  suRpccted. 

In  the  diagnosis  of  circumscribed  collectiona  nf  liquid  allunted 
bciirct-n  the  costo-piilraonary  pleural  *iirfjice.s  olsewhero  than  at  the 
base  of  the  chettt,  pliysicnl  eign^  arc  more  available.  Dulness  or 
flntnesK  on  pcrcu»»ion  is  found  over  a  tipaee  corresponding  to  the 
area  within  whidi  the  lli^uid  is  confined.  Elfacemcnt  of  thu  inter- 
costal depressions  and  even  bulging  may  he  observed  in  this  space. 
The  vocal  fremitus  is  wanting.  The  w-spiratory  sound  is  feeble  Or 
•bsent,  together  with  abolition  of  vocal  resonance.  Siirrouudiiig  the 
collection,  owing  to  the  pleuritic  udbusions  and  condensation  of  lung, 
there  is  more  or  less  intensity  of  respiration  which  may  be  broncho- 
Tesicalar.  The  signs  just  mentioned  will  be  eapecially  marked  ia 
cases  in  which  the  area  of  jileuritic  surface  occupied  by  the  elfusion, 
and  the  quantity  of  the  latter,  are  not  small ;  and  the  diagnosis  is 
made  with  more  poaitiveness  if  the  sitnation  of  the  collection  be  in 
the  middle  third  of  the  chest,  and  if  there  be  present  evidence  of 
general  plcurilts  having  existed  at  some  former  period. 

If  circumscribed  pluuritis  exist  with  a  fistulous  opening  through 
the  thoracic  walls,  the  probe  becomes  an  important  instrnment  in 
diagnosis.  An  interesting  case  of  this  description,  of  traumatic 
origin,  was  recently  under  my  observation  through  the  kindness  of 
my  friend  and  former  colleague.  Professor  Qross.  The  patient,  three 
months  before,  had  received  a  wouud  from  a  hatchet,  which  penc- 
Uatcd  the  chest  on  the  left  side,  between  the  first  and  second  ribs, 
about  three  inches  from  the  median  line.  Acute  general  pleuritis 
followed;  hut  he  was  now  able  to  be  up  and  about,  presenting  a 
healthy  aspect,  and  free  from  cougb  or  difficulty  of  reapiration  ex- 
cept after  active  exercise.  Tbe  left  side  was  considerably  coa- 
tracted.  A  small  fistulous  opening  existed  at  the  place  where  the 
wound  was  received,  from  which  about  a  tablcspoonful  of  puriform 
liquid  CBcapcd  daily.    To  evacuate  the  fluid,  which  be  was  acciu- 


S48  DIBBASEB    OP    THE    RESPIBATOET    OEOAITS. 

tomed  to  do  twice  daily,  he  was  obliged  to  lie  npon  the  floor  irith  hU 
face  dowQvard,  aod  the  body  incliiicd  to  the  left.  A  probe  intro- 
duced into  the  orifice  showed  the  exiBtcnce  of  a  circnmscribed  cavity, 
the  vertical  length  being  abont  five  inches,  and  the  orifice  near  ita 
upper  extremity.  On  forced  expiration,  air  was  espelled  through 
the  aperture  with  an  audible  noise;  and  the  patient  stated  that 
Bometimes  when  the  orifice  was  first  opened  by  detaching  the  in- 
crusted  lymph  with  which  it  became  sealed,  the  passage  of  the  air 
occasioned  a  loud  report. 

To  prevent  the  accumulation  of  liquid  in  the  cavity.  Professor 
Gross  penetrated  it  with  a  trocar  at  its  lower  extremity,  and  estah- 
liahed,  by  means  of  a  tent,  a  fistulous  orifice  in  this  situation.  This 
treatment  speedily  effected  a  cure,  the  cavity  becoming  obliterated 
in  a  few  weeks. 

The  existence  of  several,  or  mnltilocular,  collections  was  pre- 
sumed in  a  case  which  came  under  my  observation  five  years  since, 
of  which  the  following  is  a  brief  account:  The  patient,  a  girl  four- 
teen years  of  age,  had  been  subject  for  several  years  to  a  loud,  hard 
cough,  with  a  small,  transparent,  frothy  expectoration.  Five  weeks 
previous  to  the  date  of  my  examination,  she  had  suddenly  expecto- 
rated a  quantity  of  purulent  matter.  She  continued  to  expectorate 
the  same  matter  for  a  day  or  two,  and  the  expectoration  then  ceased. 
Afterward,  during  the  following  five  weeks,  she  had  several  similar 
attacks.  The  general  heaUfa  was  not  much  impaired.  On  exam- 
ination of  the  chest,  there  was  moderate  dulness  on  percussion  at  the 
summit  of  the  right  side,  with  no  distinct  abnormal  modification  of 
the  respiratory  sound.  Absolute  flatness  existed  over  the  lower  and 
most  of  the  middle  third  on  the  right  side,  with  absence  of  respira- 
tion in  front  and  laterally.  Behind,  on  the  right  side,  good  percus- 
sion-resonance extended  to  the  base.  There  were  no  rales,  and 
neither  the  bronchial  nor  the  cavernous  respiration.  Tenderness  on 
percussion  was  observed  over  the  right  mammary  region.  Nine 
months  afterward,  this  patient  seemed  quite  well,  but,  on  slight  ex- 
amination, flatness  over  the  lower  part  of  the  chest  on  the  riglit  side 
still  existed.    She  had  had  no  purulent  expectoration  for  some  time. 

Interlobar  pleuritis  with  liquid  accumulation  presents  difficulties 
in  the  way  of  diagnosis  still  greater  than  when  the  collections  are 
situated  between  the  costo-pleural  surfaces.  The  pressure  of  the 
liquid  here  is  not  directly  upon  the  thoracic  parietes.  Pulmonary 
substance,  more  or  less  compressed,  intervenes  between  the  liquid 


btdrothorax. 


549 


and  the  walls  of  the  chest.  Th«  pcrcuHsion-resoDance  kIU,  thcreforD, 
be  iDOrc  or  Iciis  dull,  but  not  flat ;  and  efTacfmcnt  of  the  intercostal 
deprewiono,  or  bulgiog,  will  not  be  likely  to  occur.  The  respira- 
tory soand  will  be  feeble  and  more  or  lexis  broDclio-veaicalar,  or  oven 
bronchial,  from  the  presence  of  condensed  lung.  Dr.  Wnlche  men- 
tions the  fact  of  the  accumulatiou  being  in  the  line  of  the  intorlobsr 
fixture,  aa  a  point  having  &  bearing  on  the  diagnosis. 

Circnrascribed  plcurilis  with  liquid  effusion  is  by  no  means  of  fre- 
quent occurrence.  It  is  only  now  and  then  that  coses  occur  to 
puzzle  the  diagnostician. 


I 


HYDROTnOHAX. 

Serons  effusion  within  the  pleura,  not  due  to  inflammation,  con- 
stitntes  the  affection  called  hydrolhorax.  The  effusion  is  purely 
eeroiu,  t.  e.,  consisting  of  serum  unmixed  with  inflammatory  pro- 
ducts. The  affection  is  never  primitive  or  idiopathic;  it  occurs  al* 
ways  B8  an  eff"ect  or  complication  of  some  other  disease,  and  in  the 
great  majoriiy  of  cases  it  coexists  with  general  dropsy,  incident  to 
etmctural  lesions  of  ihii!  heart  or  kidneys. 

The  diagnoiais  claims  but  a  few  words.  Its  pathological  connec- 
tion* constitute  a  diagnostic  point.  We  look,  as  a  matter  of  course, 
for  more  or  less  effusion  into  the  chest  in  cases  of  cardiac  or  renal 
dropsy.  The  afi'eclion  19  always  double,  unless  the  plenral  space 
on  one  side  be  aboliitbed  by  unirersal  adhe.ti»ns  arising  from  pleu- 
ritis.  The  causes  act  equally  on  both  sides,  their  modua  operandi 
being  purely  mechanical.  For  this  reason  it  is  impossible  that  the 
quantity  of  effusion  should  ever  be  sufficient  completely  to  fill  the 
chest.  A  near  approach  to  this  amount  of  uccumulatlon  tn  both 
sides  would  bo  incompatible  with  life;  and,  in  consequence  of  the 
affection  being  double,  a  moderate  amount  of  effusion  is  productive 
of  far  greater  disturbanee  of  the  respiratory  function,  as  denoted  by 
accelerated  breathing,  dyspnoea,  lividity,  etc.,  than  belongs  to  oasea 
of  chronic  pleuritia  in  which  the  whole  of  one  side  is  filled  with 
liquid.  Moreover,  the  pathological  conditions  associated  with  by- 
drotborax,  such  as  ascites,  hydro-perioardium,  organic  disease  of 
heart,  general  debility,  render  the  system  less  able  to  bear  up  under 
a  diminution  of  the  respiratory  function  than  in  the  majority  of 
cases  of  chronic  pleuritis. 

Except  in  degree,  the  positive  symptoms  offer  nothing  distinctive 


&50 


DISBASeS    01 


BSSPIRATORT    OEOAItS. 


of  hydrothoras.  Negatively  it  b  distiDgnisbed  from  pletiritia  hj  iW 
absence  of  the  symptoma  of  inflauimaiion,  viz.,  lancinating  paia, 
tenderness  on  pressure,  and  cou^h.  Those  syuptoma,  pre-^ni  to  i 
greater  or  less  exl«nl  in  m&ny  eaaes  of  pl«ariti«,  are  vanliog  i* 
hjdrothorax. 

Tlic  phjaienl  ti^s,  rcpr«»enting  in  the  plcaral  »ac  a  certain  qsaa- 
tity  of  liquid,  which  displaces  tho  lung,  perhaps  occasions  sone  to- 
W^rmont  of  the  infrrior  portion  of  tho  chest,  and  dt-prMM*  Uw 
diaphragm,  are  eswntially  the  same  in  hydrothorax  a»  id  pleorttti. 
It  b  unnecessary  to  recapitulmt«  the««  signs  in  this  connMtioo. 
Thercr  are.  however,  certain  points  pertaining  to  the  physical  phe- 
nomena, which  passess  diagnostic  significance.  The  risible  changM 
in  size,  form,  and  expansibility,  resulting  from  a  very  large  accomit- 
lation  of  liquid,  which  aro  obxerrcd  in  cases  of  chronic  plenritts.  are 
of  course  never  exhibited  in  cases  of  hydrothorax,  for  a  similar 
amount  of  iLccumuIation  in  both  sides  is  incompatible  with  life.  Is 
hydrothorax,  friction-sounds  do  not  occur ;  tho  condition  for  their 
production,  vis.,  roughening  of  the  pleural  surfaces  by  a  deposit  of 
lymph,  13  incident  to  inBaiumation,  and  does  not  obtain  in  a  purely 
dropiiical  affection.  In  oases  of  non-inSamtnatory  serous  effusion, 
the  liquid  can  ho  made  to  change  ita  level  by  varying  the  pOMtion  <tf 
the  patient ;  the  quantity  of  liquid  never  hocoming  very  large,  and 
the  pleural  surfaces  remaining  free,  this  test  of  the  existence  uf  >4r«- 
sion  is  always  or  generally  available,  whereas  in  pleurilis  it  is  em- 
ployed sncoessfully  in  a  certain  proportion  of  mmm  only.  I  havs 
met  with  several  cases  in  which  bronchial  respiration  and  broncho- 
phony existed  williin  a  limited  spncv  at  the  level  of  the  liquid  on 
both  sides,     ^guphony  is  sometimes  present. 

The  points  thus  hrteHy  adverted  to,  pertaining  to  tbe  Bymptonu 
and  signs,  taken  in  connection  with  the  oxistcntio  of  effusion  on  hoib 
sides,  and  ibe  foot  that  tho  affection  occur*  only  as  »  complicaiioa 
of  other  diseaaea  whJeli  give  ri«c  at  tho  same  time  to  general  dropsy, 
render  the  diagnosis  of  hydrothorax  easy  and  positive. 


PirBQMOTDORAX. 


PSBtJUOTBOR  AX — PkKD  HO-H  VDROT  DORA  X. 


An  aboonnal  condition  consisting  in  the  accumulation  of  air  or 
g&B  within  the  pleural  aac,  unaccompanied  by  liquid  elfiuion,  i^  de- 
nominated pneutaofhorax.  Ab  thus  defined,  this  affection  is  exceed- 
ingly rare.  The  secretion  or  exhalation  of  air  or  gas  from  the 
pleural  surfaces,  must  he  regarded  as  extremely  problematical. 
Pleural  rupture  over  the  dilated  cells  in  vesicular  emphysema,  or  of 
the  blebs  which  are  occasionally  formed  in  the  interlobular  variety 
of  this  disease,  is  an  accident  which  has  been  known  to  occur  in  a 
few  instances,  giving  rise  to  an  accumulation  of  air  in  the  pleura, 
tuaccompanicd,  for  a  time,  at  least,  by  any  morbid  product;  but, 
trader  these  circumstances,  inilammation  is  likely  soon  to  supervene, 
and  liquid  effusion  follows. 

Whenever  air  or  gas  gains  access  witiin  the  pleural  cavity  by 
other  modes,  the  accumnlAtion  of  liqaid  either  precedes  or  speedily 
ensues,  and  the  coexistence  of  air  or  gust  and  liquid,  let  the  character 
of  tho  tatter  be  whiit  it  may,  give»  ri.te  to  the  affi-ction  called  ^itmnto* 
hgdrothorai — a  more  correct  name  is  pleurilit  with  pneumolhoTox. 
From  what  has  been  said,  it  follows  thai,  although  pneumothorax 
may  exist  as  an  affection  distinct  from  pneumo-hvdrothorax.  the 
latter,  in  a  clinical  point  of  view,  ia  chielly  important.  In  relation 
to  diagnosis,  it  will  suffice  to  consider  both  affections  under  the  bead 
of  pneumo-hydrotborux,  making  incidental  mention  of  the  circum- 
stances which  cbnraclerixc  tlic  pre.ience  of  air  without  liquid — in 
other  words,  pneiimothornz.  It  is  to  be  remarked  that  our  knowl- 
edge of  tbitt,  as  of  several  pulmonary  affeotionN,  is  to  be  ilat<rd  from 
the  rc8carclie»  of  the  iUustrious  ilintvivcrcr  of  auscultation. 

Pneum  CI- hydro  tho  rax  is  always  either  of  traumatic  origin,  or  an 
effect  of  some  ttntrceilent  morbid  condiljon.  It  is  never  u  primitive 
affection.  And  with  reference  to  \\i  discrimination,  it  is  important 
to  bear  in  mind  the  various  modes  in  which  it  ortginates.  Moreover, 
ctrciimi«t.ince.'<  pertuining  to  its  different  pathological  connections, 
uffect  materially  both  the  symptoms  and  signs,  more  especially  the 
latter,  by  which  the  diagnosis  is  established. 

In  by  far  the  larger  prupurtton  of  cases  it  occurs  as  an  accidental 
complication  of  pulmonary  tuberculosis,  being  produced  by  perfora- 
tion of  lung  resulting  from  ruplnrc  of  the  pleura  over  cither  a  cavity 
or  a  collection  of  softened  tubercle.     The  rupture  generally  takes 


552 


PIGEAflRS    OF    THE    BBBFIRATORT    OBOAHS. 


p1ac«  during  »a  act  of  oongliiiig.  PneofDollionix,  tben,  hettimn 
saildenly  dcToloped,  and  is  ap«edily  folloired  hy  aciile  |vl(Dnit:>  viih 
li'gnid  uvctttniiliition.  The  vizc  of  the  porforation,  the  persi^lencTof 
»  fislutoas  opening;,  and  tlio  freedom  of  commtmicatJoi)  mUbUsbtd 
Wtireen  the  pleural  ca?itj  and  llic  broootiial  tube*  arc  circmnstaoai 
having  imporlaiit  i>carings  on  the  flcvclopuK'nt  of  cvrtain  plijaal 
sigii^.  Sintistiv*  »liow  ibal  tbis  accident  is  much  more  liable  to  occar 
on  tlic  left  tbuQ  on  the  rif;ht  side.  The  silnatioo  at  which  ii  ii 
ofU'nest  found  to  take  place  may  also  b«  borne  in  mind  viih  refer- 
ence to  physical  cxplorntion.  According  to  Wal»be,  it  ta  on  tke 
postcro-Uteral  surface  between  the  third  and  sisth  ribs.'  Its  occur- 
rcDce  in  the  progress  of  tuberculosis  is  rare. 

It  is  liable  lo  occnr  in  connection  with  cireoniscribed  gangren*  of 
the  lung,  the  pleura  giving  way  over  the  eitelmr,  inducing,  in  like 
mnnner,  perforation  and  pleuritis.  Tliis  is  s  rare  reetilt  of  a  rare 
form  of  di^teavc.     1  have  met  with  two  instances. 

Perforation  of  the  liing  takc«  place  still  more  rarely  in  connection 
with  pulmonary  apoplexy,  tubernilou»  affection  of  bronchial  jtlaods, 
0|>cning  into  the  bronchial  tubes  and  pleura,  abscess,  caticcr,  and 
hydatids.  And  it  may  b«  produced  by  an  ulcerative  process  takioj 
it»  point  of  departure  from  the  pleura  and  extending  to  the  hron- 
ebial  tabes,  in  ca^es  of  chronic  pleuritis  and  empyema. 

Perforation  of  the  thoracic  parietes  is  followed  by  the  entrance 
and  necumulnlion  of  air  within  the  pleural  cavity.  This  takes  flace 
in  certain  cases  of  empyema.  Abscesses  silnated  in  the  walla  of  the 
chest  may  result  in  an  external  communication  with  the  pleural 
cavity.  Thus  produced,  cases  of  pneumo>hydroifaorax  arc  disiin- 
guisbed  from  those  involving  perforation  of  the  lung  and  oomma> 
nicstion  with  the  bronchial  ta)>e«,  by  the  al>stene«  of  certain  physio] 
phenomena  which  involve  the  latter  anatooiiciil  conditions  in  th«r 
production. 

Penetrating  wounds  of  the  chest,  on  the  one  hand,  and,  on  the 
other  hand,  injuries  of  the  long  from  the  fracturc<l  extremities  of 
ribs,  or  from  contusion,  are  modes  by  which  the  affection  is  produced 
traumaticntly. 

Instances  hnve  occurred  of  a  fistulous  communication  between  the 


>  Thi*  b  qnatfd  n  uoro  ooFTwt  Ihaa  tbn*lat«in«nt  mado  67*0010  wTiten,  tlisl 
it  i«  tnoit  lialilo  to  «eciir  ntar  lh«  apex  of  tW  lung.  The  plmntl  ■dfaoioni  h 
abifornl;  occurring  at  Ik*  iuUBlt  r«ad«r  it  lets  liabla  to  oeeor  tii  llial  siHiBtiaak 


>SKHJIOtHOlTi 


sss 


I 


alimcDlary  csn&t  (cesopbagos  and  stouuili)  and  the  pleural  sac, 
tliroagh  which  the  gases  from  tlie  former  escape  iuto  the  Ultor  kit- 
nation. 

Finally,  in  some  very  turc  instances,  clicinical  decouipoxition  of 
liquid  conlMined  iu  tlii>  pleural  «uc  takes  place  tufRcicntly  to  occa- 
sion development  of  gaM,  irithout  perforation  either  of  the  lung, 
thoracic  pAricles,  stomach,  or  ojsophagus.  In  such  casein,  the  phe- 
noRiena  which  involve  the  admission  of  air  from  the  bronchial  tubes 
into  the  pleural  cavity  are  of  course  wanting. 

In  thiit  category  rosy  be  placed  the  transient  production  of  gas, 
JD  some  moile  not  easily  accounted  for,  in  connection  with  pnen- 
uoniiis,  of  which  an  instance  was  reported  by  Dr.  Graves,  and 
•nether  by  Vallelx.  These  cnscs  are  so  rcmarkublc  thai  if  they 
rcaled  on  the  testimony  of  less  competent  observers,  the  accuracy  of 
their  observation  might  well  be  questioned. 

Fliysieal  conditions  incideiitnl  to  pueuirio-hydrothorax  produced 
in  the  variotu  modes  just  mentioned,  which  are  represented  by 
physical  signs,  are  the  following :  The  presence  of  air  or  gas  and 
liquid,  in  greater  or  less  abundance,  and  in  both  varied  and  varying 
relative  proportions.  Perforation  of  the  thoracic  purictcs,  iu  80n« 
cases  giving  rise  to  fluctuations  as  reapect«  the  quantity,  absolute 
ftnd  relative,  of  air  and  liquid.     Communication  with  the  bronchial 

bea,  in  other  oatiK,  by  which  air  enters  more  or  less  freely  into 
the  pleural  cavity  in  reapiralion.  To  these  conditions  are  to  be 
added  those  belonging  to  different  antecedent  diseases  of  the  lung 
or  pleura  of  which  the  pni-umo-hydrothorax  ts  a  complication. 


IPhy$ieal  Signs. — Tlie  physical  signs  in  pneumo-hydrolfaorax  are 
highly  distinctive. 
Over  a  space  corresponding  with  that  occupied  hy  air  or  gaa, 
the  chest  yields  on  percussion  a  marked  <legrec  of  resonance  which 
is  purely  tympanitic  in  quality,  and  more  or  less  high  in  pitch, 
approaching  frequently,  in  intensity  as  well  as  character,  the  sound 
produced  by  percutwion  over  the  tympanitic  abdomen.  This  reRO- 
nance  is  always  found  at  or  near  the  summit  of  the  chest,  extend- 
Ejiig  downward  n  greater  or  less  distance,  unless  the  lung  bo  at* 
Itaehed  at  its  upper  portion,  so  as  to  prevent  its  compresMon  and 
ftbe  ascent  of  the  gaseous  fluid.  The  presence  of  the  condensed 
IvDg,  situated  usually  at  the  superior  and  posterior  portion  of 
tie  chest,  may  give  rise  to  dulnes.s  in  that  situation.  If  air  or 
be  present  without  much  liquid  etTusion,  the  tympanitic  res- 


654 


DISBA8K8  OP    TSE    BSSFIKATOBT    ORQASS. 


onBncc  mnj  1>e  Jiffuscd  over  ihe  greater  part  of  the  affected  nd*. 
But  lu  coit»Idcrable  liquid  is  almost  invariablj  present,  the  rao- 
DaDce  extends  to  a  certain  point,  and  belov  this  point  there  it  h,U 
ava  on  pcrcox-ion.     The  iipaccs,  relatively,  which  are  occupied  \j 
the  tjrmpaiiilic  resonance  and  the  Bslnenii  duo  to  liqaid  cfftuion,*!!! 
be  likely  to  vary  at  different  times,  especially  if  there  exist  a  free 
communicaticD  cither  with  the  bronchial  tabea,  or,  externally,  byn 
outlet  through  the  thoracic  parietes.     The  escape  of  fluid  by  expn- 
toration,  or  by  external  discharge,  will  of  coarse  affect  the  qiuDUiy 
retained  vithin  the  chest,  and  thus  occasion  fluctuation  in  iu  aiaoiBL 
The  introduction  of  air,  also,  U  liable  to  rariationit,  from  obtian 
causes,  as  welt  as  the  production  of  gas  by  chetnieal  changes.    Ai 
stated  by  Skoda,  the  boundary  line  at  which  the  tympanitic  somd 
ceases  and  flatness  h^ins,  docK  not  mark  with  accuracy  tbe  lef^  s( 
the  liquid,  the  former  being  propagated  for  a  cerlaia  distanoe  be]o« 
this  level.     Skoda,  indeed,  slates  that  wc  may  reckon  the  qaa&tii;F 
of  liqaid  present  ns  about  double  that  indicated  by  porca^sivn.    If 
tlie  quantity  of  liquid  bo  small  the  tympanitic  reeonaoce  extcadl 
over  the  whole  of  the  affected  i<iclc. 

Another  fact  has  been  pointvd  out  especially  by  the  author  JMt 
named.  It  is,  when  the  accumulation  of  air  or  gas  is  Urge,  owing 
to  the  tension  of  the  thoracic  wall  the  resouancc  is  diminished,  ni 
the  sound  may  oven  beoome  dull,  the  tympanitic  qaality  being  of 
coarse  preserved. 

The  tympanitic  sound  in  some  instances  has  a  ringing  araphetie 
tone,  resembling  that  prodnced  by  percussion  over  the  stomach ;  it 
may  be  imitated  by  striking  either  the  back  of  the  hand  whea  tihe 
palmar  surface  is  applied  firmly  over  the  ear,  or,  aft«r  tbe  illasaa- 
tion  given  by  Dr.  Williams,  a  caoutchouc  botlto  held  to  the  car. 
This  tone  is  sometimes  discovered  by  practising  aoiwultatioD  and  prr- 
ouesion  simultaneously,  when  it  is  not  rendered  apparent  by  the 
latter  alone. 

The  line  of  demarcation  between  tympanitic  re«>nance  and  Bat- 
ness  varieit  with  tbe  position  of  the  patient,  owing  to  variation  of 
the  level  of  the  liquid.  This  test  of  the  presence  of  liqaid  is  lon- 
foruly  aviiiluble  in  pneuino-liydrolhorax  unless  the  quantity  nf  liqaid 
bo  too  sQinll  to  be  affected  by  percussion. 

Over  the  portion  of  the  cbeitt  is  which  tympanitic  resonance  tx- 
ists,  the  thoracic  pnn'ctes  are  found  to  be  itiglily  elastic.  On  the 
other  hand,  below  the  level  of  the  liquid  cira;tion,  tbere  is  deficiency 


PKBVHOTBOUAX. 


555 


of  elasticitT,  and  a  marked  eeo8«  of  resistance  is  fell  on  pcrcuvnoQ 
or  on  pressure, 

Tbc  liiagnostic  evidence  affonleil  by  pcrcii«»iou  alone  is  <ttiile  con- 
jclosiTein  castes  or  pncumo-hydrothorax.  The  tjinpanilic  resoiinnoe 
Mcaaionally  obfturveil  in  coiinoction  with  oth<T  morbid  conditions 
can  hitrillj-  lead  to  the  error  of  confounding  tbem  ntth  this  affection. 
lA  Riarked  tympanitic  resonance  on  the  tcft  side  is  sometimes  due  to 
f  liui  presence  of  gas  in  the  stomnch.  The  charnctcr  of  the  gastric 
[  aound  is  distinctive ;  but  aside  from  this,  it  is  most  marked  at  the 
lower  portion  of  the  chest,  gradually  diminisliing  m  percus«ioD  is 
made  toirnrd  the  summit.  Precisely  the  reverse  obtains  in  pnenmo- 
bydrothorax;  the  resonance  exists  above,  and  flutness  below  is 
onscd  by  the  presence  of  liquid. 

The  veaiculo-tympanitic  reaonance,  in  a  certain  proportion  of  eases 

I  of  simple  pleurltis,  above  the  level  of  the  liquid,  approximates  to  the 
purely  tympanitic  resonance  of  pneumo-hydrothorax.  Bat  ausculta- 
tion shovTS,  the  lung  in  the  one  case  to  be  in  contact  with,  and  in 
the  other  case  to  be  removed  from,  the  walls  of  the  chest  above  the 
liquid. 
The  wm«  remarks  are  applicable  to  the  tympanitic  resonance 
eomettmes  observed  over  lung  soIidilie<l  by  infliimmiitory  exiidiition. 
In  the  latter  ease,  bronchial  respirnliou  ami  bronchophony  will  bo 
discovered  by  auscultation   to  be  associated  with  tympanitic  reso- 

Iauice  and  this  combination,  as  will  be  seen  presently,  is  proof,  not 
iMt  against  pneumo-hydrothorax,  than  for  the  existence  of  pulmo- 
nary  solidification. 
The  exaggerated  resonance  in  emphysema  is  not  purely  tympanitic, 

I  but  ve^iculo-tymjianitic,  and  in  this  aCTection  the  evidence  of  liquid 
in  the  chest  is  Hanling. 
On  auscultation,  llic  respiratory  sound,  aa  &  rule,  is  feeble,  distant, 
and  frequently  «uppresi(ed  over  the  space  oocupied  by  air,  except 
a  free  cvnuaunicatlon  exists  between  the  pleural  cavity  and  the  bron- 
chial tubes.  When  the  Intter  condition  obtains,  amphoric  rospira* 
tion  may  be  discovered.  It  is  in  eases  of  pneumo-hydrothorax  espe- 
cially, that  the  amphoric  variety  of  the  cavi.-rnous  respiration  is 
most  markciL  This  auscultatory  sign  is  Dot  constantly  present, 
'  even  when  the  anatomical  condition  just  mentioned,  which  is  neces- 
sary for  its  production,  exists.  The  perforation  may  at  times  be 
situated  below  the  level  of  the  liquid,  or,  if  above,  the  orifice,  or 
tubes  leading  thereto,  are  liable  to  become  obstructed ;  either  of 


556  DISEASES    OF   THE    BE3PIBAT0BT    ORQAITS. 

these  circumstaiices  will  prevent  the  occurrence  of  this  sign.  The 
opening  into  the  pleura!  cavity  may  be  too  Bmall  for  its  production. 
Other  thinga  being  equal,  amphoric  respiration  is  marked  in  pro- 
portion to  the  size  of  the  fistula,  and  the  calibre  of  the  bronchial 
tubes  to  which  it  leads.  Skoda,  explaining  thia  aign  by  the  theory 
of  consonance,  contends  that  comniunication  is  not  necessary ;  a  thin 
stratum  of  tissue  not  preventing  its  production.  He  is  peculiar  in 
entertaining  the  belief  that  the  communication  very  rarely  becomes 
persistent,  the  opening  almost  invariably  being  closed,  partly  by  the 
compression  of  the  lung,  and  partly  by  the  efi'usion. 

Amphoric  respiration,  when  present,  is  not  diffused  equally  over  all 
the  space  occupied  by  air,  but  is  either  limited  to  a  circumscribed 
area,  or  heard  at  a  certain  point  with  an  intensity  which  gradually 
diminishes  as  the  ear  ia  removed  from  it.  Its  maximum  of  intensity 
is,  of  course,  over  the  site  of  the  perforation ;  and  it  is  therefore  to 
be  sought  for  in  cases  of  tuberculosis  where  rupture  is  most  apt -to 
occur,  viz.,  p 03 tero- laterally,  between  the  third  and  sixth  rib. 

Respiratory  aound  is  suppressed  over  the  space  occupied  by  liqnlcl 
effusion.  This  space  extends  from  the  base  of  the  cheat  upward  to 
a  distance  proportionate  to  the  quantity  of  liquid.  At  the  summit, 
especially  behind,  the  bronchial  respiration  may  be  discovered  over 
the  lung  which  is  not  only  condensed  by  pressure,  but  in  addition, 
generally  solidified  by  tuberculous  deposit.  It  ia,  however,  rarely, 
if  ever,  lond.  The  existence  of  tuberculous  cavities  in  the  com- 
pressed Itmg  may  sometimes  be  ascertained  by  their  physical  signs. 
On  the  healthy  side,  the  respiratory  sound  is  exaggerated. 

The  vocal  signs  vary,  not  only  in  different  cases,  but  in  different 
parta  of  the  cheat  in  the  same  case.  Absent  below  the  level  of  the 
liquid  effusion,  the  resonance  of  the  loud  voice  may  be  wanting, 
feeble,  or  more  or  less  marked,  over  the  space  occupied  by  air  or 
gas,  with  an  amphoric  intonation,  under  the  circumstances  which 
give  rise  to  amphoric  respiration.  An  amphoric  sound  is  oftener 
obtained  and  is  more  marked  with  the  whispered  than  with  the  loud 
voice.  At  the  summit,  over  the  compressed  lung,  we  may  expect 
to  find,  more  or  less  frequently,  either  increased  vocal  resonance  or 
bronchophony,  and  possibly  pectoriloquy, 

A  sign  incident  to  the  respiration,  voice,  and  cough,  is  almost 
pathognomonic  of  pneumo-hydrothorax.  This  is  metallic  tinkling. 
It  is  a  frequent  aign,  at  least  in  cases  involving  perforation  of  lung. 
Exclusive  of  this  affection,  it  ia  not  met  with,  except,  very  rarely. 


PVB9M0TH0BAX. 

large  tub«reuloiiti  excavations.  A  sound  somewhat  analogous  ia 
I>in«linie3  produced  within  the  stomacli.  The  )«lter  ia  occasioaa], 
id  ia  readily  distinguished  by  the  fact  that  it  occurs  irrcspeclivc  of 
lie  respirmtion,  voice,  or  cough.  For  an  account  of  the  charaoten 
elonging  to  ttiia  sign  and  the  circumstances  connected  vith  its  pro> 
paction,  the  reader  is  referred  to  Part  I.'  It  is  found  generally 
rer  the  middle  third  of  the  ohest ;  sometimes  it  is  limited  to  tlie 
Bntmit,  and  occasionally  it  is  diffused  over  the  greater  part  of  the 
Irclrd  sMc.  It  hnit  hi-eii  kuown  to  accompany  the  act  of  degluti- 
Son,  as  well  rns  the  acts  of  breathing,  tpcnkiiig,  mid  coughing. 

Inspection  and  mensuration  furnish  signs  of  importunes.  The 
iffi^cted  side  i«  permanently  expanded,  and  its  movements  arc  pro- 
porlionably  restrained.  Frequently  the  acgnmultition  of  uir  nnd 
liquid  leads  to  great  dilatation  and  complete  immobility,  even  with 
forced  breathing.  The  iotcrcoscal  spaces  are  widened  and  pushed 
ontward,  sometimes  beyond  the  level  of  the  ribs;  the  diaphragTu  is 
depressed,  the  mediastinum  displaced,  and  the  heart  dislocated,  the 
latter  being  transferred,  in  some  instances,  to  the  right  of  the  ster- 
num— in  short,  the  same  appearances  are  presented  as  in  cases  of 
chronic  pleuritis  or  empyema.  The  signs  furnished  by  inspection 
and  mensuration  alone  would  not  enable  the  observer  to  diHtinguish 
between  pncumo-liydrothornx  and  chronic  pleuritis  or  ctnpycmn. 
Percussion  ami  au;<uultation,  however,  nt  once  supply  dtfTcreiitial 
characters.  In  chronic  pleuritis  and  empyema  with  dilatation,  the 
affected  side  is  Hat  on  pcrcusMon,  with  uUtencc  of  rej^pirutory  sound, 
in  the  great  majority  of  cases,  except  over  a  small  space  at  the 
sammil.  The  strongly  marked  tympanitic  rvsonunoe,  extending 
over  more  or  less  of  the  affected  aide,  amphoric  respiration,  and 
metallic  tinkling  arc  wanting. 

Dilatation  does  not  uniformly  occur  ia  pnoumo-hydrothorax. 
Liquid  and  air  or  gas  may  exist  in  the  pleural  sac,  compressing  the 
long,  without  manifest  enlargement  of  the  chest.  Cases,  however, 
in  which  morbid  changcH  in  sixe  and  motion  are  not  available  in  the 
diogno!ti»  are  exceptional. 

Pulputioii  furnishes  signs  which  belong  alike  to  chronic  pleuritis 
and  empyema,  vii.,  diminution  or  abolition  of  vocal  fremitus  and 
fluctuation. 

finally,  it  is  in  this  affection  that  succussion  is  available  as  a 


me  |i»gs  mi,  «t  ttg. 


658 


OIBBASBS   OP  TIIR  AESPIBATOBT  OBGASf 


mctlioil  or  exploration.  ^Vben  ur  and  liquid  are  contained  in  tk 
pleural  cavity,  moving  the  trunk  of  the  person  to  and  fro.  «iih  ^t 
ear  applied  to  the  chest,  produces  a  splashing  noise  resembling  tint 
oauseid  hy  shaking  a  holtle  partly  61led  with  water.  This  "  Uipf>4- 
cratio  succnssion-sonni),"  as  it  is  frequently  called,  from  the  fact 
that  it  arrested  the  attention  of  the  ancient  father  of  io«diciM^ 
is  almoist  pathognomonic  of  pnenmo-hydrotborax.  The  vonditioai 
under  which  it  is  presented,  exclusire  of  this  affection,  occur  ooly 
in  pulmonary  tuberculosis ;  and  in  the  latter  disease  their  occarrmce 
is  extremely  rare.  A  very  large  excavation,  partially  filled  whk 
liquid,  combines  the  circuoiHlanceA  necessary  for  its  production.  Ib 
tliis  connection,  hovcver,  the  associated  signs  and  symptoms,  in  con- 
junction with  the  litKlory,  arc  so  distinctive  of  tuberculous  disease, 
that  the  presence  of  the  sign,  should  it  happen  to  be  discovered,  can 
hardly  prove  a  source  of  any  perplexity  as  to  the  diagnosis.  For  • 
farther  account  of  this  sign,  as  incidental  to  the  affection  under  eon- 
eidcralion,  the  reader  is  referred  to  the  chapter  in  Part  I,  wUck 
treats  of  succussion.' 

Diagnotit. — The  symptoraa  of  pnvumo-hydrolhorax,  taken  in  cm* 
nection  with  collateral  rircuxDstances,  frequently  are  quite  agnS- 
cant.  In  a  very  large  majority  of  esses,  the  affection  occurs  in  tht 
oooree  of  pulmonary  tuberculosis,  and  results  from  perforation  of 
the  lung.  This  accident,  generally  taking  place  during  ao  act  of 
coughing,  is  signalized  by  sndden  acute  pain  in  the  chest,  speedfly 
followed  by  great  dyspn<ea,  hurried  respiration,  frequency  of  the 
piiLsc,  proi^tratioti,  lividity,  perspiration,  diminished  or  suppresaed 
expectoration,  occasionally  loss  of  voice,  and  an  expr«sJ>ion  of  great 
anxiety.  When  a  cusc  of  phthisis  offers  this  group  of  symptoms, 
manifcsteil  abruptly,  ])erforatinn  should  be  strongly  suspected.  At 
first,  and  for  a  brief  period,  ihe  affirclion  may  he  simply  pneumo* 
thorax,  but  a»  plcuritin  is  generally  quickly  developed,  with  chwc 
or  less  liquid  cfTusion,  thcdi.«ens«  soon  eventuates  in  pneumo-hydro> 
thorax.  If,  however,  the  physician  rely  exclusively  on  the  symp- 
toms, he  will  be  likely  to  fall  into  errors  of  diagnosis ;  for  the  de- 
velopment of  simple  plcuritis  may  give  rise  to  a  group  of  phenoinena 
not  unlike  that  just  mentioned,  and  perhaps  accompanied  by  a  feel- 
ing, on  the  part  of  the  patient,  that  oomeihiug  has  given  way  lu  the 

1  Vida  chap,  vii,  page  tVi. 


PKBDKOTDOBAZ. 


559 


ticst ;  to  thst,  as  rcmnrkcd  hj  I>r.  Stokes,  the  thorax  is  sometlmrfl 

Kplored  with  a  strong  expectation  of  finding  the  evidence  of  per- 

^foration,  when  the  result  is  negative.     And,  on   the  other   band, 

erforation  is  not  always  attended,  in  a  marked  degree,  \>y  the  syinp- 

[toms  which  have  been  enumerated ;  in  some  instances  it  is  not  imme- 

Idiatel;  followed  \>j  any  notable  disturbance,  either  of  the  respiratory 

I  function  or  of  the  STstem  at  large.     In  these  cases,  either  the  per- 

I  foration  is  so  small  that  the  air  and  morbid  products  escape  slowly 

i  iuto  the  pleural  sac,  and  inflammation  becomes  gradually  developed ; 

-or  extensive  pleuritic  adhesions  offer  a  mechanical  obstacle  to  the 

iccnmulation  of  air  and  liquid.     Even  when  intense  dyspnoea,  etc., 

:  immediately  follow  the  occurrence  of  rupture,  generally  after  a 

I  tine,  the  severity  of  the  distress  is  considerably  diiniulHlicd;  the 

[function  of  respiration  and  the  circulation  become  adjunted  to  the 

'morbid  condition,  and,  although  afterward  Uie  accumulation  of  nir 

I  tnsy  bo  greater  than  at  firiil,  and  liquid  effusion  he  added,  the  pa* 

[tieflt  is  perhaps  comparatively   comfortable.     In   the   majurity  of 

[oases,  vihether  occurring  as  a  complication  of  phthi^iei  or  of  other 

affections,  it  runs  rapidly  on  to  a  fatal  i».iuc ;  but  'there  are  exocp- 

tionn  to  tbiti  rule.     Although  not  probable,  recovery  is  possible; 

uid  patients  have  been  known  to  live  for  years,  preserving  sufBcicnt 

health  and  strength  to  take  active  exercise,  and  even  to  pursue 

jlsboriouii  occupations,  the;  Fiffoclion  persisting. 

Whether  occurring  from  perforation  of  the  lung,  in  phthisis,  gan- 
[  gron«,  empyema,  or  other  pulmonary  affections  which  have  been  men- 
^tioncd,  as  well  ui  from  traumatic  causes;  from  perforation  of  the 
chc«t  hy  ulceration,  abscess,  or  wounds ;  from  ulcerative  communica- 
tion with  the  stomach  or  ccsophagus,  and  from  chemical  decomposi- 
tion of  liquid  in  the  pleural  cavity,  the  signs  are  so  distinctive  and 
readily  ascertained,  that  a  positive  diagnosis  is  rarely  attended  with 
any  real  diflicutty,  assuming  the  practitioner  to  be  acquainted  with 
the  characteristics  derived  from  the  combined  physical  phenomena. 
The  more  important  of  the  points  involved  in  the  discrimination 
from  other  affections  have  been  noticed  already,  incidentally,  in 
treating  of  the  physical  signs  which  belong  to  the  affection.  It  seems, 
therefore,  unnecessary  to  make  the  differential  diagnosis  the  sab- 
jeet  of  formal  oonaideratioii. 


560  DIBEABE8    0?    THE    RESPiaATOKT    OBQANB. 


STTMMART  OF  THE   PHYSICAL   SIOMS   BELONQINO  TO   PNEUMO-HrDBO- 

THORAX. 

Tjnipanitic  resonance,  usually  intense,  at  the  upper  part  of  the 
chest,  except  ia  some  cases  in  which  the  ascent  of  air  or  gas  is 
prevented  by  pleuritic  adhesiooB ;  the  tympanitic  resonance  extend- 
ing for  a  greater  or  less  distance  downward,  and,  if  the  accumulation 
be  sufficient  to  produce  lateral  displacement  of  the  mediastinum, 
being  sometimes  apparent  beyond  the  sternum  on  the  opposite  side. 
The  percussion-sound  sometimes  presenting  an  amphoric  tone.  Flat- 
ness at  the  base  of  the  chest  extending  upward  in  proportion  to 
the  quantity  of  liquid  effusion.  Marked  elasticity  of  the  thoracic 
parietes  accompanying  the  tympanitic  resonance,  and  an  abnormal 
sense  of  resistance  below  the  level  of  the  liquid.  Change  of  level  of 
the  liquid  with  different  positions  of  the  trunk. 

The  respiratory  sound  feeble,  distant,  and  often  suppressed,  if 
free  communication  between  the  cavity  of  the  pleura  and  the  bron- 
chial tubes,  do  not  exist.  With  such  a  communication,  the  ampbo- 
ric  respiration  frequently  discovered.  Possibly,  in  some  instances, 
these  signs  are  produced  after  a  perforation  becomes  closed  by  a 
thin  stratum  of  false  membrane.  The  amphoric  respiration  oftenest 
heard,  or  the  intensity  greatest,  between  the  third  and  sixth  ribs, 
on  the  postoro-lateral  surface  of  the  chest.  Suppression  of  respira- 
tory sound  below  the  line  of  Batness,  or  below  the  level  of  the  liquid. 
Bronchial  respiration,  bronchophony,  and  possibly  cavernous  res- 
pirittion  and  peotori!oquy,  over  the  lung  at  the  summit  of  the  chest. 
Exaggerated  or  supplementary  respiration  on  the  healthy  side. 
Vocal  resonance,  over  the  space  yielding  tympanitic  sonorousness 
on  percussion,  either  wanting,  or  feeble,  and  amphoric  voice  and 
whisper  in  cases  in  which  the  respiration  is  amphoric.  Over  the 
space  yielding  a  flat  percussion-sound,  absence  of  vocal  resonance. 

Metallic  tinkling  frequently  discovered,  especially  when  the  affec- 
tion coexists  with  perforation  of  lung,  and,  if  produced  within  the 
pleura,  the  sign  is  pathognomonic. 

Enlargement  of  the  affected  side,  and  diminished  motion.  Fre- 
quently great  dilatation,  involving  cffacement  of  intercostal  depres- 
sion or  bulging,  depression  of  diaphragm,  displacement  of  medlas- 


IMTBROOSTAL    !riCIIAl:.QIA    ASTD    rLBtTRODTITIi. 

I'tinntn,  snd  dialocatioo  of  (he  faearl,  ami,  umlcr  t1ic«o  circuouUnocs, 
kftlmost  complete  imniobilitj  even  with  Torcctl  breitiliiiig. 

Dimioation  or  abolition  of  vocal  fremitu»,  mid  in  «omc  c*sc8  fl^l^ 
ttnatiOD,  ascerlnined  bjr  pwlpation. 

nippocratic  succu»sio»-souiid,  or  splashing. 


Ihtbbcostal  Nkubalgu  and  Pleubodtsia. 


The  local  Bjinptoms  in  ca«ea  of  intercostal  neuralgia  and  pleu- 

[rodjni»  arc,  in  bodic  respects,  very  analogous  to  those  which  belong 

^to  uoulc  pleiiritis.     The  differential  diagnosis  from  other  alfeclions 

relates  almost  exclusively  to  their  discrimination  from  llie  lutter 

disease.     And  it  will  suffice  to  point  out  the  distinctive  characters 

I  involved  in  this  discrimination. 
Pain  is  a  prominent  symptom  in  both  the  neuralgic  and  rheumatic 
•Section.     In  it«  charnotcr  and  situation,  the  pain  may  simulate 
closely  that  which  is  due  to  acute  inflammation  of  the  pleura.  Vary- 
ing in  degree  in  different  cases,  it  may  be  considerable  or  intense, 
even  exceeding  the  pain  usually  experienced  in  acute  pleuritis.    It 
is  frequently  lancinating  in  character,  and  may  be  felt  especially  in 
inspiration.    Acts  of  coughing  or  sneezing  occasion  sometimes  excru- 
cUling  suffering.    The  pain  is  generally  referred  to  the  lower  portion 
of  the  chest,  in  front  and  laterally, — the  seat  of  pain  in  many  cases 
of  acute  pleuritis.     It  is  accompanied  by  tenderness  on  percussion 
or  pressure.     Guided  solely  by  the  rational  or  vital  phenomena,  it 
is  easy  to  confound  intercostal  neuralgia  or  pleurodynia  with  acute 
pleuritis,   and    this  error,  in  fact,  is  not  infrcciiienily  committed. 
Moreover,  in  both  affections,  the  physical  phenomena  which  belong 
Bto  the  first  stage  of  acute  pleuritis  may  bo  equally  present.     The 
tnovements  of  the  affected  side  arc  restrained;  a  disparity  in  this 
respect,  and  even  a  slight  difference  in  width,  may  bo  apparent. 
■  The  respiratory  murmur  is  feeble  and  interrupted.    PercuNaion  may 
Vdicit  relatively  slight  duloess.     How,  then,  is  the  diflcrlminalion 
H  to  be  made?     It  involves  attention  both  to  symptoms  and  sign»,  to- 
I  gethcr  with  the  circumstuncoe  under  which  the  affection  is  presented; 
and,  with  proper  care  and  knowledge,  a  positive  diagnosis  cannot 
^always  be  at  once  made. 

Intercostal  neuralgia,  except  as  an  occasional  coincidence,  is  tin- 
rsttenilcd  by  febrile  movement,  which  is  wanting  also  in  the  great 

3a 


562  DISBA8BS    OF    THE    KE8PIBAT0BT    0BaAK9. 

majority  of  the  cases  of  plourodynia.  On  the  other  hand,  acnte 
inflammatioQ  of  the  pleura  gives  rise  to  well-marked  and  more  or 
less  intense  symptomatic  fever.  This  is  an  important  point  of  dis- 
tinction. The  absence  of  febrile  morement  is  evidence  againet  acute 
pleuritts,  if  we  observe  the  disease  at  its  commencement,  or  shortly 
after  the  attack.  But  the  presence  of  febrile  movement  is  not  to 
the  same  extent  evidence  against  intercostal  neuralgia  and  pleuro- 
dynia, because  it  may  accidentally  coexist  with  these  affections. 

The  extreme  severity  of  the  pain,  and  the  exquisite  sensitiveness 
of  the  side  to  the  touch,  in  some  cases,  militate  strongly  againet  the 
ides  of  acute  inflammation,  provided  symptomatic  fever  be  absent. 
In  neuralgia  afiecting  the  walls  of  the  chest,  the  tenderness  is  more 
superficially  situated ;  the  contact  of  the  hand  or  slight  pressure  is 
not  so  well  borne  as  in  cases  of  acute  inflammntion,  while  firm  steady 
pressure  made  with  the  open  palm  occasions  a  disproportionately  less 
amount  of  suffering.  Movements  of  the  trunk  and  upper  extremities 
produce  distress  in  a  severe  attack  of  neuralgia  frequently  greater 
than  in  acute  pleuritis,  the  respiratory  movements  being  more  espe- 
cially the  cause  of  pain  in  the  latter.  The  pain  at  the  same  time  in 
neuralgia  is  more  independent  of  respiration  and  the  motions  of  the 
body.  It  is  less  uniform,  marked  remissions  and  sometimes  distinct 
intermissions  occurring;  the  latter  especinlly  are  quite  distinctive. 
It  may  be  sometimes  promptly  and  effectually  removed  by  a  full 
opiate  ;  whereas,  the  pain  from  acute  inflammation  may  in  this  way 
be  perhaps  mitigated  but  it  is  not  controlled.  Cough  is  a  more  con- 
stant and  prominent  symptom  in  acute  pleuritis;  it  is  generally 
wanting  in  intercostal  neuralgia  and  pleurodynia. 

Both  neuralgia  and  rheumatism,  when  seated  in  the  thoracic  walls, 
may  be  associated  with  similar  affections  manifested  at  the  same 
time  in  other  parts  of  the  body.  This  is  ground  for  presumption  as 
to  the  character  of  the  chest-affection.  In  herpes  zoster  the  acute 
pains  in  the  chest  may  he  presumed  to  be  neuralgic,  because  severe 
thoracic  pains  are  well  known  to  accompany  this  affection  without 
involving  inflammation;  this  pathological  association  thus  becomes 
diagnostic. 

Bassereau  and  Valleix  have  called  attention  to  characteristics  of 
intercostal  neuralgia  which  are  important  in  a  diagnostic  point  of 
view,'  and  which  serve  to  distinguish  this  affection  from  pleurodynia, 

'  Valleii,  op.  dt. 


INTKRCOSTAI,   'KBBBALOIA    AKD    PLBUBODTHIA.      568 


On  exaiDi nation  of  the  chest  hy  palpation,  the  Horeness  ia  founil  to 
bo  not  difftiscl,  but  confined  to  cortnin  isolate']  points.     These  points 
hsre  pretty  uniformly  tlirco  in  number,  viz.,  lt>t,  By  the  side  of  one 
Br  more  of  the  dorxul  vertebra ;  2d,  over  one  or  more,  usu«lly  two  or 
three,  of  the  intercostal  spaces,  generally  of  the  sixth,  seventh,  and 
eighth  ribs,  about  midway  between  iheir  two  extremities;  and  3d, 
Dver  the  costal  cartilages  or  in  the  eptguetric  region.    The  tenderness 
these  three   situations   ts  often  extremely  circumscribed.     The 
lints  correspond  to  brunches  of  the  dorsal  nerves  which  have  a 
Ituperficial  distribution.     Fressure  on  the  first  point,  viz.,  by  the  side 
}of  the  vertebral  spine,  is  moat  constantly  and  in  the  tnoat  marked 
degree  productive  of  pain.     When,  aa  is  not  unusa&l,  pressure  over 
a  tender  portion  of  the  spinal  column  provokes  a  paroxysm  of  pain 
is  the  affected  part,  and  especially  if  the  nerves  distributed  to  the 
Iftlter  are  connected  with  the  medulla  spinalis  at  a  situation  corres- 
ponding to  the  seat  of  tendernc&s,  the  neuralgic  character  of  tbe 
affection  is  altogether  probable. 

Shifting  of  the  locality  of  the  pain  is  another  dingnotttic  trait. 
^This  ia  apt  to  occur  in  neuralgic  and  rheumatic  aOection-i,  whereas, 
pleuritia  the  pain  t»  fixed  in  the  same  situation.     In  some  cases 
of  pleuralgiii,  the  pain  is  seated  in  both  »i(lc«.     This  is  significant  of 
^»|ts  neuralgic  or  rheumatic  character.' 

^P  But  a  [>o»ilivc  diagiiosis  mt»  on  the  nb^icnco  of  the  physical  signs 
B4eaoting  the  presence  of  inflitmmatory  products  wilhin  the  pleural 
aac.  A  well-marked  intra- lb oracic  friotion-sound  is  eonclusire  as  to 
the  existence  of  pleuriiiH ;  but  itA  absence  is  not  negative  proof  of  a 
neuralgic  or  rheumatic  nflcclion,  for  this  sign  is  not  uniformly,  and, 
indeed,  but  rarely,  discovered  in  the  early  stage  of  pleuritic  inflam- 

B nation.  Acute  plcuritis,  however,  is  soon  accompanied  by  more 
or  less  liquid  effusion  giving  rise  to  physical  phenomena  which 
bare  been  described.  If  those  phenomena  be  not  developed  after  a 
oertain  time  from  the  date  of  an  attack  of  acute  pleuritic  pain,  the 
diagnosis  of  a  neuralgic  or  a  rheumatic  affection  is  settled,  reasoning 
by  way  of  exclusion.  In  cases,  therefore,  in  which  the  symptoms 
and  a«sociatcd  circumstances  leave  room  for  doubt,  it  is  prudent  to 
defer  an  absolute  conclusion  for  two  or  three  days,  nbcn,  from  the 


^' 


•Igic  aOcciion  icMod  in  both  lidoi  U  lignificant  «f  loue  ImIoh  of  lh« 


664  DI8BA8ES    OF    THK    BSBPIKATORT    OBGANS. 

abaence  of  the  evidence  of  effusion,  the  non-exiBtence  of  acute  pleu- 
ritis  is  almost  certaia.  The  difficult;  thus  attending  the  discrimi- 
nation of  intercostal  neuralgia  and  pleurodynia  from  acute  pleuritis, 
pertains  chiefly  to  the  first  stage  of  the  latter  affection.  So  soon 
as  it  may  be  decided  that,  assuming  acute  iDflammatiou  to  exist, 
effusion  should  have  taken  place,  the  differential  diagnosis  ceases 
to  be  an  intricate  or  doubtful  problem.  Effusion,  it  is  to  be  borne 
in  mind,  usually  follows  speedily  the  access  of  inflammation ;  and 
it  is  certainly  extremely  rare  that  an  appreciable  amount  of  effusion 
fails  to  occur  within  the  first  three  or  four  days.  In  the  majority 
of  instances  this  is  the  case  as  early  as  the  second  day. 

A  fact  stated  in  connection  with  the  subject  of  acnte  pleuritis  may 
be  here  repeated.  This  disease  is  occasionally  preceded  by  neuralgic 
pain  in  the  chest,  more  or  less  severe  and  persieting,  for  several 
days  before  the  symptoms  denote  an  inflammatory  attack.  Several 
cases,  already  referred  to,  illustrating  this  fact  in  a  striking  manner, 
have  fallen  under  my  observation. 

It  is  stated  by  some  writers  that  liquid  eSiision,  causing  all  the 
phenomena  of  acute  pleuritis  may  result  from  a  rheumatic  affeo- 
tion  within  the  chest.  This,  in  effect,  is  saying  that  acute  inflam- 
mation of  the  pleura  may  be  developed  in  connection  with  the  morbid 
condition  of  the  system  in  which  consists  the  essential  pathology  of 
rheumatism.  In  other  words,  such  cases,  clinically,  are  neither 
more  nor  less  than  cases  of  acute  pleuritis.  To  cases  of  this  kind 
I  have  not,  of  course,  had  reference  in  the  foregoing  remarks. 

The  occasional  development  of  pleuritis  during  the  course  of  acute 
rheumatism,  is  a  fact  to  be  borne  in  mind.  The  occurrence,  under 
these  circumstances,  of  the  symptoms  of  pleurodynia,  is  by  no  means 
proof  of  the  non-existence  of  veritable  inflammation.  Careful  and 
repeated  explorations  of  the  chest  are  to  be  made,  and  equally  in 
cases  in  w-hich  circumstances  point  to  intercostal  neuralgia,  in  order 
to  determine  as  regards  the  presence  or  absence  of  the  physical  signs 
of  pleuritis.  In  view  of  the  liability  to  pleuritis  in  the  progress  of 
rheumatigm,  without  the  information  to  be  obtained  by  physical  ex- 
ploration, the  existence  of  inflammation,  as  well  as  simple  pleuro- 
dynia, might  be  incorrectly  inferred.  It  is  hardly  necessary  to  refer 
to  the  possibility  of  attributing  to  pleuritic  inflammation  the  pain 
sometimes  incident  to  an  affection  of  the  heart,  occurring  in  rheuma- 
tism.    This  would  more  properly  have  been  noticed  under  the  head 


DIAPHRAOMATrO    HRBNIA. 


565 


Plpuritii.  The  positive  signs  referable  to  llio  heart,  »n<l  th« 
I  abscuvc  of  tlio  eigD8  of  inBammation  of  the  pleura,  suffice  to  obviate 
error  with  ntepectto  tbia  point. 

A  subacute  but  persisting  neuralgic  afTeotion  is  very  frequently 
net  with  io  females,  tbe  pain  being  reft-rreil  to  the  lower  pari  of  the 
cheot  OQ  the  left  side.  It  is  not  severe,  but  of  iiulefinite  (luration. 
It  occurs  especiallj  in  anaemic  or  cblorotic  persons,  being  a»8ociut«d 
frequeutly  with  disorder  of  the  menstrual  function,  and  generally 
with  tenderness  on  the  side  of  the  spinal  column.  The  circiimslancea 
JQSt  mentioned  embrace  certain  positive  characler»  by  which  it  may 
1)«  distinguished;  but  the  absence  of  the  physical  signs  of  intra- 
thoracic  disease  conRrras  its  neurop.ithio  character. 

Tho  symptomatic  phenomena  of  angina  pectoris  are  so  peculiar 
uid  distinctive  that,  as  regnt-dji  the  po.tsihility  of  confounding  it  with 

tany  other  affection  referable  to  the  chc»t,  it  claims  but  a  piwsing 
notice.  Its  paroxysmal  recurrence;  the  pain  shooting  in  various 
directions,  and  CHpecially  into  the  left  upper  extremity;  the  pnlpi- 
talton,  great  anxiety,  and  sense  of  impending  dissolution,  together 
with  the  physical  mgnt!  of  an  organic  affliction  of  the  heart,  charac- 

Eie  tJiis  aScctioD,  so  un  to  render  the  diagnosis  generally  easy. 
■ 


I 


DUPHRAGMATIC   IIbB.VIA. 


I 

I 


In  consequence  of  tbe  congenital  absence  of  a,  portion  of  the  di*> 
phragm,  the  occurrence  of  perforation  by  rupture  and  wounds,  or  a 
yielding  of  this  septum  at  certain  points,  and  sometimes  over  its 
whole  extent  ou  one  side,  tbe  stomach,  intestines,  and  other  of  the 
abdominal  risoera,  may  either  be  contained  within  or  encroach  more 
or  leas  on  the  thoracic  space.  This  transposition  of  organs  gives 
rise  to  certain  phenomena  discovered  by  a  physical  examination  of 
(he  chest.  Diaphragmatic  hernia — a  term  which,  with  strict  pro- 
priety, is  applied  only  to  protrusion  through  the  diaphragm  of  parte 
•itiulcd  below  it — is  extremely  rare,  but  the  physician  is  liable  at 
■ay  moment  to  meet  with  an  instance,  although  I  believe  no  one  has 
ever  reported  more  than  a  single  case.  Tbe  very  infrequency  of 
the  affection  renders  it  peculiarly  interesting  to  the  diagnostician  ; 
and  it  is  desirable  to  be  prt'parod  to  recognize  it,  should  aa  instance 
happen  to  fall  under  observation. 

An  affeouon  so  rare  that  it  can  hardly  be  expected  ever  to  occur 


666        .    DISEASES    07    THE    BB8FIBAT0BT    OEGAKS. 

more  than  once  within  the  experience  of  a  lifetime,  must,  of  course, 
be  studied  by  means  of  cases  contributed  by  numerous  obeervera. 
For  this  reason  it  has  heretofore  received  bat  little  attention.  A 
distinguished  American  physician,  Dr.  Bowditch,  of  Boston,  in  con- 
nection with  the  report  of  an  interesting  case  observed  by  himself, 
gathered  the  greater  part  if  not  all,  the  cases  contained  in  the  annals  of 
medical  literature  (88  in  number),  and  subjected  them  to  an  elaborate 
numerical  analysis.'  The  present  brief  consideration  of  the  subject 
will  be  based  on  the  results  contained  in  this  valuable  paper. 

The  different  varieties  of  diaphragmatic  hernia  may  be  classified 
as  follows:  1.  When  parts  of  the  abdominal  viscera  are  forced 
through  some  one  of  the  natural  openings  of  the  diaphragm,  vis., 
that  of  the  aorta,  vena  cava  inferior,  an  intercostal  nerve,  or  the 
cesophagus.  2.  When  portions' of  the  diaphragm  are  wanting.  This 
results  from  an  arrest  of  development,  and  is,  of  course,  congenital. 
3.  Hernia  from  accidental  wounds  or  lacerations.  4.  When  one  side 
of  the  diaphragm  is  violently  forced  up  into  the  chest,  so  that  the 
lung  is  compressed,  and  all  the  signs  of  the  affection,  as  seen  in  the 
other  classes,  are  observed.  This,  strictly  speaking,  is  not  hernia, 
but  from  the  similarity  as  respects  the  physical  conditions  and  phe- 
nomonii,  it  may  be  included  in  the  same  category.  In  their  relative 
frequency  of  occurrence,  the  four  classes  rank  in  the  following  order : 
(a)  hernia  from  accidents,  constitutitig  more  than  one-half  of  the 
number  of  cases;  {b)  from  malconstruction,  about  one-third;  {c) 
from  dilatation  of  natural  openings,  about  one-twelfth;  (d)  from 
diaphragm  being  pushed  up,  about  one  in  thirty  cases. 

The  affection  occurs  much  oftener  on  the  left  than  on  the  right 
side  (41  out  of  59  cases) ;  a  disparity  for  which  anatomical  reasons 
may  be  offered.  It  is  evident  that  the  abdominal  parts  contained 
within  the  chest  will  be  covered  by  the  pleura  and  peritoneum  in 

I  11  Peculiar  Case  of  Dinphrngniftlie  Hcroift,  in  which  nonrly  Iho  whole  of  Ihe 
left  I'iiti^  of  the  diaphragm  was  wanting  ;  so  thnt  the  stomnch  und  a  );reHt  jwrt  at 
tho  intestines  lay  in  the  left  pleural  cavil j  ;  compressinR  the  left  lung,  and  forcing 
the  heart  lo  the  right  nido  of  tho  etiTnura.  This  condition, eviiientlyeongr'nitikl, 
eibtud  in  a  uiun  who  died  at  the  Maasachusctls  Ui'niiml  Iluspital,  with  fracture 
of  thu  fpine,  caii.'^od  lij  a  heavy  I>luw  upon  it;  lo  which  U  addt'd  an  aniily^ix  of 
most,  if  not  all,  of  the  cnsca  of  diuphragmiitic  hernia  found  reeordi'd  in  llie  annals 
of  nitdiCBl  science,  By  Ilenry  J.  Bowditch,  Member  of  the  Boston  Society  for 
Medicnl  Observation.  Presented  to  the  Society  in  ltt47."  Published  in  tho  Buf- 
falo Mt'dicul  Joucnul,  June  and  July,  1603;  and  issued  by  the  author  in  a  sepa- 
rate publication. 


>IAPnBA8MATI0    IIERXIA. 


567 


Isome',  and  not  in  other  cases.  'When  thus  invested,  tbe  hernia  is 
[•aid  (o  be  sacculated.     Sacculated  hernias  are  vastly  more  frequent 

»n  the  righi  thau  on  the  left  side  (3  only  out  of  II  cases  of  beroi« 

[on  left  aide  were  naccnlated,  and  II  of  18  cases  on  the  right  side). 

he  weHkncK*  of  the  diii|)lirHgin  on  the  r!frht  (tide  at  a  point  jast  to 

the  right  of  the  ensiform  cartilagt^,  afford;*  an  e^tplanalion  of  this 

ict.     The  particular  parts  of  the  abdominal  viscera  which  are  con- 

[taiDed  within  the  chesl,  and  the  extent  of  the  malposition,  will,  of 

'course,  depend  on  the  situation  and  size  of  the  opening.     The  solid 

organs,  vix.,  the  lircr  and  spleen,  as  welt  as  the  hollow  vjMera,  are 

liable  to  hernia]  protrusion. 

»  Strangulation  ut  the  orifice  i»  liable  to  occur.  The  pnrts  may 
present,  or  not,  in  cases  examined  after  death,  evidences  of  inflam* 
nation,  reecnt  or  more  or  lees  remote,  affecting  either  the  pulmonary 
^or  abdominal  nrgnnis  or  both.  In  several  instaoces  all  these  parta 
^prcMnted  a  healthy  appenrance.  The  coexistence  of  tubercles  is 
f«re.  The  lungs  are  of  necessity  compressed  in  proportion  as  the 
thoracic  space  is  occupied  by  the  abdominal  viscera.  Frequently 
the  compressed  lung,  exclusive  of  condensation,  is  found  to  be 
hesllby,  and  is  readily  inflated.  Solidification  from  pneumonitis 
has  been  observed.  The  heart  is  frequently  displaced,  generally  to 
the  right.     Pleuritic  effuhion  exi«ta  in  »  ocrtain  proportion  of  ca^ea. 


»  n 
ill 
L 

mi 

Btb< 

■  pr 


Phy$ie<tl  Sifjn*. — The  c«*c»  on  record  of  dinphnigmntic  hcmi* 
•(ford  few  data  for  determining,  by  menus  of  nuuK-rie.il  analysis,  the 

ihysieal  phenomena  which  belong  to  the  aSeetion.  Many  of  the 
ea«e8  were  ob.ierveil  prior  to  the  discovery  of  nu^ctiltatton,  and  in 
BO«t  of  tlio«c  reported  since  that  era,  cxplonttion  of  ilie  chist  dur- 
ing  life  was  either  performed  imperfectly  or  altogctlicr  neglected. 
Laennec  never  met  with  an  instRDCo  of  the  affection,  but  it  did  not 
escape  his  attention,  and  he  suggested  that  it  might  be  recogniied 

>y  absence  of  the  respiratory  murmur,  and  the  presence  of  borbo- 
irygmi  in  the  chest.  In  the  case  observed  by  Bowditeh,  the  signs 
were  carefully  noted,  and  in  a  few  of  the  cases  aunlyEed  by  him 
more  or  less  of  the  physical  phenomena  were  ascertained.  Upon 
ese  facts,  together  with  the  inferences  which  may  be  rationally 
predicated  on  the  anatomical  conditions,  must  rest,  with  oar  existing 
knowlc-ilge,  an  account  of  the  physical  signs. 

Of  the  cascv  annlyxed  by  Bowditeh,  in  five  percussion  waa  resorted 
to.     or  tbcsc  five  cases,  dulness  over  the  back  on  the  affected  side 


668        SIS8ASBS  or  tbb  kbspibatort  obgahs. 

existed  in  four.  But  in  three  of  these  four  CBeee  there  was  either  pnen- 
monitis  or  pleuritic  efiiiBion ;  and  in  the  fourth  case,  the  liver,  colon, 
and  omentum  were  embraced  in  a  sacculated  protrusion.  In  Bow- 
ditcb'e  case,  percunsion  elicited  a  highly  marked  tympanitic  reso- 
nance. It  iB  evident  that  in  proportion  to  the  amount  of  the 
hollow  viscera  contained  within  the  chest  will  be  the  degree  and  the 
extent  of  the  tympanitic  resonance.  And  this  resonance,  both  ia 
degree  and  extent,  will  be  likely  to  present  at  different  times  fluctua- 
tions dependent  on  the  varying  quantity  of  the  stomach  or  intestines 
within  the  chest,  and  the  greater  or  less  distension  of  these  parts 
from  gas.  The  presence  of  the  solid  organs,  the  liver  and  spleen, 
must  give  rise  to  dulness.  Liquid  effusion  will  lead  to  the  same 
result.  In  any  case,  at  the  upper  and  posterior  part  of  the  chest, 
over  the  compressed  lung,  the  percussion-sound  will  be  likely  to  be 
dull ;  and  the  more,  of  course,  if  the  lung  be  solidified  by  inflamma- 
tory exudation. 

A  satisfactory  account  of  the  auscultatory  signs,  with  a  single 
exception,  appears  not  to  be.  contained  in  any  of  the  cases,  save 
the  one  observed  by  Bowditch.  In  these  two  cases  the  respira- 
tory murmur  over  the  greater  part  of  the  affected  side  was  want- 
ing, and  on  the  opposite  side  it  was  exaggerated.  In  Bowditch 'a 
case,  the  respiratory  murmur  was  heard  and  was  perfectly  vesicular 
above  the  second  rib. 

Aside  from  these  cases,  in  three  a  sub-crepitant  rale  was  noticed ; 
but  in  all  of  these  cases  the  existence  of  pneumonitis  was  found  at 
the  autopsy, 

The  most  significant  of  the  signs,  as  anticipated  by  Laennec,  are 
the  peculiar  gastric  or  intestinal  sounds  diffused  more  or  less  over 
the  affected  side.  Bowditch  describes  these  sounds  as  gurgling, 
whistling,  and  blowing,  and  although  excited  at  times  by  the  act  of 
respiration,  they  were  heard  when  the  patient  held  his  breath. 
Metalhc  tinkling  was  occasionally  observed ;  such  as  is  sometimes 
beard  over  the  stomach.  Bowditch  suggests  that  auscultatory 
phenomena  may  probably  be  produced  by  pressing  suddenly  on  the 
abdomen,  and  thus  forcing  air  into  the  intestines  while  in  the 
pleural  sac. 

If  the  heart  be  diaplaced,  the  cardiac  sounds  will,  of  course,  be 
transferred  to  an  abnormal  situation. 

In  three  of  five  cases  in  which  the  chest  was  examined  by  inspec- 
tion, there  was  more  or  leas  enlargement  of  the  affected  side.     That 


VIAPBBAeMATIC    QERHIA. 


569 


I 


this  \»  gcnernllr  incident  to  the  aflection  may  reaeonabl;  be  inferr^ 
from  the  Urge  proportion  of  instances  in  vbich  the  accumulation  of 
■bilotninal  vincera  within  the  cheHt  is  sufficient  to  induce  great  cotn- 
pre*eioD  of  the  lung.  In  fiftj-five  of  eigfatj-eigfat  caaes  the  lungs 
^VSre  found  to  be  much  compressed.     Diminished  motion  or  immo- 

ity  of  the  affected  aide  rau^t  necessarily  accompany  ita  dilatation. 
'Sbcw  signs  will  be  likely  to  vary  from  time  to  time,  in  accordanee 
with  varying  conditions  as  respects  the  amount  of  hernial  protra- 
Mon  anil  of  gaeeoiia  distension  of  the  protruded  hollow  viscera. 
Liquid  effusion  in  some  cases  concnrs  in  producing  dilatation  and 
diminii^bing  the  mobility  of  the  affected  side.  It  is  superfluous  to 
add  that,  in  determining  thetic  cbtingcs,  mcusuration,  as  well  as  ia< 
spectiun,  may  be  empluyed. 

By  means  of  palpiitiun  the  abnormal  position  of  Ibe  heart  may  bo 
wsccrtHtnvd.  It  i»  probable  that  tlio  vocal  fremitus  will  be  dimin- 
ished or  abolished  on  the  affected  side ;  but  observation  has  not  been 
directed  to  this  point. 


I^iagnotia. — The  symptomatic  phenomena  which  are  in  any  man- 
ner distinctive  of  the  affection,  relate  to  the  respiration.  The 
analysis  by  Bowditcb  shows  that  in  three-fourths  of  the  cases  of 
the  different  varieties  of  diaphragmatic  hernia  there  was  more  or 
less  embarrassment  of  respiration,  consisting  of  oppresKion,  in- 
creased frequency,  dyspnoea,  and  in  one  caKC  orChopntea.  Posture 
has  been  observed  to  exert  a  marked  itifliieuce  on  the  symptoms 
referable  to  the  respiration.  In  some  instunoes  the  difficulty  of 
breathing  was  greatly  increased  in  the  recumbent  posture,  which  is 
explained  by  llie  teiidenoy,  from  gravitation,  to  a  greater  protru- 
sion either  of  the  viscera  or  their  contents  within  the  chest.  Irre- 
spective of  position,  the  Huuluatingconditions,  as  regards  theqnnntity 
of  hollow  viscera  protruding  through  the  diaphragm  and  their  dis- 
tension with  gas,  will  ae<M>uiit  for  the  difficulty  of  breathing  occur- 
ring  paroxysumlly,  or  for  its  being  much  greater  nl  some  limes  than 
at  others-— a  fact  repeatedly  observed.  But  embarrassment  of  tho 
respiration  is  not  always  a  prominent  symptom,  even  when  one  side 
of  the  chest  is  nearly  filled  with  abdominal  viscera.  This  is  shown 
by  the  case  reported  by  Bowditch.  In  this  case,  the  patient,  aged 
IT,  was  able  to  perform  the  duties  of  a  laborer,  and  died,  not  from 
this  affection,  but  from  fracture  of  the  spine  produced  by  a  blow 
from  a  heavy  piece  of  timber.     Moreover,  the  characters  belonging 


570  DI8KASB8    OF    THB    RESPIBATORT    OBQANS. 

to  the  embarraBsmeDt  of  respiration,  do  not  possees  diagnostic  sig- 
nificance. 

Judged  by  past  experience  the  dtagoosiB  would  appear  to  be  ex- 
tremely difGcult,  for,  of  all  the  cases  collected  by  Bowditch,  the 
nature  of  the  affection  had  been  determined  before  death  in  but  a 
single  instance.  This  instance  came  under  the  observation  of  Law- 
rence, of  London.  In  the  case  observed  by  Bowditch  the  diagnoais 
was  made.  The  difficulty  is,  however,  more  apparent  than  real. 
From  its  great  infrequency  the  affection  is  not  suspected  or  even 
thought  of,  and  the  physical  signs,  having  been  but  little  studied, 
are  yet  to  be  fully  settled  by  observation.  Upon  the  latter  it  is 
sufficiently  clear  the  diagnosis  depends ;  the  existence  of  the  a&ection 
can  never  be  positively  ascertained  by  the  symptoms  alone.  With 
the  symptoms  and  signs  combined,  Bowditch  is  probably  correct  in 
saying  that  ''  the  diagnosis  of  diaphragmatic  hernia  is  as  easy  as 
that  of  almost  any  other  chronic,  and  possibly  acute  disease." 

Dyspnoea,  either  constant  or  produced  by  exertion,  and  more  es- 
pecially when  it  comea  on  suddenly  and  as  suddenly  goes  off,  should 
suggest  the  idea  of  diaphragmatic  hernia,  provided  it  be  not  explic- 
able by  the  existence  of  some  other  affection  the  nature  of  which  is 
positively  ascertained.  If  the  affection  be  congenital,  in  most  cases 
more  or  less  embarrassment  of  respiration  will  be  found  to  bnvo  ex- 
isted from  birth.  If  due  to  a  rupture  or  wound,  the  difficulty  will 
date  from  some  accident,  and  this  fact  may  assist  in  the  diagnosis.  In 
connection  with  embarrassed  respiration,  to  a  greater  or  less  extent, 
the  following  signs,  in  combination,  constitute  the  physical  char- 
acters by  which  the  affection  is  to  be  recognized  :  Tympanitic  per- 
cussion-resonance ;  absence  of  respiratory  murmur ;  the  presence  of 
sounds  identical  with  those  observed  over  the  stomach  and  intestines, 
viz.,  borborygmi  and  metallic  tinkling,  both  taking  place  when 
breathing  is  suspended;  dilatation  of  the  affected  side  in  the  majority 
of  instances,  with  deficient  motion  or  immobility,  and,  probably,  ab- 
sence of  vocal  fremitus. 

Assuming  this  group  of  signs  to  be  present,  diaphragmatic  hernia 
can  be  confounded  only  with  emphysema  and  pncumo-hydrothorax. 
The  differential  diagnosis  from  these  two  affections  involves  points 
which  are  suilicicntiy  distinctive.  Emphysema  is  frequently  accom- 
panied by  paroxysms  of  asthma,  the  symptomatic  characters  of  which 
will  serve  to  distinguish  it.  It  is  accompanied  by  more  or  less  congh 
and  expectoration,  these  symptoms  being  only  occasionally  present 


PIAPHBAOMATIC  BBBHtA. 


571 


in  diaphragmatic  heniis.     But  physical  exploration  in  cinpliysoiiiK 

isliowK  »  resonAiice  not  piireljr  tjinpanitic,  but  vesiculo-tympanitic; 

I  dilatation  and  de&cient  motion  especially  marked  at  the  upper  part 

I  of  Ihv  chest  on  both  sides ;  the  nibilant  and  aoDorous  broiicliial  rales 

gciicrntly  more  or  U-k^  r1ilTii9L-<l,  together  with  the  abBcnco  of  borbo- 

rygmi  and  mvtallic  tinkling. 

Pneumo-hydrotboniK,  in  nine  ouMOUl  or  ten,  !#  sudilenlj*  developed 
I  tbc  result  of  pfTforiition  of  thv  Inng  in  tho  course  of  phthifiH,  the 

•existence  of  which  has  been  established.  Or,  it  results  from  perfora- 
tion taking  its  point  of  departure  from  within  the  pleura,  in  the 
cowrao  of  chronic  pIcuritiB,  the  latter  affi-ction  having  been  previously 
SBCcitaincd  to  exist,  if  the  case  have  been  under  observation.  It  u 
only  in  cases  in  which  these  antecedents  cannot  be  ascertained,  that 
diaphragmatic  hernia  is  to  be  suspected.  As  respects  physical  signs, 
the  two  affections  are  in  several  respects  similar.  Tympanitic  reso- 
nance, absence  of  respiratory  murmur,  dilatation  and  deficient  mo- 
bility, abolition  of  fremitus,  and  displacement  of  the  heart,  are  com- 
mon to  both.  But  each  afiection  has  its  positive  signs.  In  the 
majority  of  cases  of  pni-umo-hydrolhorax  roetallic  tinkling  occurs  in 

■  couucction  with  the  respiration,  voice,  and  cough  ;  and  in  many  in- 
itances  thoinnphdrio  rcipiratioii  and  voice  ar*-  present.  The  huccu*- 
sion-eound  may  be  always  prgduci'd.  In  diiiphragmalte  herniu  hor- 
borygint  constitute  a  positive  and  peculiar  sign ;  and  tinkling  or 
ftmphoric  sounds,  if  found  to  occur,  arc  not  in  synchronism  with 

»«cts  of  breathing,  speaking,  or  coughing,  and  are  independent  of 
the  movements  of  the  body.  The  di«crimi nation  must  W  bused  on 
the  presence  of  the  latter  phenomena,  and  the  absence  of  the  signs 
and  the  circumstances,  relating  to  the  previous  history,  which  cbarao- 
terise  pneumo-hydrothorax. 

■  Farther  clinical  observation  of  diaphragmatic  hernia,  especially  as 
"  respects  the  results  of  physical  exploration,  may  lead  to  the  knowl- 
edge of  new  diagnostic  points  which  cannot  now  be  foreseen.    At  a 
future  period,  some  one,  imitating  the  leal  and  industry  of  Bowditch, 

twill  be  able  to  gather  together  and  analyze  an  extended  series  of 
cases  in  which  the  s'gna,  as  well  as  symptoms,  have  been  carefully 
observed  and  noted;  but  in  the  meantime  it  is  important  that  the 
affection  be  recogniiod,  not  mendy  for  the  gratification  afforded  by 
skill  in  the  diagnosia  of  rare  and  curious  forms  of  disease,  but  be- 

■  cause  much  niiiy  be  done  by  judicious  management  to  contribute  to 
the  comfort  and  safety  of  tb«  patient. 


CHAPTER    VIII. 

DISEASES  AFFECTING  THE  TRACHEA  AND  LARYNX— FOBEIGN 
BODIES  IN  THE  AIR-PASSAGE3. 

In  its  application  to  the  diagnosis  of  tracheal  and  laryngeal  af- 
fections, physical  exploration  is  lesB  important  than  when  the  lunga 
are  the  seat  of  disease.  The  symptomatic  phenomena  belonging  to 
pulmonary  affections  are  never  to  be  dissociated,  clinically,  from  the 
physical  signs,  but,  relatively,  the  latter  are  in  general  much  more 
distinctive  and  reliable.  It  is  otherwise  in  disease  affecting  the  air- 
passages  above  the  bifurcation  of  the  trachea.  Here  the  symptoms 
are  mainly  to  be  relied  on,  the  resalts  of  physical  examination  hold- 
ing a  comparatively  subordinate  rank.  This  being  the  case,  I  shall 
not,  as  hitherto,  consider  the  different  affections  included  in  thia 
group  under  separate  heads,  but  refer  to  them,  individually,  in  an 
incidental  manner,  in  treating  of  the  general  application  of  the  prin- 
ciples and  practice  of  physical  exploration  to  diseases  affecting  the 
trachea  and  larynx.  Another  reason  for  pursuing  this  course  is,  the 
same  physical  signa  wilt  he  found  to  be  common  to  different  affections, 
and  the  general  principles  regulating  the  practice  of  exploration  are 
in  a  great  measure  applicable  alike  to  all. 

The  foregoing  remarks  in  the  first  edition  of  thia  work,  published 
ten  years  ago,  require  modification  only  as  regards  the  application 
of  inspection  to  affections  of  the  larynx  and  trachea.  By  means 
of  the  laryngoscope  the  interior  of  these  parts  may  be  brought  into 
view,  and  accurate  information  of  the  seat  and  chnracter  of  morbid 
conditions  thereby  obtained.  Admitting  the  great  value  of  this 
instrument  in  diagnosis,  the  author  must  refer  the  reader  for  infor- 
mation respecting  its  employment,  to  monographs  treating  specially 
of  laryngoscopy.  The  remarks  which  are  to  follow  will  relate  to 
methods  of  exploration  exclusive  of  inspection. 

Dr.  Stokes  has  suggested  that  the  application  of  percussion  may 
in  some  instances  furnish  results  worthy  of  attention.'    He  does  not, 

>  Diseases  of  the  Chest,  etc. 


I 


however,  present  an^  facta  illustrative  of  its  value  in  this  applica- 
tion. The  inventor  of  mediate  percUBaion,  and  the  ardent  advocate 
of  its  capiibililie»,  Piorry,  asiiigns  to  it  a  very  limited  scope  of  availa- 
bility in  these  affectioiia.  He  claims  in  behalf  of  this  method,  that 
it  may  so  me  time!*  he  useful  in  dcterinining  the  precise  line  of  direc* 
tion  of  the  IracliCA  and  larynx,  when  they  are  buried  beneath  or 
imbedded  in  a  large  tumor  on  the  neek.  The  percuflsion-sound  may 
also  afford  eomc  aid  in  estimatinf;  the  distance  of  the  tnbe  from  the 
surface.  An  amphoric  rcBOnancc,  attributed  by  Piorry  to  ihe  pre«- 
CDCc  of  air  and  liquid,  he  thinks  denotes  the  presence  of  seoretiona  tit 
this  situation ;  but  this  vicv  of  the  signilieance  of  Ihe  sound  is  more 
than  questionable.  Finally,  in  a  case  of  subcutancoiia  emphysema, 
in  which  very  marked  resonance  exists  over  the  neck,  iliero  ts  ground 
for  the  suspicion  that  rupture  of  the  larynx  hns  taken  place,  giving 
exit  to  air  into  the  surrounding  areolar  tissue' 

The  discoverer  of  auscultation  attached  very  little  importance  to 
t^  application  of  this  method  to  the  diseases  of  the  windpipe.  Of 
those  nho,  since  the  time  of  Laennec,  have  given  speciul  attention  to 
phyucal  exploration,  few  have  decinod  this  branch  of  the  subject 
deserving  of  much  considcrution ;  xnd  the  sum  of  what  is  at  present 
actually  known,  is  probably  embraced  in  the  writing''  of  Stokes,*  and 
in  two  papers  contributed  by  Barth,  of  Paris.'  Thu  materiaU  for 
the  few  retnarkfi  which  are  to  follow,  will  bo  chiefly  obtained  from 
the  sources  just  referred  to. 

Auscultation,  in  discuses  affecting  the  trachea  and  larynx,  ad- 
mits of  a  direct  and  imiirfct  application.  By  the  term  direct,  I 
refer  to  auscultation  of  the  windpipe.  Indirectly,  the  physical  ex- 
ploration of  the  chest  is  applicable,  in  order  to  determine  whether 
pulmonary  disease  coexists  or  not.  The  importance  of  physical 
signa  is  much  greater  in  the  latter  than  in  the  former  application. 
Indeed,  the  examination  of  the  chest  in  connection  with  diseases 
affecting  the  trachea  and  larynx  is  often  of  great  importance.  We 
will  consider  firat,  direct  exploration,  in  other  words,  the  physical 
signs  developed  by  auscultation  of  the  trachea  and  larynx ;  and, 
second,  indirect  exploration,  or  the  examination  of  the  chest  in  the 
investigation  of  tracheal  and  laryngeal  diseases. 


>  TriitA  Pradquo  d'Auicultntion,  etc.,  par  Bortb  sad  Roger,  ISM,  p.  7M. 
»  On  Dl»eMM  of  the  Chnnl. 

*  ArcbiviM  Otnitules  de  Modocinv,  Juillet,  1B39,  et  Juin,  I8S0;  abo,  Traits 
Frall^uu  d'AuauuItallou,  etc.  pM  fiarth  and  Kug«r,  18M,  p.  2SG. 


574  DISBASB8    OP    THE    KR6PIBAT0KT    OBOAMS. 

1.  Atucultation  of  the  Trachea  and  Larynx. — The  resnlte  ob- 
tained by  auscultation  in  health  have  been  considered  in  Fart  I.' 
Briefly,  also,  the  adventitioua  sounds  or  ralea  produced  in  this  situa- 
tion, have  been  adverted  to.*  It  remains  to  notice  here  the  rela- 
tione of  pathological  phenomena  to  the  difierent  forms  of  disease. 
The  anatomical  conditions,  givingrise  to  auscultatory  eigne,  are  the 
following:  1.  Diminution  of  the  calibre  of  the  tube,  either  at  cer- 
tain points,  or,  in  some  instances,  over  its  whole  extent.  This  occurs 
in  connection  with  various  affections,  viz.,  swelling  of  the  lining  mem- 
brane and  submacouB  infiltration  in  laryngitis ;  oedema  of  the  areolar 
tissue  above  the  vocal  chords  (oedema  glottidis) ;  spasm  of  the  glottis 
(false  croup) ;  the  exudation  of  lymph  on  the  mucous  surface  (true 
croup)  ;  accumulation  of  viscid  adhesive  mucus  ;  tumefaction  of  the 
margins  of  ulceration ;  vegetations  or  morbid  growths,  and  the  pres- 
sure of  an  aneurismal  or  other  tumor.  2.  Loss  of  substance  by  ul- 
ceration from  tuberculous  or  syphilitic  disease.  3.  Membranous 
deposit  becoming  loose  and  partially  detached,  and  a  pedunculated 
polypus  admitting  of  change  of  position.  4.  Accumulation  of  liquid, 
mucous,  purulent,  serous,  or  bloody.  The  presence  of  foreign  bodies 
will  be  noticed  under  a  distinct  head. 

Contraction  of  the  space  within  the  tube  from  the  several  causes 
just  enuuieriitcd,  may  give  rise  to  abnormal  modifications  of  the  res- 
piratory sound,  consisting  of  augmented  intensity,  roughness  of 
quality,  and  marked  elevation  of  pitch ;  or  adventitious  vibratory 
sounds  (dry  rales)  may  be  developed.  The  latter  may  be  on  a  high 
or  low  key,  and  they  frequently  have  a  musical  intonation.  They 
represent,  on  an  exaggerated  scale,  the  bronchial  sibilant,  and  sonor- 
ous rales.  They  are  often  sufficiently  loud  to  be  heard  at  a  distance, 
constituting  stridor  or  striduloua  breathing,  but  when  not  thus  ap- 
parent they  may  be  discovered  with  the  stethoscope  applied  over 
the  larynx  or  trachea. 

Do  these  diversities  of  modified  and  adventitious  respiratory  sounds 
possess,  respectively,  special  diagnostic  significance  ?  Observation, 
as  yet,  bus  furnished  but  little  ground  for  an  affirmative  answer  to 
this  question.  They  appear  to  belong  alike  to  the  different  forms 
of  disease  inducing  the  same  physical  condition,  viz.,  diminution  of 
the  calibre  of  the  tube.  Earth  has  observed,  in  some  cases  of  laryn- 
geal ulcerations  with  tumefied  borders,  involving  obstruction,  a  pecu- 

1  Vide  pngc  129.  '  Vide  page  1»8, 


I 


liarlv  toud  aonoroos  rale  (en*  aonort)  in  inspirstion,  ginng  tbe  im- 
pression of  the  rapid  pnsiinge  of  air  thnoiigli  a  narrow  onfic«.  which 
be  regards  as  distinctive  of  the  morbid  condition  jiii^l  inrntioncd. 
It  is,  boFever  difficult  to  obtain  from  bis  description  a  vvr^-  dear 
idea  of  the  special  cbitraetcr  of  aouiid  to  which  he  rpfrrs.  Tint 
same  obserTer  Ibliika  that  a  sonorous  rale,  presenting  a  vtronglf 
marked  metallic  quality,  like  a  sonnd  produced  within  a  tube  of 
briH.  is  heard  ofteiier  in  croup  than  in  other  afleclions  which  di> 
minisb  the  calibre  of  the  windpipe.  Stokes  describes  a  rale  pro- 
duced within  the  larynx,  resembling  "the  rapid  action  of  a  small 
valrc,  combined  with  a  deep  humming  sound,"' which  he  regardti  as 
peculiar  and  quite  characteristic  of  chronic  laryngitis  with  ulcera- 
tion. He  states  that  this  rate  may  exist  on  one  side  of  the  larynx 
without  being  perceptible  on  the  other,  its  situation  perhaps  cor- 
responding to  a  circuiDBcribed  ulceration.  With  reference  to  this 
sign,  the  came  remark  is  applicable  as  to  the  loud  sonorous  rale  (m 
aoHore)  above  mentioned.  In  both  instances,  the  data  are  insufficient 
to  establish  a  pathological  significance.  It  is  not  improbable  that 
further  clinical  study  may  lead  to  distinctive  chnractvrs  pertaining 
to  particular  sounds.  As  already  intimated,  I  have  nothing  to  OOD- 
tribute  to  this  brunch  of  the  suhjoct  from  itiy  own  observation. 

The  sit.unlion  of  the  auscultalwry  nigiis  which  have  been  men- 
tioned may  furnish  information  as  to  the  seat  of  the  diseaM)  and 
iia  extent.  They  may  be  limited  to  a  small  space.  If  they  be 
persistently  heard  in  the  same  spot,  there  is  reason  to  siippoite  that 
ibe  local  aifeotion  is  thus  circumscribed.  This  may  iiosaibly  be  found 
to  be  useful  with  reference  to  the  feasibility  of  making  topical  ap- 
plications, and  may  serve  as  a  guide  to  the  proper  place  in  the  di> 
rcctton  of  the  instrument  used  for  that  purpose.  If  the  abnormal 
sounds  be  not  thus  localized,  they  muy  be  found  to  present  at  some 
point,  distinctly,  a  niaximiitn  of  inU-nsily.  This  may  equally  indi- 
OAte  either  the  seal  of  the  disease,  or  the  point  at  which  it  is  greatest 

{•mount.  To  serve  as  a  guide  to  the  locality  of  disease,  the  ab- 
normal sounds  must  be  repeatedly  or  constantly  found  to  be  circum- 
scribed, or  to  have  their  maximum  of  inlen.«ity  well  defined  and  in 
tb«  tamo  situation,  for  in  certain  instances  the  sounds  are  due  to 


*  Dr.  C.  J.  B.  Willimna  nuggmta  that  the  hummiDg  Mimd  may  ba*«  b««a  pro- 
duced in  the  Jugular  Toiu.     (On  Dticuci  of  tlic  Empirator;  Organa.     Amoricao 


676  DIBBA8E8   OF  THE   BS5PIKAT0BT  0BSAS8. 

traoaieDt  physical  conditions,  viz.,  ap&sm,  or  the  accnmulation  of 
Tiscid  mucus.  The  laryngo-tracheal  sounds  are  sometimea  so  in- 
tense and  diffused  as  to  be  transmitted  over  the  chest,  obscuring  the 
pulmonary  sounds,  and  they  are  liable  to  be  mistaken  for  the  latter. 
This  Bonrce  of  error  has  been  already  referred  to. 

A  tremulous,  flapping  sound  (tremblotement)  has  been  observed  by 
Barth  in  cases  of  croup,  at  a  period  of  the  disease  when  the  sound 
was  supposed  to  indicate  a  loosened  and  partially  detached  condition 
of  the  false  membrane.  He  regards  this  as  a  sign  affording  valuable 
information  in  cases  of  croup,  denoting,  in  the  first  place,  progress 
in  the  processes  by  which  the  exudation  is  detached,  and,  ia  the 
secoad  place,  enabling  the  auscultator  to  judge  respecting  the  extent 
over  which  the  exudation  is  diffused.  If  the  rale  be  limited  to  the 
larynx,  it  is  a  favorable  sign,  showing  that  the  false  membrane  is 
probably  confined  to  this  part,  and  that  the  conditions  are  favorable 
for  ite  speedy  removal  by  expectoration  ;  but  if  it  extend. over  the 
trachea,  and  especially  to  the  bronchial  tubes,  the  prognosis  is  ren- 
dered unfavorable  by  this  evidence  of  the  extension  of  the  disease. 

Theoretically,  we  may  suppose  that  a  pedunculated  tumor  within 
the  larynx  or  trachea,  moving  to  and  fro  in  the  respiratory  acts, 
might  occasion  a  sound  of  friction,  which,  taken  in  connection  with 
the  symptoms,  should  render  probable  the  nature  of  the  affection. 
In  a  case  reported  by  M.  Elirmann,  of  Strasburg,'  a  valvular 
sound  {bruit  de  soupape),  was  heard  distinctly  in  a  forced  respira- 
tion. 

Ulcerations,  which  sometimes  destroy,  to  a  greater  or  leas  extent, 
the  vocal  chords,  it  may  be  presumed  give  rise  to  modifications  of 
the  respiratory  sound,  more  especially  in  expiration,  by  enlarging 
the  space  at  the  glottis.  The  contraction  at  this  point,  from  the 
approximation  of  the  chorda  in  the  expiratory  act  not  taking 
place,  one  of  the  conditions  upon  which  probably  depend,  in  health, 
the  intensity  and  elevation  of  pitch  of  the  laryngo- tracheal  sound 
in  expiration,  is  wanting;  and,  under  these  circumstances,  it  may 
be  anticipated  that  this  sound  will  become  relatively  feeble  and 
low  in  pitch.  This  ia  an  interesting  point  to  be  settled  by  observa- 
tion. 

The  foregoing  remarks  have  had  reference  to  abnormal  modifica- 
tions of  the  respiratory  sounds  together  with  dry  or  vibrating  rales. 

>  Vnileix,  op.  cit. 


DISGASBS  APFBCTIXO   THE  TBACBBA   AXD   LABTNX.      WJI 


I 


I 


■ 
■ 


Bubbling  or  gargling  sounds  attest  the  presence  of  liquid  lo  the 
trachea  and  larynx.  Owing  to  the  size  of  the  tube,  and  the  force 
of  the  column  of  air  which  traverses  it  in  rcBpiration,  the  presence 
of  a  conBiderable  accumulation  of  mncoB,  or  other  liquid,  is  indi* 
Lt«d  bj  loud  rales,  heard  at  a  distance,  and  commonly  known  aA 
Ae  tracheal  rattle,  or  (since  such  an  accumulation  rarely  takes 
place  except  toward  the  fatal  termination  of  disease),  the  "death 
rattle."  These  sounds  are  not  distinctive  of  any  affection  of  the 
windpipe;  they  denote  deficient  sensibility  and  loss  of  muscular 
power  to  such  an  extent  that,  either  efforts  are  no  longer  made,  or 
they  prove  insufficient  to  expel  the  accumulated  matter  by  expecto- 
ntion.  But  moist  rales  may  be  discovered  in  some  instances  by 
stclhnscopic  examination  when  they  are  not  apparent  at  a  distance, 
and  to  some  extent  they  may  be  made  available  in  diagnosis.  Thus 
it  i»  8uggc«ted  by  Piorry  that  in  certain  cases  of  bcemoptysis,  & 
moiitt  rule  localiiied  in  the  larynx,  provided  no  rales  are  found  at 
the  lower  part  of  the  trachea  and  over  the  pulmonary  organs,  is 
evidence  that  tho  hemorrhage  butt  taken  place  from  withiu  the 
larynx.^  Again,  Barth  ami  Hoger  state  that  in  ca«H>s  of  ulcerations 
m  the  larynx,  a  gurgling  or  bubbling  sound  found  ut  a  particular 
part  of  the  organ,  may  point  to  the  seat  of  these  ulcerations,  or  the 
maximum  of  the  intensity  of  ibc  sounds  may  indicate  the  side  on 
vbitfli  the  alceratiunB  are  most  numerous  and  extensive.  These 
sounds  are  most  likely  to  be  produced,  and  to  be  available  in  local- 
izing ulcerations,  when  the  Utter  are  situated  at  the  bottom  of  the 
Tentriclcs  of  the  larynx. 

In  conclusion,  the  direct  application  of  auscultation  in  alfectioD* 
of  the  trachea  and  larynx  furnishes  certain  physical  phenomena,  but, 
with  our  present  knowledge,  tbe^e  phenomena  embrace  very  few 
characlera  which  arc  distinctive  of  particular  forms  of  disease.  They 
ahow  the  calibre  of  the  lube  tobediminishcd,biUnot  tbeoauaeof  the 
contraction,  nor  do  they,  in  general,  afford  definite  information  a«  to 
the  amount  of  obstruction.  The  luttcr  point  i.i  determined,  oa  will  be 
Mcn  pre-senlly,  much  better,  indirectly,  by  an  cxaminalioD  of  the 
cheat.  They  show  the  preHcncc  or  absence  of  liquid;  and  in  croup, 
information  may  gomolimes  be  obtuincd  which  js  of  aid  in  forming  an 
opinion  as  to  the  condition  of  the  fulsc  membrane,  and  the  distance 


'  Burih  and  Roger,  op.  cit.  p.  268. 
3T 


578  DISEASES    OF    THB    BBSPIRATOKT    O&OANS. 

to  which  it  extends  below  the  larynx.  The  seat  of  inflamniation  or 
ulceration  may  in  Bome  cases  be  ascertained,  by  finding  that  the 
morbid  phenomena  are  persistingly  fixed  in  a  particular  part,  per- 
haps eren  confined  to  one  side  of  the  larynx ;  or,  if  more  extended, 
by  observing  that  at  a  certain  point  sounds  have  distinctly  a  maxi- 
mum of  intensity.  These  few  words  comprise  the  summary  of 
what  is  actually  known.  The  other  points  mentioned  in  the  preced- 
ing remarks  require  to  be  confirmed  by  farther  observation.  It  is 
by  no  means  improbable  that  cliaical  tnTestigations  may  hereafter 
develop  facts  which  will  render  the  direct  application  of  physical 
exploration,  exclusive  of  laryngoscopy,  to  the  diagnosis  of  diseases 
afiecting  the  trachea  and  larynx,  of  much  greater  importance  than 
it  is  with  our  present  knowledge  of  the  subject. 

2.  SJxamination  of  the  chest  in  the  investigation  of  diseases  affect- 
ing the  trachea  and  larynx. — Examination  of  the  chest  in  cases  of 
laryngo- tracheal  afi'ections,  as  already  remarked,  is  of  much  impor- 
tance. Grave  errors  of  diagnosis  may  be  thereby  avoided.  Bronchitis 
with  collapse  of  pulmonary  lobules  and  capillary  bronchitis  are  some- 
times mistaken  for  croup,  and  treated  with  repeated  emetics  and 
topical  applications  to  the  larynx,  when  the  phenomena  revealed 
by  thoracic  exploration  would  show  the  existence  of  these  aSections. 
It  is  true  that  the  existence  of  these  afiectiona  does  not  constitute 
conclusive  proof  that  croup  does  not  exist,  for  they  are  sometimes 
associated  with  tho  latter.  Taken  in  connection,  however,  with 
other  points,  the  greater  importance  of  which  will  be  admitted,  these 
phenomena  are  to  be  taken  into  account  aa  affording  an  adequate 
explanation  of  certain  of  the  symptoms  which  might  otherwise  be 
referred  to  the  larynx. 

To  determine  whether  pulmonary  disease  coexists,  or  not,  with  an 
affection  of  the  trachea  or  larynx,  ie  a  grand  object  in  examining  the 
chest.  In  cases  of  the  affection  just  named,  croup,  it  is  very  desirable 
to  settle  this  point  with  reference  to  the  prognosis,  to  the  treatment 
to  be  pursued,  and  especially  when  it  becomes  a  question  as  to  the 
propriety  of  resorting  to  tracheotomy.  The  advantages  of  this 
knowledge  in  these  relations  ia  sufficiently  obvious. 

In  cases  of  chronic  laryngitis,  the  question  arises  as  to  its  coex- 
istence with  tuberculous  disease  of  the  lungs.  Pathological  obser- 
vations have  established  the  fact  that,  in  the  vast  majority  of  cases, 
the  laryngitis  is  a  complication  of  an  antecedent  pulmonary  tuber- 
culosis, and  that  the  laryngeal  affection  is,  in   fact,  tuberculous. 


DtSBASBB   APFECTtSO  TUB  TRACBBA  AND   LAKTNX.      579 


I 


I 


But  this  rule  ia  not  mvariable.  The  affection  may  hare  a  syphilitic 
origin.  The  taw  of  probabilities  will  not  tbea  saSce  for  the  diag- 
nosis; and  the  symptoms  are  not  alone  adequate  to  settle  the  ques- 
tion, the  more  because  the  most  prominent,  viz.,  the  cough  and 
•xpcctoration,  may  be  attributed  to  the  laryngitis.  It  is  not  an* 
common  for  practitioners  who  do  not  avail  themselves  of  physical 
exploration,  in  cases  of  phlhiitiii  complicated  with  laryngitis,  to 
persuade  thciDSclTes  and  their  patients  that  the  disease  is  seated 
exclusively  uithin  the  hirynx.  It  is  by  means  of  tlie  precision 
giren  to  the  uurly  diagnosis  of  pulmonary  tuberculosis,  that  the 
consecutive  occurrence  of  the  laryngeal  affection  has  been  estab- 
lished, and  that  an  extension  of  liiseaMC  from  the  larynx  to  ibe 
lungs,  as  implied  in  the  term  laryngeal  phthmt,  is  now  known  very, 
rarely,  if  ever,  to  take  place.  A  persisting  chronic  laryngitis  nar- 
riints  a  strong  presumption  of  a  deposit  of  tubercle  in  the  lungs, 
but  the  proof  positive  is  the  evidence  afforded  by  the  prcet'nce  of 
the  physical  signs  revealed  by  an  examination  of  the  chest.  On 
the  other  hand,  the  non-existence  of  tubercle  ia  to  be  inferred  from 
the  negative  result  of  physical  exploration. 

The  syphilitic  origin  of  a  laryngeal  affection  may  in  some  ia- 
etsnoes  be  inferred  in  connection  with  the  result  of  an  examination 
of  the  chest.  This  conclusion  may  be  reasonably  entertained  when 
the  affection  is  found  not  to  be  associated  with  pulmonary  tubercu- 
losis, and  the  patient  ia  known  to  have  been  affected  with  syphilis. 

Another  grand  olijttct  lo  be  attained  by  an  examination  of  the 
chest  in  the  various  forma  of  disease  affecting  the  trachea  and  larynx, 
is  to  determine  the  actual  amount  of  obstruction  to  the  passage  of 
wr.  This  important  point  can  be  settled  vastly  better  by  an  ex- 
ploration of  the  chest  than  by  auscultation  directly  of  the  windpipe, 
and  frequently  more  satisfactorily  than  by  the  symptoms.  The  eii- 
dence  of  the  amount  of  obstruction  is  the  degree  of  diminution  or 
the  suppression  of  the  vesicular  murmur.  This  diminution  or  sup- 
pression, when  the  obstruction  is  seated  in  the  trachea  or  Inrytix, 
will,  of  course,  be  uniform  on  the  two  sides  of  the  chest.  In  fact, 
the  existence  of  some  affection  of  the  air-paKsnges  above  the  trachcs] 
bifurcation  is  to  be  suspected,  even  should  the  symptoms  not  point  to 
disease  in  that  direction,  if  the  vesicular  murmur  be  found  to  be  equally 
diminished  on  both  side^  in  n  notable  degree,  or  to  be  suppressed, 
provided  the  phyKicul  signs  of  einphysemn  of  the  lungs  arc  wanting. 
The  error  of  attributing  tlic  diminution  or  suppression  of  the  vaaa- 


680  DIBBA8B8  OF    THB    KESPIBATOBT  ORaAKS. 

ular  murmur,  due  to  an  obstruction  above  the  tracheal  bifurcation, 
to  emphysema,  iB  to  be  guarded  against  by  attention  to  the  other 
signs  which  serve  by  their  presence  or  absence  to  establish  or  ex- 
clude that  affection.  Whatever  may  be  the  disease  which  diminishes 
the  calibre  of  the  windpipe,  so  long  as  the  vesicular  murmur  con- 
tinues to  be  tolerably  developed,  the  patient  is  not  in  immediate 
danger  from  sufTocation,  notwithstanding  the  manifestations  or  ex- 
pressions of  suffering.  The  progress  of  the  disease,  as  regards  ita 
dangerous  effects,  may  thus  be  ascertained  from  time  to  time,  and 
the  fact  of  an  actual  improvement  may  be  established  more  posi- 
tively by  an  increased  development  of  the  vesicular  murmur  than 
by  an  apparent  relief  from  the  labor  and  distress  attending  respira- 
tion. In  acute  or  dangerous  affections,  then,  of  the  larynx,  viz., 
acute  laryngitis,  croup,  and  oedema  of  the  glottis,  vastly  more  im- 
portance belongs  to  auscultation  of  the  chest  than  of  the  larynx 
itself;  and,  in  fact,  the  predictions  of  the  physician,  his  hopes  and 
fears,  as  well  as  the  therapeutical  measures  which  he  employs,  must 
he  influenced  in  no  small  measure  by  the  pulmonary  signs. 

Exploration  of  the  chest  assists  the  auscultator  in  determining 
whether  an  obstruction  seated  in  the  larynx  he  due  either  exclusively 
or  in  part  to  spasm  of  the  glottis,  or  whether  it  depend  entirely  on 
a  diminution  of  the  calibre  from  a  physical  cause,  such  as  cedcma, 
exudation  of  lymph,  or  submucous  infiltration.  In  the  former  case, 
the  diminution  or  suppression  of  the  vesicular  murmur  will  be  inter- 
mittent or  variable ;  in  the  latter,  it  will  be  more  persisting  and 
uniform.  Thoracic  auscultation  thus  affords  valuable  aid  in  making 
the  differential  diagnosis  of  spasm  of  the  glottis  from  other  and  far 
more  serious  affections  with  which  there  is  some  liability  of  its  being 
confounded.  Moreover,  spasm  of  the  glottis  forms  an  important 
element  in  other  affections  of  the  larynx,  viz.,  laryngitis,  true 
croup,  and  perhaps  ccdema.  The  extent  to  which  the  symptoms  of 
suffocation  arc  due  to  this  element,  may  be  fairly  estimated  by  the 
development  of  the  vesicular  murmur  under  the  circumstances  in 
which  relaxation  of  spasm  occurs ;  for  example,  directly  after  a  fit 
of  vomiting.  It  is  important  to  determine  how  much  of  the  obstruc- 
tion arises  from  spasm,  not  only  in  order  to  form  a  correct  opinion 
as  to  the  immediate  danger,  but  with  a  view  to  therapeutical  measures. 
In  proportion  as  spasm  predominates,  arc  the  indications  present  for 
remedies  addressed  to  this  element  of  the  affection. 

Dr.  Stokes  has  pointed  out  a  method,  available  in  certain  cases, 


DISEASES  AFTBOTIXO  TBB  TRACREA   A:rD   LABT7IX.     581 


'  hj  wliich  pressure  on  the  trachea,  of  an  aReurism,  or  other  tumor, 
[may  be  distinguiHhcd  from  laryngeal  obiitruction.     Id  the  foriniT 
I  ease  it  froi^iienlly  happens  that  the  direction  of  the  prc'^urc  U  upoo 
I  one  of  the  primarr  bronchi,  before  extending  to  the  trachea;  and  if 
I  exploration  of  the  chest  be  practised  while  the  effect  is  limited  to  tbe 
bronchns,  the  consequent  diminution  or  suppression  of  the  vcmcular 
[jQuriaar  vill  be  confined  to  the  corresponding  side  of  the  chest. 
Subsequently,  when  tbe  tumor  increases  sufficiently  to  diminish  the 
fcalibre  of  the  trachea,  (he  vesicular  murmur  is  lessened  or  lost  on 
,  both  sides.     On  the  other  hand,  an  obstruction  seated  in  the  krynx 
or  in  tbe  trachea,  will,  from  the  first,  alTect  equally  ihc  vesicular 
murmur  on  the  two  sides.  Diminution  or  suppression  of  the  vesicular 
murmur,  then,  first  oti  one  side,  and  afterwards  extending  to  the 
other,  provided  pulmonary  disease  and  the  presence  of  &  foreign 
body  in  tbe  nir-passages  are  excluded,  indicates  an  ancurixmal  or 
other  tumor  originating  below  the  bifarcatioo*  and^exte&ding  gradu- 
ally upward. 

To  rccapituliilc  the  several  polnbii  of  view  in  which  »D  ezsmiiifr- 
tion  of  the  chest  is  useful,  in  the  investigation  of  di»eftecs  afieo^g 
the  trachea  uud  litryux,  it  may  prevent  the  error  of  attributing  to  a 
morbid  condition  of  ihe  >Oudpipc,  plicnomcnu  belonging  to  a  pulmo- 
nary affection ;  it  cnabii:*  the  physicittn  to  determine  whether,  or 
n«»t,  o  laryngo-tracheal  affection,  e.  g.  croup,  be  complicated  with  a 
ditiease  of  the  longs,  which  will  infiuenco  tho  prognosis  and  treat- 
ment ;  it  fami»hu«  evidence,  or  otherwise,  of  tbe  coexistence  of 
pulmonary  tubcrculoeis  with  chronic  laryngitis,  and  by  its  negative 
result  may  warrant  tho  conclusion  that  the  laryngeal  affection  ia 
syphilitic ;  it  furnishes  the  most  reliable  index  of  the  amount  of 
obstruction  incident  to  the  various  forms  of  disease  which  diminish 
,  the  calibre  of  the  laryngo-tracheal  tube,  and  it  aSbrds  evidence  that 
the  deficiency  of  respiration  proceeds  from  an  obstruction  in  tJie 
tube,  nnd  not  from  u  morbid  condition  of  tbo  pulmonary  organs ;  it 
is  a  means  of  ascertaining  whether  nn  obstruction  bo  due  to  spasm, 
and,  in  cases  of  aff'tctions  which  involve  a  spasmodic  clement,  of 
estimating  the  relative  importance  attributable  to  this  element;  and 
it  supplies  a  method  of  distinguishing,  in  some  cases,  an  aneurism  or 
other  intra-thoracic  tumor,  extending  upward  and  making  pressure 
on  tbe  trachea,  from  an  obstruction  seated  in  tbe  larynx. 


583  DISEASES  OF  THE  BBSPIRATORT  OBGANS. 


FoREiaN  Bodies  nr  the  Air-Fassaqes. 

Foreign  bodies  occasionally  slip  from  the  pharynx  into  the  orifice 
of  the  larynx.  This  accident  is  not  very  infrequent,  occurring 
oftener  in  children  than  in  adults.  The  bodies  vliich  have  been 
known  thus  to  become  lodged  in  the  windpipe,  form  a  heterogeneous, 
motley  collection, — morsels  of  food,  coins,  grains  of  corn,  seeds  of 
Tarious  kinds,  nuts,  teeth,  bullets,  nails,  etc.,  etc.  Their  size  is 
often  greatly  disproportionate  to  the  aperture  at  the  glottis  aa  ob- 
served in  the  dead  subject,  so  that  it  has  been  difficult  to  account  for 
the  manner  in  which  they  gain  entrance  into  the  air-passages.  This 
difficulty  is  removed  by  our  present  knowledge  of  the  respiratory 
movements  of  the  glottis.  It  is  now  known  that  dilatation  and  con- 
traction of  the  space  at  the  glottis  occur  in  regular  alternation  dur- 
ing the  respiratory  acts,  the  first  in  inspiration  and  the  second  in 
expiration.  When  dilated  with  the  act  of  inspiration,  the  size  of 
the  rima  fflottidia  is  nearly  double  that  which  it  has  in  a  state  of 
rest.'  Now,  it  is  in  the  act  of  inspiration,  at  a  moment  when  the 
epiglottis  fails  to  protect  the  laryngeal  opening,  that  the  foreign 
body  ia  drawn  into  the  air-tube  instead  oT  passing  down  the  cesopb- 
agua.  The  approximation  of  the  vocal  chords  with  the  consequent 
contraction  of  the  Outlet  in  the  expiratory  act,  and  still  more  in  the 
act  of  coughing,  constitutes  an  obstacle  to  the  expulsion  of  the  for- 
eign body  after  it  gains  admission  into  the  windpipe,  and  hence,  in 
a  large  proportion  of  cases,  a  surgical  operation  becomes  necessary 
to  effect  its  removal. 

The  presence  of  a  foreign  body  in  the  air-passages  gives  rise  to 
serious  effects,  according  to  its  situation,  size,  form,  and  character. 
More  or  less  disturbance  of  respiration,  and  disease  of  the  air-tube 
or  lunga,  almost  inevitably  follow.  Frequently  it  occasions  great 
obstruction  to  the  passage  of  air,  and  not  infrequently,  unless  speedy 
relief  be  obtained,  it  proves  fatal  by  inducing  asphyxia.  The  render 
is  referred  to  the  valuable  monograph  by  Prof.  Gross  for  a  digest 
and  analysis  of  nearly  all  the  cases  that  arc  to  be  found  in  the  annals 
of  medicine,  in  addition  to  those  occurring  under  his  own  observa- 
tion and  communicated  to  him  by  his  professional  friends,  together 

'  Vide  I  111  rod  Oft  ion,  pngc  52. 


rORBIOIF  BODIES  IX  TDK  AIB-FASSAQBS. 


588 


I 
I 

■ 

I 
■ 


■lit  dMliictionB  pertaining  to  tlic  effects,  symptoms,  diagnoeis,  an<l 
tre>lm«nt  of  thin  necident.* 

Fhynicnl  «x[>lorat.I»n  furnig)io»  frequently  important  infonnntion 
in  cu«»  of  foreign  bodies  in  the  Air-p.t.>t.>*Jige)i.  1.  It  assists  in  det«r- 
mitiing  tlie  fact  of  the  pri^Nencc  of  a  foreign  bodj,  in  some  instances 
ichere  it  \»  ti  mnttcrof  qno^lion  whether  the  symptoms  are  due  to 
this  cause  or  to  disease.  C>i»v»  have  been  reported  in  vhich  patienta 
with  a  foreign  bnrly  in  the  windpipe  have  been  treated  for  croap, 
ordinary  laryngitis,  and  .i|msin  of  the  glottifi;  nud,  on  the  other 
band,  in  cases  of  these  affoctions  the  presence  of  a  foreign  body  is 
sometimes  t>u?pccted.  The  importance,  in  a  practical  point  of  view, 
of  settling  this  question  is  sufEciently  obvious ;  in  the  former  in- 
stance, there  is  gceat  danger  that  lifo  will  bo  lost  for  the  want  of 
proper  surgical  interference;  in  the  latter  instance,  a  severe  and 
dangerous  operation  may  he  needlessly  performed,  and  other  inap- 
propria^e  measures  of  treatment  resorted  to.  3.  It  indicates  the 
situation  of  the  foreign  body,  whether  in  the  laryos,  trachea,  or  one 
of  the  primary  bronchi.  A  foreign  body  may  be  lodged  in  each  of 
these  situations,  and  the  relative  proportion  of  instances  in  which  it 
is  found  in  each,  is  a  point  of  importance  with  referenco  to  the  diag- 
nosis. Of  21  cases  proving  fatal  without  »  surgical  operation,  which 
were  analyzed  by  Prof.  Groins,'  in  11  the  foreign  body  was  found  in 
the  right  bronchus:  in  4  within  the  larynx  ;  in  .^witliin  the  trachcn; 
and  in  1  partly  within  the  larynx  and  in  part  within  the  trachea. 
In  no  instanee  was  it  found  in  the  left  bronchus;  but  examinations 
made  during  life  show  that  it  docs  occasionally  become  fixed  in  that 
situation.  The  fact  that  in  the  vant  niujoricy  of  instances  it  falls 
into  the  right  rather  than  the  left  bronchus,  is  to  be  bomo  tn  mind. 
The  anatomical  reasons  for  this  fact,  which  arc  ftilly  presented  by 
Prof.  flrofta,have  been  already  mentioned.*  3.  The  physical  signs 
show  the  changes  in  the  situation  of  the  foreign  body  which  are 
liable  to  occur.  Prof.  Gross  states  that  in  scroral -instances  falling 
Dnder  his  own  observation  a  change  of  place  occurred,  and  in  one 
case  it  was  transferred  from  the  right  to  the  left  bronchus.  The 
same  fact  has  been  observed  by  others.  The  movableness  of  the 
body  may  also  be  ascertained  by  physical  exploration ;  and  this  ts 
sa  important  point  with  reference  to  the  probability  of  its  being 


■  A  PraetlcftI  Trosti»e  nn  ForoEcn  Bodicw  in  the  Air-piutBgei.  bv  S.  D.  Grow, 
M-D.,  Profcuor  of  Suigcry  in  tlie  Uoivemiij  of  LouUritlo,  oic.,  1S64. 
*  Up,  cll.i  p.  49.  *  Introduetion,  p.  46. 


584  DISEASES   OF    THE    BBSPIEATOBT   ORQAHS. 

removed  by  a  anrgieal  operation.  It  has  been  known  to  become 
permanently  fixed  and  encysted  at  some  point  in  the  air-passages. 
4.  The  effect  produced  on  the  respiratory  function,  as  determined 
by  auscultation,  authorizes  an  opinion  as  to  the  size  of  the  foreign 
body,  or,  at  all  events,  it  shows  the  amount  of  obstruction  which  it 
produces,  and  the  consequent  immediate  danger. 

Physical  exploration  in  cases  of  foreign  bodies,  as  in  diseases 
affecting  the  trachea  and  larynx,  may  be  said  to  have  a  direct  and 
an  indirect  application.  Using  these  terms  in  the  same  sense  as 
heretofore,  in  its  direct  application  it  furnishes  certain  signs  ema- 
nating from  the  windpipe  itself;  indirectly,  it  ascertains  the  phe- 
nomena which  represent  the  effects  produced  within  the  chest.  Here, 
also,  as  in  diseases  affecting  the  trachea  and  larynx,  the  information 
obtained  by  an  examination  of  the  chest  is  often  much  more  im- 
portant than  that  derived  from  direct  exploration  of  the  windpipe. 
Proceeding  to  notice  the  physical  signs,  we  will  consder  them  in  the 
order  just  mentioned,  hut  without  a  formal  division. 

Percussion  over  the  trachea  or  larynx  is  of  little  or  no  avail,  but, 
in  addition  to  auscultation,  palpation  is  sometimes  resorted  to  with 
advantage.  Mainly,  however,  auscultation  is  to  be  relied  upon,  so 
far  as  physical  exploration,  in  its  direct  apphcation,  is  concerned. 
In  auscultating  both  the  windpipe  and  the  chest,  much  difficulty 
will  be  likely  to  be  experienced,  in  children,  from  their  resistance, 
and  the  restlessness  occasioned  by  their  distress.  Prof.  Gross  sug- 
gests, that  to  secure  a  satisfactory  exploration,  chloroform  may  with 
propriety  be  employed.  The  objections  to  this  measure,  if  there  be 
any,  are  yet  to  be  ascertained  by  experience. 

A  dry  rale  may  be  produced  at  the  point  of  lodgment  of  the 
foreign  body,  which  may  present  either  the  sonorous  or  sibilant 
character.  This  sign  was  observed  in  several  of  the  cases  analyzed 
by  Prof.  Gross.  The  sound  is  described  by  different  observers  as 
whizzing,  whislUnff,  cooing,  whiffing,  "puffing,  and  snoring.  Those 
terms,  with  the  exception  of  the  last,  denote  a  higli-pitchcd  or  sibi- 
lant rale.  Diversities  in  the  audible  characters  are  unimportant. 
The  intensity,  pitch,  or  quality  of  the  sound  give  to  it  no  special 
significance.  The  practical  importance  of  the  rale  consists,  first,  in 
the  fact  of  its  existence,  and,  second,  its  being  either  limited  to  a 
particular  part  of  the  windpipe,  or  the  maximum  of  its  intensity 
being  found  at  a  certain  point.  The  situation  of  the  foreign  body, 
it  may  be  presumed,  corresponds  to  the  part  where  the  rale  is  heard. 


rORBIQV  BODIBS    tK   THB  AIR-PASSAOKS. 


585 


I 


or  irhere  it  is  moist  intciiso,  cspccinll;  iT  other  sigas,  to  be  preeratly 
referred  to,  are  in  accortlanc«  vrith  this  coiicluHioD.  Thiw,  tlic  rale 
may  b«  obserred  only  orcr  the  larynx,  or,  if  it  be  suiEcicnily  load 
to  be  propagat«d  downward,  it  may  bv  dfi:idvdly  mon;  intense  over 
the  larynx.  The  same  may  be  true  of  the  trHchea;  but,  in  the  rast 
majority  of  iitstiinces,  if  the  foreign  body  be  not  di-tuincd  in  the 
vontnclo  of  the  Inrynx,  it  becomes  lodged  in  one  of  the  bronchi, 
andulmost  invariably  in  the  right  broDcliUK.  A  rale  may  then  be 
heard  near  the  Bterno-claviculur  junction  on  one  side,  or  more  marked 
ID  that  situation  on  one  exile  than  on  the  other,  thus  indicating  the 
bronchus  in  which  it  is  situated.  A  curious  case  was  observed 
and  reported  by  I'rof.  Macnnmaro,  of  Dublin.'  A  boy  while  oc- 
cupied in  wbiiitling  through  a  plum-stone,  perforated  on  each  eide, 
and  the  kernel  removed,  by  a  strong  inspiration  drew  the  stone  into 
the  larynx,  where  it  became  fixed  transversely,  without  occasioning 
tDOch  inconvenience  for  several  days.  During  this  period  the  pas- 
sage of  the  air  through  the  perforation  produced  a  sound  as  when 
the  stone  was  placed  across  the  lips,  and  the  boy  for  some  hours 
went  about  pleased  with  this  novel  and  convenient  method  of  whis- 
tling. The  stone  wa.<i  localized  by  means  of  this  sound,  and  an  opo- 
vation  pt-rfgrmeil.  The  triiuffcrvnce  of  a  rule  from  one  part  to 
another,  warrants  a  suspicion  of  a  change  of  place  of  the  foreign 
body;  but  this  point,  as  will  be  seen  presently,  is  ascertained  more 
po«ilivcly  by  an  examination  of  the  chest.  If  the  foreign  body  be 
lodged  in  one  of  the  ventricles  of  the  larynx,  it  is  not  improbable 
that  the  presence  of  a  rale  on  one  side  and  not  on  the  other,  or  a 
greater  inteneity  of  the  sound  on  one  side  may  indicate  in  which  of 
the  vcntrieles  it  is  situated. 

When  the  foreign  body  remains  in  a  certain  position  for  soDHi 
time,  it  prodtices  local  irritation,  inSammation,  or  even  ulceration  of 
mucous  membrane.  A  moist  or  mucous  rale  may  then  bceome 
eloped;  and  the  same  inference  is  to  bo  drawn  from  its  being 
limited  to  one  part,  or  from  the  maximum  of  intensity  being  local- 
ised, as  in  the  case  of  a  dry  or  vibrating  rale.  If  the  foreign  body 
be  lodged  in  one  of  the  primary  bronchi,  inflammation  is  apt  to  ex- 
tend to  the  bronchial  subdivisions,  giving  rise  to  bronchial  rales, 
either  dry  or  moist,  or  both  combined,  over  the  clieet,  to  a  greater 
or  less  extent,  on  Ute  corresponding  side. 


t  OrOMOii  Furei^u  BuJIm,  y.  110;  SIoVm  oa  |ha  Chwl,  p.  2A8. 


586 


DISEASES  OP    THE    RESPIBATOBT    OtOASt. 


A  flapping  or  ralvuUr  »ouii(l  on  ausedtsting  the  trxduA  and 
lirjnx,  has  Leon  obHcrvi><l  in  some  instances,  dae  to  the  moTennni 
of  the  fomgn  bocljr  to  and  fro  in  tlic  tube,  hy  the  carrent  of  urn 
the  re«piratory  tict».     I'hc  shock  occasioned  b^  the  impulsion  of  tbt 
suhvtnncc  agiiiust  the  rocitl  chords  in  acts  of  coughing  baa  ako  Um 
found  to  be  distincllj  appreciable  hj  the  touch.     vVnd  it  ia  tn  ndi 
a  cmt«  that  palpation  maj  prove  a  valuable  method  of  explotatioa. 
In  •  case  reporter!  by  Brantbv  B.  Cooper,  this  taetite  sign  was  m 
veil  markc^l  in  a  boy  who  had  inhaled  a  pebble  into  the  windjope, 
that  the  presence  of  the  foreign  body  was  predicate*!  mainly  npon 
it,  the  sympiotuiilic  phenomena  being  slight,  nnd  an  opcratieo  toe- 
cessfslly  reported  to.'     It  is,  of  course,  only  in   certain  cases  that 
this  sign  is  available ;  bnt  vhen  preiteat,  it  is  highly  aignificant  of  a 
hard,  movable  substance,  like  a  pebble  or  shot,  wriitiin  the  trachea 

Ad  examination  of  the  chest  often  aiTords  eridcnce  of  the  prca- 
enoe  of  a  foreign  body,  and  of  its  situation,  more  definite  and  re- 
liable than  the  signs  obtained  by  direct  explonttion  of  the  windpipe. 
Aa  already  remarked,  the  former  of  Uiesc  two  applications  of  phys- 
ical exploration  is  much  the  more  important.  The  pntmonaiy 
phenomena  are  made  to  supply  positive  proof  with  reference  to  tke 
points  just  menttoncil,  by  a  simple  process  of  reasoning.  If  a  for^ 
eigQ  body  be  lodged  within  the  larynx  or  trachea,  in  proportioa 
as  it  presents  an  obstacle  to  the  passage  of  air  the  Tcsicalar  mnranr 
will  be  rendered  feeble,  or  it  may  be  suppressed,  and,  assumiag 
that  there  exists  no  uScctioa  of  the  lungs,  the  percussion-sonikil 
remains  undiminished.  Under  these  circumstances,  the  dimina- 
tion  or  suppression  of  the  vcsiculnr  murmur,  coexisting  with  good 
resonance  on  percussion,  will  be  found  equally  on  both  sides  of  the 
chest.  Now,  if  it  be  known  that  a  foreign  body  is  contained  some- 
where within  the  nir-passngcs,  the  combination  of  signs  jnst  sUted, 
viz.,  the  vesicular  murmur  diminished  or  suppressed  equally  on  both 
sides,  and  a  clear  percusstoD'Sound,  imticates  with  positirenesa  that 
it  is  situated  above  the  bifurcation,  either  within  the  trachea  or 
larynx.  But  let  it  be  supposed  that  the  presence  of  a  foreign  body!* 
not  known,  and  the  qneation  is  as  to  the  diagnosis,  being  amtred 
that  Uie  lungs  themselves  are  free  from  disease,  and  assuming  that 
there  has  saddenly  occurred  marked  dimiaution  or  suppresalom  of 


■  Otqm  on  Portlgn  B«dl«4,  etc.,  ]i.  111. 


VOBBieTI  BODIES  IN 


587 


I 

I 


I 


I 


the  vcsieulnr  murmur,  the  inference  is  jmsitivo  that  cither  there  is 
H  foreign  body  in  the  windpipe,  or  that  there  exists  some  dincase  of 
the  hiryngo-tracheal  tube  which  involves  obstruction,  such  as  acute 
luryngittt*,  oedema  glotlidis,  spasm  of  the  glottis,  or  croup.  We  h»7e 
lh«ti  only  to  dcoide  from  the  history  and  cymptoms  that  none  of  these 
aHections  are  present,  in  order  to  reach,  by  way  of  exclusion,  the  fact 
of  the  existence  of  a  foreign  body.  The  differential  diagnosis  of  b 
foreign  body  in  the  laryns  or  trachea  from  the  litffercnt  diseases 
aeateil  in  the  windpipe,  is  to  be  based  on  the  vitnl  pbcnomeua  and 
pathological  laws  which  characterjao  respectively  these  diseaacft. 
To  consider  the  distinctive  points  would  render  it  necessary  to  treat 
of  iheir  diagnostic  features.  It  must  suffice  to  say  that,  in  discrimi- 
nating between  them  and  the  presence  of  a  foreign  body,  thej/  are 
to  be  excluded,  and  the  characteristlea  derived  from  eymptoms  and 
pathological  laws  which  belong  to  each,  are,  in  general,  sufficiently 
constant  and  striking  to  constitute,  when  present,  evidence  of  its 
existeucD,  and,  conversely,  when  nbscnt,  to  warrant  its  exclusion. 
In  one  of  the  affections  named,  viz.,  oedema  glottidis,  the  touch  is 
often,  if  not  generally,  available  as  a  means  of  diagnosis. 

But  in  a  targe  majority  of  instances,  the  foreign  body  does  not 
remain  in  the  larynx  or  trachea.  It  becomes  lodged  in  one  of  the 
bronehi,  generally  the  right  bronchus.  In  thi«  situation,  according 
to  its  size  and  form,  it  produces  cither  more  or  lc«s  obstruction,  or 
complete  occlusion  of  the  broncliinl  tube-  In  proportion  to  the 
amount  of  ohalniction,  the  vesieuiur  niuniiur  on  the  corre«ponding 
side  will  he  diminished,  and,  if  there  be  occlu^oa,  the  murmur  will 
bo  sappressed.  If  the  lung  be  free  front  diseusc,  the  pcrcussioii- 
reaonaoce  will  continue  unafleetcd,  unless  the  occlusion  lead  to  more 
or  less  collapse  of  the  lung.  The  latter  effect,  it  is  slated,  may 
follow,  and  then  there  will  be  duliic<ss  in  proportion  as  the  volume 
of  tlie  lung  is  diminished,  together  with  contraction  and  let^encd 
mobility  of  the  affected  side.*  Thi.t,  however,  is  pn^bubl}*  only  an 
occasional  result.  The  respiratory  function  of  the  lung  on  the  op* 
posite  side  will  be  increased,  giving  rise  to  a  reticular  murmur,  ex- 
aggerated  in  proportion  as  the  fujiotion  of  its  fellow  is  compromised.  - 
Ilere,  then,  we  have  an  assemblage  of  pulmonary  signs  which  point 
with  certainty  to  the  situation  of  the  foreign  body,  assuming  its 


I  n&  OroM  Mi  Foreign  BodtM,  p.  107. 


688  DISEASES   OF   THE    RESPIBAIOBY   OEOAHS. 

presence  in  the  air-paasages  to  be  known.  A  vibrating  rale,  heard 
exclusively,  or  with  its  maximnm  of  intensity,  over  the  bronchus,  is 
a  confirmatory  physical  sign.  The  same  may  be  said  of  a  mucous 
rale,  in  like  manner  circumscribed  or  diffused  to  a  greater  or  less 
extent  over  the  affected  side. 

Even  if  the  presence  of  a  foreign  body  somewhere  in  the  air- 
passages  he  not  known,  the  combination  of  physical  signs  just 
mentioned  is  almoBt  proof  positive  of  its  existence,  provided  it  be 
ascertained  that  they  have  been  suddenly  developed.  As  remarked 
by  Stokes,  there  are  but  three  affections  capable  of  producing  a 
similar  assemblage  of  signs,  viz.,  pressure  on  a  bronchus  by  an 
aneurism  or  some  other  tumor ;  obstruction  of  the  tube  by  hyper- 
trophy of  the  mucous  membrane,  and  its  occlusion  by  an  accumu- 
lation of  viscid  mucus.  The  symptoms  and  the  previous  history 
Till  rarely,  if  ever,  leave  much  room  for  doubt  when  it  is  a  problem 
in  diagnosis  to  decide  between  the  presence  of  a  foreign  body  in 
the  bronchus,  or  the  existence  of  one  of  these  three  morbid  condi- 
tions. 

Evidence  still  more  demonstrative  of  the  presence  of  a  foreign 
body  ie  afforded  when  it  is  found  to  shift  its  place,  being  removed 
from  its  situation  in  the  primary  bronchus  by  an  act  of  coughing,  and 
carried  upward  into  the  trachea,  or  perhaps  transferred  to  the  bron- 
chus on  the  opposite  side.  Its  dislodgment  from  the  bronchus  is 
immediately  followed  by  the  reappearance  or  the  normal  develop- 
ment of  the  vesicular  murmur  on  the  side  where  it  had  been  found 
to  he  abnormally  feeble  or  suppressed.  If  the  body  be  easily  dis- 
placed, and  hence  thrown  upward  from  time  to  time,  the  physical 
evidence  of  obstruction  of  the  bronchus  will  be  intermittent ;  and 
if  the  body  occasionally  be  transferred  to  the  other  bronchus,  as 
has  been  repeatedly  observed,  the  two  sides  will  be  found  to  present 
the  characteristic  combination  of  signs  in  alternation.  Under  these 
circumstances  nothing  could  he  added  to  render  the  diagnostic  proof 
most  positive.  On  this  point  Dr.  Stokes  remarks:  "There  is  not  in 
the  whole  range  of  stethoscopy  more  striking  phenomena  than  the 
sudden  rush  of  air  into  the  lung,  on  the  foreign  body  passing  into 
the  windpipe,  or  the  equally  sudden  disappearance  of  all  sound  of 
expansion,  natural  and  morbid,  when  the  bronchus  becomes  again 
obstructed."  The  effect  is,  of  course,  more  striking  when  the  foreign 
body  produces  sufficient  closure  of  the  tube  to  arrest  all  respiratory 


rORBION  BODIES  TIT  THE   AIB-PABSAOflS. 

omi,  but  the  eriilence  is  oqnally  clear  wh<?R  there  U  obstnictioa 
;h  to  onuse  a  notable  diminution  in  intensity  of  the  Tesictilar 
aur. 
It  is  obvious  on  comparing  the  phenomena  fitrniabod  by  kd  cxami- 
Inatjiin  of  the  cheat  in  cartes  in  which  the  foreign  body  is  seated  in 
^thc  litrynx  or  trnchcn  wilh  Ihoae  which  indicsitc  ita  situation  to  be 
thu  bronc)in»,  that  the  diagnostic  evidence  in  the  latter  is  more 
Btriking  and  positive.     In  ccinncctton  with  this  fact  it  is  to  be  boroe 
iiiinil  that,  of  n  piven  niimbftr  of  cases,  in  vastly  the  larger  pro- 
portion the  foreign  body  fulls  into  the  right  hronohuEi. 
In  the  diagnosis  of  foreign  bodies  in  the  air-passnges,  not  only 
f»te  the  physical  signs  to  be  assoctutod  with  the  symptoms,  bat  in 
^Dany,  if  not  in  moat,  instKnccs,  as  regnrds  their  rcliilive  rittik,  they 
ire  subordinate  to  the  latter.    In  treating  of  this  subject,  however,  aa 
'of  the  diseases  affecting  the  trachea  or  larynx,  my  purpose  was 
to  consider  it  only  in  its  relations  to  the  principles  and  practice  of 
physical  exploration. 


80MMART   OP  THE   PHYSICAL  BIGSS  OF   POREIOK  BODIES   IK   TDK 

II  AIR-PASSAaBS. 

A  sibilant  or  Bonoroua  rale,  either  limited  to  the  larynx,  trachea, 
wr  bronchus,  or  having  its  maximum  of  intensity  over  one  of  these 
portions  of  the  air-passages,  and  in  some  instances  changing  its 
place  from  one  portion  to  another.  After  a  time  a  mucous  rale  in 
either  of  the  same  situations ;  occasionally  a  valvular  or  flapping 
Bound.  Motion  of  the  foreign  body  sometimes  perceived,  during  aots 
of  coughing,  by  palpation, 

Feebleness  or  suppression  of  the  vesicular  murmur  equally  on  both 
•ides,  if  the  foreign  body  be  situated  within  the  larynx  or  trachea ; 
the  percuss  ion -resonance  remaining  good.  If  the  foreign  body  be 
■ituated  in  a  bronchus,  the  vesicular  murmur  on  the  corresponding 
side  enfeebled  or  suspended,  the  pereusgion-rcsonancc  remaining 
good,  if  collapse  of  the  lung  be  not  induced.  Feebleness  or  Sup- 
preasion  of  the  mnrmur  sometimes  suddenly  giving  place  to  n  well- 
evolved  and  normal  respiratory  sound,  after  an  act  of  coughing 
which  dislodges  the  foreign  body  and  carries  it  upward  into  the 
trachea.  Occasionally  feebleness  or  suppression  of  the  vesicular 
murmur  transferred  from  one  side  to  tlic  other,  indicating  a  removal 


590  DIBEABBB   OF    THH    BISPIKATORT  0BQAK8. 

of  the  foreign  body  from  the  bronchus  of  one  side  to  that  of  the 
other  Bide.  Exaggerated  vesicular  respiration  on  the  side  opposite 
to  that  on  which  the  murmur  is  found  to  be  diminished  or  suppressed. 
Dry  and  moist  bronchial  r&les,  after  a  time,  more  or  less  diffused 
over  the  side  corresponding  to  the  bronchus  in  which  the  foreign 
body  is  lodged. 


INDEX. 


A. 


AbaencA  of  ruDDmnce  on   pfiranaalon    (ntf« 

PlBtD«!a),  B8 
AbdomiDiil  reipintion,  24 
Acoustic',  imporUnoe  of,  in  B<ady  of  phj«- 

cal  siplatdtioD,  S6 
AdvenlitioDs     rsBpiratorjr      toandB,       {vidi 

fgupbosy,  231,  !4I,  25S 

itt  pDeumoDLtiB,  S6A 

in  Icuta  plaaritii,  fil4 

in  rhronic  pkutLtij,  £31 
Air-celLs,  dantiptioQ  of/  41 
Air-pauagei,  foreign  bodiei  in,  582 

■ummary  of  signi  of  foreign  bodies  in, 
&8B 
Ampboria  reppirBtlDD,  188 

Toice,  242.  257 

revunancA  on  paroQuion,  1D0 
Apoplaij.  pnlmonarj,  483 

phydioal  sigaa  of,  484 
dingaoiis  of,  484 
BUiDmarj  of  lignB  of,  487 
Afltbrns,  363 

pbjBic&l  BigD0  of,  3ftS 

dlagnoiiB  of,  301 

BDmmary  of  signs  of,  3BT 
At<l«cU«iB,  398 

pbjiBicsl  signB  and  diaLguosii  of,  101 
Attrition  sooDds,  223 
Ansoultatioiif  dafiailioQ  of,  66 

mediata  and  immediate,  117 

mlas  in  practice  of,  124 

in  beallb,  128  ' 

in  diaenBe,  151 

liiBtorj  of,  272 

in  acute  bronohitiB,  324 

in  capillarj  broncbilis,  332 

in  dilatation  ofbronshial  tubes,  S50 

in  uthma,  364 

in  acnle  lobar  pDenmonltiB,  37S 

in  reaicalai  ampbjaema,  408 

in  po^mooar;  tubarcutaiia,  431 

in  acute  plenritiB,  SOB 

in  cbronio  plauritis,  528 

in  pneumo-bjdrutborfti,  655 

In  di»pbragmatio  beruia,  568 

in  diseaaea  of  larvni  and  trachea,  S73, 
5T1 

in  foreign  bodiei  in  »ir-psissagaa,  534 


Aiillsr;  regions,  80 

rasonance  on  peronision  in.  S 
respiration  in,  143 
looat  reaoDanoa  in,  l&l 


B. 

Beau  and  Hassiat.  types  of  breathing,  26 
BellowB  arterial  eonnd,  271 

in  pulmonary  tuberculo^,  141 
Braatbing  in  baatth,  23 
normal  Ijpas  of,  26 
in  the  female,  26 
modified  bj  age,  28 
Bronchi,  primary,  deacription  of,  IT 
Bronehial  phtbislB,  471 
rales,  IBS 
raapiratioD,  nonnal,  ISB,  HI 

abaormai,  166 
aeptam.  48 

lubeB,  description  of,  40 
dilaUtion  of,  316 

phjsical  signa  of,  S10 
diagDosia  of,  351 
summary  of  phjaioaJ  Bigna  of, 
367 
oontraotioD  of,  S68 
vbitpet,  normal,  147 
Broosbitifl,  322 
Boate,  323 

phjaioal  aigna  of,  323 
diagnoala  of,  327 
eammarj  of  aigna  of,  S31 
oapillary,  331 

phjaioal  signa  and  di*gnoaia  of,  33S 
Bnmmary  of  aigna  of,  310 
chronio,  340 

phjaioal  aigni  of,  340 
diagnoaia  of,  313 
seeondarj,  346 
Broncbo-cavernnna  respiration,  136,  Ml 
Bronebo-Tesionlar  respiration,  176 
BroDchopbonj,  231,  233 
whispering,  231 


Caiipen,  2B2 

Cammann'i  Btetboaoopo,  121 

Cancer  of  the  inogs.  187 


592 


INDEX. 


Canoer  of  tl]«  langa^  phjnoal  ii^i  of^  4Bd 
diagnofliH  uf,  489 
lammarj  o(  ligni  or,  493 
ID  mcdivlinuDi.  494 

phjsical  ligoa  at  495 
diflgnopia  of,  496 
C&pillnrj  broDobiul  tabcB,  40 
C&vsrDOUFi  coagh,  21)0 
Tupintton,  182,  441 
voice,  242 
whisper,  25B,  258 
Chest,  file  of  in  hEsItli,  33 

Biaminatinu  of.  indiHuaeof  the  leryni 

ttud  trachea,  5T8 
maaeurer.  29 

morbid  appearaaoei  pertaining  to  lite 
and  form  of,  277 
of  Teapiratorj  movenentfl  of,  2S4 
pbjFicnl  exploraCion  of,  gtnenl  remarlu 

on,  AG 
■ite  of,  as  determiaed  b]>  msnauratloD, 

292 
topographieaL  diviaionv  of,  54 
ClaTipular  region,  S6 
Collapae  of  pulmooarj  lobnleg,  100 

phjpical  sigDB  of,  uid  (liagnoua  of, 
402 
ContooanCB,  tbeorjof,  237 
Costal  reiplratlon,  24 

cartilages,  deaartption  of,  18 
Coagb,  QBveraouB,  2A0 

bronchial.  260 
Coughing,  pbeoomona  of,   on  ansonltatiDQ, 
154 
phenomena  incident  to,  259 
Cracheil-tDetal  resonance  on  percassion,  110 
Crackling  rale.  231 
Crepiionl  rnle,  JU9.  378 
Crumpling  rale,  219 


D. 


Deferred  injpiration,  190 

in  emphysema.  409 
Diagnosip  of  di?ea?e«  of  the  respiratory  or- 

gan.x,  prelimiunry  reinarlte  on,  321 
Diminiahed  inicnsiij  of  the  ronpiralorj  miir- 
moT    (rii/e,     respiration,     feeble    or 
weak).  15U 
Tocat  resooaoce,  241 
Diaphragm.  20 
Diapbragniiitic  hernia,  5n5 

physica!  signs  of,  687 
dinRnopi?  of,  589 
breathing.  24 
Dilatation  of  bronchial  tabes,  340 
DaloeFS  on  percussion,  9S 

physical  oonditioni  represented  bj, 
101 

B. 

Emphysema,  40fl 

interlobaljir.  41B 
Tes  icuUr.  408 

phvsicnl  piitns  of,  407 

diagnopis  of,  415 

tnoimarj  ofphpicsl  signs,  4IT 


Exaggerated  respiration,  ISO 

vocal  resonance,  231 
Empyema,  541 
Expiratory  sound,  31 
prolonged,  101 


P. 


Feeble  respiration,  159 
Flatncu  on  percaisioD.  98 

physical  oonditioni  represented  by, 
99 
Fremitus,  Tocal,  300 

rbonchal,  308 
Friction  marmor.  pleural,  223 

in  aoule  plenritis.  513 

in  pneumonitis,  378 

in  pqlmcnary  tabercutosis,  449 


Q. 

Qangrena  oflnngi,  477 

diagnosis  of,  480 

physical  signs  of,  478 

summary  of  physical  signs  of,  483 
OtoUJs,  51 

respiratory  moTemanta  of,  52 
Gross  on  foreign  bodies  In  air-pasaagel,  40 
Qurgling,  199,  219 


H. 

Bajmcptcic  lofarotas.  484 

Heart,  abnormaltransmis^Ionofsoundsof.IBO 

Hepatic  flalneps.  line  of.  80 

Hernia,  diaphragm  alio,  505 

Ilippocratic  sucuussion -sound.  310 

Hngeboom's,  Dr.,  modiBcationofCammann't 

stethoscope,  124 
lloognDg  eoagb,  301 

HulcbinBon  oa  vital  capaoity  of  lungs,  44 
Hydrophone.  123 
Hydrolhorai.  549 
Hypervesicular  respiration,  150 


Increued  intensity  of  respiratory  mnrmur, 
15ft 

Indeterminate  rales.  219 

Infra-clavicular  regions,  58 

resonance  on  percussion  in,  81 
respiratory  murmur  in.  137 
vocal refonanee  in,  149 

InfrB'mamraary  regions,  58 

resonance  on  percussion  in.  86 
respiratory  murmur  in,  143 
vocal  resonance  in,  1^1 

Infra  and  Luler-scapular  regions,  00 

resonance  oa  percussion  in,  83.  90 
respiratory  marmur  in,  140,  142 
vocal  resonance  in,  150,  151 

Inspiratory  sound  shortened,  190 

Intercostal  spaces,  19 

Interrupted  respiration,  1S5 


INDEX. 


S93 


Inspection.  dftADition  of,  66 
rigu9  dsttimlDcd  bj,  S75 
inmmarj  of  tisDi  by,  28V 
hlslor;  of.  2U1 

in  dilatation  of  biDQshl&l  tabei,  350 
in  a»thmji.  3A4 

in  &cuLe  lobar  pnanmonilli^  380 
in  Tsiiculu'  enptajisiDB,  4  IS 
in  pulmun&r;  (ubBiculoiit,  44S 
in  pneumo-bjdrolborux,  ibi 
in  acDl«  pleurillA^  516 
in  obrunio  pEeuritis,  529 
InvDfflalLon  in  alflMtaflia  Had  oollapflB,  100 
InUrccllular  punges,  40 
Inlrrco'UI  ncuralgiit,  &61 
lutsrlobsr  flisure,  37 

delineation  on  obeit  b;  ptrannion, 

103 
in  poenmonitip,  374 
Intcracapular  region'.  00 

rejonaocfl  on  percniuion  in,  63 
reipiratorj  murniur  in,  140 
Tocal  reaoDBUoe  ia,  150 


Larfngophony,  145 

LarjnJi  and  tmchBO,  diHU«  of,  571 

Larynl.  d«8criptiDn  of,  40 

rfl^piriLlory  BODnds  in,  120 
Lohcfl.  pulmunary.  30 
Lobular  puFumonitiB,  39S 
Lobules,  pulrnnnsry.  3S 
Lnngi,  dfluription  of,  34 


H. 

Munmarj  regfoni,  51 

reviDttDCe  OD  pBronKion  in,  63 
respiration  in,  142 
Tocal  reponnnca  in,  151 
H*nBnratiuD,  deflnilion  of,  06 
in  vrsEoiiUr  frmphyiema.  414 
in  pnimooHrj  toberoutoflis,  44T 
in  pneumD-bjdro thorax,  557 
in  acuta  pJeuritLfl,  510 
signs  obtained  by,  202 
suminiiry  of  rigns  by,  300 
HeUllis  tinkling.  302 

in   dilatatiuD  of   bronohial   tubai, 

351 
in  pulmonary  tDberealoiia,  445 
in  pneumo-bydrotborai,  556 
Hnsons  TBlae,  204 


ir. 

Nsnrnlgia,  intercoita],  661 


0. 

CBdemaof  Innj;!,  474 

phypicnl  Bigot  in,  475 
diagnofie  of,  47B 
summary  of  signs  of,  471 


P. 

Palpation,  deflnition  of,  66 
nigni  obtained  by,  303 
summary  of  jigus  by,  300 
in  aeutn  lobar  pneumonitis,  387 
in  Teaicolar  empbysemo,  414 
in  palmonarj  taberoolosis.  440 
in  pneomo-liydTuthoraT,  557 
in  aoute  pleuritis,  510 
PeDloiiloqny,  231,  242,  257 
Paroussion,  drfloition  of,  65,  76,  77 
■aimuUatory,  78,  420 
in  health,  TO, 
rules  in  proctioe  of.  03 
in  diieose,  97 
eij^B,  tabular  viair  of,  115 
hiatory  of,  110 
in  acota  bronohitis,  323 
in  onpillary  bronehitis,  331 
in  dilatatioo  of  bronohial  tubas,  340 
in  asthma.  303 

in  aouta  lobar  pneumonitis.  370 
in  Tesioulnr  amphy»ma.  407 
in  pulmonary  tubereulosle,  424 
in  acule  pleutitia.  503 
in  cbronic  plauritia,  538 
in  poBumo-hydrotborax,  553 
in  diaphragmatie  hernia,  567 
in  dlseaoes  of  larynx  and  traohea,  5T2 
Pertussis,  361 

physical  signs  and  diagnosis  of,  362 
Pbtbisis,  acute,  405 
brmobial,  471 
chronic,  vitie  Putmonarr  tnboroalosis. 
421 
Physical  eiploration,  IT 
adraijtagas  of,  TO 
■igns,  deSaitlon  of,  66 
tabular  view  of.  313 
Plenra.  34 
Plauritis  acute,  501 

pbysical  signs  of,  503 
diagnosis  of,  521 
summary  of  aigns  of,  525 
chronie,  527 

pbysical  signs  of,  528 
disgnoais  of,  531 
reirospecliFe  diagnosis  of,  535 
circumscribed,  with  affusioD,  545 
Pleurodynia,  501 
PI  1^  1 1  mete  re.  TO 
Pneumu-bydrnthorai,  561 

pbysical  signs  of,  553 
dingnosis  of,  558 
summary  of  signs  of,  550 
Pneumonitifi,  308 
acuta  lobar,  368 
physical  signs  of,  370 
diagnosis  of.  388 
summary  of  signs  of,  308 
ohronis,  403 
lobular,  390 
Pneumorrhagta,  483 
Pulmonary  ndema,  4T4 
gangrene,  477 
apoptely,  483 
PoBlt>claviealar  regions.  56 

reionanoa  on  perciuelon  in,  SI 


38 


694 


IlfDBZ. 


Prolonged  «ipir«tlon,  Ifll 
Pnuila  ceipiistion,  1S6 


Qnliin's  itttbomater,  30  - 

B. 
Balei,  lei 

trachesl  HDd  bronchial,  IBS 

subcrcpitBDl,  199.  207 

oretiituDt,  ID'J.  210 

caTarDoan^  orguT^linjr.  190,  SIT 

indeLermiomte.  ISO,  21B 

sibiUnl  and  nmorona.  200,  203 

muooDS  or  bubbling,  201 

pifurni  friolioo.  2S3 

tabl»  BhowLqg  aumber,  nDmaB,  AQd  ana- 

laidical  situatioDi  of,  ZUO 
tabie  thawing  diitinoLive  obacacten  uid 
diagnoatio  impart  ot.  222 
RcglODB  of  cbest,  baundsrieB  of,  55 

normal  reBODnccc  on  pvrcOBflioll  Id,  81 
rcBpiratory  mnrmor  in,  H5 
SDramarjofpointBofdiapmTityaareRpeaU 
respirutoTy  and  Tocal  phenomfina,  152 
Kfieislanofl,  iflnao  of,  on  percuBBion,  77 
SsBonance  on  perouaaion,  normal,  79 
abienee  of,  98 
diminution  of,  98 
tjmpaDitio.  98 
Testis  u  I  D'tympaDitio,  08 
amphonc,  109 
crack  Ed-metal,  110 
narm&l  vocal,  147 

in  different  regions,  149 
Tocal  FiaKt^erated,  231,  2'<2 

HiiiiiiLished  and  aupprerij>ed.  2ST 
Kc'piTntion,  orj^ans  concerned  in,  17 
tracheul  and  laryngeal.  1-9 
Teaicninr.  132 
compariai^n    of  tracbcal  and  v«aicqlar, 

i:i& 
paerile  and  senile,  l^fi 
in  diffi^reai  re^^i'm?,  !'I7 
normal  bronchial,  1-19,  HI 
muvrmenU  of,  in  health,  22 
in  th«  femnl«,  2A 
modified  by  age,  23 
rhythm  of,  Xi 
Bonn ds  of.  abnonnatly  modiGed,  Hi 
exaggerated,  151^ 
feeble  or  nenk,  159 
gnppresBed,  164 
bronchial  or  ttihular,  164 
broDoho-veBicular,  176 
cawernou^,  la2 
amphoric,  ]AH 

tabubr  vion  uf  diBlinclive  ch&racten-uf 
normal  vesicular,  bronchial.  hroDcho- 
vet^ienlar,  and  caTornoDB,  1H9 
inlerruplcd,  IMS 
adventiiiouH   soundn     iooideat   to    (Bee 

Kalep).  I'H 
morbid  ii|]pearancea  pertaining  to  more- 

meiili^  of,  2(11 
morbid  movernenta  detertained  bj  men- 
luralioD,  297 


Rfaonelit  and  rattl*!  (aide  Kaln). 
Rilw,  false,  true,  and  Baaling,  18 
Eode  reBpiration    (virf>  BrDacho-Taaiaiilfti 
reapiratioD),  17S 


Scapula,   aletation  of,  dimloiBhed  or  sup- 
preSBed   in  tabercnloalfl  and   other  affea- 
tiooF,  289 
Scapular  regiona,  59 

reaonance  on  perflnBalon  in,  83 
rBBpiration  in,  140 
tooh]  resonance  in.  ISO 
Sense  of  reaiBlanee  in  parounioD,  11 
SborUn«d  iuBpirallon,  190 
Sibilant  rale,  200 
8ib«on>  cheat-meaBurer,  29 
Signa,  tabular  view  of,  with  phyateal  Condi- 
tione  which    they  repreBenl,  and  tiia 
diuaset  In  which  they  occur,  313 
deflnitioaB  of,  Aft 
different  aapecU  of,  72 
Soundi,  different  characterB  of.  67 
Spirometer,  44,  299,  301 
Sploshing  or  anacuBBion-aound,  310 
Sonorous  rale,  202 
Sternal  regions,  59 
Stethometer,  30,  44  T 
StetboBcopes,  118 
Stethoscope,  Cammann'i,  121 

differeatial,  128 
Suborepitaot  rale,  199 
SaoouBBion.  60 

Signs  obtained  by,  310 
in  palTnonary  taberculo*is,  450 
in  pneuiqo'bydroiborni,  55S 
Suprn-cluviculnr  region,  56 
Symmetry  ofcbeflt.  devialioua  from,  21 
Symptoms,  de£aition  of,  OO 


I. 

Tapo  for  iD«n4iir[rig  cbert,  394 

Thorn*,  pjirietesof,  18 

Tupn^rapliical  diviaioas  of  ohe9t,  54 

TrochFA,  46 

r«9pif&torj  aonndg  in,  129 

Traehea  and  luryni,  diseiuBa  of,  572 

TrhchDophony^  145 

Tuberculuf'is,  pulmnDAry,  420 
physical  eigoa  of,  424 
diagDOiiiB  vt,  4AU 
Hummary  of  nl|;na  of,  464 
r«tT0»pectiY6  diagnoHi^  a(,  448 

of  bronchial  fElMcds,  471 
Tubular  re)^  pi  rut  ion,  166 
Tyuj^iuDitic  resunimra  on  p»rca?BioD,  98 

\a  pnQuiBODilia.  3T2 

physical  condiiiuns  Tepr«»Dtri1  by, 
11)7 
Typ«aof  breathLDg,  3& 

V. 

Vfelcular  mnnnur  of  nspirfttlan,  133 


IKDEX. 


695 


Veiioolo-t^mpinitio  ruonanu  on  parDuuian, 
98 
phTiioal  aonditiooi  ctpreMntcd  b^, 
113 
VdobI  fr»iiiitu«,  306 
Tocdl  aigiiB,  lamm&r;  of  bott  psrtaining  to. 

25& 
Voice,  soKaltatioD  of.  In  heHlth,  144 
truheal  and  larj/ngeal.  145 
phanoniflQft  of,  JDcidDHt  to  diHMe,  231 
dimiaiibad  and  BappraSBed,  231,  S4I 
OTamooi,  242 


W. 

Wnvy  ralplratloD,  19S  > 

Weak  rp ftp] ration,  1&9 
Wtuaper,  CKiernoni,  331,  S46 

amphoris.  246 

aiaggaratad  bronchial,  231,  240 

normal  bronahial,  147 
WoiUfii,    raHearohB$    ralatlra   to   dariationi 
from  symmotry  of  cheat,  22 

OD  meoBUration  in  aeata  diHasas,  298 


HEISmY    C.    LE^'S 


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per  annaai 
in  adrance. 


In  thu!'  ofleriDg  to  the  priifeniua  this  unprecedented  smoDBt  of  VAloabie  practical 
itter,  the  pnbliaher  can  only  be  eaiod  from  Io«8  by  a  very  Urf>e  iiter«n8C  in  the  avb- 


J9>  Gcnllerucn  receiving  this  Catulo^ne  wonhl  conrer  s  (avot  od  the  Pab- 
Ksfacr  by  ooininunivutii);;  ft  to  their  profes^iooal  friend 


•criptiom  lut.  It  u  hi*  dain:  to  rnnrish  t4  tb«  prtetitionor  in  every  Beotioo  of  ibt 
country  tht  ntoiMt  that  can  he  »iip[ilinil  tot  m  nioonst  iriUria  the  mcb  of  enrj  me, 
am]  hi?  loO).'  cooncction  villi  the  p^1^■!ll^i«D  w.-imiiu  him  in  lli«  hope  ibul  his  i^orU 
vill  h»  iMotulril  )'v  ihf  intcrc-ii  whii.'h  hi)  prnvtiiinn^i:!  mud  Trcl  id  ionuriaK  the 
■access  of  hia  trndenttkitig  uad  rvB'lcriti^  it  p«rm»Dt>Dt.  It  is  oat;  b^  n  circalalioa 
hilhmo  unknown  in  the  liidoiy  of  AncricaD  mi^ilii'iil  Jonmnli^iiB  thkt  in  tiui  an 
Mioaal  or  l^c!  choicMt  rcadisg  can  lio  •ffonlod  tit  ao  inoiitimte  a  ftUdi,  ftud  the  pnb- 
I  luhci  tbc^nTurv  r«Iic*  on  the  c»op«rolion  of  Ibc  profeasion  at  Urge  to  nsipoad  to  hi> 
^If^ftvor  itf  luy  on  livi  luhlr  i>f  vvcrf  phjiJcun  x  mootbl}-,  t,  qunitetlj-,  ud  »  bolt 
^Mrtj'  juarniil,  ut  a  price  nhicfa  i"  wil.lioul  uxninplo. 

'  Theee  perloJlt-ats  an  unlvprmllj  known  for  tb^lr  higb  proAwional  stnadlag  In  tbdr 
,  leTcral  sphcrM, 


THE  .\MERtCAN  JOURNAL  OF  THE  MEDICAL  SCffiKCES^ 

EniTED  BT  ISAAC  HAY3,  M.D,, 

is  pntiliilicd  Qiurtotly,  oo  Ihe  Qnl  of  January,  April.  Joljr,  tad  Oetolier.  Eadi 
nambcr  <OBtaioi  nearly  thrae  bnndrad  huga  octavo  \MgfHi.  appropriately  tUotlrateJ, 
whorcvcr  met*»axy.  tt  hiw  now  huta  inaacil  regularly  for  over  rotw  )-ean.  daring 
nearly  liic  whok  or  which  linur  it  hux  Ihto  iim!<T  ihi-  romrol  of  ihv  prviteat  editor. 
Tlironghoat  fbis  Iod^  pt^riod,  it  boa  BUtialaiovd  iu  priiiillDn  la  lk«  Ughcft  rank  of 
medical  perlodtvala  l>ntb  nl  home  and  nbroml,  nnd  hii^  ri'i:etvcd  ikc  cordial  aupport  of 
the  ouliro  profeuion  in  thiii  coiinlry.  Among  il«  Collnhoralort  wlU  be  found  a  Urga 
numliGr  of  tlio  moat  distin|,'iiinhed  nnmcn  of  thi:  profMsion  in  GT«ry  section  of  tht 
United  Stutet.  r«ndartnf  ibe  dspatlmeat  devoted  to 

OUIGINAI,    COMMIfXrOATIONS 

follof  varied  and  inportaat  matter,  of  £r«at  iDtereil  tool!  practitioner*.  Tbng, daring 
lt)t><>.  conttibution*  have  appeared  in  ita  pages  fron  tlie  following  gcatlcmcn.* 


B.  allk:(,  m.  n.,  aui,  WBrj.  v.kx. 
J0II5  lAiiiu-wrr.  jl.  x.  i>  .  i-hiuivirtiU. 

E.  V    liUXXKTT.  n.  1> ,  Kiabujr.  O. 
BCMJ,  I.    B1KI>.  In.  «.  tl. 
J.  n    llLArK,  «.  B..  Xov.rli,  O. 
KOB&RT  DC'RVK,  M.  0„  rraiialara,  T^ 
.  VX   O    UALKWl^f,  M  ^.  lIonrjiMaof  Co  .  ato. 

I  BonEirre  iMuni'n.iivr,  u  n ,  (nudOMiii,  v.' 

tfnUX  ■>.  1tIi:llA)l.  >l  p.  MIlUt-hiirjT  0. 
|j01IX   H.  UR]XTi>I(,  X  f.  I'hll>i1>lphu. 

jo«u>it  <:Aiuii:f,  u.  i>..  Pbii*<>i|>tu«. 

inriKti  T  CARWKI.L.  n  a  .  IVi'ild-ar*.  II  I. 

n.  p.  imnmc  m.u,  Piiiiwiripw*. 

KOWAltD  X   CT«Tl«.  MO.  BfuUerhfliill.T, 

s.  UEifKV  DicKwK.  ».  n..  riii|ii4tiriiii. 

J,  C  [nl.TCy.  M  l>,  N.wT»lt. 

II.   B.   Kl-9l)!f,  M  P.  CIdttUuiI, 'I 
IL  T.  KVAN».  M.  O,  PliltnilcIphLL 

ausriii  ruxT.  u.  n.,  :<•*  iifn. 

CIABKSOK  PRKEXAX.  iS  l> ,  Hlluo,  Coiud*  W*>l. 
C  C  (IHAr,  U.  D.,  AhI.  ftnrj^  CI.!, 

: •'-     ' ■— 


w.  vr.  aEBEl*B^.  k.d„  Pbii>a*irkto. 
n.  OLiiATt,  M  n .  i^xikad.  ontm. 

HfeO   C  IIIKLAX.  M.  El .  Pb1l»4clfaM. 
JOUX  KaUT.  X.  U..  Bdiua.  Hu>. 

gowARO  BABmitnitxg,  u  i>    i-i. 1. 1^1.144. 

PUIt.tP  IIARVKV.  X  0.  Pi  .1 

K.  n  UAruiiTiix.  K  (1,  ij  . .  LM^ 

ISAA«:  UA1>   M.  0.   ] 
n.  L   WnlKJC  M_D,  : 

J.  II.  iiPTcntSitrtS,  ■  IV.  n,i(.<!.ifa». 

Idl.IRT  llAJJ'tvllullNK,  X  P..  riifiilXifck 

It.  iiowAiin,  «,D,  uun.i.  a. 

VIIL  Ill'Xr.  X   [>.  |-lilLwltl|4M. 

A.  HCKvi:!  Jtrtuo-f.  K  o ,  ^iR..4itai«,  r«h 

SAMUEL  J   jnXS^  M  tf^  S«>«<4>  C.  1  X. 
EAXirNI.  JACXA'tff,  M  D..  Pl.lI>d<l|.VU. 

':iiAnLGs  II  it-ititA,  K  0-.  Awl.  aouM*  r. & , 

X   KKWrP.  M.  U  .  IViini..iil.  l»L 
W.  KSXI-STRK.  U  II  .  B;iK*M.  Jl.T. 
A.  W.  KTSi].  X.t>,  llllimli 

/.  I.  txvuitc.  X  i>,  phiUdUfau. 

M.  CakEV  LU.  Km.  l-blUadpkM. 

jaua  1.  ttuKr.i..  x  p.  sntpHn  cut. 

IKVISa.  W.  LTUX,  ILfi,  Idnlord,  Ol. 


•  (^sannalHilau  sr*  Isriisd  fiaB  «*BiJ<iBtd  In  sU  virtt  «r  lb*  naaUy     All  tUbtni*  MtMlM  i 
bj  Ik*  IWllar  mn  F>ld  •»  ty  lit  Pabiiibir. 


niitiLT  C.  Lxa'ii  I'vaLicAtiovs— {Am.  Jmrn.  Med.  Scityictt). 


lAXlK)  )l.  >l  ITfO.T,  X.  I>,  Urwiiimih  Pt, 
B.  ll»IIKt.  M  ft  .  Purl  Oib.oo.  m-. 
H-^'tSI.I.All,  »  O  ,  II.  »  *, 
JCEIA!tI>   ME8BEKIIV.  H   D.,   B4lllii>orc,  114. 
I..  UKAU.  M  [),  albsDy.  n.  T. 
^.  ATTKKH  MBiaa.  U.  b.,  PhllodaLpU*, 
r.  MKItHil.U  H  ■>..  NfW  Yark. 
r  HITCIIRI.L.  M.  D.,  Plill>id>lpbla. 
r.  P.  KOOK.  «  U.  SI.  l^uU 
k.  W.  MUUKU.IX.  M.  D..  IUrilu>liur(r.  Hj. 

rnfis  n  tKiErt^K.  x  i>.  rixtkJriphik. 

topis  UACKlLL.  Jt,  M   O.  .(^or^ol.ifB,  DC. 
K.  B.  MUWKT.  M  U.  AII«>(Ii>i>T rnr,  1^ 
'        J.  n.  I'irKAKI'.  M.  D„  PhUruloli>M». 
OSOKnR  E'f.l'l-KU.  H  U.,  Plilliiili'IpliJx, 

wiiLUM  I'Ki'i'KR.  N.n,  riiiiojuphi*. 
J.  e.  pnETTiuAH,  u  D„  tuirwd.  d<i. 

bAVIU  nilXCi;  M.  D.,  JjieUvmrlllp,  111. 
B.  K   PEA^LEK  M.  D  .  Ruv  Tirk. 
DBWirr  c  l-KTKIUI,  M.  0.,  Kntj-.m  D.  1  A. 

f.  B.  Ht.  jobs  V.'i06^  U.  D ,  S**  rsrk. 


A.  ROTHROCK.  K.  U  ,  McV>ru»t.  fk. 

Vr.  S.  IT.  n[il!i:ilKKBII]ii>EK.  X  U.Suriwe  C.8.A. 

J    H.  SALl^nfRV,  M  D  .  Cl.i.Und.  O. 

ELI  D.  BlRQEBT.  KB.,  C  S  S»»y. 

J.  w.  iiiiKurr.  M,u.,  Aci'c  i-uwd  mi  9sr|.  u  an. 

CHAXLU  C  SROYER.M  ».  UiToimunli,  Kia>u. 

ALmBO  i>rii.ut.  M.  dl,  rhii&^uiphiB. 

L'HARLE^  RKARr,  H-D,  AutiL  »ii>|>aB  C  )^  A. 
STEPHBJI  -mmi.  M  U  .  »«  V.Kk 

I,.  II.  ifrxixxu.  it  0.,  \wii.\iBott.  xa. 

W.  B.  TKI'LL,  B.  ft  ,  *«■!,  8UIJ..IU  t;.  «  V 

J.  D  TWirtlSO.  M  B.  Affi*«lil.tui(.  u  a.A. 

JAMbi  -n-iil).*!,  M  I>..  PMUilolfhlm. 

cuhtox  WAUMm.  ti.u,  amu.  ttmf «-■  c.  s.  A. 

J.  J.  Vi-DOBWAKU,  M.  ft.,  AMLII.SutpiDS  U.S.  A. 
TII0a.C.  WAI.TOX.  V  D.I-K>i>4  Au'lSuri.  UIK. 

i]<RAK(.  H  WA-ViiermN,  x.  d  .  ui*  smc.  tr.s.T. 

W,  A.  WBTUERUV.  M.  ft..  ».w  Vurk. 

U.  Wll.l.lAUt.  M.  U,  I'bUsdilptiiji 

WX   J.  WILSOK,  M  D..  M»<wa.  Mu. 

BftWARD   WItr.VSKT.  V   II.,   rati  MnitliOD.  Icn, 

HUKATl  0  C.  WUOU,  Jr.,  H.  P..  Pl>lli>4flf  Bla. 

Pollowloi;  this  is  the  "itminw  Dki-authknt,"  eonluioiog  *itt'oJed  ami  impaitiil 
riev;*  or  >l]  imiiorlnnt  new  workv,  together  with  numurou*  daborulc  "biouo- 
iSAriiiL'Ai.  NoTiL'B*"  of  nvurl;  nil  Ihu  piil)lici»ti(inji  fif  the  day. 


"HiUb  roUoir^ilb;  tho"Qi;AK4Kai.v  Hv«B*tii  o»  Imchovkkk-mii  ako  PtmnTKxtM 
In  mi  MkuicauBl-ikacks,"  (rliumifii-d  Buil  ormnKuJ  under  liiffLTent  hcudi.  procntini; 
H  terj'  cuniplcie  BDeuunl  or  nil  that  U  new  und  iuleresiio);  lo  the  pbysiciaa,  sbrond  m» 
I       well  lis  at  home, 

H^Tbn*.  doriog  Uic  year  1^6,  the  "lontxin.'  has  runiinlici)  to  its  ftulncnbon)  Oii« 

^KBltiklre')  and  I'wuutj  OrigiunI  Communii-'utioiix,  tiixty-iivc  Urvicw*  imd   HibtviK 

^lyrkphkal  Nutives,  anil  Twu  Uucdrt-d  and  Tbirly-tnto  Drlitlt'K  in  tho  QnnrU-ily  K«m- 

niATica,  mukiug  a  Total  uf  over  Fniin  HcxDmni  article*  raiantting  from  the  Yirtl  pro- 

.ftsiAoDiU  minds  in  Amcricu  and  Kui'ope. 


¥ 


To  old  jnbdciib*™,  many  of  whom  hikvc  bWD  on  the  list  for  twenty  or  thirty  yoar». 
Ihepobli^vr  frpU  tlmt  no  promiBcs  Tor  thr  foiore  arc  necCMafy;  bat  ppntlcrarn  who 
may  now  propone  for  the  tirti  limo  to  subscribe  m.iy  rest  Minirod  thst  no  exertion  will 
be  Kparcd  to  maintnin  the  ■-JntmNAi."  in  the  hi^h  position  whicb  it  has  bo  long  occo- 
pird  on  a  (i>itioiinl  expniienl  of  scii-Dlillc  mediciuc.  and  ss  a  medium  uf  inlcrcommn- 
QicatioD  between  the  profevsioo  of  Rnrope  and  Am«riea— to  render  it,  io  bet,  qcc«»- 
sar7  to  cvsry  pmcuiioner  who  do»ira<  to  hoep  on  *  lovol  tritb  tbo  progm*  of  hi* 
0cien<«. 

The  iiibsciiption  price  of  the  "Amkricax  Jodrkai.  of  thi  IUkdical  Scirkcim"  liu 
^^rer  bc<'a  mixed,  diiring  its  long  career.  It  is  still  Fivk  1)oi.i.AnH  per  uunum  in  nd- 
Tuce,  for  which  *nm  the  Kahiiribcr  receives  in  addiltoo  the  ''Mei>ii?ai.  Nkwi  amd 
LiBmAXT,"  making  in  all  nbont  1500  l(ir([C  octoTo  po^*  per  annum,  free  of  pnalmga. 

U^ .„..,.„„.,..„ 

pHBBBic  "Nkws  DurARTueNi"  prceents  the  curt«ut  inrurroalioa  ot  the  diy.  with 

Clinicnl  Lectures  and  Itonplinl  Gleauingt;  wUlu  the  "  Liiibahy  Dkfahtxkvt"  i*  Je- 

TOt«d  to  pnblialiing  st.indftrd  works  ou  ihc  various  bmnehes  ofinudiual  scienei-.  pM|[eiI 

■opamtely,  fn  thai  thej  '■ho  t«  roniored  jiod  bound  oo  eiiinplelion.    In  lIiiN  raunnet 

,  tnbtt'ribtm  h»vo  roi.-«iT«d.  mlbout  expnnM.  wcU  nutVn  i»»"\i  ».twrt>'*  V».i.«vi«».T 


1 

I 


II. 


TlIE  MKUICAL  NKWS  ,\M>  UBHART 


if.        HUtMr  C  IiBA'8  PiiBUCAriox»— (^m,  Jovrn.  JfetL  Seienc^). 


"ToDi>  jun> BowMAv'fl  PaTfltOLCOT,'*"WMToxCHiiA«»,"''H*LaAid*ir#  SimaniT,'' 
ke.  kc.  A  nev  unil  valuable  practical  work  will  be  comneBced  b  tfce  Boiaher  fbr 
Jkunurf,  18(7,  Tvudi-iiog  lliis  »  p«rIicuUt<7  dusinblc  iIdmi  Tor  am  nlMriplkiB*. 

Aa  dated  ubov«.  ttu  eiibwripttoo  price  or  ilio  "Mcoktal  Vmrt  avo  LtaKARr'*iaJ 
Oxc  Doi.i^H  t>^  ntinuui  in  ailvnncei  and  it  is  foruiibtd  wiUi»ut  charge  to  ail  mb- 
suriben  to  the  "AHemciH  Juvrnal  or  rax  iiumcxu  Sl'ixmobs." 


HL 


J 
I 


I 


RAKKING'S  ABSTRACT  OF  TRK  MEDICAL  SCIENCES 

||4nHd(lB  haif-y««rlv  volume*,  wliich  will  bti  dcliron4  t«  fobfcribcrs  aboQl  thi)  Bnt 
trtnSa,  aiul  Hral  of  Bcpicmtipr     KotIi  volamo  trill  oonuin  aenr\y  300  closely 
[ plated  OCUvopa^Cs.  ntubing-itcarljr  iJx  lumdrvd  page)  {vcraDlUB. 

"BisdMi'e  AmrKAirr"  hii*  now  hifc-d  puMislicd  in  Knglawl  ir^fulnTly  tor  more  than 
IwcDl^jurs.  aad  bit*  UKiuiml  lbs  bigh««t  rcputaiion  Tor  tbo  nbtlilv  nuii  inilaFlTj 
Willi  wbieh  Ifcc  Mivaco  or  miMlieal  litcntarc  is  condamed  isto  ib  pa^rr*.  It  pnrports 
to  be  **^B  AnnSylii^l  and  Critieal  Di'jfl  iff  'Ac  pnneipt^  Bntink  and  OfnUinvtilot 
fcdKal  n'orki  puhlirhfd  in  the^prtcrding  Six  JtotUhtt"  and,  IB  additwD  t»  Ifao 
pT  Ibiit  dvrivud  from  indc^pi-adcot  irvaiiac*.  it  pmcnti  aa  ab»lnicl  of  all  tliat  it 
ortnnt  or  inttimting  iti  about  tixtj  Briiifli  und  Cootuicntitl  jogrvuU.  Aboat  (onr 
I  biindri-il  uTliclos  ak  thuH  innnnlly  prcArntpd  to  ilH  mikn,  nlTordiog  *  vrr;  complvte 
view  of  tbo  progrcn  of  nwulical  (cicnoo  tbrougtiool  lb*  world.  Kaob  volnmc  it  >^ta< 
nuticaUy  arravgad  and  ihoroogblr  iadoxed.  lltiu  fiuilitetiuf  the  renarcbca  oT  tfao 
nodcrin  pnnsit  or  particular  aul^BeU,  uid  nnabligg  him  to  rafer  wilfcoat  loM^of  tuna 
to  tba  vast  amoDDt  of  iafurmitlton  ooniKioed  iu  iW  page*. 

The  Mbtsriplton  price  of  Ibo  ■■Amtbaot,  "  mulled  fr«e  of  poHtas^.  will  b«  Two 
Sdu^b»  AXO  A  Half  pcranaunt.  pajrnblc  in  adnocu.    Singlr  voIubm,  $1  Mtwii.' 

As  sttiteil  itbove,  Lowovct,  il  will  b«  supplied  in  ogqjnnctiun  with  tb«  "Ajirticui 
t  JoriixAi.  or  THK  Mrdicae.  Scibxcks"  uid  tbi-  "Mgdiuai.  Nkwa  ind  Liaa^ai."  tbo 
\yih»le/mofpMta^,  for  Six  D<>i,u>rs  na  anxuh  ix  adtaxck. 

For  iy«!innjl  mm  the  subtcribcr  wiQ  tber«rDre  rvcdre  lliA«  pcriodicak.  «iicli  of 
tl)c  hi^bctt  rcpul^tion  in  ils  class,  conluioing  iu  nil  uver  two  Tac>inAnb  rAOHs  uf  tin 
^^icmt  n)ii4icis,  and  prvscatiag  a  cou^tleU  view  of  muikcol  prMjfrca*  ikroaj|boul  tlk* 

lit  tJiii  effort  to  tiring  ao  lnrs«  an  aniiuDt  of  practical  inromation  wilkin  Ui«  Math 
'  of  K*eni  uietalier  of  tlio  profeauou.  tli«  pnbluhcr  cDDri<Unily  aniicijiaiice  tbt  (iwndly 
>  nil]  of  ull  wlio  arv  ial«Ksiod  in  the  duM'tniniitiun  of  .luuiid  mcdic-Al  Ijlrniiiire^  Ub 
.  truits.  fBpeciolljr,  ibat  tbe  suliacriluvn  lo  ibe  "Aukhhux  Msdicai.  Joi^kxai."  Ptl)  call 
I  tbe  alletiUoD  of  tbeir  actiuuiolaucus  to  ibe  adraatai^'i  thna  oBm-d,  aed  ikat  be  wlQ 
;  be  euslatnoil  in  Ibe  endeavor  to  pcrmau^utlf  establish  medical  p«riodic«l  Uteniure  vd 
■  fooling  of  cboapnces  oovor  bcrclofore  uliempted. 

*a'  Gentlemen  dct^iring  to  avail  ibcniHclvcs  of  tlio  »draDtagca  Ibst  ollvrcd  will  io 
voU  to  forward  tbcir  subicripiiou)  at  ^  uuly  day,  in  order  to  insure  Ui«  recript  of  | 
flompleU  sets  for  tbe  jrew  ItfCI. 

tf  The  eafirat  mode-  of  remittance  is  bjr  poiUJ  money  order,  drawn  to  Ibr  ordrr  of  ^^ 
the  nDitiirtlgne').  Wherv  money  order  post-offices  nic  not  accMsltilt,  ii'init(4(ict«  fer^| 
tb«  -' JoUkkal"  may  lie  made  at  the  risk  of  the  publiiber,  by  taking  the  poat&MAtn'i  ^^ 
eertiDcQle  of  th«  lodusurv  and  rorwariUug  of  tbc  moucy.    AddrCM. 

nKKRT  C.  I.KA. 
u,  ,,      No*.  ~0G  and  708  S^aaoM  6j.,  Piui;AifW.i'Hi 


I 

I 


ai*.  Ta.     H 


ITkkrt  C.  IjSa'8  PontTOATTOKS — ^Victionariet). 


S" 


ryCNQUSOK  [HORLKV).  M.D..  V      ' 

AtKDirAI.  LEXICON;   A   HinTro^Aav  op  Miti>ifi.\L  Rnirari::   Con- 

Uiaitiir  1  ODncitr  ttriluiMion  of  Ihr  *arioU9  ^iibJMti  unl  Trmt  of  Amtc-irt,  Ph)  4«|0||7. 

P»Uiulo|ty.  HtkUq*.  TbaiK]i(Btle«,  Phtnniimhigy,  PhamaeT.  Siirfrt.  Uluiatrioi.  M*Hi(>kl 

JurifpraihDee.  atid  ll(dlMij.     NMleo  of  Dhnala  aad  of  Mlk*nl  Wal»ri;  foraute  br 

OlAi'inal.  Kinpirir'Ar  Anil  Dittalir  Pr*pBralJODii ;  wtlh  tba  ApamluatioD  and  Ei^oIa^  of 

Ua  Tbioii.  >di1  ib*  Pi«nch  and  athir  Sr^o^TOia*  i  (o  M  U)  aanoUUiU  a  K'isdoIi  a*  ■>!!  al 

Bn^Iixh  Mftdinvl  Lvilroti.    Thorntijfblf  H«r»ad,  uid  T«rj  fraaU j  Modiflvd  and  Anj[iD«a1Mt' 

I*  oa*  rar;  larga  anil  bandiaina  rn^al  oetava  Talana  of  1044  daabla-calumnad  |uc«,  in 

(Diatl  t;v«  i  ittongt;  do^^  op  la  ailra  cloth,  $4  0(1  i  lfatb«r.  laiicd  bandi,  S4  II. 

HlV  ohjwl  of  t.lia  author  fmm  Ihfl  nult*t  hu  not  batn  Ia  muka  Ilia  work  a  maira  laiJoMk  or 

Istlmurj  oC  t«Tini.  bui  I'l  aSanl,  ludcr  oaah,  a  cinidaawd  itaw  of  tta  *arli»U  nadlAal  lelaltnni, 

ail4  (hM  Co  nndar  Ibv  wnrk  itn  vpitmaa  of  tba  aiiatmi;  ffnnflrlloa  of  madiffnl  anl«i)«<*,     Scartlng 

»ilh  lki«  Tiav.  Ibe  ImmeiKc  dnuand  vhlah  hai  •iblcJ  fuc  Iba  ixirX  hu  anobled  blot.  In  n|>*arad 

raililoat,  tn  angnicl  iii  r^lIlpl^t•^«fr  and  iia*fuln*n.  uotil  at  Irngth  it  hai  Mtaiaod  Iba  poaltlOTi 

of  a  CKujintiifd  acil  lUudnrd  aulhurit)'  wbttotcr  th«  Unxuaija  la  tpolwii.     Tho  awohaai«al  aaa- 

of  lliii  tiliiion  intl  ba  found  p«a>l]t>apfrior  to  thatof  praTioua  Imprnoinoi.    B;  rnlatiglng 

of  tlia  luluniK  to  ■  rojsl  ootBTO,  and  by  tba  atnplof  Daal  of  a  nnall  bM  claar  tf  p*,  on 

M  t*P<''-  th'?  addlUoni  bare  beta  tDeorporat«4  wlUiaut  matorlaltir  tDonaatn^  the  bulk  of 

Off  tdIoih*,  anil  iba  maltar  of  Iwa  nt  thr4a  ordlBaiy  oclafua  ha*  ba*n  i  iim[ii  iliiifl  isto  tba  ip^ce 

at  ««■  Dot  uBhnnd;  fat  eoaiultalloo  uti  rafiianoa. 

Il  muM  ka  a  work  af  M^HncalHa  I*  bHtov  a  [     11  l>  ae^nslilonT  Iba  Boal  MnflM*  and  nBhl 


lb 


Ci^biBd^n,  «Yri(kiili>iy,  flr  iffflnUlon  of  ftatn.—yttiO 
U  vpftld  bo  luor*  wulof  vqMa  1o  uil'>fiprf^ 

ad  la  tt^rr  la^Uac*  lUiit  n   Ilay*  luFuit4 

9  jr<kik«i  ^nnvti,  Juuvr.  1W4. 

A  vprt  to  wbltib  Ibnr*  I*  ni)iTii««l  In  tfa*  En^tlab 

It  la  HUflhtuf  mur*  Ihaa  a  JIqIIudiU/.  «Bd  >'>»»- 
f.b«  aftli  vUh  irnlh  tbkl  Bi^r^  mnilitinl  nag 


V«W«aritfcarib*<lAa4iiiULMlkctAB4l(r  noauotat 

P«f  pcUfliiE  r**«4fEh  itbit  cif  iMDl«niLAc  Jorv^    Tbotiuaiil 

of  th*«alf  nf  iblt  Uil^nn  UiUlffrUht  In  Iptllfy  to  ItB 

at4f*l»f*A,  aM  1'>  tali  ri'^U  •rrv]<«'^kTibrrt^  hy  ^'r 

Bdbltif  l>itaj(Uaci|i  ufl  thn  prj/i-"lij[i,  unJ   liir|<.^J  vo 

Qtbtm,  bj*  Ibi  Ida*  —  Idmfnn  fi^ncf,  V^ir  ^^  1"'^''*- 

Tli«  oil]  vJFMoo.  vlilch  U  >t>«  ■iif»'«r*^^  bj  EK^ 

p,  bu  b*4a  amiimcJJ J  luu^Md  ut^bu  tj  ib^  uMi^ 

,  gf^ftiiua  *■  «  wurk  ^r  iTHiuuii**  i«i'«rcJi  unil 

■t  tkla*     Tbfi  D'v  b4*  lacr¥4**J  mpfulQiud  ;  fvr 

■Iff  tbtt  nmr  of  it  Ibiiu*  ti\A  »arhjtru  btv*  i^ 

■Uj  bvB  iBttPdavM ;  «]-i  of  wbL^li  may  b*  iVrDflil 

"  r  4tfla«d  lit  tbe  [irc*«at  v^ijUgi*.     Wa  knoir  of  09 

^AUlLoatf^   \a  lb«  EajL^lib  lufOic*  th»t  T4« 


WbM  ve  iik4 14  b«  iJe«U«4lr  lb*  Wm  Bi*dl«J  4b^ 
ElaouyiPlbv  BHelUhtedfoacoL  tiMi pmni *ttil^ 
b  brobjibl  AtMyftpta  Ui*  Adv«>r«ilBUl*or  ■tiM«.  ' 
I^H^  mtar  A  Innf  yfftr  *ndAff1l«[t"  bu  l»vii  tt  onf 

p1b*W,    A    ^ItliUal    fOIDpkAlOD    KOll    frTf^Q^.    abA    w*    . 
jcr*vt  hini  In  bl«  r*p1«ij1*be4  and  Impruvvd  fonn  vtlb 

aSi,  Jut  3?.  1S«A^ 

TU*  K  p#rtAlrt.  Uw  b«a1r  of  hU  Mhm  irWnh  iW    ' 
plijTBldutar  vhffHbBboqLiI  b4**«n  hi*  aIi*!***,     |i 
ri  mnrfl  flp«d*4  »t  tb»  pTwoi  dhj  ihihii  ■  fev  vAin 
bk«lL— OfNO^  JhrT  yuwir.  Jnl/,  ]tta 

It  ddMFTfdly  iiUDd*  III  Iba  faaad.  iipd  raoni^l  b# 

Wavud  alpc^rdlj  ratniaAEiJ  ttr  DDiaftlann't  vorl 
M  mivl  Ihorad^hH  BflnalLUr^  and  u<TQr«I«  Wd  hKv* 
l«alrd  1(  bj  tHrrhlnc  U*  p»*rt  Tor  aw  Ldrnt,  vhKb 
"bin  Aboanddd  ao  ancli  vf  tita  In  infiflctl  BjiDvfi* 
cU(tif«,  «ni|  Dur  Hoirch  bu  ba^q  tncaauTnl  In  avrrf 
iTiAUmf*,  vr<  hatab(vcipi>riifUJ4;;jr  irraah  w^lb  tb« 
fdtaw«ortb«*f*pta5fnf  kP<l  t1t9 it4^if%aw  tH  tJig  4^. 
vlThitvaiAf  «*>na.   i|  it  M  urgHiaej a^urk  luprvrjr 

iiDDviT  k4  a*  *ir«rT  oat  urbowaU  k**p  •»  nit  bb»«- 
^4i>«*  or  tb#  KoflllAb  LdBfU*  ID  1b«  Miiad*M  •!  Iba 
ptaviiL  dMj.    It  K  (lU  Vflf  blad.  tba  n'M  ««i»pt«a» 

wiftV  of  lb*  irlad  wllb  irblcli  w«  nr*  sbiBalalfd.-w 

W*ar*lk«B«OMarv»tbat  itakDn-of  a«na4taA  > 
illPllobArr  iB«4*  annbl***;  aa  oa*  btli^r.  If  to  ir^ll 
*flHpu4  n>r  lb*  VH  of  tb*  ■!* J**( ;  »« T>k*  ib^l  may 
b*  tODMilLcd  vtlfa  Bin*  talMaellott  by  lb*  iai>d1a*l 
[varllliDur.-~-^tiL /i<«r-  JM-  ATHnAtf,  April,  tF^U, 

Tb*  tiTti«  nf  th*  pr**rnt  odltliiii  bM  bt-^n  ^ra^ll/ 


lama,  aod  x  uior*  t^Eai^lAvaJjfuc^Jtvj'  Ba^l  AnT^nluka 
Itan.  irhirb  ntadurB  thn  Viirli  nut  anir  aA;l«n»<'liufT 

ba  aad  anarHT  of  ataMoMal— X  T.  JVair-    <^*™>^'  »"'■  *»»«'■  *?">-  '««*- 
CImiar,  ISM. 


X<i  loifilTf^pl  PHDibar  vf  1h'  prnfhaBlda  can  orvlll  " 
bo  wlihiiai  IL — at  fffwlr  JtM  ami  Surg  Jourital, 
'■nac- •rltX  o.n»i 'pi.tmlt.o-  .-»>'".  >*«, 
,-_:  10  <kl*  <AonEijr,  an^l  Vf  f.Au  r^Fulolv  fnnmoiiil        tE  hv  1h4  rara  marll  that  It  ««r1ala1f  hv  jin  rlrii 
LUav*rk  to  ilf*  rvai-«f-l  fobfldaocr  aciJ  FTfard  of  la  ih*  fin^iliita  Wajaaaa  fot  aitwraaj  aatt  ajrtaolof^ 
aui  nulan— Ltiadniuili  i;<in?<  iiiill,  IMd.  -  nrcnnpta.— Iflatfoa  IMMil  «a*Mi. 


Far  maof  r«an  TTanc>tviD*i  Dfcriunarj'  hu*  hpca 
fh*  alaadard  tnKik  of  ntan 


A  niCTIONAUV  OF  THK  TRRMS  t?aEI>  IN  HRDICrNH  AND 

TUB   COLUTIfKAL  dClBNCES.     A  nrv    Ami'iiMn  adltioo,   raiiaad,  «kb   niuiaraw 
aiMitioiit,   h*  lii4iti'    Hava.  M.  D-,    Kdiliir  uf  U>a  "Amactnn   Joonul  ot  tba  Madigal 
Sclcuora."    'in  <iaa  lBici(a  royal  llmo.  ToidiDaol  ot«i  iW  doobl»4al«ma«d  f^rii  aiu* 
ololb,  «t  to  ,  laolbfr.  (3  00. 
I  U  Urn  I'M  boater 4ttaiiUnvtimt*,%»A  oo»Mal»»ia*o^«»wali>a  ■*«*»(a'.'vMM»— •a-ftan* 


UxuKr  0.  Lka'k  PvBucATiom — (UonuoU). 


AN    ANALYTICAL    COMPENDIUM   OF  THB  VARIOtS 
BHANCUE8  OF  UEDICAL  aCf£!COB .  f«r  tW  Vto  Bml  BMmn«ll»n  «f  Stadvnu     A 

Tllp*fVnriT>«Dd^riin   7^*111  uJ  MmtlbUlBonmraf*-  <      In hAodbaoli  for  «|iidvata  tl  la  ■■<mtit04«,  «<- 
hly  Ll*«iuot(tAlovU4wiri^i>rutDL4H<v*rm)bll*h*d  i  uiblaf  (■  (h*  mui  «vad«bHJ  frnk  tho  *«l#w»b«d 

iiMi  Pr^ltn  Of  r   -     -        " 


»iid  (TbdinMrr  lii>o«fllDfl«  ikf*b"«i:  but  thf  optr^ 

ii^"  ' ,...11,  i_,i^i    .  Hi..,  J |,„f  .ji  ujjirt  hjb 

>.; u   P^ ,j   I,  '  '  J,  vad  t^a  aol^nn 

■  .p^  rriM  I'  1  1^  ^«IlUtl|  n  ih*  (T^lffnl  eamtdM^UaB 
a'  II"     '<k<i    iti  nf  «irifry  <lh«4  — Jtr.  O,  JM  mmdihatp- 

hiiDVD  ll>A(  II  rt^uIfM  UL}  Aipra  mX  Itia  bt«da  of  m 
iB«d><«l  9A\Ut  EliaD  Iba  ADttDnfUhou  ff  »  d«v  mil 
impnTffd  •dLtluti.  Tli«r*  li  flo  Bvrt  9f  fompcri^'a 
bPlv#pn  llili  w»rk  itnd  hor  othtr  on  ■  itmlUf  jtUo, 
■ad  fvi  ft  •liDlI*rDbJ*«L— A44b  yam  i|f  JMft«iL 
t^an  iirf  Tinl  r#«  Madtiil*  nr  r^n^tM^ODtfi  «f  n^ 

vbul*  >a4<fe««  9t  D*dklii«  *rpiT«ma  hm*m  bf«Ci  aLl+il. 
**  lb«  «Q|d-hM<Uic  ■Vidt  «i  Hi  l>or4drs  HDd  Iho  v^^ 

■  tAQi  J!*«t«  lr«wiu*1  op  tq  tbJ*  IIUl*  vvlbuia,  A  <jlu' 
liL«t*  pvrtftbln  U^r»T/  pa  coodHBtd  tbM  tha  aUAvdl 

1b4JX  ],0nfaCA*t»4abii|iAuiblI1lf.  Val  VALMrik  (hM 
Ihtbuok  iMf^n  u*  •[>|>r0hcUn  u  amt  tit  ILk*|*M' 
tibU.  Allcfffth'vr,  11  it  ib«  b«Al4f  ttf  clu*,  Aad  bu 
IBM  witli  fe  d*-i«r*f tl  •uaofH  Aa  »  *t*DfDurT  laiil- 
bfpok  frr  •1iiAmiI«,  '1  r>iki  hr^a  QBtfuT.  4U't  wUt  4on- 

«1&*«S  Vblltl   ft  VlU  ifroD   1j4  rtf</jrrd   Id  }ij  Iho 


Ii>1n*il0fl,  ft  tMHprtd  !■  n4l  diilj  fftl^aUa^  W<  U  M 
■Inoal  ft.  liH  fwa  vim-  Hi*  ao*  btlbrt ««  K  l«  ■■■■ 
ol  iti4  dnrUkofl-,  ti^A  matl  ui»tkMpn*ul>W4r*Ji  b*4ka 
*f  lilt  ktaJ  (hit  wt  kbov  of'    Tirf  ii«ve%1  *ft-l  ftt^ftd' 

Ml  d«clrtQ«ft  »d  Tlia  Urrtil  tiD]trMiPHi«M>  ft»4  dl^ 
40*artaa  ir*  ftrpltelllr,  1^'>n(1■  uiuc^^ij,  1*14  Wt>f« 

ih«Bri)4«nL    Of  ro«ni*K  i*  aa«i#Hft«q*  t«  ?!»■ 

iDvad  11  to  all  Iftat  M<ff*fl  flndfrBlih  lul  (ban  bft  •  clb« 
lo  wbom  «■  r«rf  >laArtf*1yr>finn4>Bd  Ihl*  ekva^  Avt%. 


AVk«    iB    IHdIrInD  <Hf   rH'ir 

Vh'j  Tift*a  D<^  tEaiflnl  i 
pnrbftpft  and  tbt  ttvm  it 
Ull*  stiir  *Q4I   11   ■*•  1 

l1ftTtii|[  niidiifrr*a*aQrtbl«TalHift«  La  om* 

ftcpvrl*.   .  ._ 
IIW1.J  U*  a44^ 


<oiba  It  aol  «3- 


Dittuui  of  pa]iU'.  «d  'IB  tp«ftk  fnm  txpnit9*9  la 

nevnibipuJtnc  u  b>  &d  kdnli^^i^i^ 


tnf>  Ibi^lr  iiii[>ft»     II  w[t1  «Ar<  i 


nf  ihin  >nn  ihitiiM  tHin  ivo  btftdi-V  ■vrr?  o»*  v^s 

I^(«vpT7prarfriliiori»r  «li.»hfta  fopili  trnTLAt  bLaaglf 
itfltri  II.  iiitil  bfWin   Brill  Ih"  !•■«<''  ^^f  fflfimAIW  b*ft 
kuovlddtf  irt  umfih  fftfllDlaltf^  iKil  U  irur  b«ftM«f 
dirjuidd*  U>  bU  pdplla  «1  rory  tlUl«  mH  otf  I 


J^UPLOW  {J.  I.),  M.D., 


A   MANUAL  OF  KXAMINATIONS   upon   Anatomy,  riiywology. 

Sutftrj,  PnoIlM  of  U*dlein*,  Obft*lrlM.  SUtnrla  Heill».  Ch*in\9ir7.  ninnncj,  a»4 
Th<rap«iilto*.  Ta  whiah  liadrlcda  Utdia*!  Fnrnnliirj.  Thiril  i^tiiinii.  Hinrnnrtlj  r>'i»*4 
■nil  gniUljr  »»%anS*i  ami  mlarcvd.  Willi  ITQ  Uluilratinni.  In  ant  lu»liaiB*  tojtt 
lliuo,  Tblnme  ef  ^\t  iargt  pugrs.  eilra  sloth,  t^  li ;   Iciilhcc.  (3  <i. 

TH*  ■mnc'intiil  of  ttli  rolnid*  (n  thf  roim  sf  iiiiHtinn  kti'l  ■amrr  riBJl«7a  It  ««p*«Ull>  mUI* 
iibU  far  thg  Dfllga  fiaaiiunUMi  «f  ttudenu,  biiiI  f<-r  thuH  prapntiiiK  (ur  enJuMloD. 

nfltrn  iriiiliBl  In  i>«|<*rtii( '»!  M*  la*l  atunluHM. 
U  Mlfhl  ha  rr>i1t»hlrMu(Dli^  V  ">*  l"u<1li<a>r 
tdftK  w^a  te  matl  a^l  (4  Damn*  rki<*r  i«  IIh*  nrj  \Sm£ 
al  iIbIdIIi  h>n  «l»'i,  (all  wlia,  aiiitj  Ikii  hnrrr  af  Ui 
dftllr  mnllLi-.  ^a  lint  irtiiHikM  tnot^H  lli*al«d*a^ 
iDnp>>U1iiiittf  «'<it!>  T>*  inMfiatH  0<  •  TialiM* 
odfiLi  kind  ffiitlii  Hmiiab  IaifiM«Bafti  fir  hlw  «* 
»n]u  Iba  mDmanI  v'  41c1T'>4  t^riottty  **  laftf*  bl^ 
•airm  aafiabjMi.  anf  *»Wkia4thni>lHM*«At> 
■tldnil  10  |iaH  nnlB^nnA— W.  load 


Wa  ka4ir  or  rkiv  t'^IMr  fi^m^hnlnn  tar  Ilia  aludfiil 
dnr^nic  *lia  lii'iii*  4puaL  LD  Ehf  If^tarfrraiim,  ot  lo  ra- 
fcwh,  al  A  Kliui^i.  Iiii  nrnmorr  u(  Ilia  vtiiooa  toji^ 
?ram>nnl  Inri  lil*  liD»d  tr  tb«  T4jliini  pruAdaora  la 
«hvid  La  JiauuiptlJAl  1i»  Nafea  — HV4<'nt  ^isff^ 

Ab  II  tlnliricva  tb*  wbclu  naca  of  mndkal  tludIM 
It  U  nrr»4u'lif  valun>iD4nt,  fanuialai;  Ki  Juif* 
duotlaflii'i^  r^iC*.  An*r  ■  aoiaaKbal  f^rpful  axtml- 
MAliiiu  I  if  ]t>i»iitcot>.  w*  haTa  furm#d  a  marb  ntra 
faiotfiMu  vplnlaa  af  U  Uiaa  va  ara  >raa1  ta  n^rJ 
nab  ■''•ika.  Alllioa^walla>lapMd(»ai*MUiavaiiu 


4 


fpASSEIt  [THOMAS  BA  WKBS).  M  D.. 


I  NOSrS,     ThiH  AiOCTii'iin.  fnm   Ihf   aaranil  nlarga'!  and  ravliaj  BnoHih  tdMoa.     T# 

I  vbli-h  if  xUad  TbaCeds  uf  EILIi^i  of  tba  Amarlean  Msillcnl  AhmiaIUb.     Id  ■>••  Iua4- 

Tblt  ■Ofk,  iflar  «nilar|;<'>nffa  T«if  tharonrh  raTiftOn  al  tbs  b>n<ti  ot  tb*  aatiM*'.  Mar  irair  ba 
•ipa«tHl  lo  ap]>Mir  >burli7.  Tb*  tills  fMr««rr  allardt  a  )iroprr  i4ta  «r  tba  tas^  of  aabjarit  aa- 
braitM  in  Ui*  volnxit*,  »■  It  oonUdDa  nnt  oaXj  twj  fnll  ilatiiilt  af  dligiMMk  ijB[>liHaa  prapavly 
tfUoalflr'].  but  aUd  a  larg:*  amoant  ol  laformatlon  aa  mnltan  of  ann  ^y  fnatlMl  l»n»rl»BH. 
aj4  u^bbDj  MUebed  upen  la  tba  ijitamaiUa  arorta,  m  nattand  t)u«g|^  ■■■?  diCankl  vol 


Henry  C.  Lra's  Pcbi,icatios8 — (Anatomy). 


t 


tAF  (HEA'Itr).  F.R.S..  ^-'TT 

Lmtwrtr  oit  Ji»tCviii|r  4f  Af-  rtmrfft't  JitvpA»4  I^ndon., 

AUATOMY.    DESORH'TIVK    AND    SUUGICAL.     "The  Drawing  by 

lioriB  jninUjr  65  thv  AiiTiKJii  and  Im.  C^nTBt-     Sw«Dd  AinvrJmi.  frvm  th«  nvond  tvHfwl 
«ml  EiQpKn«d  Lcndtiu  «ilitmn-     In  nna  maipiiflaanl  Enparntl  ocUvo  TDlumo,  of  ovrr  ROO 

T¥c  *nlbor  bu  *«<!«» T«r«d  In  IhiK  trork  1i>onv»r  m  nnr*  •it4ind«d  rutgt  or*nb/«tt*  thftn  i*oai- 
tomvx  in  <hf>  ordJnivrjr  t«it-bi>«|u.  bf  ;;tilnjr  a«<  *<nN  th4^  ilHa-ili  noHHuy  fiM  the  nudvnt,  bat 
aIhi  Ihn  •|>f>lic*tion  of  Ihosa  d^UtiJi  in  th*  pnusllpo  of  ntivlioiTit*  and  «ai|^rj,  tbiu  nndirins  it  belli 
"  I  for  (he  lHm«T,  bn<{  ka  lulRilnLlfl  nark  <*f  rvraiiMki.-a  fur  Uu  Mtlv*  prnoliliaDPr-  Tla  od- 
n  tfnno  A  (jnoijtl  iMivrn  in  thi>  witrk,  mtoty  of  tbrni  brtnn  tba  aua  *r  nalnr*,  nflarlir  ttU 
in  »d4  baling  thr  iia^ntii  nf  ibn  iHrium  imrli  i^rint^-l  nn  lb«  bodj  of  tba  tnK^  Id  ti]*««  of 
» *f  rtl>r«D?o.  nitb  dvtorifitioni  kI  tb«  ^xit.  Thvj  ibuv  for^  •  ootiipl«tr  u-v^  tplentlio  feri«iL 
bl*h  VJU  yr*fttlir  itniqt  Um  rtniifrnt  in  o]>l<iiiinjf  a  cifMtr  idam  of  AimUim.v.  lutcf  wiU  kLn>«rv0  Id 
^^T<iA*ih  tfa«  mnuory  of  thuao  who  may  flnil  In  tbo  *it|teaal«a  at  pfAc^ieo  tho  noocuitj  of  rt«&Uiu 
ib«  dfUlbi  of  lb*  4Ji*^iT(inir  room;  while onmbt^injc,  «c  UdoWr  «oonipl<U  Atlwof  Atim£»tnj.  vtib 
a  t^onn^b  uvatlH  im  tytUiuRCie,  iliiiieriTitir*,  BiM  *pplMI  AaBtomj,  lb«  work  mU  bo  fouud  of 
«MMMlftl  m»9  tq  ell  phTflcUna  vihi  Tf<<i?iTp  itudrnir  In  XhtU  oflh>«.  relievfne  boLh  fir*««f>tor  AAd 
pvpll  of  mucib  [jibcir  in  hi\Uin  tho  ijnmu'lH^irk  iiT  a  ib'^c-ntiifli  mddtfifl]  vducBtiou- 

Kot«LUiPUadlDg  lit  txcirtiiing^y  Low  tjrko.  the  work  wlU  he  fonnd,  in  9tWj  ii«Uil  4t  tnnhhjiichl 
■Kigirtton,  one  of  thv  bniitiffimnct  that  D«*  yet  bnrti  qITk^ »rl  lo  th«  Ani«ri«Ui  pnlbwion  ^  whilv  tbo 
awtfld  HraUny  of  b  i^tiiDpttaat  anslirmut  fau  rallofvd  it  of  wluitcrer  tjpopmphicftJ  Brttat  tJu«bnl 
tn  tbo  Si^h  cdtoon. 

Tbtti  111*  iLfti  bo4>1r  Attfr  b^iok  mnVn  ibolilj^jf  nf  iinf  wltb  wftTTAi  nf*ptnff  10  iiiv|nl«VM  lavl.  The 
lb*  lilD^enC  »*»lt-r  (him   btr^ijv.  *od  alucK  wv  bun    «ii»1chI  fep[iliMilvii  of  (ha  vftn4n*r^Uo»  la  aEmi  p»- 


tO(iy,<*rT«^oiy  i^o  flnc»i  work  "T  tTtn  kt*id  urjir  cj- 
lABl.  ««  would  faio  ho^ij  ItinL  Elit  hufbttruf  iBirdlciil 

fin^At^op  of  phjkloW^Hl  arianr^  wUJ  b*  HQph  C^ 


UDli'il  w^[h  foTcni  mill  rlnftmiM,  imptiuBlii^  apoa  (b* 
»lUH]eill  Al  fVfli  «t4^  rrf  bit  T«HUTh  nTl  (bf  liapoTUnc 

fh^t  l«,  wd  bvlMTn,  tbn  bftnilviinr't  b^hnk  oq  Ao^ 
(OTrtf  fc»y*f  puM^'lioJlfl  oilr  r^nrrnA^,  tjt4  MA*  rfcTf 
i  tn  t«mu«lA  *  ihurl  llna  ni  •lUt'Uril  lutl-bijuk  vt 
Th»  TUidnt  peiQEf  Mlmtnl^J  afv  nuik^d  irirVDElj  1  auf  iri4[4fr«  Hud  uludln,     Aiaii«iit*  ui^i  |ij«.vUL]i>b«r* 
4a  |fa*  'VoMan;  IbktK  «b4lbC/Jl  btma^B.  Bro-i  wkl>  bI^Ii'  &ppr<v]4t«  ibU  tank,     W*  firajLcftfor  fi  l 
,  Artcrf-  aar*«.  vul  rs,  «(e.  «|c  — v«taf  ^b  polol     brl^Ll  rure^i,  auO  iff  faU/ i>'4}>4rnLl  m  PU'Iurv^  iht 


i%  dUttaflljr  inark'i'l  by  l^tltrvd  iPfrfeTlAfp^  mi  Ibll 
lb«<liid*ot  o«rfTl*r4  ti  i>Btwr«fb  p'>lnl  i|f4«rtVi«tf  m 
r*B411r  ■*  if  iiHhin[jn|  r>m  ipu  thv  >ubjufl  hr  Ibv  Jo- 
nfiO*tr»tor      Hoif  of  th*  lUmimti*]!]'  nt*  (hit'  rail' 


th« J  latvo  I*  cauvAb  Iba  tuviuOFf  vlUi^rBtl  rgodlooM 


•  Ufmnnl  rif  ib^i  ionJflfi  f^nfrf^  IhM  *Vf(t  tr"  ool 

r^u  Uko  fiual  TDbk  wUb  Xhif  "nv  tiofbrp  i]«s      P*por, 
^rltitLoi,  bmillu^  ^l^  hfv  tLPDUauT.  aud  ivr  fuet  lbfe( 

f 0  luiTVVBrdtd, — A'iufvotlU  Mmt  and  Sifff.  /ipurbnL 


OX/Tn  (irEXRV  n.).  M  D..        and  JJonSEU  [WILLIAM  F..).M.D.. 
AX    ANATOMICAL    ATLAS,   illujrtriitifii  of  tlio  Sl.nitlur.-  of  th« 

Oamna  Kcnly.     In  one  volume,  I*rgs  ttdptrl&I  odnro,  exb&  eloib,  vitb  aboac  di  bondlrod 
■nil  URt  bmiiltrul  TiKurvi.     H  ^^■ 


!     "Hi*  pUa  uf  fl-li  All&>^  wfjirh  Pnjd^r*  Tt  *n  pnrrt' 
"ulf  rnit*D1«al  fnr  llir  rHiiilonl,  *ni]  tl<  iDi-i-rh  *r- 
4Jfl■l«b•<ul1aD.  hnvabeanAlnnilj  [lOinEBduiit.  W« 
ail  vMtfntiaLiiia  tJi*tiqEj«(il  vp«B  iJhi  ennpIfTiva 
r  Ibl*  AiUu,  M  It  1*  Ut«  IBM  eum«l««t  'Mk  St 


ih*  lilari  IhHl  tin*  f  1  tppf«r«d ;  iitd  tvA  n>iiil  «JTJ, 

!•  in  Fn-^litlitf  i-i  till  mmtrr  at  in  k*  ■tilWtsf  to 
oar  BUiuul  iirMk—^mriaa  K>J«<iJ  /HrwiL 


SPEOIAL  ANATOMY  AND  HISTOLOOT.    Eightli  wHtion,  cxten- 

•iTilj  mittd  and  luodlflcil.     In  [»(i  Urgv  OcUio  vdIuUoi  «f  OVel  1000  pigw.  irltb  mai* 
Ihan  3aO(rno<l'OUUj  (xlta-iluUi,  Vi  00. 


*  SHARPBT  [WILLIAM],  H.D.. 


UfUl 


Q 


CAIN  {JONES ^RICHARD). 


HUMAN  ANATOMY.   RevWd.  with  Notes  and  Additions,  by  JogWH 

Lbeut,  MrX^,,  ProA*«or  <jf  Anhturojr  in  tbt  Uniromtj'  of  PaoDxjWiuiiA.     dimplvCo  ia  two 
Urge  uDtBvif  vulumok,  of  Bbout  ]^00  pogBB,  wtib  bll  lUmUBUonf »  dJtTB  ololb,  |iO  00- 
Th«  vrj  low  firico  of  tbt*  iMndard  work,  and  it^  comptotonHw  in  alt  dopaitoianta  of  tbo  ful^jaot, 
ftbuuiU  otjinuianj  li>r  it  a  j>tHiw  in  tha  hbrary  of  bII  Bnifinmiaal  vladonU.  i 


\I,LES  {J.  M.).  if.D. 
THE  I'llACTICAL  ANATOMIST;  oB.TiiESTrwstrr's  OnmK  mTHz 

I>I)s«Ti]ie  Soon.     Vilb  inC  iUunlmiimii.     In  an«  1*17  LtoiliaiDa  rojaJ   llmo.  laluat, 
ef  «nr  dUO  mfM,  ciIM  oldth.  •!!  OU. 


Hmkv  0.  Lka'*  fvtui:/LTto»« — (Jnatomy), 


yrjLSOff  [ERASMUS).  F.K.S. 

A  SYSTEM  OF  UUMAN  ANATOMY,  Gcmeral  nod  Special.    A  oev 

knd  r*i4M<l  AOMAwn,  (nm  ili*  lul  Ksd  •nW^  Ka«Hili  tdiUra.    Kdlicd  br  W,  H.  Oo- 

•aarnT,  M.  D..  PralWor  or  Omntri  nndSurtwa  Aa*M*jiD  Ite  ll«iliai>IC«a*ie«arOlilo. 

Jlliuintad  wbk  lIuM  kaBili*4  nail  itla4ly-mi*a  sagnTlai:*  on  vood.    la  >«»  ■■>!•  bbiJ 

baad^ora*  ocMva  ndaoMk «(  of m  AM  langapacM;  MineIMb,  M  Oti  ImUim,  ti  bO, 

Tba  tnblbb*T  InaU  tb«  Uu  -mll-auiMd  r^nla*j(in  «f  Ibto  hac«flablUtMd  fatorit*  will  bs 

more  than  mniBUSnal  hj  Ibc  prcaaal  •dllifln.      KHid»  ■  itij  ihanatgli  miilon  bj  lb*  author,  1% 

baa  baBD  idmi  oaratallr  •xaadaad  by  Um  adit  or.  and  th*  vffatU  of  both  ban  b*ni  ilitMlwl  M  h. 

Iradaotoii  anrythinit  whieb  lacrwunJ  •ifeti**ea  ia  lu  lua  hai  aocfaaMd  aa  Aaalrabl*  ••  n^dar  it 

'  aaaaapleM  Uii-booli  tor  ifaovg  ■wkiuR  to  Dbiatn  ar  to  watir  HI  aovBalBtwaaaBtlb  Umua  Ad»- 

^amJ.     Tba  kinoant  et  ■■Idiliuni  wbiiib  it  hat  that  nmrad  maj  ba  aMioaUil  bMa  Ilia  linit  Ibat 

I  ttw  pm>nL  wlilum  eanlalni  onr  ona-fbiuth  moT*  mklUr  i^u  iha  lut,  raDdaiiiiK  a  •■uilln  tff* 

1  Hd  aa  enlaiarl  fan*  t<<^iii(lta  lo  ki<i|i  tha  T<>liu»t  Ritbin  a  «nnnni«nt  rita.     Tb*  anUivr  haa  aot 

r«Bl}'  thnt  addad  IktcatT  *■>  *1»  irarfc<  bat  ba  luu  bIm  made  altoraUona  ibnoghoMi  *bw*iar  (bar* 

I'Mppaand  thaoppsManarar  InptaHoa  Ibaarraatlaonaiit  aralfla.  aaaatapiwant  aiary  bat  la  tta 

I  M«*i  ainvoprioto  maniHT,  aad  to  raodvr  Iha  Kbota  a*  elaai  and  iMellipbla  ai  paiaibla.    Tba  adilsr 

b>a  aiaiebsd  ilia  otAMt  oaotloo  Ui  ubiaio  anUra  aeanfaoy  io  iba  i«i(.  and  bu  la/^l^  tooraaaad 

Iha  anmbar  qf  illa^ralMnv  ol  whwh  ther*  lua  ebool  an*  buadnd  and  6l\f  man  in  tb»  ■riiUoa 

Ibaa  in  Uw  laal.  ibiu  brlogiiig  diittDcU;  btfaia  tba  aja  oC  tba  Mndant  *TarjthtBg  of  taCacaat  or 

ifntiortonca. 

Tb«  pabliahnr  baa  fait  that  D^tbar  sata  dot  aipMiaa  abonld  ba  afarad  la  raadar  tba  aitanat 
flttlabirftbaToiiimaircirlby  of  Iha  nn^Ttiaal  favor  wUb  vktc^  M  baa  baan  lataivad  bj*  tk*  AlaartoaD 
I  praiivlon,  and  b«  baa  aadanrond.  sonHiuanllj,  id  pndvoa  io  iia  maehaakal  amuliiru  an  tai' 
TprdTaniani  corrtapandiog  with  Ibal  *lii<'li  iba  irit  hu  bbjujhI.  Ii  will  ikHafara  Iw  fawid  ooe  of 
lb*  haodfoaiatt  >pt«)inaH  of  (jTMiEtatihr  a*  jnt  prodooed  in  tlua  aoDotcr,  aad  in  bU  ratprrli  anilvd 
:  In  iki*  oSv*  (abla  of  iha  ]naBliliooar.  natwiLbitandiDg  tba  nrnmliinfj  l«*  priea  at  whMi  It  baa 
lk«D  ptaead. 


I  nr  rffR  aAXB  AtnnoK. 

TIIE  DISSECTOR'S  MANUAL;  or,  Practical  asp  SiliOlOAI.  Al*A- 

Toar.  ThinI  AiDiirisnn,  train  Iha  laal  reilaad  and  ankruad  GnglUb  eitltlaD  MedlSad  and 
Teamncail  by  Wi  1,1,1  ih  IIvht.  M.  I>..  Into  Damanilrator  of  Anatony  in  Iha  tiaint'ty  of 
PanniylVuiia.  In  one  larga  and  bandf«aa  nfal  Itoio,  taluina,  of  iSS  pafaa,  wUb  IM 
Utualratlaoa;  aitrftilolb,     (1  00. 


'  J^ACUHK  {JOSEPH). 

SUULilCAL   ANATOMY,     liy  Jobrph  Maolisb.  Surgeon.     In  one 

aotuma.  nrj  Urf^a  Imperial  lautoT  arllb  flfl  lar][a  and  ■jilvniUd  |daUi.  drawa  In  Iha  b«t 

ttjria  und  hrtBlilallj  falatrA,  vontaining  IVfl  llRnm.  loanj  of  Ibeni  Ihr  iiia  af  IHk;  l»t>lb«r 

wllb  onniniu  siplaaatory  laltor-ln«.   -  l>troiigljp  and  baadtomvly  bonad  la  ntia  olatlb 

Prioa  »H  00. 

Ai  naaoRipIaU  wfirk  of  th»  kind  ba>  hrratofbra  bMn  poblUbail  la  Ibv  EnglU  tascoaca,  Iha 

,  nalal  Tolima  will  aoi'ply  ■  ••ant  land  fall  tn  thia  ntuolrj  »r  aa  anuvata  and  aaaapMMoalTa 

I  kttaaof  SwKleB)  ADatoioy,  lovbiob  tha  aindast  uid  ineiitloDertaaat  BnUaaaralbt  toaarai- 

tatn  tba  aiiLPt  r^lnllva  i^tiUouii  of  Ihn  riLriiti  ■  porlion*  e(  tha  hirman  fruaa  tvwarda  aaab  oihn 

I  and  l«  the  (ur/icr.  ni  wnll  aa  Uiali  nbpuriaal  ilafiitioo*.     Tliu  iin|iuitaDca  of  tuoh  •  work  lo  tha 

LihidaDl.  in  ih-  nbatnca  of  sutomltal  matariol,  and  to  praDtitioDpn.  tilbor  for  aaondtalloo  in 

■  mafgiiuniot  ur  to  r«fraah  Ibalr  raooUaailoBn  ol  tba  diaaoUoK  room,  iievidant.     KatwIthMaDiUBg 

bba  tnri^  (Ire.  bmaly  and  Dnnh  of  Iha  tnry  namrroiu  111 OM rail ont.  It  will  ba  abataaad  Ibal  tba 

priiM  U  ta  low  aa  la  plaoa  It  wilhln  the  naoli  of  all  loamban  of  tha  proCmlon. 

Wn  Xaowtff  oa  warn  aa  turfloBl  kDBtoinx  wbl<h  1  r«rn*4h«d  l,f  thai*  lirtt  aa4  AialoN  4lHaann«^ 
vaa  aoTDpAla  wnt  II,— LoniW-  ^  ' 

Tba  vorU  of  NHll*f  an  anri^otl  aaalnanr  !■  af  1h« 
^UTiiAt  *i}ne.    ?rL  tan«  ra«|vat«  It  It  Lbaatvi  pubtl. 

'-^     '  .  -">  )utf<  H*b,  ftp,!  u  v^rit^r  **t  * 

p:  s-  ft  aay  mr>ilii>%l  m«r».  wlilFji  Ihf 

-I''.' "IrfOikn  P>lJT:ipr( !!»»•* ra»*l  Ib^rj 

lli»  — 7"\r  l<'--'"n /umuJi/ JliiUi;lMon-(  Sar(wv 

ITg  antk  lliliojorapbla  lt1o«lra(l«aa  of  «qi)eIu!  ■*- 
(leai  lisii-  l"ih»no.  ■•  ihinli,  two  Il»^n.  wiiita 
"rt  apoiKlat  U  flimrn  r*9rt  *«a"tt  had  itArra  wlipfa 

latamliiD  !■  (uDMiDtAlM,  Iba  aaanl  aaaMniM  It 


wiJoH  awr  OH  Dia>(  anpiaMtla  waa  bat  a  fa'flrtp 
■^r  vDlhaikatia.  Tbt  bfli*b  la^Val  pra^^^  h«*  i^^aa 
laalianudiba  wantaitinlai,  I*  rMaawaadina  ihii 
tplai^rfttilrt  ifr^n'A  T^Ma  wio  bat*  aair  ^^t^tkHj 
>a  fT.ifff.  In  iiAnriH  In  IM  pftfMIlWlltr  at  Ua 
lJi&af;np1kiaart  ia  dviratBUna  tlfea««a>^i«w  WKalAB- 

lim  of  111"  llT.mvq    hn^J.  *P*  Iknird    '  ■'    '»«T 

tj-rtmfa  f'yy      1'  a^TlhlfU  wtlE  '  .^ini 

■Bl  iiuilrnt>  i«  r>lt,»i»>  a  Emrii  •,!  .in* 

ki],l  fvar:ril»7  liT<'                  .     H.     p-    .  ,   ^^,.,ffy 

of  |b*afiid|»i  '  dotiiflief 
nalaaa— JlH4ri 


!  pRASLKK  (R  R.),  M.  li.. 

'  "^  pT^lmar  vf  Jlntitimwiitt  rtiuMnpy  n  DaifBaaMMtf  CMtiva  ^.  If 

HUMAN  mSTOLOOY,  in  its  relaliona  to  Anatomy,  Phy«iorog>-,  uiA 

Patholoay ;  fur  tba  oaa  of  nadinnl  rtodanla.     Wilb  tool  hundiad  aad  thirly-Iaai  illoftf*- 
tl<inL    In  ono  bandaana  coIbto  Tolumo  of  ovat  ADO  p^aa,  attra  «Mb.     13  Tt. 

Va  voaid  Fot'iminfail  It  aa  roarMulfv  a  *i]u»«ar 
Lat  all  Ibil  la  tBLjwD  of  ^ha  Inpcrr^nl  frL|]i]<^^f  wbic^b 
Iwinan*  ■•'  •'!  llmt  1«  in  ISn  i(t»»i  wtrl.nf  Hlfncn 
'-  aa'  iUbmaaa.  an>l  f b*  411^*^10  flbtiaUu  la  fvaaral. 
IUmim  iktt  oaa  Tdlamt,  and  run  hnaw  aW  \\»Il  Vt 


koawaaf  U>f  frtti  ruaAMaffal  arltn^Vt  ■!  1 
tit*,  tat  *i  kiia  u  ^t•l'•lt•a  (a  atji**  iiiaiu  i* 
an  baaac  14  IK*  AntilfBi    bcM»]   fiw>'«loa  — 
m.  ttruu  mtd-  sHd  Avy.  .'laraaf 


I 


4 

I 
I 


I 


IIrkkt  C-  Lka's  PoBiiCATiONs — {Physintogt/), 


fJAItPENTER  {WILLIAM  It.].  M.D..  F.R.S.. 
"TlllNOII'LES  OV  HUMAN'  I'nYSIOLOOY;  irith  tlioir chief  appli- 

utIoQi  10  ftjchiiiogy,  Pulholiisj.  Thpntpgalici.  Uf  ntnr  nii'l  Ferfcnilc  Mi-llalna  A  now 
AiofHcbn  frotn  tha  IilpC  ui<1  rviiKj  1#A»Joa  vdilloo-  with  ha^uTj  Ibr40  hunJrrtt  mtttlr%liDiii. 
KdlMd.  *Ub  wtdldon).  bj  Fbiucih  Urnia*  £iiiTa,  M.  D.,  t^fiMor  (>r  tb*  IniUUUa  of 
M*4lriiw  km  *h*  Ilnlnnitf  of  PtnntjInUiiii,  Ar,  In  on*  nrjr  lu)^  Mid  twautiful  ihUto 
valano.  «f  kbaot  VOD  lug*  {aew.  tDuidnmelf  |irint«l ;  cnra  «laih,  |S  50  j  lHlb«r,  raiM4 
linidi.  fK  40. 

Wfdosht  DM  lil>dMtla*4 10  NUIa  •■■»•(  fttll 
Ob  puSh«  bvpr.  kad  rviMla  ib«  b  *4tli«  Mi>-b«4^  la 


■  ■(•41  vort  lit  !■(.  Ckrfailff  )•  lo  »II  i>i<«nf1»B 
nttt4  of  Ih*  rr«l*vl<ia  kuMlM  Sir.    Cu-pi.atvr  i> 


^ju  or  utdic&l  <L4Hj«iit  will  ttt^ia  1i1*  liLnnr  ■* 
vijfbplrto  MLEb4iit  ■  tOTT  "'  Il.^<-^iicfqn4f4  tin.  Ofr. 


Wlli  t>t  Smkb.  »■>  eoiiBJ«ii11)'l^iliiT«  -lliu  (ha 

fffVMDt  *Vl  morv  lb»  HlMUlll  fb«  OBfUbt*  HpBUl- 

liaii  aln^dr  klMlsc'l  I'T  fur»i«  adiitoMi  •(  Mof 
Oa*  of  llie  fuLlttd  «dJ  ai.i>(  CL»i1ijit«4«  rnaLl»4  on  Uit 
mttiiu  la  til*  iBfllili  Uniuuii.''  Wo  kmir  tl  aoai 
tnm  Ik*  (■>>•■  ■'  vblah  ■  (tnituiarf  linn>l><1^  d 
lbatthr>lolojtf  of  ibobviaa  oiMaluQf*!!  t«  at  vrJi 
tMUaad,  BOB*  bMiw  alapud  ht  Ilia  uh  or  lurta  a* 
lika  «p  tko  aiadrof  fbyiiolafy  id  Iia  nf*rv&4ik  lo 
tbaUullBMa  aai  praMU*  ol  anllcts*.— Jai.  Jaur. 


A  (nmpIHo  nolapsdla  of  lUa  bnoeh  of  talam.— 
Ir.T.V-l  Ttmrt 


W*  hatn  u  onvu  opakra  la  Mma  ef  M(«  aan- 
DaaD^auoB  of  !>'.  CarywiM'a  alalpinl*  vorV  oa  4tB- 
laaa  pbjriloLrfy  IJjhl  La  aonouocLbj;  ■  naia  ajtcloB, 
It  ka  pmitfv^arJlDadil  BUJttilDf  loir  bat  U>ib  horalo- 
foo  liMn  aaM.  (D4  wpMlallf  lo  lUa  Ua  (a<a  aiDM 
avafy  toMllhjfvat  pbfiilBlan  la  m  vail  airara  of  tha 
rbanolaa  aod  (vailiafiribawotkBairaoQnaltot  afo 
— «.  /Aula  MmL  and  Oafp.  JuipmJ. 

TbralMva  la  Iba  till*  of  whal  la  ampballealljr  M* 
craac  varli  on  j^jtAoiffj;  *B>]i^aniriiji>cl'>Ba  (bat 
It  «<i<il4l  tip  a  livlaaa  r>br(  lo  Vtatnpl  tii  aifjany' 
(blac  lo  ti)^  r^i'iifiOoT)  '.r  xhU  lavaluabla  Vh>rk,  atid 
lan  ooty  itT  lo  all  »llb  arhoB  nof  i>i>(oId«  baa  >bt 
IrafTuanu.  Iraat  It  b  our  amU^arltjf —Aitaniit  Jftaf^ 
/nurauf 

Tbo  rfoataat,  (ha  m«a  ratlabl^  ^nd  iba  taai  tiwit 
on  Ihn  lobjaii  vblcb  w*kBo*iir  la  tba  Eu(ll>b  lan- 


J}' 


rax  sixti  AvrnoK. 


PniNriPT.ES  OP  rO>tPAKATITE  PHYSIOLOOV.    New  Amcri- 

ran,  (tva  111*  Foiiilli  and  RvTiaad  I.<>n<I"'>   ROitinn.     In  ana  larc*  aoil  haiiilaomv  ocUti) 
valum*,  wUb  ■iv*r  llun  kundml  boauiilvl  illuilralldni     I>p.  Til.    Sitra  eldth.  |1  00. 

Ai  •  tonifilct*  and  gondeiuad  CreBtifo  ti  II*  eilcn<l*<l  ami  ImportanC  inhjont.  Iliu  itbrk  btevmu 
k  iMOfwily  H  aladonta  ef  lutaial  MJ*tir>t,  aUil*  lb*  rttj  Iob  fulca  at  wliub  H  i*  ua'arrl  {iIbmb  it 
irtlkln  Ihc  tMob  sf  all. 

W  TBE  StXS  JCTBOIt. 

TinC  MIOROSCOrR  ANI>  IT8  REVKLATIONS.  With  »o  Appen- 
dix t«DlBlalns  the  Aiiplloatloni  uf  Ibo  MIoi(u(Hi|m  lu  Ctlnloal  Mcdlolnik  A«.  Dy  F.  0. 
^ailii  H  1>.  Illoilmlwl  b;  funr  liuii'lro<l  uiil  Ihirly-Oiur  baauliful  •nxnrinii*  vo  mood. 
Iq  oiDc  Urg«  aad  isrjr  liaadauiaa  (elan  nlana,  of  731  )iaeaa.  siUvtlolh,  f5  li. 


fpOVD  tROBEBTB).  U.D.  F.B.S..  and  J^OWMAN  {W.\,  F.R.S. 
THE    PHYSIOLOGICAL  ANATOMY   AND   PHYSIOLOGY  OP 

MAN.     Wilh  abuul  tbr**  Tini)<lr*d  Urf*  ud  banuUful  lUusItmEotu  dq  v*n>d.     C<>iO]iUt«  la 

Tltc  DftiP4>«  i>r  IVidd  and  SviTieAa  h«t«  lubf  h««a 
Iknin^  lu  Lb*  •Ia4tal  uf  pbjnlvloftr.    In  ihU  v4rK 


«a  fiiUMt  111*  UOMl  lliorvijcU  LKd  f<H[k«l«K«Ealuii' 
1100,  1ll«  wr>rk  ibitt  LMitM  wtt  *'a>(nj4U(a  t^9i^o<<D( 


Td  II  thf  ntlof   ^Qnim^ii  «/  u*d1<ttl  oa«B  win 

h\i  Etid  ct|i«f  Irurlii  rpt^ri^rUaK  I^p  liPAtlbjr  tlni^lar* 
an^l    frirUtnj;  <^f  IFi*  Tramr*  wtateh  <ir*  1*1  farm  lh« 


triRKKS  (  WILLIAM  SiF.NnOUSRy,  U.!^:, 

A  MANUAL  OF  PHYSIOLOOT.    A  niiw  Amcikon  from  the  third 

nai  liDfaoivd  LnndoD  c lillon      With  tm  banilnd  UlO'lnliont.     In  an*  latg*  uiil  ban<I- 
Kiiaa  lOjral  Ham.  voluin*.     Pp.  tM.     Kitia  clulb.  tl  2i  ;  laalbai,  (1  Ik 
Bj  tha  naa  ot  n  Ao*  Mid  clear  type,  a  i«ry  larg*  amniinl  ut  nalur  lia>  bran  ocinitanHil  Inlo  > 
I  «om|aintir*ly  nonll  TolBmr.  anil  M  It*  c»<*Mlingly  Io<b  priM  II  will  l>*  AiunA  a  nodJaatiaU* 
,  Suiiial  fur  (tuilsnlii  or  for  g*utl*iu*u  dc^iront  Ut  ittitth  tbalr  Xauoladne  ut  luudara  pbyalvli^. 


II  U  at  tarh  ^inVfnloni  1d  iJi^  ^>ia^folie(ti4»<  la 
dc*l«B,  anil  aopctaa  la  tiajAnn«nl.  aiiA  alluatibor  w*n 
•dapMt  Tor  lit*  pMpM*  d*al|tB«>I.>-JL  XoM*  Hit. 

Tba  ptiyaldciflcal  na4*r  vIU  Hut  H  •  noal  miMl' 


teDl  na\St  Lb  iba  aludy  of  pVjt*i't}-'jiy  Ui  II'  lO'ial  ad- 
inaQooil  and  iiaafbipl  fofm,  Tbp»  *ul*»tir  baa  ahvwa 
btaaaif  aapabl*  of  ratac  dicalla  anfflolaaily  aiB|i)t 
Lb  a  aoadaaaad  apd  **u(«aLniiMl  ■liai>*,  o*  a  aflnaea 
la  vhlob  tl  la  Bamaar;  aloBCrla  baaonaataad  BOt 
lMitb*D«d.— Miihuv*  SaL  oiuf  Xur«.  /uwnul^ 


\ALTON{J.  C.],il.D..  ,    ,     ,        ,m,  , 

,>  TREATISE  ON  HUMAN  PHVSIOM>QY,  IU-*igii«l  for  iXvt  n«c 
of  SlaAroU  uiil  Pr«et)tl<>a«rt  of  ll*dip{ne.    Third  (Jilivn.  iviifiJ,  irilk  oMiij  ibr>*  hnn- 
dnJI  Ututtntloni  on  wwchI.    I>  on*  vvrjr  iMutifUl  mUt(>  tctIubm,  uf  TM  p*tu,  •lUacIoUi, 
^,  9SSi,' iHihor,  l«3a. 

■  In  lb*  ttmam  •dltlon  of  Lhii  «ark  tho  RpntraJ  |ilui  uid  «rniii|[>iD*iit  nf  th*  l*«  (btnat  odm 
[  |r*  relaloM.  Tbo  intiTvnnioih  and  kddUion*  nhiib  kir*  ^lrro  iatmluMd  ix-nurt  Ik  Uia  iursr- 
I  ^rulinn  isln  ibi>  Irit  of  ferlain  nev  nicl*  and  dlioafTtin.  rrlntinj;  loatnlj  to  delalU,  nklcli  hST* 
I  Biivl<  ll»''  nppMnnca  sjlhin  lh«  lut  ItirM  »u«.'' — Aalier't  Pttfott- 

Tlu  i»|dd  damiuKl  (or  unoUut  olillan  of  UlU  *oik  luflltlrait];  tfccnn  Ibat  Iba  SHthM  Km  lae- 
I^Msdtd  In  Ui  aSiMla  U  ptodoM  a  teii-book  of  (taaduil  ukI  invnannit  talof.  MabodTiiig  wUUri 
)  K  modoral*  soufan  all  Ikat  b  ibBiiIUTa];  and  poittl'ilj  kcDita  ollbin  tlm  domain  of  Hnnn 
(^rh]r*iolon.  HI*  hirb  rapotallon  u  an  orfiftnal  otaarrFT  and  InrMtl^or  U  a  ^ituiIm  tbal  In 
[■Bun  r<iTUia|[(t  be  hu  inlr^doiinl  whslnnr  b  D*o«ttij  lo  randti  H  IlicrciUKhlr  on  *  l>*rl  nitb 
FlBa  kdranofd  mImm  of  ll>*  dVi  'i*"  *^  ''**  '"*"  •'iv<"''Fll>btil  laUbuat  audul;  lacmtlog  Uw 
|4ll*  of  Um  tdIdom. 

Ho  oiaftion  ha*  b*«>  fiartd  is  aialaUtin  tbo  *taa4•^l  of  tr^iosrkpliieal  Bioeniitin  vblab  hai 
I  nndartd  Ibb  work  adnttUritf  ode  ef  tha  hutdtoniiM  *alniii«  ai  74!  froitiiciAl  In  Ub  ooBBOy. 

W«  brtlvt-f  vi>  f^^  TK^^fik^ta  ih*  ft^vi*  tit  1jrap«r 

^r  hH4  of  lt^»  h'E.  fLir  cjiuLULn-KjrrArlr  fTmrDMftE**!' 

.  .:n  Ut  ImiiciuUE  (Mlor*  af  tUnMnillai',  uiIud'i  ><>rk 

la  vltliiiuL  4  \**t.  flilitr  Ju  bdtpE*da»Ai  10  tlio  tvii, 

i  altppIlcUjr  Aud  tfn^jhlgflDH  of  Joitca,  dr  fl^AUOd  itt 

I  ■illiiltrii'CuilnD.— CVKnriro  J'"''  GMn<av. 

Ill  i*Ulo(  ulfodoo  lolkf  rtfHt  pibluulnii  Drtb* 

I  lliir<1 1'lKli^n  of  ihU  1i«ii.  II  irlll  oeTt  b<  DHmHir 

L  ID  aaj  llllil  11  rtlalot  >U  Iba  Biartl>  idJ  BH'nllnlly  Cliv 

na  |>Un  of  th*  iw  fonavr  Aiuiaiia,  irtth  which 

I  avvtr  Autrlf^B  «tud^al  of  Bt«4Kir>^  1*  vodoDiii^dJx 

AmkEtAT     Tta  iU*LL]>cii1>b«d  Hth4r  bat  aJlJ<>il  lofhe 

|DK(  %X\  llLi  tiii]>cjtc«at  4)i«cov*Tlda  Id  «xp«rlaM0UI 

S^r<<<'''>f7  '"d  •(KbrfalDgjr  whiib  bin  auinnd 
urUkir  1iir<  lb*E  {hf«  jrfbrt.'— £a«(<-n  tfipif.  onbf  .V^ry 

Tbv  arrnapaBeaC  of  Ihit  wttrk  l«  #ir0U«ol-  T1t« 
fadtautd  lb«on«4  frnl  fonrtrd  In  II  4rr<  bn^uitl'l  np  I'* 
Ub  ptHinl  Elnw.     ludeid.  ti  fn>|r  b<  Inulttd  upus  ■•• 

Sr#**b1Laf  th«  Ihlrtt  tIfVraf  phr^^nlit^fili  In  a  nm-  I 
>nt«^  fi^rm.  wrllttD  ko  ft«]r<aF.  ji-iidpi  nk^nn^F.  bphI  i 
'  Id  a  ■lj]4  *bJ«b  tnaMH  1(  a*jI  uulr  a  bn/^ili  of  ■!■  J/  I 
10  Ihtdailuil.  uruT  Hrirson'  t.i  lbs  iiia>IJ«l  pnell*  1 
L  llobar,  bal  a  locih  wbTeh  max  ba  lakaik  a]>  tad  mt<1 
p  with  both  plQVLimKni  pjviflt  ft!  aujr  llva.'-Ovuaato 
JM. /ixmUtiL  OtUUl.  li«t. 

lb  Dt-  Daltaa^a  airvll^Dl  tnaltm  wv  bar*  onn  or 
Ibv  Lb'«*I  niDinhai1p>ii«  of  dor  Amvrlpao  hrpihr^n  m  1 
nodltal  Miraa.auil  lut«palani|r  mar  b*«aUBatBl , 
br  Ihr  Aid  ihii  iiTii,  ths  HKud  MlllAa.  fullAn  oton 
tbr  am  ultli  Hi"  'hori  intomi  at  iw  ^taS,  rti>  1 
!  fturbflr  ^«■  nivpicdvil  Ib  fi  Tiof  M*  rfoJtf  aa  wiftjp  | 
I  biir  ac«ai*bi  ikuJ  11  Ui*  uias  tia*  Dual  Tatdakla  I 


rdnmU  af  (li<  t>maai  atedltlan  ai  pbridalaitaal 
•iA<bm:  anil.iiinnoTH.  bthwaMbfaaaHWal  wtih 
u*n«iDi|i\luJ(ifl.  bql  haa  aWjr  lanaalBkt«d  lb«fii^ 
Moba  of  Uia  b«i4T  ftir  Hinaal^  maar  al  tba  ««toaat 
aipntnuBM  and  cbaamUoa*  bataa  at  iha  nuuM 
Talaa.>iA»>dM  JfM.  Xtttab 

TUa  wutt.  racjcslMd  aa  a  «aB<*r4  l>M-bsak  ^T 
Iba  ntiUail  acboola,  aad  «Mb  wUth  ibt  Bxaiban  "i 
III'  prnffMloB  w*  H  lUnlliar.  driaaada  aai  •  brit^ 
iiollra.  Ut  |io|ihlultr  la  ajleaaad  IrJ  Ik*  fapldll^ 
vUh  Thich  f^ribpr  adliliriiB  baTa  baaa  aa^aaLadiX 
(■Mcn^o  UM.  Sautnal.  April.  ItM, 

To  ibfl  itadoat  af  Hijatidacy.  oa  mat  aa  ^al  |^t>- 
llaTiad  c-tvld  be  m^ra  latlkfLC-orr  a*  a  iriUo,  a<4  onlf 
In  a  r-trrael  knoirlHlir*  (<r  Ih'  ^j^nh^ral  •nbjf'la 
iwt\m*tmli  la  tl>  llintlt.  baL  wbaa  \\  at  ttr  irMVr 
liii]]or(aij«4iL  w]LJ  IPhivalbabailtaaiJiar  of  lliKmodaa 
of  UTntE^llitD  "bj  wblcft  Ibat  bniiwl'^lf*  oaa  Nf 
af^slrnd.  aail.  If  omawrr,  taattd.— n<  Ctdiwla* 
ErHrtt  '1/  ifW  oad  Burff^. 

t'utll  Hlihln  a  »rjr  noDt  daM,  Amrrlean  voitj 
on  phjaioTit^j  wrr^  a^ntaai  aaiitHy  oakaowa  ra  Ba- 
^iU<rt  4  clrfUirmtaDO*  •ilaljr  ijaa  ba  tl^a  fKI  af  tbalr 
bnlui  IKIla  altc  ihiD  ornJ*  f<niipl'all«»  4^  Ranr*> 
wurlB.     WilblB  iba  J.-!  -    ■  .   •    ,  .    .         ;rn> 

abanc*  haa  takra  plaf  "a4a 

oa  fho  ulliQt  B^da  it(  LI  -.E  ad 

pnaaMaln^  qaavtla  aqsk-iLfn  I'r  ^'*  BDo  rar«ui*4l  1^ 
iiona  or  nnr  nwpr  la  Dr  Halloa'a  Irvalla*  va  af« 
flad  In  find  a  ralqablv  addition  \a  iiliralafaclaal  Hi*. 
raian.  Wlib  idMaurtwa  ka*«  nbawrad  ibavafWM 
Ihrt  T-o[uma  prvvf  af  Iha  aitllifr  aal  Waf  a  sav* 
■^■mjj^laf  or  Ehn  1dr««or  L»tbm,  bvl  aa  hflfalalicirat 
III  4Fia  r>U  nf  HlFaf*,—rita  Jifft  aad  Ap.  JMliw- 
twivtirirrnif  flmfcia. 


IE 

4 


i> 


VKGt.ISOy  (JtOBLBD.  «•  />- 

HUMAN  PHYSI01X>0y.     Eighth  wJttion.    Thoroughly  revUciI  wnl 


•lUiiiIrtlT  uiidilUil  and  aEitai);ad.  wltli  Aia  hundiad  and  IhittT-l'n  illaMntlaaa. 
lar^  and  hamboiDaljE  pnnt«d  ootar*  rolainaa  uf  aboal  IbOO  pagaa,  Mlf>  ololk. 


la  Mo 
«TM. 


J^KUMASS  [C.  O.) 


PHYSIOLOGICAL  CHEMISTRY.    TnmtUted  ftom  the  Mwnd  e^. 

lion  lilt  atoatKi  K  I>>T.  M  D  .  r.  R.  S..  Ac  ,  adlud  b^  It  K.  Itonaat  H  t>  ,  rmlnatafidr 
Chtmliln'  la  Ibi  MaiUnnl  Jlai>ailR)aBl  of  iba  Dnliwiltf  Af  PrnnfTlvanla.  vltli  illiulnlliiiu 
aalanUcI  finm  Faoko'i  Atlai  of  Ph^Etlilighial  Chamtilry.  and  an  AupmdlX  of  «Ial«t.     Coa- 

Slata  in  Ivu  lar(*  and  han-laima  oolam  *olamat,  cvnIaUing  ISflO  ^fH,  «tlb  Baafi;  l«o 
ondrtd  lUoitrMlosi,  ailra  oluth.     fi  00. 

1^1*  rat.  SAMB  Aomoa.  

MANUAt-  or  CHEMICAL  PnYSJOLOOY.    Tr«n«liit«<l  from  ltM> 

Ocnaan.  KlthVolM  and  Aildiiionii,  bjE  J  CoiaTua  UoMui,  ILD..  irUk  •«  Iiilr*taM« 
KtatT  an  VEtal  F<.raa.  if  Vrofaaaor  SAidiBi.  Jacaaoi.  U.  D„oflh>  V^inttiff  mt  rtawji. 
Tanii.     M'Eib  ilJmiraliaai  on  wood.     In  ona  rarr  htndiaaj*  asUTo  i-oIuN*  it  MO  ■<•(■■> 

•iim^loih.    tip. 


1 


nBUBT  C.  Lea's  PuBLtOATloiVB — (ChrmiMrjf). 


11 


^RAXDE  {W£.  T).D.C.L..  and  mAVLOn  {ALFBEO  S.).  M.D.,  F.B,S, 
CUBMISTRY-     {n  one  kftndaoiue  8vow  voK     (JVcto  aitd  r^vUed  edition 

lb*  ciTtarMt.  »»d  ttoM  pr«»l1<«l  i>>M  4*^ti  b«  pot  l«tb« 

II  abfiaEidt  in  LDBtiDiiVHM*  tfjurHtinjr  AicU  bM  fo 

lb  wbtob  tvfrj  *q«J*«l  LahikiidlfxJ.  vllb  lit  |<J«4MlDtf 

fkVI  ft  pM*«  Hvpbiblo.  nol  oplr  I**  <brvt  rur  wbvu 
IJ 14 1<it0iii|f4,  l■atla1h«p^^'twtnaKEL■r|lr^— il^iHrfn 

W«  hATfl  fur  fc  Tone  Fine  iVifi  ihki  |h«  pFvpai^JiluD 

At  ft  iirapMT  cbfUBleU  ifXl'book  fur  »(ud«<Bl4  irould 
W  I1ID»  lrtLl*f  vppnc  ibltD  tn  ihr  1iti-i«nrU.n  'tf  i  n^VfiL 
«jrt|«b)  pf  claMiatMlOQ  or  Ibv  4kHv*#f]r   vf  faUf  a 

wfciii  hm  Kl  U'f  b*cm  im.(liiOr<it 'n  ETit>  dook  iti»*  bi-Zor* 

•iBideaL*  \ff  Cwo  vl  thv  caoBl  «K|wiifbc*d  Ukchon  of 
ifi>  -cUu*  Id  &oflikad^~aaitan  M01L  and  Stirffinat 

JuvmaL 


A  puwt  AtrnpnbaaiLvB  und  tanp*^  voTiin*.     EU 
■ftltixi  14  Ftc^nr,  httd  I*  rT>ar*yrd  in  di^u  IkD' 

ft  wKh   vliai  turr  bw    il<«uiavor$A4  Itnv*  Iwrni 
I  la  m^Mmviru  AtrC*— 7"^  CKniifW /Tah. 
I  lUhfiBnnM  !■  nHnmrrmr  or  nrft  #rP0«irr.— 

>f«Bl   uf -.uFo ruin c Sou,  *uA  tffrOixiut   Tmn  p#dft&lpf 
Bd  n^tirLiDLH  a»  nihtf  (ml'buak  eiibiai  Lnitf  con< 
clXlwa  v^ih  IE. — TAr  ^finn^ 
Til*  t.aTfiDr>  «el  oat  wuli   1]>v  dcflntl'v  i>iirpo»o   tf 

danud  nL«D.  Ttiat  ooitr«LTnL,  ■□■!  •mrliiHl  nnMo 
I  HOil  vtardj,  MDiBan-*«niMi    mnEhH^J,  1M4  btflk 

«■■  la  Iho  efuftFaH  ■ml  JbuBi  vuiMhftr^  invlboil 
vLbl*  fell  tbfl  fihfU  aud  dvcUlov*  vi  chtiultUj,"- 

We  UD  cvHUUj  r««(BmciLd  iLIt  work  u  ona  of 


0  WMA  y  {JORy  E.) .  M.  D. 
PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    Edited 

IfjC,  L-  Bloxaw,  Profoiiiar  of  Praolienl  Chemblry  In  KSng'*  Colle^*,  London.  Foortb 
Amflrl»n.  from  tho  foutlh  and  rert«ad  Engliih  Sdition,  la  dd«  nvdit  volninv,  roj«]  ISnao  , 
pp,  361,  vitli  Di«marou«  illuitrftUbai,  nitr*  cititb.     $3  2&. 

Tlin  mf-Td*!  rtoJ^'Pl  *oJ  trftfl[ltlAu«T  lifcT^  •trT*'1» 

iitftUacUrm  fi<r  lun '][iiiniumi^>u  hHil  au^tJ^'ii  at  iX\9 
itrlar,  hr^iiil^rKl  01 'it  «i1]ii4t  farrtilntT^.EiuiJL  hfAflhr 
•od  /norl-M,  itn  ^pforAlvl^  ilrYn.  Tn^  ^Lrvrllaoi 
fur  Hid  J«td*lE'^D  *>t  I^ul*4iu«  111  tjrxt'ii?  mliiurt*  Hiid. 

b*«b  Lhtfrotuikjy  rtvited  bjr  Uia  tf^iJt'r,  4nd  brt>u|bl 
^^/i^  jfdA  arid  S^trp.  /pMffi^. 


f 


*dU1aO  Af  Ihlii  UtBlathlfl  int-bonk  of 
_^_^_j|Mr7  wv*  pubUabrdlu  KaiUnd  1n<>«lo- 
-INlBiXTur-  Tba  Edllur  hiu  b»uxbl  duwri 
TfudTt04>k  I0  Ebtt  dill*.  1i(tri"liiciEi;H  *■  f^'  ■■  *** 
CBia(ulllil4  vkTEi  Ufl  flWPtmry  «op«iua0,H  yif  'urb  « 
vqn,  kJ[  [Uir  vk]q&bfa  d!Bci>v<iif4  In  lln  Kkrui'o 
wbitli  lin'rcnm*  lo  Ufihi  ilnfr  flia  pnvlEiuii  cjlllQa 

ttutfatof  iii*di<:1iiv  irr  FftlLxliIcu^'ii  |'f*qlkUou*r     1< 
1«  |n1»iftl   ID  cifpaf   Irpp,  4ud   Eha   ilLu-Eiuiloni  *r« 


T  rjf«  Jt4J*ir  AVTtms.  

INTRODtTCTION  TO   PRACTICAL  CnEMtSTRT,  INCLrOING 

ANALYSIS,     Foarth  ADieriuva*  If  am  tha  Anb  Add  nTimi  London  adltlon.      Wilh  Dniii«r- 
ooj  fcUinlrHliimit-     In  oua  noftl  tuL.  roy*l  I2uiu.,  ixUit  clulii.     ^2  2h.     (JuMt  rmuly  ) 


Ob«  (if  ibt  muii  runitjiorv  »»do*]"  iliai  bM  for  « 
tPbf    tlm^   buni)    ^iT-iv    la  Ibn    uvdhcAt    tladaaL-^ 

T«  ronrd  H  u  rrnllfltrrf  ftJnaal  fivl^tblAf  %ei  bti  1 
dntliad  \a  m  iDirkdurfloEi   Ei^  Pnullnl  ChoidWlfv 
ll  t«  bjf*'  l^*  h^l  tilnprM  for  (Fip  ^^h-iiq^c^t  vEudrut 
vt  %ny  tbiic  bm  jnf  ftfTm  So  nnr  irsf  — IfrtfUft  iml 

Tb*  h*4(  UU^nctorv  work   ou  iha  labjoct  wlib 
<Ultr  Af r  bvf ]HB«<a^    Wub  iblv  tl*^  tbainiLbDr  b«4 


l1vD>  *^  uiflrb  ■■  fMAAllilo.  and  |-r*k*1it»  sH  ^r  Ika 
daiJilti  phr(«]plBf  la  «brrnh<At  iinjlj^ftl*.  ft^i)  atk«r 
|>«T'Lhijib  JinlniiEi    a-   bf-if1  u novn   b^  o^iiift^haDd,  ia 

doubl  or  dllBciitt/.  Thai  a  mthj^t  wbii^b  Ea  ntUkilT 
rmardiit  bj'  ttixf^'nt*  *<  vlrn^i  h*7'iiii4  iliilr  mfn- 
prvhHiil.kn.  »i  F«idA"d  v#ty  A4*f  nT  ■«-4ulBEtl«n. 
[Wv«rftl  T*lu<tb]r  ubla»,  b  ikmHry.  *(c  ,  lU  cvinblb* 
ta  rrmtrr  i^n  «ittt  pMCu lUrE ir  Ldnplrd  tn  rb«  wvnrk 
ot  <Df b :  hM  k>  t«ib  «*  cdVDteifJ  U  (4  Lbrio.'— 1>^ 


IRAnASHTBOMAS),  F,R.S. 


THE   ELEMI-:NT?!   of   inorganic   CHEMISTKY,  mcluclinz  the 

wtTtB  mil  itottut  BKiuait.  M.  D.  C»uii]«u  in  nii"  Isu*aod  bHitliomv  octato  cotutoc, 
or  OTw  800  i*FT  Urgs  pagw.  attb  liro  hanUrMl  uid  (hirlT-l**  wcad-enU,  aitiB  rlMh. 
*6  }b. 

Part  ttMOmplMineUin  vntk  Tmin  ji.  4JI  tn  i-nj.  wUh  Todfii,  TMi  tUttor,  A«. ,  m>r  b*  htd 
Hi|iani(*,  cliilh  buln  anil  paper  iHa.     Ptlc*  %S  UU. 


li  ba*.  In  Iw  p«tll«'  iiiij  Un  p"rfiisl  •iIIH(»d"i  ^f(■o 
bfnflUr  14  at,  ttii   Thv  r^?4{1faf^  of  L1>  pith   mtiA  ' 

a**  loUK  ''O  inT  >Jfntrsiinn. 


■in>t>l  in  fciviilioni  tbli  (dlilwi  of  Pmf.  Onhani 
KlaBEOIIii.— M(Jinini*(^unriuil.  Hmnb,  lUfc 

Th*  vrnrk  U  4a  ajialr*lil«  <>uc  i»  aU  napvR^aAj 
^  f«pukiictfcUva  hvt*  cabbvt  Jail  Iv  viuii  a  podttlTB 


■  Maditf  of  SofUiA  irurJu  on  tbli  ivtano*  can  '  VbBqqiLtmtkV'iu^^BV^V**'^^^'^^^^^^^'^^^'^^'^^^^^^ 


,  ^fi        Hexby  C.  hKA'»  PunuOATtoxit — {Chevni^rt/  and  Pharmacy). 
A   MANUAL  OF  ELEMRN-TAKY  rnEMISTRT; 


Tttt'OiAlifnl  nnd 

PiMtlcml.     Vltb  on*  hniiiliKawl  ninalr-MTanillMUaUttOt-   Kiliui  V|-[toa»T  8*i>a>*, 
U.  D.     lB«o*I>r|;arDjal  lltuo.  tuluiav,  ufOUU  |>»(««,  •ilr*  Aulb,  fJ  OO  ,  ItMfcw.  i2  M. 


W(  liiuiw  at  ao  Inatlt*  In  ih*  l>tja>«<  *s  v«tl 
Ml(iiUU<  IB  Uil  lb*  Modtal  L>  IHH-Bing  (kaUlu 


lirliMbaiwiiiana*  fHliia  Il»  Inuliult  MlMM  oa    kaok.  naili  lur  mmki*  irf  4<|>1I  tail  aAtaiiAa  M^ 


*bl(«  II  tTHl^  or  OH  Ixtlar  uicuUM  h  a  MM' 
hook  111  iiiM*  UUcOtai  ClwalBl  latluw.  ■  •  a  • 
rb*l»»Mul-b>wkaaC£*Dknr]'iliat  tLatlaatdbOBi 
^M'  l*mM.—AiiuriBm»  JM(ea< /owwll. 

We  ajfcin  m^vl   o^^trfnU^  T*<*iitiii'-  :  ii- 

I  Ifxi-buok  rst>iu<l<'iitini  niidiiJai. 
__,.-al  loclBma  thai  W4  Hfcr*  j*!  ^Xau-jc    .      .   '       I'V 

A   ent'ni*  mrK  ni>0D  ■  llr*l-t«l*  mtija*!.— A. 
'  Aoalf  Jhd.  an.t  Sursl.  JiwmI. 

t(a   wibnfti  fif   CHfatI«lT7  vbUb  *a  liarr   mtf 
atinat  w  uar  dhUbjc  Uw  *wiU  cI  IIib  lirsloair.  ~ 


U'a  havir  «i  aaia  laiiUka  liia  taaM  Linus  vhi^b 


macsugsi.— J  •«»•<»  Jfol(aJ  Aanwl. 

W>  kiiDv  of  an  un-Wwk  aa  (kvHMtry  llnl  *• 
vvQld  aattocr  rroxaia^bA  I"  1^  tlailiAl  Ikan  1M* 
t*>lla»  *t  FiaL  Fvaada'  voik.— J(>i^nal  JbdMul 
mrnai(4t. 

A  ntv  (ad  nvlaHl  tdUla  alaa*  d((W  hail  rfMaaa- 
Ulit  woiti  <in  rhcmlarr  attwitUa  lu  Ilia  AoMIno 
•ud  Eotllik  HuOhikL— J^,  I.  ^tfariHilV-KalUaioa^ 

Wa  nnliMlulUMtjr  msBVaad  ll  In  aadUal  ••■< 
daaw— #.  IK.  il-L  iMfOwv.  Jmnial. 

Thia  t*  a  ROM  eCHlhal  i»n-t>*«k  E.<r  (tu<  )a>WM- 
tiaa  Ifl  tl»iiil>ln.  Vkalbn  fcr  mLhIi  ar  tollan*'- 
aailntaWiJmrmaL 


1 


ADtl.  hXD  BLilXAire  HIKDBOOX  O?  CHKMIS- 

TUT,  TlieiiniirU,  Fiulkal,  aadTaekDieaL  Wlik 
a  rvcommvndiUorj  I'rwfhfA  %j  l>r  hofrmAV-  Id  . 
anv  lir(*  txuvo  Ti>)un-r  «t  eia  rafca.  «Ilt>  Ulua- 
llmlloui.  (XIotUiU.  li  M.  I 

MAEbKlllc-I  MEUIOAL  cniHISTHT.  f^i  Ihcro  sf 
fflil'Ni^ti,  «A<1  tt**  l'r4fM*l0L  la  Gpa"  T^>raL  Llfaan,  | 
wium*.  w^ib  vtiud'fuJ':  pp«  SM.  lUia  iU|b.  i 
•1  VO.  1 


KXAPP'STErnXOLOOV:  ar  Cbnttlr^  Ar^lal  l* 

Iha    AiH  inil    In    SliBii(uiaT~       U>l^     vltli 

Baninni.-  M.l    aAAIIlaak  t-y   Mr    k»9n> 

K^^AA'-  ■■•  KtL'klAJt ■•—''«       SVilk    l^nf 

iHi  <■■  I  ..f  Vfaitu  II   Ji-it»<.>)i      la 

ir      '  .  i..imo  Diia>(  TijBlaw.  mvuiaiac 

' '  .'•,  m4  ;at  vaai  anfiaiU^  axtra 


PARRISH  {EDWARD). 
A  TKEATISE  ON  I'irAltMAOY.     nisigncd  as  a  Text-BoGk  forUie 

Rlndnut.  and  at  a  fluidr  (ui  llio  I'lijiiolnn  anil  I'banoactutliil.     Wilb  iDAiiy  Fanoata  asd' 

I'rTaDriptlana.     TbInI  KihtioD.  em>'')'  iBiiiivinl,     la  ana  handiaina  «laT*  toIi^w,  af  AM 

pajCH.  witb  leTtral  hnadrci  illnilntirRi',  ■ilrBEliith,     $i  0(1. 

Tti*  ratii'}  pnwnaa  mada  in  Ih"  mirixi*  aa<l  a,!!  ut  rhannacj'.  uitl  lb*  nnj  oIian||a*  Ib  Ite  lart 

•flLiioD  of  tba  Phanaaro|iaU  hr^va  rf-tiiiri<d  A  ^rj  Uioniap^b   revl>Juf>  ur  tliii  v^rlt  Wi  r«da«  tl 

WDcUijr  lb*  conlinaad  dooAJaiiDt  nilb  wliii'h   il  ba>  b*r*lofor*  bran  (aTirrd      la   •*t>1ini!  Oih. 

many  pattloD*  haaa  bean  eandantcd,  and  avrrr  ('flan  ba*  bsMi  inaila  |'>  aioid  {ac rruiftc  ntidvlj 

flit  bulk  oT  Iba  leluniai  JH,  lu>t<rilhiU>»'UnK  ^LiU,  U  vlU  ba  fauail  (nUrfol  l-r  absat  ob*  Imaitm 

•ltd  Bfly  pasH.     Tta  aalbor'a  aim  hai  bcrd  1(<  bnitot  la  ■  {ilsar  and  roWpiindloui  inASaar  araij- 

thieit  nf  I'ltue  Id  Ibc  prtaprlbcr  and  dlipteavr  •>fRi*<Ii«ln«.  and  Ibeverk.  ti  li  ItojiwI.  will  bftfoaail 

nuM  than  avar  a  aomplat*  bonk  af  nfbranaa  and  laxl-linnli.  InitiTjonMUalaall  wha  dwir*  M  b«*p 

.,Sii  a  larti  vldi  thaadvoDM  of  knawledsa oannrelad  wlih  itiiir  i^cufaailuu. 

.     Til*  iaiiiMim  amaaat  at  practiaa)  iDlomalann  ovndaniwii  in  lU  rVi—  ■*/  I**  aalinatad  boa 

-  <Uw  bet  Ibal  Iha  Indn  aniitain  aboDi  (700  IUin>       U  nder  iba  ba>>l  ufAddi  Ibara  an>IS  nta' 

ranma;   under  Eiii|iliutraiu,  3« ;   EilraeH.   )fi9|   l^nngaa,  U|  ULiiuna,  M  i   Ptlll.  AS  ^  Il3ra«|ai 

'^  ]>I;  TiuulitrH.  l^H.  CnK"">'»i'>i  S^.  ^<* 

Wa  han  agmalnnt  i>ii>  l>r(*  rolaini  ■rtin  a  (ood 


J 


,imi9t  aara,  aad  BuiI  thai  UwaaUior  haamspJalvlx 
.  UbaaMad  lli*>nlit>o  bhb  vUeh  ha  Imat*:  anar* 
.  MBplfW  *>>».  <n  tblak.  It  wald  fc*  Impetalbl*  tn 
.  Jted.  Tn  [hn  «nd<al  of  pbuva*]'  iba  ir»c1i  la  ludii' 
pta«a1]te;  Ibdiii^H].  t*?  far  at  wt  kitoir.  UUlWaalyaDA 
of  U*  hint]  IriPvUInDH,  and  (Teii  l<*  Iba  pS^tJckau  or 
nadlcaJ  bmiiUdI  wbit  <aa  afiarf  Pt«  ilLtlurfe  ti>  pur- 
<bua  tl,  or  n*l  tatt  tba  giraallnl  lalaimallnB  li> 
will  obiala  vltl  bora  thaa  coeapaafaia  hlu  for  (be 
4<U)a)>'— <^»o^  Itat  Journal,  Hit.  IISL 

Tb(  nigdltalaladnaland  Iba  vraciuini  ph>>ldan 
VIII  Aa4  Iba  vfllana  ol  laaaUaiablv  a-uriii  for  »^4r 
_aad  .rahcaaca. — Sua  Jtwtttri   JAd.   /Vui,   Jslr. 
■  '"Woi, 

WhtB  ir«  fla^thM  tMg  bohk  t4  In  ■»!»•  r**|MoU 

'  'III*  hHl  wblth  tiH  b»a  t>gMI>1lail  «ii  thg  inbJfM  It 

tta  EaKllth  laii(n>«a  tar  a  cfaa«  wall/  raars  «a  •)• 

aol  vl*b  tl  it  Lb  nadtralAad  u  nry  aiiravi«aut 

pralMi      [n  IrTilJt,  U  U  ani  tn  IDllch  Iba  bflBt  aa  lb« 

•Ij  baak^ni  ioadoa  GAiNId^  IAm*. 

Ab  allamiil  Id  TurDlih  aajrUilUK  Uli*  aa  Aaal^li  at 

Tsfrltlh^a  tftrf  ralOAbla  aqd  vlabDral*   TWaffM  aa 

|*^raalMiiJ  J'«nfwa(ii  TeaMMaalraiaora  apaaaUtaa 

W4  hava  ai  oat  ffltpuaaL    nf^  bowaaar.  la  aaa  aa 

I  lanah  a  nailar  uf  r^crar*  iBMinoeb  v  U  Tould  lia 

,  tflltcull  l»  llilnV  or  nnf  piitrkt,  licpxv^r  miDula  Aad 

■l»Tpai1x  irlvial. 'i)r>ii'r«'d  «tr^  Ih*  maitrnalarl^a 

r  ylianDWaaui  aubiUniaa  at  •fv"'"™*  *blib  kH 


BQt  ba*D  alf^arl/ and  tafrfaU/  4}«awJ  'a  thW  ral' 
Dmr.  Wanl  nfat^^t^  ^itaau  au  luUffia^  furlA*' 
OB  ihia  riluabla  v-ntk,  •■■!  wa  »nii  Starlada  br  a 
tltPtda  anrroaiDs  nf  gni  baan*  awH«(aUae  at  iia 
■aartla.— AUMb  QaorlM* /tar.  ^^jlilwrt  Wf  II  k 
Aniatl.  IMl 
Wa  ban  la  IMa  abia  aal  alaWnla  vai*  a  Mr  ». 

Ci'liioD  or  plUTUataaoaalHWataaa  II  adiiala  Iba 
Btiad  Staiat ;  and  n  tbtm  ibai  oar  Ifaaaaitaana 
Frlcndi  bava  flvan  Ibr  aubjHt  ■«!  rlabarata  aaa- 
•IdiiraUon,  aail  Iwra  tansfbl  VMi  an  la  a  duana  at 
[Hrr<ritim  irTii^h,  i»  xtirrs  w  anrftly  In  ta  air- 
f<**«J  ihU/wl]r-T*.  Tbt  booh  It,  aJ  **>**>•,  <J  »qra 
rflrnl  raIu.h>Uiaa»dlfla<lBa)g>rlW>aul*apkr^> 
fUd;  r*l  ^'  I'taiiaa  )-»•  BKI  final  M  lUfoAan 
inailH  10  vhirh  lb*  piwnbar  t>  ^alM  t>  barb 
lultfatalad  aa  Iba  aoiapaaaAal  N  t— irdla^  la  aaa* 
alailan.  ■•laaonlraiinaaaaBtbtfb  DtdAaa  at  lAa 
rdiiK  ol  iMn  •L.Ik  a>  ■  |aiAa  In  Iba  |<karaaa>BUA 
•Dd  lu  u)a<i]>  r-ii-iit  i»  Ibr  t^fdataa.  aai  aelr  la 
Ainarln,  bul  U  ulbai  pula  aC  lAa  valH.— #MM 
Jtr^  JwrnuJ,  :(oT.  lUb,  IMt. 

na  fsnaar  HlttisBi  kaia  bMB  anSiklBlljr  laat 
bahira  lAa  nadlaal  puklla  tn  rradtt  IW  Kutla  a(  Am 
B«t  rail  kaa«B.  Il  la  (Hlalalf  aa>  •<  tba  Bati 
cgDfila'e  aad  laluaUa  vorAa  na  pnMMJ  ptonMdj 
l«wb<cb  Ihattadoal.  Iba jneUUtat*.  ar  >>t  Adaftt 
•srr  i^n  l>a"  aiitia.— dican  MlillBBt  ■ 

Such,  itm. 


Hkxbt  0.  Ixa'b  PcBtiCATioKB — (JfoUrria  MeJ.  and  TTntrapmliM).      IS 

IRIFFITH  {ROBERT  B.).  M.D.  ^\ 

■A  VNIVKKSAI,  FOUMIU.AKY.    Cr.ntrvii>}n"  flip  M.-tlimU  ^.T  ('i(v 

pariat  flod  AitminlfUiinfr  OfflotDul  snd  mbtr  Mpctlrlan.  Th«  irtiole  mtitplvd  to  PbjiioUnii 
ftbd  Itiftrmuvolifitf'  t^ouH  ^if.im.  Ib'kmivhiT  rPt'iiii#A^  with  nouivrmm  frdditinnx,  bj 
ttAKKiiT  V.  tn-wia.  M-D,,  frDrmtir  of  Mslaria  Mrdiek  la  the  I^IIadchAlii  Collrs*  of 
I^annioy.  la  one  lant*  and  hnBdMUa  mUt»  volana  of  SAt  pagM,  dauble-oalniniu. 
Gxm  nlor.h.  (4  AA ;  UaUxr.  fS  00. 
|Td  Ihii  V'lliiiiii,  tha  P«niiulary  prr^jTr  DOenpSai  otw  400  JuaUa^ealuniD  pa^H.  and  annUiIn* 
^oDt  MISQ  fariBiilu.  tmoDi'iih.iC'ri.  hMidr*  Ibme  ttricllj  lOtdilBl.  witi  befriind  DUis*toai<aIuiible 
iplt  (ii  (h<'  pnnirntiDn  Df  *u*ni''^  istfiiiDM.  idIiii.  (oap*.  vaniifbu.  ite.  jq.  In  addilinn  lo 
,  iba  D-ick  eunlaini  a  Tait  amount  of  1afainiali<>n  ia<IU|KU*a1>1a  toi  daili  nffimcc  l>j  tlia  prae- 
i{  Jibj-ilpUfi  and  apfitliii-ary.  irnhtarine  Tiibloi  of  W»i(rbU  »nd  M^'umtT",  Sl»villii  OiaTlty, 
„|iira(iirf  for  Pilar run<?euiicftl  Ojrfir^tioii'^  Hjdmniwtrii'dl  Kiiuvviilecit^  t^T*ojfii*  OtavUiu  at  rfia* 
t^»  Prriiarotinni  nf  Ih"  Pbarniiu"in.vi»i.  R»!n(ion  bdUHfl  dl(r»TM>t  Tbtrmoioftripal  Pfoloa, 

f^natifiik  of  Abbra^'iKtidna  t»**?Fl  ttt  K"rwiiO:i',  Topnbiilnrr  ff  WnrHj*  luwd  *n  Pro*«--ri]itronT».  Wj- 

■pcrTviiabJt  An  the  Hnna^rmfnt of  th«  8L^k  Koi^m,  Dii^^?*  rtf  MrdE«Enn,  llnW  fertile  AdjnLniitratlDii 
f»f  Mfrllpwpf.  Mnn»^m*"ni  of  T^nwa^^'^'i^r*  und  lt*lopFr".  PW-'tir  Ptypflmtimis  xif>t  inn1iiil'"1  In 
la  FnrratitirT,  \AA  :ij  InrnmpaiiblH.  PnKiln(;i<i»I  T^lil*,  Tabtg  of  PiiiirTiin<<cu Ileal  Naoini  wliioh 
■fr  In  th»  t'tii>rTii»?"TiH'i»i.  Oflhilna)  Prvparallnni  and  I>it»(tl*nii,  and  Pnismit. 
Tbr*'  rnmpl^lf  and  ititriLdccI  Indanaa  iwndur  lh*<  mi^  rapnrlallj  adajUol  t<nt  frnraadiata  rnnml' 
lallofl.  Oat.  nf  T>iti:Aii!*  yya  titriu  Rentnm.  pntenl*  undft  llic  hnd  nf  «ich  iSatttta  tha 
rptt^UlafrTTrtirirbiiih  baT*b«4n  unaTnTl^ath^bUMfl  in  tt,  vitTi  raf^nn^ff  \n  \hr  fTnnuIiv  containing 
Ihaia — niile  auutharef  I'nAiiM  Ar'n't  10  III  and  IloT«iric»i.  [!*■■•■  »"''  a  T«y  ihofoojsh  Ua^iaRki, 
IvDET  "ffipT*  the  m*aninf  ntitninine  at.  nnw  nny  infornmllnD  rl^ilwd  Th*  P'Tinijlnry  (tailf  \M 
^il  >l[^at>*lliTaIlj,  DndrF  Ihc  haaila  ctf  Ih*  Ixailini;  e^nrti^uallII  a(  l)ia  jiraaarijitldiiii. 


Ttl«it  QU'  oS  Ebfl  mr^l  HM^  iMtoVfl  tilt  th*  rrtir- 1      W*  ku^^w^f  iii>a«  ta  unr  Uof ijia  d*  mj  oth«r|l 


«f  lAta  fHf«,  «t>iit«Liifiiir  1   r%n  TKrt'Jy  if  ri<tiiiJ»Ti* 

rlt*.  «1l%    trii  '^vtal^LliHA  A(t[F>*l    to    fun.  n^thovl 
Tl 


On»  otlbn  mnil  c"ni>lrt«  iriirli»  .idhoXlnd  is  aaj 
W»  aro  not  oognljant  nf  ihq  axlit^aca  cf  a  |4nUal 


r/Z-f,/S  {ALFRP.D).  M.  P..  ; 

THERAPEUTICS  ANI>  MATEUIA  MEIHCA;  a Sj-stcmatie Treatise 

«D  ihe  Action  anil  Cirj  of  Mxlinmal  A^^ni^  inclmlinK  ibair  l>Mrti|itiaD  and  Uiiloi;. 
SMnad  adilivn,  tavit"!  aud  aoUigad.  In  Iwa  larva  and  haBdaun*  aelani  volomaa,  of  IMS 
fags.     Kxiia  ctiilh.  tlo  UO;    lealfacr.  raised  baodt,  ttt  m. 

Vr.  9illlt*i  i»1i>n>llil  w:,rV  m  'bcnptntld  and  mirl     W*  t*>a  plaHit  Urd  oa  Ua  HU  I'r  Gtlllt't  naat 
Mria  laWla— foiulxa  Kit.  7V««,  aprtl  t.  ISM.       |  wsiksalhtiatKaUa— £JM&Br«a  JfoI./vunk.lUa. 


TL/,K  {BF.SJAmS').  M.D. 

^TUK  MKDICAL  KOUMn.ARY:  heinpn  Collection  of  r«>Hrnption» 

■nil  Earopc.  T*>>:?tfa«T  wit.H  tb*  t^nnnl  rfi^Uiir:  TrapqiriilinnA  iind  AntldDtvn  f»r  roiivmii-  Ta 
vbirb  it  adilr^  ui  A|j|ifn')ix.  uq  Iha  Kdi^fiuk-  luis  of  MudLeU««,  aad  bn  tb*  «U4  of  Ktli^r 
fOkii  ClCiitaftifjat^  The  nhoU  »4]nin|4jij^0  with  ■  fnv  britf  rbArniwutiQ  mfi  MmIuiaI  Ob- 
■^ri-klivB*.  RT4>F«nth  •aiii'iiiH  f^nftFuUjr  rwWcl  nnd  umc-U  silvinlnj  \iy  HdjicBt  P.  TdoKA*, 
U- D-.  rr4>fr«H»r  of  MiilefU  M^dka  ia  th«  PhtlwMphtfc  Coll«j»«  of  Pbarmne?'     Is  oi>* 


W«  ■n4or*4  tha  fK*itrmtj1c  opIbfOD  wtileh  tb«  Uiok 


Ioi>4  4tttMuL4d  ff^r  ilwH  >ujd  tHk4  IM*  WCA-    cdLUuut  hfp»r«J,  lliaf  U 1*  tiidcirul.  vo  Hit  prvi*hl 


I  VOilE  IhM  Toof  bt*b  VnfrtfWlh*pfpf*^nQ.  »d 
P^M  *xtf*,\\j^^\j  rrinv>^DiL<nL  ami  dxrful  i'H>li>Hin  For 


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1Ji4  f  l««iaBlti  Hillllpq  *  Uff*  nmEmnt  of  ikht  laiillfir. 

i,Wf-  Biiil  fHi-romnty  uwfiit  ^Diln  hat  wo  bnfB  «y|H 


»{> 


VNQLISON  (RODLET).  U.D., 
GENERAL  THERAPEUTICS  AND  MATERIA  MEDICA;  adapted 

P-i  a  H>dl<BJ  Tnl'Pniili.  With  tniloio*  nf  B*ni»l<>i>  ami  af  riiMiHai  imd  Ikair  Ramadi**. 
(iiilh  »dili.>n,  raitiwd  aiid  imiircived.  With  ona  bundHiJ  and  nlBclj-ttrw  lllnjltallonl.  In 
two  larft*  and  handwuotlf  prtntwl  cnlSTO  toll,  of  aboat  1 100  pact*,  «im  tlotli.     $0  it. 

KKW  KHMEJUES.  WITH   FORMUL.fi  FOR  TnETR  PUEPAnA- 

TIOX  ASD  AbMINISTRATIOIf.  Sercnth  adttloo.  «ltli  eUtuKa  (AtltioM.  In  <m» 
»i7  iMigr  iKtaio  Tulumg  of  770  pagfi,  c^tbcIqIK     f  I  Wl. 


]<     Bnn  C.  LxAs : 


JHW-oad 


MATERIA   MEPICA  ANP  THERAP«T  bniL- a  iki^ 

-  |- -^.      --1    ^-.  ■  - 

fc.  rtiy  :  ^M7  rf  «>*■  Uato.  M*  fej  HnsKT  «  uuscvu.  tS^  b^ 
■ ntfl?  Ota  d<A.  S7  Mi  l^l-.  iMrf  Mat 


fSTiflc:-,"** 


iw •■rfr  '       —    -  -     - 

or  sMfe  Aa 

rUcWi 

iTIil  111  1«-li  rigllit     'II    ■■III!    Yt    iiniiTiiil  -*^tT-'  |-      r 

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— >f  ■iiBfc  ■  iiii»»w*  fw  a^iTUii 

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•ilfii  hn>  tela  HuatwBl 


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c^i 


SYSOPSlJi  OF  THE  OOrRSB  OP  LBCTITRES   ON   MAI 
U»m»«»lWII»J»iC>i«—iirfll«*iiii«    nM**lM.n«iM^    Ia«»l 

s>nn  amzu  Histu  up  tvesapw- <  CAmrrm  Min  lauT  qm  tsti 

on:  )«<>«■(  Aa  ftiiiimlwi  rf  tt*  ^la*        jmjbh^-Liwii  a  >»»«»  inttaiwat 

t*M*»»it   wa— ywBiWiM  L    ■■mI     -Till     "I m>  I      >■<  — 

trfi  iwrmiy.WD.    W>  abiay-^M Wh^ [      iika      tp   IT   inTIi  il   n      «• 


TiiialtUia,  OmMbit.  naoMn.  ItilMi.  7a^ 
m4  P— b4  tW  *nMK    r  11    Vriii¥inii 


iTOflW;  VL  C>^V9V4BT '     a«t».    f^  ••    ?•  nviA 

On.  wMk  OMT  riMlat  u4  ItawfMM  hr 


Ittrkm*  WWW.  iiOii*  iBl  laitTti<  w*it  ■  l^«-  . __. 

j^n     «^     ^^       ^T .  _.  -     ■ .     »fr.il«i4  la  ika  Ana   sntiik 


Bkmbt  0.  Lka'b  PDBQOAXioas — {Faih/t^ogy). 


li 


'f^ROs.'HSA.vuKr.  p.),  M.n..  -■■  ''     ■—  'r    ~   ■  ".-; 

^-^  Prarnnir  <•/ tarj/rry  In  tSt  J' frrini  U-Uial.  l\.Brff 'if  fhilaiUlphla. 

*^-     ELEMENTS    OP    l'ATHoU)«IOAT,   AN'ATOMV.     Ttiir.l   e.lition, 

^^B  of  n«*rl7  ntA  -pii<a^  wiih  nhnur  thr*n  hnnAnd  Mill  Aft;  iH-nultful  ■lluitra.liiiB*,  of  uliinb  ■ 

^^1  lirfa  Buuibtc  aro  from  oilj;lnal  ilMirIng*.  extra  ciDlh.     tl  00, 

^^1  Tho  orf  bcsntiru]  Mfcatlon  of  thii  viinnbtr  work,  tui  th?  t:iviYilDjrl;  luw  jirter  at  irUob  it 
^^^h  ii#md,  »bvuM  niminAiKl  htt  tt  ■  pfjui«>  in  Ifm  Ufiruy  of  *vdrj  |'rrUTlUii>u<T- 

^K^^twtf  »»  ir#r^  vtiKlj  w<-  e\n  miTr  L>>^*rtll^  com- 


t  will  Fct«7  «  c*r«fuJ  p«fu^,  AbJ  4buuJ'J  be  upon 


rOA-fi5  (C.  n.\S'PFlELD),  F.R.a..  and  SIRVBKrxa  [BD.  a.).  M.D.. 
A  MANUAL  OP  PATIIOT.OCIO.VL  ANATOMV.     Fir*t  Am«riciin 

«dkIlon.  rvTitvd-     With  three  bunJrtd  and  Dlnet^-tei^a  hnnplBomc  *ttod  t'DgtavlnE/*^     la 
onv  lArgn  Bud  Ifpi^utirully  i^ribltd   uct«tD  TUfiliB«  n(  nuatlir  tbft  {>■£«>.  Pilr*  olnlfa,  $Jt  60. 

tt*f,   if  It    vroiiM    tb<u]¥4i   ft   •PNpATKtr   Bail    Jpii£lb:r 
4*iiii(ii)pnU'>ri  ff  i\'sttty  i-irirj  m^^ajxHTi  itEvi'iiMpd  ;  noi 


1fii|lL    LIji-  V»Tlp,rDi    ^vhlv'it   Uttlft   'il  |u 
!«jh(Ji]£  wiirk,  it^^uUlla,  ■■>  IE  J  jr.,  ;Ht  vxvnl- 

a«  Ibl*  dtaldanlitin  U^oppllnd,    WLiJHu  ibpUm^Ex^^f 


•mTAS'SSr  [CAUL).  M.D.. 

A  MANUAL  OF  I'ATnOLOGICAL  ANATOMY.  Translated  liy 
W.  B.  SwAtxa,  KvifAim  8ii:rxKiKc.  C.  11.  Houu.  ftod  U,  K,  Utv.  Vuar  vi.Iduku  cuMtu, 
bvaid  in  t««,  of  about  liOO  psgw,  oitn  alolb.    $T  aO, 


ATtASOri-ATIIOLOIitCAI.  llWniT.OUV. 

I«'«4.  Hllh  Noltn  tad  AitJldou*,  tiy  Jotipii 
'.  H.  i>-    1%  ao*  vitlnm*.  rviy  lutgrn  1nip«rt&L 

^■Uln,    with    no  f41iltr,r'pL>l.t*    fltDtv*,    pEjLlO  Jkod 

•aioMJ,  »l»  ilMh.    11  00, 


MMO^'it  lirSKRAL  rATIIOLnOT.  «•  fnndOFire  10 
ttir  Ktiiliii-hioaol  ar  BmIodiI  Prtatlpln  tot  iltt 
PrafraliuEi  LLuJ  Cura  of  P1m>.m-  Tn  0114  oatbTV 
vDlaraaar  ttipi^vt,  aicmffTarb,    $1  iA, 


PRINCIPLKS  OF  MKI>!OINR.     An  KU-nicntary  View  of  the  C«U9©fl, 

Katan,  Trfalmmst.  Diii|fni>ni^  luii  rrnicnovlji  (^rDlicue;  iHtb  brief  rtm^kJ  on  U^^Dnlcn, 
or  the  pr«Hrv*XU'Q  of  buaJlb^  A  iirw  AuJeriann.  frotn  tb«tVtn|»n(1  nrtM'l  Loatlua  ecUtioo. 
lo  one  ooUvo  Tolum«  of  iibout  MIO  yn«fo.  eilra  clutb-     $li  fiO- 


Tlio  aoeqnlTonl  Uv,ii  vriib  whji^b  iMa  wifk  bu 
>■—  H«a|t*d  bj  ib^  prvlWaldA.  l4ib  Ln  EurOfW  a.i>A 

wbdfta  «A|^B>i«  Milling  Bt  t*lQS  la'bi>ir  Llul  lb«rq 

MlalJkBul4fpiv4]oLii«,— tf.  iM^tgJittt.  tindSurjf 

fftvorli  bw  tTpr  ul^lovel  or  m^tDttliiPi]  t  iDorv 
4»«Wd    rvpiiUUia-<-lfrprtiilu    MtiL    anJ    Sur^. 

Oso  «f  tb«  bAtf  V'»rk4  4B  |b«  tubjA<'l  iJ  wblcb  It 
tr««U  iv  Vfir  lAujtuAjGt. 

II  bjk*  «]rrt>4r  c^  mm  Hinted  ttj>«]f  lo  lb(»  hl||h  rxgtril 
of  tk«  tirnrpMroii ;  fcQ4)  VA  rsiiy  «H)  »5  ibil  ir* 
kwef  a<>4lUjiTd  vulumc  iTiM  « 111  ntTirr*!  Ib«  trmrto 
of  i»1h«Tvncli  4  drlLTtflff  Ed  lb*  prluitplf*  of  priiel1» 
ft*  llili,  VmdfnLi  Alt'!  |ir»a|](tnnpn  >h'>nM  inft^n 
ib*AwkrM  [Qitmalfflr  rtuiLllBf  wiih  [[«  ie«i?bLoth— 
ttitj  w^U  Afid  ib«lr  Lll^u^  aad  »tady  muK  unply 
r*pjild.— (*in(?i«nuil  .«*(,  *y*mTWr, 

ThM*  U  Mow^fk  IB  Uii-dlrvl  Itivrttn'Wbltfb  rvt 
All  the  plArt  itf  Ihli  tnif.  [t  It  Tbf  fritn-er  nt  Ibo 
TOBfif  f<neUtl0ittT,  tbv  f'>nmef  theiclnBliflflfiue.^ 


A  iviT'b^vk  La  wbEcb  m*  oibf^r  Ln  one  IftUfaailt  Ja 
aiiiip4mbU,^OiUirUi/«i  JVAi  JVunuJ.  {  V 

ThA  Unf  (ttcit'd  tD«Vi«[*  w*  ^vr  fivrn  iifJtT.Wlf-. 
Tlin>'«  rria?lj']pt  til  HoJlrfltiA  «il1,  >r*  LriL>1.  lU^rly 
prtiv*  lutfiir  n*ili<»  bi«  ^ftfkCI  tviaprtmaty  tat  tbfl 
U«k   bn  bu  niflvrUltfP— tbm  «f  lm)>*fliM  to  ih? 

"tOiIOdl.  B4    TT^I    «4    l4    llld    MIUlT    f  I ]4<ir1l- |j «J    pncll- 

IIUEipr,  ■  kuuwTviJfa  itf  ihirwi  (Vnnrmi  prlnclpJoi  ut 
imlbcirnit;  Ml  whlvb  iinat  »  TDTT<Pti  ^rvf U^  eotp  hn 
foond^ll.  Tb«  At4t^|DlA  iiHi*Hlir  *>'  ^■J'^b  B  v^'ik 
uiutl  ba  VTldoul  tH>  »]|  w1h^»  pvH'^ii.l  ii»  mi-ru  cb^n 
iDflTv  amplrlclBijt^  W'«  jnuiil  ^'^nrloffe  liy  if*^'*  *^' 
;]riuB]Eif  "TUr  bijfb  ftrutt'  nf  ibr  IrmiiAiiM'  bikixfli  vhlch 
|>r,  WNtlBmi  bAK  tt•aTml^f"^  ni>  ni^nHrln'*  hy  t>pn  pub- 
ItnOoo  trf  fill*  varH  W«  ar#  fpr(4PD  fhiL  tn  Ib4 
pr«Bc*nl  »La£«  df  uut  huuBliiIjeahJ*  PftDnjilHtvf  Merit- 
c\ati  fitfDld  Bill  BuBalb^j"  b«  BUipuurd,  Wblle  iv<< 
r^Xi^*  ^^'  ^^*'  ifblvb  nmnjr  rrf  iJm  rl^1r»K  vrnprtt^Hjii 
of  pFBrlillowi*  hhvm  ttfWtitfi  hj  hi'  ri'ilftJinUtia  u 
ibn  Cbftlr  Al  Cttvifniif  Collfef**  It  I*  '^^utrortih^  lo 
t**l  Ihjtt  bin  vnlUffi  iim>l  fLiDri  faalluti^  |n  '^iierl  t 

tie^vrTnl  iqJtaf'OOr'  en  tbe  ruhrtie*  nf  xhm  |ih<rLjBt1uii 
L>r  tbe  Iruprwnicul  uf  irbltb  bf'  b^r  »t<  n*aWluni»l^ 
mi\A  fiun«HfcJiit]f  JHbiiAd,  4nd  le  nrliLfih  h^  h»l-t>  'n 


u 


Henrt  C.  Lka's  PwuoxnOKt-^Praciice  of  Mtditrine). 


JpUNTiAVSTIS).  V.D.. 
A.  TKKATISI-:    ON    TUK    ]'RIM;il*LI-:S    AND    PKACTICE   OP 

IIBDICIZIS;  iltdtcntd  tut  (h*nwiiI8tB-l<ntiuUI'T4«Utiao«>'rf  UcdiciB*.  In  mm  iMxa  ' 
ftnil  (iMoly  pcuilHl  scUia  ir«lnia«.  budMOw  axtn  oIoU,  M  M(  a*  tUva^f  buiud  la 


A  liwlL  of  Iii*>U(uftbla  niii*.  ••  III!  nnordfil  raiii- 
Tk^Mof  ona  of  rbvfl'irtat  mid  b«*l  r4^n*iti  mluiU 
<TM  0><gi*1  lo  lbs  liitoiT  •nd  pritrtin  or  iKdMnr. 
J>r.  r&it'*  TMuaf  MQ  Puscvu  a»  Mnum  *in 
ba  •4«4rLr  p«(u»d  b^  kll  hitt  uaJao    wtU  b«  r*- 

SMad  u  iht  Uit'      '    ...  .1  OMiUolB*:— HHficIa 
>f.  whI  Mu-f. ''  IBM. 

IfL  IhLEaialtif  v^i  *a    Dr.   PLlnt  hlB  •««> 

f*4i)vi]  rnijst  ^JidEiaM^^  aUlI  j1ir«  tbi  tail  rwlf>n  * 
Wura  llial  b  uol  UJIIjr  ««rf  ntdnUt.  IsWtwIlac. 
»qi]  ^>u»K.  bnl  iv,  trtty  r««pHl  cilfliildttJ  lo  mnat 
Ihg  r'ii)uinn>»lii<'(  piMlwIvnaT  nina  or  t-mj  il»>* 
Tl>4  xiLiIi^nL  li«*  prv*«al«i]  [<■  blm.  In  (La  EfUlifrttl 
p-j*4j1>iv  Iua0b4r,  Ibu  lym^lvmB of  iin4iTr.  Lra  fvlu- 

Cijll«  vlflfJl    »hJUU  JCHJ'Io  tilEU  tb  IIB  tr«4tIA*Dt.  kad 

ih^diDiiikUlM  whirh  h><pti>1v  4nrio'>i]iiUil  in  order 
bifida  r  liAvlUff  «ii«L  aU».  Ij|tto1Taf*d  to  him  tV*  C4EI- 

«4iiJii>;t  wt^Eh  tb''  4ip#iin)rfl  «r  tb*  fiTurHAot  bu 

vnablp-l    IlLlil    tl  Afttvv  k(  To  rvfoiVDV  LO  IVlf  nUtliTt 

InqfUn  i>f  Hl1:r«fTlil  Lbpr&^mklk«t  a^cjjEk  4ud  JSIf<<4bt 

irllt  *44  ]u>1  ft  tLL£lf  to  EIlo  Bi-ll-ivrnrJ  mpwEfetl^in  4if 
IVaT  XUnI  A4  &  inailLi^l  wflcor  tud  trifliH,  Tic 
ILilinl>rf  ^'f  VDAftlu  wlilulf  bt  Jiuliii<iioLijM<J  la  lb« 
IUUr«  ituDuii  -it  bi«  v^TwjiLaQ.  tx^tij  Ln  piiblEc  4njl 
^r«l*  Ikfa,  h»T«  fiv«n  hkjn  &0  kjiiunbi  ^f  «ii|^rt- 

MM  wb»ih  hai Iiifiiily  I1iii->1  bluj  f^i  l>ic  |>riinlae- 

0n  Af  Ji  vork  vbkrb   nkUal  PDr^Aftrn^  tlUbd  ottr 

nil  Ihll  to  nitwi  wiili  viiniHl  iknoi.— .v.  r  Ittd. 
Itirvr4.  Apitl  1.  I«M. 

Il  prrAPDCt  *  lirivf,  liut  rubclBD  nad  T«tkb!*»aiU' 
m&ij'  '^r  ib(-«>  |4li]ola4teftL  had  iJ]«n|jvEjilf«l  *lw» 

ibo  pr**fn(  LiDo;  and  coii**i|ii«iiiiy  II  la  «oll  ■dA|ir«d 
ti>t  k  i»t-buak  1«  lb*  luuiU  or  •UHLaBU.  Ii  vlllalM 
ktsi  ■  n|n(U**dd|iloB  Miltw  IUirHT4{  Ilio  rnall- 
llMfT'—rM  OUmya  ViillMr  SMMtiwi  ^nl,  IM« 
Th*  Pru«la  uT  Mtdlflua  of  PnC  nial  U.  n*- 
duublnlly.  •lU'.xl  imllcul  wurk.  (Od  UniWbbDllM 
outfAd  la  lEio  »p«Ut  QH^da  .iT  lh«  Alnvrloifi  alDdv&l 
,  And  prirrlnuiirr  lb*n  any  *>lfi*r  a'l^iiallplo  t&  Iben, 

KF  luntlici  fvr  ibc  bvuk  ■  mi  imi.  wit,  h  *•  b>. 
n^  vi^l]  dVMoirffd  pfyaUmj.— CInciaiibill  ^o**^ 
iMf  V  jrHfli-lia.  Hitcb,  IIM. 

titnlalni  all  Ibil  hM  iMMlIx  bMB  tMti  •*««! 
kaowladKa  or  lb  la  dipaalnoBl  <jI  medldno.— AtfruU 
JtaHW,  Apcll,  IMS. 

Pfoiu  J>  Aiiaju  AlliAh  M  H..  LL  H.. 
Ar^fVMBr  1/  Prinelfl—  an.l  iVuctlDi  qr  JfANttn*, 
£ui*  MtJle^  CtJUft,  tVil^j/a. 
1  iiliall  lal.-  >i.  -r  1'^ I..  I»b  rtfvumfndUtf  lift 

nil  (sa  l.'l'    I.       >.    I .r    r  .llnlf,  Md    idM  Mil  llW 

llbnirina  III  i.ii    L    ■  .-^'itll/,      ]|  La  A  ljm«J/ 

And  ab'iiot^iy  inrii^t'iin^^je  MalTibatl^B  to  tba 
llwnitnr*  sr  (b*  pmfhBlot. 


/Vo/MUr  «r  nmry  aiiJ  frati^  of  JtoUi^at 

ruM.  V  Vtnm-iM. 
I  eonaldf*   "rnsi'*   Pitai^Ua  uA  PnclU*  at  j 
9(*Jlfl>n"  u  Ibi  ¥«(  buuk  arua  tba  atllnt,  lba( 
bfta  yal  <(irj|4  uirdar  147  bitlloa,  tot  bia/dlbar  r*a- 

aoEia    ■«    HpU    aa  ih*  EiD4  alrirTit  In^HlLODtd       I    tball 

■mnl  isr^lj  rimininrDd  ibo  iroik  M  n7EUi*,ud 
mljr  irlih  rrtaj  nansfcar  lud  a  tvpj. 

rrDiB  Iticnu*  HtMiaut.  X  D,, 
r*r!f.<,fmt*w^3l>atflmi.  r»l»  i/Jbr»Mit>l 
I  »n  aifldi  ttnaol  sUh  ihli  wt4«.  ud  I  Uka 

pioLiai*  la  rMuniiBisdlos  li  M  U*  Mal*kU  nrha 

atload  uf  Icelania. 

Tnui  luAU  T-  Dtai,  M.  D, 

JV/.t'niarynJJVwNwVlMtOnfiaSi-MlMB 
OiUafa,  »*>ii(vM.  JTi 

Ob  rltniliillli'O  f  iu  laodh  i^lnuaJaiU  1h«  bvuk, 
■  dd  abA.1l  varEiil7  ificoi&tEiQDLl  FT  !■»  <4f  rullf^r  aln- 
ilisala,  iieiii  Riuniii,  vliiB  Dr  iKiorH  u  Hrauirldi 
coiaiiK'Bk't  afalji, 

*i9n  L.  t  Pnm,  H  O.. 
/Vs^  •/  rkorv  irad  fVuiffn  </  JMKrttit  uk  Bar* 
■luMA  J*if.  n<I>|ir,  |r  *. 
f  tn**  Rl*>a  It  an  KtiBlaMl-ia.  aad  an  yumuvt 
(•  nnaromd  It  lo  1*7  altaMa  a>  a  i>i(«Ht. 

PtoaJ.  V  Mnrar,  M.  I>. 

JIM  tiitltg4,  Ptnplnwril,  (Mia. 

)  an  mil  plaaaad  mb  l(.  acd  ik*)!  1 
la  ib«  slua  et  kUual  HiitiKl  Call*** . 

■  Pf>iiB  i.  P,  »nvii»».  Itfc. 

OtnHit  Btrp.  JW.  cut.  iVwIaiMl,  a 
*a  *  ixMnok  £ir  •■ad^BU  It  ■•  aalmUf  la  aa* 
iroFk  Iiiaaii<|iialgr4d  vMli.aadaaadf^  1  ba|4tlarUI 
ba  ado|j|ad  bj  afar/  lUAllnl  rulMfa  la  Iba  iaad. 

Tnm  Did.  C  ttninraK,  M.  D, 
Ppqlkaav  1/  navyaail  /VoMlea  t^  JMiMi^ 

JAu*  JMOMtwK 
I  baTr  (KnaiBia(id>d  Iba  ba«*  la  ika  uadaaia  aM 
adilplad  U  ta  a  Ull-hiM^ 

frvm  Timaaa  t.  tmwunt».  XV.  , 

Prifi^rar  </  ^rtn^lrta  aaJ  rraiflor  ^  MMMM 
raiaBwiiy^  INoiN. 

I  an  niatk  plw»l  vab  '  ib* 

■lalv,  I  ad*lacO  Ilia  aja^a  '  i^ai 

l(  aDlf  Vtllad  111  Ibl*  hi;  j<i->    ni    inr  <i,-<i  ..|    lb* 

larlo     I  aliiLll  Mlplar  II  a*  a  HU«*««, 


jyVSOLISOS.  FORBES.  TWEEPJE.  AND  CONOLLl'. 

THE  CyCLOF^KPTA  OF   PRACTICAL  MKUICINE:  «»mpr 

Traallxa  nn  Iba  Kala<t>  and  Traiilmanl  nf  r>Ian(r<4,  Mnlirda  Mtdka  hn'i  n>n)i 
Olmita  -if  Wimrn  HR')  Cblldf m.  Mailloal  J  uriii|'i»'lvn''>.  kf  At'-    In  f"ur  UrSa  •a[wf-l 
ootavc  *olam(i.  of  J3M  duubia  vntamuMl  pasvi,  iiimiiil}  nuil  baoibumalj  boB*4.     t  IJ. 
*a*  Tbi*«4rknijntaliUDoltaB  ihu  (bur  handnd  kod  d^'^laa  i)WI»«  Il nallw^  «« tribal ai 
b;  tilt}  (IghldullDgnlibtd  i>fajtlclfin«. 


Tba  BKl  (ooplolo  Wink  on  |»a(ilaal  madiitB* 
ailBBI,  Of  ailaut  ik  uar  lancDt^*.— VnjfialaiJMleaJ 
■  «iaii  Anyimi  J"a™<*l- 

Par  n^fatxa,  11  la  abuTt  all  ftU*  lo  aTar;  ^taco- 
liaiar.— mirtnai  tiitmttg. 

0«a  «f  Iba  nml  MltaMf  BtMnl  irabllnulnia  sf 


Iba  fay     Aa  •  waM  (f  MItNwn  n  M  taaUiMbte^ 


II  baa  btia  lu  aa.la>lb  at  Itaraaf  aad  lataW, 


work  fjf  raailT  an-'  ''~ 
inifjiirn  SafllaL  I.. 


Itaraar  aal  lataur,  a 

.-•.,.,,.^afc,li  rtft^ 

I  IB  tka  MaM  afc 


y? 


ARhOW  [(/BOROB  ff.),  M.D. 

A  MANUAL  or  TilK  PRACTICK  OT  MKPiriNE. 

hf  D.  r.  COBUIII.  MP.,  ailthui  oC  "A   FlMlioal  Traaliaa  vU  Vwaaiaia  . 

«ino  hiDdMiBa  oolavo  valma  «t  exci  WA  \a£ta.  ut»  elotb.    (1  M. 


ITxxBs  C.  Istx's  PvsLiOATiOHS — (Profirtcw  o/  A&iUoine!), 


M 


OP 


WJISCV  {TUOitAS).  M.  D..  fl-c. 

LECTUUErS    OS    THE    rUINOPLES    AND    PRACTICE 

PIIVSIC.     tie1iv>!»d  Hi  linig'*  Collcsp.  f.«ndnn.     A  n*<r  Atioiicwa.  fmm  Ih>  luM  rutiind 

vi<l  pnlArifM  Kngliflh  Milum.  vrith  AdrtitJOTkn,  hy  ]>,  t'uAiictit  (X'ViijK,  U.  D..  ftdbuf  of 

■'  A  Prtrtl^nl  Tmtiio  on  Ihc  lltn»iia»  o(  Childnsu,  "  Ac.     Willi  uiiu  iinmlriiil  and  •ighly- 

Ave  illu^trHiiiins  on  wood.     In  ou*  ntj  liirv"  iDd  hna<b>>mo  vofUflw,  iupBflAl  ODlaio,  of 

onr   i20n  Bliinljr  ininUJ  |ia||«  iu  ituail  ly(>a;    Kiln  lilutl^  tA  iO .  ttiDBuljr  Wiuid   Id 

luthor.  Hllb  iklMd  Iwndt,  •!  »U. 

BtBrilDf:  IblFln  b*  tii«rh  vbiefa  ihoold  lia  OD  Ihn  t*bl*af  «Ter7  phjtitilui.  bbJ  bo  in  Ilia  luudt 

vf  vTtry  ■t.udaiir,,  ■Viiry  HlTori  hiyi  b4irn  aijutv  ta  iuihUh]**  Uld  tut  mnouni  of  inaUflr  wbioh  it  con< 

]oji  wUbin  ft  «ODrtoUnt  conifwaf.  Asd  Mavwy  rcAaonablfr  |irla«H  to  plbjo  U  fiUblo  fwh  uT  sIL 

it*  pr'wnt  »nliir((«d  fniln.  t.bi  mirk  onnlkinii  Ibn  mmiar  of  ■!  IcMt  thI^9  orillnory  oclaToi, 

A*t\Bjt  it  our  iff  thv  chflapati  K4irk>  iiifi*  uTTarfr'i  tn  tha  Aiuoflciut  iirofaHfofi,  vhilo  \\i  lanbud* 

«•■  einuiidii  mikwitwi  oi««diDglj  BltrMtlv*  Taliuua- 

Cuiit***nlly,  L7  lire  (nrifori^ai   i>[iuUv(i*  vf  th«  ;  (bp  ttu<)«Qt1b  U>«kC^iilrenioAt4f  hfaprvfiiHlaa,  ftnd 
tUkHl  ■tUlc.l  inlhuritlai  *olli  4f  OMKBrfrdB  ■nil  -       -  - 

thUfnantr^  ih»  t^ii  rnmiMDil  urih*  prlael|i1iiB  md 
ffHtit  Of  rbTilK  IhU  bw  r*'  »PPMtI«4/-Kliii.  Anv. 

ODOiBtoAmllBB  vt  tJkH*  UeLfln4  VDdld  ha  only 
rlttntfOf  tb»  flfli^n  fvditrilpti  ajiisins  of  rhf>  prnTn«- 
M*a,  By  nfilT^TBAl  eoavtert  (hv  vorh  nak*  Mnuu* 
tba  nrr  b»I  IotI-VmiIii  )a  unr  laafuBfiL— fU.  <k1 
tmd.  HuL  nml  Kofy.  /lurnot. 

Il  statdK  Daw  cabfBut^l^  tQ  ibi  nral  nnl:  of  fbn 
nUlMdimi  nUiln(  to  ihf  [iciiillirii  of  uHdlflac— 
lKiiilv*^>»n>«l<v'Jfo<,i»ilji<.TV> 

1>r,  WATHiH^i  L'cluraaai/,  wlltiaq(VKUBHall4D^ 
b«  «ljkd  «  Hirrnr  of  ib«  pfMtfuo  *f  nwdtwafc  »Cf n- 
Human  lofitir. 

work  OD  th»  jirmHM  .:tni«tWno     Tlilo  It  4II  In  (11. 
Ilia  ttie  iirf  bHiuf  tuKkt  of  ]!■  VluJ:  iiuillivl  br 

ft4Bt  Id  Wall^  Uld  llll^UlC4  of  Uu'tLim.  kod  not  «!].[■ 

pavHd  lb  tli»  coiQplfi(";i<«a  lUiI  i^'fmtirnJL^ii'lTvno** 
Of  tU  »il*EiU.    II  wUI  b*  (u  iBdiaT'""^'"  (K'<^  <o 


uol4?*i«onhf  "f  fnri0««t  r«iiBalEaddoKiidr»f«r«a4 
br  tH*  njQAt  «ilff  tnmtfid  pnetliuavr..— CWMfro  JM- 
^i>tarna/. 

Dr.  WjTMi'i  liMMna  IM**  bBD  K  lait  kanm 
mrul  e*labnU«d  f»r  tbilr  Hr*  •anbtnaUaa  nnmhtiBif 

•imlalKW  Hd  kllfMltn  UrK  !>■>  *•  B''*<I  ■•/  BO 

Dinf*  nf  tb1>  odIUuB  Ihaa  Out  tl  li  Uw  Im  viu*  h 
■  ba  aBbjMI  In  Iba  BaxlUb  Untiiajl*.  f"r  ■■>■  faniinJ 
parfKiaaa  balliaf  atiidoaltsad  ikf  pnf  EH1aa«TV*^ll  af 
wtkofn  wi*  adri>«  Tii  Y'"'****  tlivnaalvc*  «f  a  OOpJ,  If 

Ihoji  ar^  lii>[  alrvBily  n>  furlimula  ■>  10  Uava  una.^ 
Sutii'a  Jtulv.iil  'iml  Hitfgtail  JuVfnai 

yoniig  mva  Hill  And  la  (lia  w^rrk  liofvra  na  Iba 
tDUJicili  of  utidutu.  lud  lbs  »M  uiug  llig  iroida  sf 
comftiTl-  Fair  oivQ  haTa  aacraadf^  av  wall  a*  Dr^ 
WflTaojr  In  tbronof  lotatbfr  vilanro  ftn^l  rowmou 
aaaia  la  iha  IrvalmaDl  of  dlxaaa.— I>^frt  JITitf  ^(nirh, 

!f  u  VMcl^ilunar  ibouM  ba  irlcbaul  rb4  avw  tfdlUvn. 
— .V.  0.  ,lfnJ  Xrai. 

TbUvgik  la  au«  liulf  a  ajvloarjla  uF  praatlnl 
uMUlaa.—jriu  lark  Jsuruui  qf  Jfaltnai, 


JCKSON  {SAMUEL  ff).  J/.  P,. 

Pnfttmirnf  Priuticii/ll-llrlatinJi-firri^  Knl'ml  OJlffft,  PKi>ad4iAta. 

.KMENTS  or  MKDICINK;  «  Coiiir>fii.li<>tw  Vwwof  Patlu.lngy  aii'd 

Tb«r«|»iilirv,  nrthn  lliatnry  and  Tr*attnnit«f  Did^afa.     Sscoiid  adllian,  tariwd.~  InoD* 
latf  aiiil  hanUaiiiiiii  uutara  mliuna,  utltD  paff**.  aiUaolnUi,     $i  HO. 


^^H«a 

I* 


p4rlicitl&ra  »bkb  Jp^iply  llllfl^[^»l  xiiA   »lr.>nicly  IJn- 


n*  fdU  u  L>  ei>niip|i>ar  vjEh   Hid  chmrif  Eur  anJ   llmlti 
lif    III*    w.-rV,  La    »    4[|rlr>.  for    hlOHA-t    «Dil    -'lO^afV* 

tli^*ii;nr»in[n  Irni^  ftU  Id  AmeflnEL  oipindnB.— Jt  0. 


>ABCLAr,{A.  m).  Jf.  i>.  ; 

A  MANHAt,  OF  MRPrCAL  mAGXOSrS;  being  an  AualyMS  of  tbe 


TH*  bouh  ^>  A  V4IV  VKLambIt  od«  to  tb«  prfiflH<|«it. 
id  •■  fnori  hrtartiEr  i.--uimmii  U  t-i  out  nt»d»fi-— 


^■'To  lb 


To  Ibo  JdBlur  mmulwi*  it  ihn  prufiMitluii,  «bj  la 


tint.  ^n.  MpiL  J^urnttL  ^ 

»U  LW  p*cH  wiLiL  Aitviinlatf^  mJ  vbo  nil  nni  a  nit 

tnv|^1Wi«|«u*of4ljVkMi^iWi^JtfbildiHrAir0. 

A  MOal  v«ld*b|a  dnni«ii1pn  Iv  Ik*  pndlUabv  la 


'O.VDOX  SOC/KTV  OF  MKmCAh  OBSKRVATIOX.  ; 

WHAT  TO  OBSEUVE  AT  THE  BEDSIDE  A\D  AFTER  DEATH" 

IN  MBUICAb  CASKS.  l<<ibll>b«l  uikW  Ih^  i.ulhorilr  i<f  Iha  I^ ndin  !>oaii'ij  f.<r  H>41oal 
ObpwrTaltoD.  A  Qotr  Am^rii-'an,  liuiu  thv  aeooitd  and  roiaoil  LunUoa  c^tUou,  In  uuu  rtrj 
haoditoma  TuluiDa,  royal  llirtu.,  axtra  ctulb-     $1  00-  «  r 

LMnrlR*   Ol    TRB   rBINOIPI.U|HOLLAIb'll    VXDI'^.lfl.    3Vnn    «M»    RirttO 
Hrrwu*  ar  MttitAb  Hfnaoiniii  •*!•  Ka-       iwu.     Vroai  tb>  t>.lril  ami  rTi<a>i(a«  B^Uahadl- 
awH.    Far  iha  ikaa  of  ai]«aae«d  <(ad«au  ayd        tloa.    To  uiia  baiiil4<iEii#  "1:1^*1/  vuluha  «f  abval 
'ir  prtMltlvaan.  lu  onii  «i)i  ami  rojalliao,  |     MS  rafia,  aximlull,    (3  ». 
Br,  <im  aitilb,    f  I  00.  I 


18 


HxNaY  C.  Lia's  PuBLicArtOMS — {Praolice  of  ifcdioi'n^ 


pL/yTlAOSTttf).  M.D..  ■  r    il 

.  A  PIlArTICAL  TKKATISK  OS  THK  PHYSICAL  KXI'I.OKA- 
TIOK  OF  7I)K  CKIiKT  AND  JUK  lHAQSo61h  ul'  bUKASllS  At'^'KC'lINU  TUR 
IWtlPIKA'lUllV  (.'UGAXS-     lifooD'l  will  rniwd  «d*lion.    !■  vM  LMiilnaia  tolaiv  rolana 

^  Darinj;  (hs  l*n  ;t»ni  w!ud!i  hm*  alapwd  ilaM  the  pr*f>iiml<in  nf  Ibi  Artt  ntitinn  ut  Ikia  nuik. 
■nuch  liu  biwn  ■'liliid  lo  OUT  knowIvilK*  D(  tU  ■nbjwl  'tlir  [nxitlon  nr  Ih*  nuthni  bu  b««ii  toeb 
■■  !•  hg»|i  bin  nwmaiWy  Iwniliw  villi  tttj  ■l«i>  'tt  tcoarui,  uid  lo  MiftbU  bin  lo  Uiit  Um  Io- 
potMoo*  «r  *ll  invMliKMianf.  Uft  bu  nviiMt  tb*  vork  Uii>«iuchlj.  kuiI  U  miif  Ibarafeia  b« 
NltiU4t<l  Mvntircljr  m  ■  lava)  «ilb  lbs  moil  adtaiMad  conditioa  ol  iU  impoH'*!  U>|m. 

'^r  TOK  ».iKK  AVXItOlt.  . 

A  I'llACTR'AL  TKKATI.Sr:  O:^  TITT:  niAOXOSIR.  PATirOLOOr, 
.  AHD  tBBATMEMT  OF  DISEASES  OV  THE  OBART.    U  oi>4  nwU  mUv«  rptBrna  ot 


iM«UP  prvltulog  btnc  mopr  «>lt*n«lviiJr  kuvWD,  or 
BMf>  dnfrrtillT  •<lt-ii»il  In  ihlt  ivaalrT  tbu  l>f 
FlIvL  ^*  vtLiiiitIr  ■rttB^'wTodipv  Ma  ■■<»■*>,  miir* 
fkiUaUrly  )■  Ibt  tdIuibiib  illm^  of  ib*  liH>n.  I  n 
aakiai  u  aiMeJad  ikimimI  lUglml  iiartir  ■•vlil.la 
t>r  >arpn«i  or  illuaraMa*.  la  naasMlaa  viife  omm 
Wbteb  aa*a  b«a  rip»ii>d  br  uitai  iraHwofikj  oh- 


•mar*.  Tba*«r«  af  Pr  Rial,  irhlfti  ta<pwi4*«4 
IMi  ilmri  uDllMkl  our  liaDd*.  la  •BBa*a<l>«  vtlli  kti 
M»4r  nIaiMk  *>>•■•  Uil«  «a  b>  •*»■»>■<  al  «ba  bakd 
«r  uar  ate«f  TitiDfl^  maj  |4  nfaMttl  ««  (vHi[fInltaf 
**fiit[^^4l«  cuiJo  IM  lh«  4kaNi***l*<'  "  '  Lh* 

ami  4Trr7  ffnUklfdr*  La  i^&iwaadi''  ^'-U. 


VUKlST<3!t   OS  CGItTlIH    DI^EISES   OV   THE 

BrCKI.Ut  il.t  FIOIICI-IIKU.NOIITK  A)tU  Jlllir- 

UATIC  i'J-EUXUXU.    lu  oaa  otUTo  *ul,  axira 
<ilu<t>,  rp.  111).    |1  U^ 

rWKK  irsi)  rtirjs  wmt^— t,i:i.  lo'  riiK  kv- 

KlfT'    OF    TLIMATB   OS    Tl  ■'   ■    XllH- 

XASIL     tNb  W,VIIitK.<«  <l.1  '[  I:  .<  HOr 

FRWJSiScr  fl.1|TI(«  ItKVir  CTU 

XKIC^LIW    Ti>ffMhcr  la  4ii«  bta&  .'OUi.>  ¥olntQ*, 
riiia  cli>ib,    fl  mi. 
ytlOIIES'  CtlMCiL  ISTRODircTlOS  TO  ACS- 


riTLTATICIll  AXI>OTITEIIHnDn<irnimCAI. 
DIAiaHOilfL    aaaad aUNaB.    Osa  totama  raral 
l1niD..*iiH  cbuh,  Ki.»4     tl  av 
WAl.iJIKX  l'K*cnC*tTnSiTI»K"'>  ■"-i'isM 

OF  TKE  LITAa*.    TUrd  Anaficau  iiH 

tflixHj  mil  fDa<h  aalaffad  Laedi>|] '  <  "Jta 

aaali-rlaT^  t^Eflinat-riftajl;  W|i4h'-,  ■  nsm  <  j'.tk, 

WAWIIFS  nUCTICAL  TREATtn  "S  TIrg  DI». 
KAUUI  i->'  -T-i!''  <r''M<r  AMI  OKtAT  VKMIL*. 
Tti1r»l   Al  ..   ;[ia  lluzJ  ntlho^  4dJ  mflfb 

raUfi'']  :  '<*,     ru  L^OQ  l.tt'l-iBaweurv 

■Klniiiavi  ;..,.«...  iilniloib.    la  ca 


I 
I 


CONSUUI-TIUN;  IT8  EAllLT  AND  R£)IKDIABI.F  STAGES. 

DDE  naal  ueura  TolBm*  oT  tt(  ff-  wttr*  elmb.    M  W. 


In 


gALTEB  (tt  //.),  Jf.Z). 

ASTHMA;  its  Pathology,  CaiiSM,  OoRScqoencC8,  nnd  Trfntiiwtit.     In 

ffLADK  [U.  IK).  M.O. 

DIPHTHERIA ;  Ha  Xatun;  and  Treatment,*!^  an  Account  or  Uh  US^- 
torj  af  it*  Pr*ii4j*D«a  In  vhIoiu  D«un(ri*«>.  $#nnnil  aad  nrtmt  adlUuiL  Li  voa  dw 
ro;nU  iSmo.  Tolsttia,  aim  alatb.    |1  IS.    (/hj(  luutJ.) 


^RLVTOy  (W/LUAM),  M-D^  F.R.S. 

.i,KCTURES  OX  TITE  DISEASK.S  OF  TlIK  STOMACH;   with  an 

IntrudueUfin  nn  \U  Anotamv  uiil  2hy*'ttt\9%j.     From  Ibn  MOODd  ^tiil  nnUr^rJ  L4n4«D  •A- 
tii>a,     Witb  LlIuitTAtioiu  «o' ««>oda      In  oua  handiomfl  ocUto  >olij,ffia  of  fttA«t  IM  | 

Qpiia*rnlti4  iir^Aihitf*  of  U«  bIiti--         ""^  -   Afe*f0)f» 


'H^wlitro  cm  b*^;<ap■I  ■  mnrT  full,  prfnnF',  pUlo, 

Itituhrv^nvvrHiiimuE  tli4<li  [■"(fii'r'Jtj  nil']  Itirfhpvn' 
l*r«.— Jm.  /MM-*^  ft^  e;i«  JVfr<  tfirioinj^  April.  ItO 
Tbtf  flf^I  ^IHob  J-Fthlt  wark  iMwmr,  ImmMliiltilf 

— Jiftt.  ttiuC  Atf-.  JbJL-OJUr.  AolWv  April,  tt^^ 


/? 


'AtiERSHOy  {S.  0.).  M.D.  "■'  *^-'    ' 

PATHOLOOIOAL  AND  PRAOTirAT.  OBSEnVATinv- 
EASK8  OV  THi:  AI,l^fR^■TARi■  CASAI^  (K.^'Pntors.  ST««Ai 
lyTESTISES.     WUb  lIluilniiDM  od  ovqJ.    In  cd*  bamlioina  vcu,.     .. 
ptgm,  aitrkeloth.    fl  (0. 


_,  B^SHY  C.  Lba^6  Vv^LiCAjiovB-^iPmr^icc  of  Afedicvt^y 


19 


THE   PATHOLOHV   AND  TRKATMEKT  OF  VKNRREAL  PIS- 

BA^K-fl-     Inclufling;  lUa  ruuEU  "f  rvAvjji  iQ<'<ligiLli<inF  UiHin  tht  nLJ#oi,     A  i>vw  and  rtt- 
fittd  fUUon.  viih  tlliufnvUoEui.     In  009  l*rt«  uid  lun-lvuin*  uDtBTo  lulumtvr  440  p*f*i, 

Xhufng  Ihv  nbori  ttrne  which  hu  vlarDwl  uln^a  lh«  Ai>|«u-4noii  nr  ibu  itf>rk>  It  Ku  u«uiii*4  (^ 
ithm  of*  r««ofali«d  ■uthothj  on  th«  inbjeot  «horeT«r  th»  tui^A^«  li  ^rpoktu,  ttnd  lu  tnD*W 
[|«r|i  labi  TIaIIbd  niAvn  lh*t  ltj»  rtftiiUiti(>n  i*  ii<»t  oonflnfl  (o  out  0«n  tonsvo.  Tbv  «taj;ular  olctf- 
'  HBh  vtth  Thkb  tht  raoilern  doctrlnu  of  T«nar*A]  dlfDOfdj  ltq  nnt  fcitlh  rflndurs  U  juluinblj 
idiipttJ  tn  ttip  p(n<1ifcDt)  irbn«  ihff  J^ilor^  of  lU  pr44^lic■l  ■TpIaITi  ftad  clir«otIr>ni  u  to  tr^ALcuBPl 
fluk«*  it  EnilE«|wniablA  lo  1h«  pnfULUiuar,  Tba  fiM*  iu'licna  jmbjuiD«d  will  ihciw  tli*  r«rjr  high 
patfklQQ  aDlfvraillj  >«««rded  Xo  II  by  Uw  mrdi^al  pm«  'if  both  h«ltiiip1xcref' 


prvAuol  d^T  t>D  Ibff  tnliJdcL  —SrUUfk  and  fbr-  M*!.- 

^ktfon  i^iKvf.  Fob.  tt,  I9M 

A  r«mkrkabk^  t\r*r  idJ  full  iTalAniilla  lrn»tU«  oa 
lb*  «boI«  •«bJa«L-^£0iwl.  jr«f.  nnuf  n'l-r  ff«^fi. 

Tb>  bnl.  «aBplt4«f1.  fsilvt  BnniiCTYpki  An  thli 
«sb^l  W  DBF  Ubkuwk— ^rd  UA  Aift4nai  n  Juarrtal . 

fihl^«pn«nbAr  ta  »  OMhc»J  libturr^— fVic^lf  JfaJ. 

^^V  A  fvTeot  f omplUllon  of  ill  ITkikl  1*  vr^rrh  IfitowlQp; 
^^M  TVBVrvl  iltk«<««  Id  fKoerk].     II   t\U  u|i   i  my 

Wt  biT*  not  in*t  wtlh  uf  v^Mh  >o  bt^hlj  turlU 


Til  fToil  In  fii>fr>(  uf  r'MBpi«irD"Bt  in<]  |tr^<*if^Bl  *1id> 

AD.  U.  19C1, 

LkTv  In  h.Ltf  puia«4Al0|L  buJ,  wt  ihai  furlti^i  Oij.  [be 
1-ufybovk  apoTi  tb«  lubJtcE  *Mcti  h'iJib4>LiJJ  ^nlLUDir' 

<  lb*  iaa«l  «]Ar«ali<Ql  bui4-bonk  far  llin  bai/  pradfl' 

'      Ttiniirth'irbM'piiroJfinTibOrt'imiVr  ThfB«dtll0u 
Wrirthy  lift  ho  H;rREi(h>rj  B^iiDlri-J  b^  \h*  UnT,  nad  vd 

.  bju  brr^u  ri-fi  ii[iuk»[TrM.— /JfM^Pt  QtJirttrly  Ji^Mmnl 
I  ic^  AfcjJLfnJ  AVUfUv,  Asf  iLht^  ttCL 


\ALLKMASD  ASD  WILSOX. 


i^^lCORD  {P.).  M.D. 

HL-LETTERS  ON  SYPHILIS.    Tratislalcd  by  W.  P.  Lattimom,  M.D. 

^^H  In  ona  aeat  ikUt<i  vuIorc.  ot  ¥!Q  pik£«J.  iittn  clotb.  t>  00. 


■^ 


A    I'KACTICAI,  TRKATI.SI-:   0\    THE    CAUSES,   SYMPTOMS, 

ASI>  TRBATMENT   OP  fiPKHMATOHRUOCA.     B»  M.  I.>i.i:.iM*xli.     Tr»u.la(.d  ftnd 

■diinl  hr  i1»iRr  J.  Mi'Doruti.i,.     Fifth  AmcripaD  f-mlnn.     To  vhkh  It  idilcil O!) 

blSKASKS  UK  TUK  VKf<lCl'I.AC  S);M]NAL(:A.  Aan  inKiB  iRhiniitsn  oitoiia.  Wiib 
»|wqiaJ  t#fvr«DC«  to  tli«  Morbid  S^nliapiof  tho  ProiUUic  and  ITicihrml  Miipgun  MembfKno. 
By  Utnnii  WiLaoa,  M.II.    In  uoa  bhI  ootam  vulums,  atoliuut  100  p[h .  talra  ululli,  %t  tft. 


B 


UDf)  [t}KORGE),  M.D. 

OX  DISEASES  OF  THE  LITER.     Third  Amftrirnn,  ftwm  the  tlilnl 

■nil  MiluB^  iMinilnn  iHliUim.    In  oDe  vmy  luiDilinno  oMiro  toIhids.  eitta  ololh.  irtlbfoar 
b«ilBtll'uUjr  o«iu»d  platu*,  •nil  Bulneruuii  »Di>d«uM.    fip.  bW. 


$t  00. 


JjA  ROCHE  («.).  Jf.i). 
YELLOW  FEVER,  oonsiderccl  In  It*  Ilistoriwl,  Patholodeiil,  Etio- 

li>t-ii->il.  nnil  Tbf<rn|wiilfiiiil  Rslalinnt.  Ingliulinic  ■  Skrlob  or  Ihc  I)l»»»  u  it  hu  ocvninH) 
la  PbilDilelpllU  fniiD  IRDO  in  I8^t.  wllh  ui  eitoiinMion  of  tha  rAniifrllnni  Ixitiimm  it  nnil 
Ibv  fevrn  ItDi^vn  Dnrln  thv  Fam*  Ikuno  in  DU»«r  pafU  of  t*Ta|«f*tu  vm  wvll  Ai  lu  trr>pLc*) 
ra|[i'in(.   In  (wo  Unci  uiil  liwiildum*  o«IUTg  toluiam,  ofntulj  liOO  paxH,  Mtrk  oloth,  %i  00. 

j^t  Tut  stMK  AVTimu  -^— 

^PNEUMONIA ;  itn  Rnpiwjecd  Connection,  Patliotopcal, and  Etlolo^c*!, 
irtlh  Aulumnd  Fcvsm,  Inpln'ling  an  In'juirf  lalo  [ha  BitlUnee  ui<l  MorWil  A|^ntj  o( 
Mnlarls.     Id  onn  baDdiama  ootntg  TOtiuna,  utra  cloth,  of  ADO  piigci.     (3  00. 


^rO-VS  {ROBERT  D.).  K.C.C 
A  TREATISE  OX  FEVER;  or,  S>dcctioaa  froma  Cour«eof  L«:tui«8 

on  Pa»r.    Balnft  |»ri  of  •  Conn*  of  Thanry  and  E'thIIm  of  Madlelna.  In  «M  Da*i  MUne 
(ulam*.  of  Ml  pa|[«f,  cstrt  obitk.    )1  U.  .  ^ 


BaBTLKTT  QX  THB  HISTORT.  DU0BOSI8.  1M> 
TiotHnnt  ur  ma  Fi'iiu  or  tr>  Umio  fiiATBa. 

W.  T  r*tl*ipr  of  Pb 7*1^^1 1>*  nn'1  Hii'ifrtn*^  4r.     la 
ODaKtaT'i  Tulona,  Df  BU4  pl)n.  oiin  (loUi.VIU. 


CLTlUa  OS  FEVSU;  THOlt  DUGKOfltft  P*- 

ruubHi  aii>  Taiiuiian'     la  vcw  utuio  •oUa* 

nrKOOtK...    I>ji1K<>r      41  '.li. 
TOiiii'gi:i,lM<;.*i.  i.KcTliltBiimf^MTAIXACrTB 

Ihaaiaw    lit  oht  fival  afiaro  rtrtaoii^  uinO  iHigva^ 

atnclmt.    |a  mi.     ^>  _■  .« 


So 


H  EitiiT  C.  JjFA'a  Ptmi-icATiOKS— (PMch'4W  of  3ledicl»t). 


TfOBBRTS  {WIl.UAU).  M- P^  '  '  " 


A  PRACTrOAI.  TREATIPR   ON  riUSAItY  AXV   ilKSAl  1115- 
SA8ES.  IsolwHiif  Trlnuy  Drjodt*     TRmtnlol  b;  Titm«fv>ia>  cs*f«  »»4  lai  m  iti    Ii 
OcaT^r^lnndmnn  i>tUii-n  Tal«ntp'<>f  tin  pji.  pxln  r!Mli,      %i  8C      (AW  Jfw<n 
Ttit  HBBthw  Cot  fomt  tiiot  bMn  TcIC  of  n  iroik  nhick  ■hciiM  rvn^or  B«c(aQ(l*  tDttetaaiaa 
l^prefMtioD  in  ■  r(.iBi»n-li"iiii  *ni  aonitminTil  fatin,  t^  multi  vf  ihr  sboimssi  lai  %i|««a 
'-'a^rrliit  vhidi  bmri'  'if  Inis  <rp*n  rlmidolnl  lb«  fiiilbilluj^  cf  t)ciiiir>  wmI  K<**lUBaBa  fc 
t  liciMi  tW  nln  or  th*  kothir  Lii  tlio  piFHOt  Toliuog  t"  nA  forth   ia  a  fvnn  4!nAM  tl nfc 
Olt^Alilj,  lh«  pnctioil  c<m'lit]L-n  nf  Ihv  tultWt  in  tU  ntift  adT^Dc*^   itac*  ^K^C**^   b 

'  qilrfOBMiil  Jpt«|li,  wbifb  would  unfit  it  fnt  i[»  iilij  jhjaciatfiA 

ilj  prtftkr,  »bl  to  tbr  >luil*nt  ■  conjenirtl  nii<:  liim  sf  d  tei 

Hy  impoftutt  en  tb«  lolJMt.     To  aid  la  lbii>  ncccr'i'Ui  cdp;  in-i  iiia.-waliiw  hm\ 
diji'«(t  1hruu|;l}»ul  tbd  irorh' 

^ned  HB*  oi  hU  >]tE4  prvi^ral  JfanirlaJp,  but  hiL- 


■•  Kwd  hj  ih>  priitr-ndm  In  Ibli  wBOIir.    We  iau*I 
'now  bntij  nne  rtnTI^m  nf  thl*  *oolf  to  ft  cln*«,  r*- 

Cltl>f  nalT  Ib4i  <n  >n  nM<tt4  In  rnlit  Ihn  IMip- 
ot  or  ()*lBt 'uMhrc  vKnitt  &WB  II.  Sf.  R'-brnt 
h9»  ftln«^f  Ob  airivnt  ofdaOduB  plilr*4  WfLrr*  rti* 
llipttdvidgd  thg  Tvaolttof  *|"<»M>IM  Bad*  ^  Mn  ict 
I-  ■aMDatrolBOfaiDHiaitiriiiittHiaMH.uid  laill«ii> 
1    ttil  a>  i'i<ip«itMin  hlB»ia<(bl4ipi«d»tB  wMib 

I^»ip40l»tlnk1ir4  llAT*biwa  bf  do  VtHM  dt*ll4>l>filBC*d. 


,3rk*  bonk  u.  bg^iiDit  ^uaWloo.  Ill*  niMl  wapribvn*  |  IT.  IM*. 


W«  hira  tn^  tbi*  liodk  wlA  axxk  ' 

Xm  tbt  I*U1  *f  lU  ntrtu  tl  UMI  Ika  : 
•oibA  dthttr  WA^-mak***,  ta  e«aa*«da 
Tnscll  lh»  kail  irrll  ^UKlItHl  t<  «>li>i  i  tl  •_ 

lisrvH"  'ii'  T"i«in«  •«cb  ■  inrnlj  |iiiiiiaf>i» 
b4ra«mir[iil  r»iF  lo  f^udrr  It  f^^alxj  UH^MM 


"BMoa  CflaariT  DcumU*."  b«ii;lbrtb«pn»*Dtcitlorprtat,  g«DUaiitMi>lBtalhBi  I 
abOTB  moA.  H  truHtanrlbit  aiih>litut«. 


MonLikTCD  ON  mi:  H[>Nnii>  KFriKTT*  orTXs 

IISTKICTEOX   lit   THB   BLOOD    OF  THB  RL«- 
MENTS  orTHEtTRIXARTSBCKSriOH.    Ib«> 

■oibM   nrt4t4  votuaiB,  9)  PI0S  OKf*  <l0lb,     ifl 

*    Malik 

BLOOD  X»l>  ITRUtE  (XAXDAU  65). ,  Br  J.  W. 


Cairm,  d.  A,  Bimk.  asA  A.  ■am' 
To)ain*.  r»nllIiB*-.wtm  tt-^MM,  w>t4  •■ 

FKICX  UK  KKXAt.  ArrnCTloXt;  iWh 
(oiT  tSAoktr.  Wlilt  lllB>ln)l*ML  0* 
ivjol  Itoft.  UUA  dstk.     » 


nuCKSlLL  [J.  C.).M.D..        <ntd         fiASlEL  ff.  TUKR.  M.n. 
A  MANUAL  OP   PSYCHOLOGICAL  MKPIOI>'E;  eontitiahig  (k 

Riitniy.  Niimlofv,  DsHnplinn.  SlUMSoc,  IHii(ni>(ii,  Palhfili<v.   akd  Tmtiatat  tt  b- 

taoKj.     Wbba  Plats.    In  an*  bandwinaiwUTu  Tciiimt^  *t  §M  f»^tm.  mxtrnrimk,    U  ft 

A  VDTft  ftllfei  rbinpuirliffj  hj  jtrrtt  «1utl<al  «>*•  '  r*i*7^,  In  n>iAp1ot<  anJ  lo^^t^l  tiojt— a^  ■■'  ^ 

«*Ba  aada  canr*lan<l  |a<l1<itn<iiidlinrtaiInMI<«  aa  i  dau.  pruilal  mm»itt  Is  irkl*h  Ihtto  imt^Bnf 

ttix  diueoiii.  pu'liiiOKj'  tg<l  tnvmrntnrtliiidrwil-    Jiu:n-u<l     Tt»;  sill  to  Mtnl  ■•  a»ifc«*Wt  »t— m 

FbI  KalWj- — ya.  Jfrd  uhd  Awr^.  /onriui/.  ,  th^  itDvoac*  t*  nwd,  isd  vttk.  kmi  ^r^K.  b*  4ka 

W*  do  Dot  ^<>v  vhfM  aarlbinji  caa  bfl  f^uad  Ea  ,  liviil^  iraatlali'J.— ^hut.  ^iHfrvdi  ^titm:^^ 

J|lw  IU«MtaN  at  Uut  lyitgiaUx  La  fumpan  wtlh  lb*M  i 

FtaTitaW)>.  aad  DIaaaMa.     rna  IW  »a—i  laf 

'  naab  •alioiitd  !.>■<»■  laluwa.     la  •■•  ■■»! 

*i>liiiDa  nf  MO  I«CH,  artlk  U>  I 

<lo1b.    •!  M. 


iBtmirgoic-s  ESAT  towjirm  a  corkict  [ 

THEOBT  Op  TUE  NEBVOi;*  SYaUEU.     Is  •••  I 
oclavo  filam*  at  1fi2  pp.    tl  fin 
HOLLY  OK  mt  nvtlis  UHAtS;  lu  SirDnlai*.  I 


\.TiJ.\-BS  {C.  BAKHFIKLD).  M.  D.. 

It  PI^Htiai'lo  St.  Stify-t  Jthtfi\iai.*e. 

h     CLINICAL   O  Its  KU  VAT  IONS   ON    PUNOTIOXAL   XERVOT 

IIISOfiDKRS.       la  ODO  hnndfoins    ootalo  ««Iuna  of  3U   pagaa,    avtrs  rlaab,  #1  It 

Thi«  wnrli,  wbinh,  in  purinjc  througTi  lb»  ■"  Library  Drjiiinmoil ' '  af  rt*  Ma*mt.F*«*  Ma 

^IdllLUii-.  ba«  nltrael*d  tn  mUrfa  allahiioD.  ii  a>«  (^aahta.     Tbaaathor  1>  >«uiM  at  ■  >*J*J  i» 

K  pf  Uic  rlptciiwcc  and  KJcnUftc  rwaanb,  and  b|a  Mnpla  oppoitaottU*  tt  iBUdUcaliac  mi  •JfP' 

lomi  and  traaluisnt  iif  Ibw  ubtciira  and  iDtn«labl*  (|a«a  uf  dimiwi  bat*  bt«B  tMnWlofood 

^Mvoant.    Few  dbordtn  odour  lumr  rr«]a»nU;  la  practlco  or  proct  mm  cMbanaaBBf  I^M  liw^ 

Lnd  Iha  fimfMfinn  b»*  long  foil  the  iraot  ef  ao  autborilalira  pra^tiral  traaiiac  d*Tata4  aijiaiMlj 

<to  IbnD.     The  iubJMU  itianuuad  \>j  Iha  author  ar*^  Oiosal  Patfaola^ — Carthnt  AbbbA- 

AnvmiiL  of  iha  !^i>inii1  Cnrd — Ujprnrniia  «[  tbp  Bmia^^pis'l  BvpfrvmLa — Oribial  Faniit  far 

[■"VarBljili)  — Spinal  Patnir— CVnbral  Kinilamaat — H»llrittm  Trimant  —  T»«anM—  Cila)»f»f — 

I'KfUviT— ITovlaiihi— V*<rtlE»— Chorta  —  Panl^lk  Aj^ani — SpiMnodIa  APkHvo* — BlMfla*- 

;  nm— Fiuriu]  \iuiral|itn— Fuini  Par al  iriin—  Rj linal  HypataiWln  "ia    Thw<»  PyiM 

Ifauial^a- — braohhni  Neural^a— 5':iali?ii — ^An^aa  P«ctorlii — HtfplraloFy  2?«o 

|~-JtbdoBinB]  TCouraJgia— Xooniaaft  of  Tritiarj^ri^n*  and  ta1*rtli>*a^->1Ttinaa  3ta 


Kannuat— UalaKoId  Dlmrdcr  — Steration  riiiii      TTjl   i1r       "jibriflr  1111  rfciawitli  Til— 
,  AJaatinni — IUd  fdlai. 

Tba  vidx  Mspa  of  tl»  truliia.  aod  it*  pnu-ttoal  phnraal^r,  m  maitiatcd  by  IW  b>;(>  a^abar 
of  eaati  ni;>nrt«l  tn  datail  bi  Vlt«  wiAiti« ,  tan  \w4lbj  U\  va  w.^b«  te  « 1 1 1  i^i  iglj  nlaaUi  H 
tb*  pnftHlao- 


HKNHr  C.  Lea*s  PnaucATtoss — iJtieea^et  ttfihe  Si»n). 


^9t 


ON  IXSICASES  OF  THE  SKIN.    The  sixth  Ampricao,  from  tbc  fifth 

and  <ali7zc'l  En^iih  (diUon.     In  db*  luga  «eU>a  nloai*  bf  oaulf  701)  {a^M^  Mtift 
elolh-     t*  i».     Al»— 

SKKIES  OF   PLATES  TLLrSTRATINW  "WILSON  ON  PIS- 

KAt^KH  OK  TIIK  SKI!i ;"  «unii>!liiii:  of  tient;  IwtaTlfnllT  rimiWd  iitnls*,  of  whiob  thit- 

Usn  me  tiquiillrl;  culorrd,  prmptiiijc  th«  Koiuftl  Auxinmy  ■»•)  I'Uboloicir  uf  tha  6kin. 

«itd  luqhrHrii^  a«curjkltf  x*^ r«M*n talium  erf  a^out  oav  Lufiilftii  varivllut  of  <litc«A«,  moit^of 

tlwill  Ills  alH  of  UIUII«-      tYiM,  In  «<Ub  olCith,  SA  10. 

'  Al»).  tbt  Trit  and  PIbU*,  boasd  in  nnii  kaniliKiioit  *uliiiaa.  tittft  (iMli.     Piiev  $!■  ['O. 

Thin  nlurirU  wi>rk  hu  f.T  twntty  joun  oooiiplfil  tbt  ponlHon  ftf  the  iMidtHf;  lulfiorUy  on  rata. 

M»«f  dlKiiRi  [D  Ikt  HnEHih  tisgDiiicr,  nod  (br  iti'ln-lrirnrib*  *ntbnr  )»«)>■  i(  on  ■  lixvl  vUh  lh« 

•dniiT  "f  •ri'oe'',  in  Ib«  fr«iimnt  r«»i«!nn«  irhirti  H  reci'!";*  nl  fail  himji.     The  large  tite  (if  the 

VOtOBe  eiiabtat  htm  lo  enlri  thoreitgtil;  Into  drilil  on  atl  Ibe  (Lihj<'Pt«  f1D^n«Kil  fn  it.  while  it> 

rmoder&le  ytVm  plarti  ItitithlD  (henaoh  of  ■f>(7  una  inl*r*ft«l  in  fbiii  itspkilmeul  or  prlEtlc*. 

We  can  aafet^  rtcDuimiiEid  U  (.■  ib«  ;Aift<**^<iii  ■■ 
(bf  bod  oarK  ea  Ih*  «>]F«t  gcnr  In  tililcDW  10 
[be  Buiillih  \MMca*/^—ilt-ii"ii  Tiu-tanil  Pmitfi. 

Mr  WMviD>  TolDidtt  i<  tn  fti^'Mfpi  .TEgawt  of  Qie 
APIULl  nrnouEil  irf  kativTcdfo  of  pLiljicirqnt  dlteitfee; 
U  IncJmt*"  ATlDr>*f  •■-my  Wt\  bt  ^y^^tiVia  'A  1in|«rUtlH 

tMo.— *-ffi*a  ond  Titfigii  .Vfiii^^l  K-'^'W. 
Tb^mt  plMeA  an  ivry  ausunle.  AJiii  Kr*  elanUtd 

(e  I  l»«Kf  (l»l«i]  «k1  II  «f  Ibe  AmeTlHa  irilfltvrlioelwalrA 


■ar^  A  witrk  h4  Ibo  one  1i*''<>'e  Qt  la  «  motl  cvoLtBl 
1b4  afat'^Mi  M».    Xt.  WUmi  hMlVPt  toeaheld 

■A  kt^h  tulburirj'  in  rlbtk  rlqjtjkrlnipm  of  lUniiCllte.  Had 
Ua  UKk  i^ii  iflifL^i*  jf  EE.*  *kla  hiKM  [<ii]^  iMHii  ;«« 
»■  nof  it  iliD  !*■•:  li-iitmciki  »inin  <IB  llio 
TTip  ['r4t''i]i  *HllrTt'u  \*  fertfEiIlT  prrnrtd- 
lojir  tipljj  III  f«Tlil(ifiEii(b«r'e>etiE  tine  In 
dUt.in  «?  EimTA  Blan  Taring")!  !li«  tieanlirDE  >Eirlr« 
Me>  llluiusKTt «(  \Iie  l-il,  lUil  In  ihr  Ixal  rnll- 
i|«Mi«h>l  wiimKIf.  Tten  ate  iwrmrof  itiSH 
HAtIv  all  of  ihrm  tT»EE)rt4  to  uaiur''.  and  *x- 
r  vtn  inuu  Odeluy  lb*  Tuneda  ECTaap^  fur 
I  inaM  o(  la  Ik*  bod*  of  the  work  — cin- 
t  I«>M,  Jflaa^  IMJ. 
b'enf  InaUnf  aklit  4l1»«tM  abould  h*  vltbanL 
— '  «f  [hit  lUMard  *iirk ,  —  C^ini^  X^nxff. 
,IW. 


ThP  ilravl^^B  *f*  n^  piHfKI.  »Eid  lliv  Palib  and 
ealoE^'tEt  ^tlitTif'  *Tld  rfhrn-rt ;  t*!*^  Tb'liimn  E>  an  ladla* 
t«ii<«1)lq  f^ijiut-aaluD  14  Iha  1-oi>ll  SI  kll  uttrato*  and 
(MMn^lttaj^— E;Aari'a<v«  JCaJiruJ  Jtfltrntll- 


JDr  TUK  HAMK  JaTWIK.  

THK  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 

aaiKi  or  tu  mil.     In  one  Teiy  handiDwe  lujiit  lZm<i.  boIuid*.     M  £0-     (J^'u"  ifn'jr.} 
^^  ma  ar*  flbte.fkonfe  -ivlli  be  iJEn^rkbEf  adapted  le  I     TtnirviiiHlilr  pnetl«al  iaihabaatatcia*,— ^frlT,  JIW. 
"  the  aaAaaEOu  ot  t|gdaDliL~£uiici<.  |  ^aamni 

^f^UEALTIIY  SKIN:   a  Popular  Tremtitw  on  Ihf  f^kin  nn>l  Ilnir,  their 

^^m  Pr»er*a>iou  and  Hmagameitt.     On*To|.  ISoeo.,  pp.  i#t,  «HIh  illuilr&tioDi.  elulh.     81  DU 

mi 


'BUOAN  [J.MOORE).  U.D.. M.R.I.A., 

A    PRACTICAL   TREATISE    ON    DISEASES   OF   THK    SKIN. 

Fi1\b  Amrrlcan.  from  lbf>  H<?nnd  «fid  ^blnrfvd  Dabliit  edlilon  ty  T.  W.  Belcbet.  JL1>- 
la  to*  niTftt  ftjjul  Hmn,  vitlupja  of  442  p*^,  vxifft  clntb^     (3  f&.      rAVx'  Rtadjf-) 

ATT.AS  OF  CUTAS'EOrS   DTSEASES,     In  one  bcaatifli!  tiiiarto 

rt^loD*,  with  tx^tiiffitvly  rnlortd  plkU«,  Ao.,  prt««itLng  ikboDt  op*  hundrvd  vftffotJt*  of 
ExFranlfilb,  %b  M»- 

ilr4cr^L'''">"T  AvulitlitK  lbs  |<i41»ti«  irriE]Uir<au«a  irf 
PiBQj  wflJ*™.  whlii*  Bt  i%m  m^av  I'm*  ih#  wQrt,  hn 
tnnfUlmpliM.  latirtffirjpniiTiintl,— W/'JI/oaf  Vvtf, 


Tbfl  dta^fiwU  of  impLiva  dlMvn^  brnvnTur.  qnjfif 
I>r,  }lH^>i>  taMtcrUlDlj.  *'»fBr  ABpo**lM4,"  tlTtfn 

to  vhuii    (ba  ^nleulu  cki*   ml/  btUcf-      wtattn 

VxaAlB*  Alta  (he  "Prt4?Unl  Tn^ti^."  ah'I  vv  &» 
**^'^t^  14  notlJaT  it  ■  vrf  J  aujivftor  vork.  cum- 


A  «Dinp*nd  vlilrh  irlll  ^frj  mn^li  aid  iTi*  t^CTt- 
tLnniF  la  rhL»  iTlOciiII  bi>qrh  at  dlhtm^li-     Ttlin 

It  roDrikiEilH  A  Vfrry  YBUfclilD  «Ji]UlUb  (u  Ihc  ttbnrj 


t 

^■^Tb*  WDik  a(  Dr.  Hlllln  will  nsqnHtlnHbl^  aarn 
^Bj^  aludaal  aa  a  oaafvl  and  'aUKfiil  gnlilfl  (a  Ih^  a«- 
folfVBaal  of  •  taiiwiedir  ..f  (IiId  'li>r««4.  Tb'' 
l»a(IB*atlalddv«abyibaaiilkiur  bvalfnii^,  ratieuL 
a^ad  ta  afeordaoce  vttb  ib*  rwan*  ipf  aq  atE'DklM 
txyiiaiie*.  lit  V  iTeMaalt  anoMraaar^  DiiUllpIl- 
aMlon  ut  reiie41«4.  and  'iii<f(t  aU  ef  Uvuktral  ta^ee- 
^—Am.  Jtarsot  JtuL  SefnMca.  JdIt,  UU. 


ILUER  (THOMAS).  M.D., 
HAND-BOOK  OP  SKIN  lUSEASLS,  for  Stu-tcnts  ami  I'«i<litioncr8. 

I*  ana  oeat  lOfal  ISmo.  Tolama  of  abmit  JOO  page*.  vKh  two  ptaUa  i  tilra  olelh.  fl  St. 

A  ipTl-bonk  wall  adaptad  1e  Lh*  ■lEii]#nL  apd  tba 
lel^matl'.a  aonulie*  la  H  akvin  ike  ■atbar4«  be 
Oh  mtftau  wwh  the  uleailllF  mcdletoe  'ti  Ibe  dkA^ 
iLaiu£.n  ba»a«,  »k  3),  IMSl 

If  u* Uopaara. Ibt pmnltlea** irtll  nuJ •njtet*! 

a  {treat  'M^l  or  aeif  TaiaabI*  tatfamani^u  acd  ii>  be 

,  maiMabianur*  anHMlbMaaadeiiianliAvoMii  — 

J.JMlv4«wv.  BMMw|Ja<tMliw«an),U«.l.  I«M> 


99 


Hntsr  C.  Lba'8  PunuoATioini — (Disaue*  of  CAiUrm). 


XpXSr  [CHABLBS).  M.D^ 
LECTCKRS  OS   THK   DISEASKS  OP  INFAJiCY  AND  CHOfrl 

IIOOD.     Pouilh  Amsrieu  &«■  lb«  tflb  miird  uiJ  ■■tUkrswl  BacBAaMtoa,  kM  I 
Isis*  ■■4  b«lli»»»i«  <«UT«  *«lai»a  of  tlG  cluHlj-jvlxUd   p^**'     Kctn  iU,|tll 

Tkti  woih  niar  BowfilrlyfUlm  tbf  jhwIiIod  of  ■  ituidiird  iBllKirilj  sail  mwtifjl  ili^  ba 
'  cdMiini  )■  KivkIibJ,  fnur  io  Amartc*.  fuar  !»  Oamtaf.  and  trmiwMtoca  Id  r>nAI 
Dutch,  anil  Uaailui,  iho*  bo«  fnlljr  It  ha*  a*t  tb*  «an(i  of  tba  pfollBMioB  bjtt*  i 
vlnrj  and  (ba  plannitw  villi  wUsfc  tba;  an  pF»aiit*<l.     Fair  pnolllioaan.  iii4a*Ji.  I 
•fMitaalllM  af  BbiMiaUon  ■><!  ai^acwnFc  EiV9Tt4  b;  tW  AuUisr-      In  hli  Pnhw  hr 
''Tha  laaMnt  adttieu  amWdiaa  lb*  luulu  bf  1100  faca<il*d  OWM  asd  ■>(  B»t)}  4M  g 
■laniaallooi,  eallaelad  rtnoi  batveaii  30,01)0  and  lO.tW  ebUdmi,  ■bo,  ditfisK  U*  fiM  M^  i 
■Ix  yaui.  haitacnma  aodat  mjtai'a,  aitbar  ia  iiublwar  b  priiala  pcMtiea.''     TkiaJ'       "     ■ 
vUliwhieb  ILawuik  haa  baan  rccalrad  abowi  ibai  lbs  antboc  haa  uaAm  good  BMift 
■ilnntutt 


or  all  ikD  lafllili  vrlwta  as  It*  dlHMia  af  ebU- 
d»B,  Ibaf*  t»  BBaq*  ao  aallralf  taUal^clarf  la  an  ■■ 
Dr.  WhI.    rm  rakn  «a  tarr  bald  ftla  "plnloa  ■■ 

tadtlUT,  ta.f  Tiikvt  iuki4#d  bib  aa  vuf  uf  lti«  LI(Lf*1 
i*l:ik-  '  IElIbffdlfSeull<laj<illULIiEll  uf  lllt^l^ 

£41    "  .Irt    hi  Unr-l  •M'!)' '■'<"■">       ll>* 

viltii  -  .  "  .   «'unieil  b^*  >uiiuil.  j'r*<(ir4Wdin' 

n-'U  ai'iiti,  hr  r  hi«  »&iuc  Ulri«  ihil  Lli<<t  Ihr4r  IliF  mark* 
oftbaiairti  ItVor^out  ■iei^Lj  ab4  lli^i'»Hp»tSao-  W» 
aaranaatl  IMo  «ll  ««  «  nin*\  nMAkU«4>JH'«haiaby 
aataaatD*  vSaa  vri^nT  if«4il**«  oa  lh«  *«nk«  «ahj(«u 
vlll  DII'-rLj  Ibll  Id  btlfi  M  IE  1>*a)ipl1#fl  irllba  tal^ 
flvplaa*  ic«B«ral  lad**,  anil  a  aiaHlal  ladtix  id  III*  til' 
Bt^aaMlUrad  U*ooftaoBl  lb*  iroik.— SoalDn  Jlal. 
>  aM  Burg,  ■rtw^al.  Af  lU  lA,  VM. 

Bt.  Waal'a  Talnma  la,  la  aaiaf  lalaa.  InwiBTarabtv 
Ika  bwl  (uDiiirur  npoa  (ba  maladi**  of  cbllilna 
tbat  Iba  rraollllcuiii  caa  nimatl.  Wllhal.  uo— a 
■laornall*!.  l/nlr.  baiMIU  dm  aot  ibatabwBld  ba 
BPc^adfil— <&*-  WvBiV  cain(i,)«1i:l*«  ^nv^^fif  a  fr<u- 
llit  (Inrin.  Vanif  ani  tliaraaa  ar  aurw^aa,  1>a> 
afoFtlat  (ha  iradiii  niiKb  pl(a«Bca,>teB  ladafaadm 
«f  Ibal  irLlen  ■>!•■>•  rmn  IbaaetaUlloB  vf  raltabla 
liMba.— C^iainaaH/oar.i/ JMIMitcHanb,  IIM 

Wa  ba*B  Ue(  n«H>4  II  a*  lb*  oioal  kUbIUc  aW 
praMlcal  bv*t  oa  Xi~mh  cl  iMUiaa  *Uak  tea  »t 
•naaiaJ  la  Ikii  ii'aatij  — ffHjdb  Jfadlnl  /«a»Tiai. 

Pr.  W*<4'l  iMak  \t  Ih*  baal  Ibal  ba>  (Tx  baaa 
VTMIaa  ta  Iba  Bii(ll*b  lu(at«t  sa  tk*  IUmmb  tt 


ta.—ihu 


-*■( 


{ lahBcr  aad  «b*dbi 

I  mntl  Jtmriftfy, 

I     T*vr<-*pf  la  Ba4l<al  ntcratv^ta  n«Hiik 
luai  ul  ahllJna  Uia  aatUhto  jmW  i  Ttatfc  | 
WUua'i  l»*li>*  d<*>  DB  lb*  iTlaa  i    rfaMka  | 
ani*  rttj  ffti-fnlSr  B^i^fntJ  la  *v  anV^Blb 
book  kia  lU  l.*Dia  »f  iba  priKflaa  •trrHmm  1 

;aia(j<Ualira[li4rcnat  vaJaa.— JMaadr*.  jl  | 

Da.  W*H'*  vdrka  b<«4  bs  i 
dww  bwB  aar  baarfa.     Tba  *«!■■■  tm 
cLallf.  ka*  WAD  for  ll>alr  a  latip*  ^ati 
popalaiUf  BiBAaf  tb«  pt>>IV&^'^  '    —  -  -  -  - 
llib  Uincaa  la  ti^bas-     Many;' 
llwttlUmlBaadlnpcblieut!!. 

d1»*a**<d  la  a  «]A«r«r,  bio**   itjif   ««  iLmhj 
(Ilia,  wUh'iiiial  ■iMicbcli)' sad  Bj*it— a 
Md.  /<ar.  »>I  £«■<». 

n<-f*lB*atana<  ibaaataiiw  a*  i  atf  ■ 
It  tiaala  vblti  Juu  IMI  aikiUl  UflkaaafH 
Iba  ctaai  JadiiBaBt,  aad  fb*  aavad    ._ 
aatbar,    II  win  b*  rowad  a  ai,i*t  aaafbl 
|wuf  ■racdUoaar.  dIdaellBii  bin  la  i» 
■tcblUia«'>dl>aa*aal>i  tkaHwMBt 
aadaanaktaalaaUaoaaiBaj  a 
|a«M,  vbU*  Ua  ai4*t  «••  aUI  aa4  la  MMn  •  arl 
■MluB  bb4  piuUeal  fcUl  a4  sr*«l  TBtaa-M  JiL  ] 


Qo.vpiE  (/>.  Firvi.vr/5),  jf.p. 


A  rUACTICAI,  TRKATISK  0\  THE  DISEASES  OF  CmLDREaC  | 

Finb  aUtioa,  ratiatd  aiad  a*^nml«d.     In  OD*  tar|a  acta**  ral«M«  af  nM  IH  i 
prlBtad  f^tm.  aitn  ololb.    >4  10. 

St  CaaU*-*  aab^lanblrk  BtaMa,  latot!?.  «*<  laa  lb»Jt.»aaa»*««Mdl—  ta  Ika  1^ 
laaMMl  Bta*  an  ■lalliiii  I  la  tblit,  a>  la  all  kk  aad.  BJtwWbmaffa)  all  tkai  baa  ^aa 
■HMiM*  (aMKbaHoBa  ■  "      "*  ■  —  ~ —  .      -  - 

Tbkaa  a*  a  ■ : 
tovallHU 
VibiiMjiii 
-fU^mtiB-r. 
***^» 

WajaiB ll>atmi1UB>*b*tb*>nl»nb 


HtaM— J>r.  a*    il'»J*MHiitartWla1*akH«fct.     m^aatl 

T\*  TaJft*  «f  «*£h*  br  aail**  aalkv*  aa  fW  ^ 

....  ..  _  _^ 


•  a  ifkMa,  Ik  *■>  ladiarat.  »r.  (WIte'* 
lb*  aaa  ^WB  Iba  aHa«l  af  vbaib  i^ 
t  la  lU*  4-*aatryBlrUaa«tbltaffa**- 


•Maa  akMb  tki  ^/Mlaa  k  niii4  at>a  ■*  a*te 

«Fia  b(  Bm>M**b(  b>  all.  h4  Ik  «a  •(  M  Cm- 
^  ba*  ^aad  I.*  laaatt  I**  <bau«^at^Ii«k 


OX  THE  DISEASES  OF  ISFAITTa  AND  CHIIJ>REy. 

■d  aalMval  *f  A*  M*«b    S*ad.  sXk  5aM,  bf  T.  T,^ 
Kuna^lLBi    li  mfcil    hIIidImi    iImiiI       r-^ii        ni  i  *->     MW.^ 

JEWESS  { WJLUAM  r.\  jr.  P, 
A  TREATISE  0\  THE  PHYSICAL  AND  MEDICAL 


TOS  {CBARLBS  D.).  M.  D..  \ 

LA  PKtftti-r  (/ahMrfot  Ac  U  JiMtrian  IMirvt  OOt^t,  niUddfAfo. 

rOMAN:   HER  PISKASES  AND  THFIK  REilKPIES.    A  Scri.* 

ef  LwlBrM  Id  Iil*  Olu*-     Tagrib  ind  Imgiruntd  •dlliaYi.     In  oiig  tut*  •nd  bcAaUfall; 
pria>*4  (Ktem  toIbio*  dfant  TOO  {m^m,  titr*  ol«th,  (1  00 ;  lulhcr,  $a  M. 


ibaJUIlrBlll  ■•«lB««r  tHBI 


I  •JUlTB  In  ■  tttUt  «r  tHB  U««  l««lw  T*UL 

Aba  t»M«  HVh  VBbBBCBd  ^  IBUrl^^tif- 
.tillD*»  HBd  tl  C*B1«JB4  B  fvQ^  vf  BwCnl    Ls- 

B.  r«BTa7<i4  la  Bft  «<T  bbA  d«11fiifil  Mvle 


1  eri  _   , .  

ti  B  VHk  fi  vliiek  *<  u«  tliila  tvcin  fiii  IspHiB- 
Btal  —  JCii>wH«  IMVnl  AvruL 


.fx 


Wb(R<i  iUi  MV  dUllon  <^  0(.  Miini*  vnrli  na 
vvBBa  *Uh  aarb  plMivr*.  aad  <inBin<o4  it  to  Aa 
vn«H<Ma.  aBfadBllr  i«  tk>  tibb^t  uiiaWn,  vhs 

■=--■—--•--:-.—  .;-.    -V"    "i^l.."  ^  ^  ."»I    »«■'»«    "Wh  »»lllB»»»     talilBWlOS     h.™Dl     lt» 

Fblitit  Akwl^J  b7  a<  BBtbor  b  r»d*t;4»  ,  -.-^  emtBfrf  la  •  plMBlac  niIa    Tin  iwUbi 
■•  i4WrH4VlraBd«w»^t.y.TnTMtidM:   SSSJUbi  ti.  »«t  ntKUU*  tlihnl  cr^ll  sruB 

ni  D-a  |«1.  WB  MBller  II  asl  SBlf  Mt  •(  ^,  fc,^  „j  tMrtBT  tW  u<kB>.-7'JUnffn  ]M£»I 

IniaiJBUiutbiwki,  bBloMBTjirlcBlaH  nlM    ^„ar>alL 

Tli«  r»fc«  rf  111*  Bil  im  i»«rn1>"d.  lk«  olnirtrirBl 
spliiiBBt  h(i*  fapnaa*.  »■  (wmbI  4ltT<ilnB*  bbA 
>4tl«asliiB  m4  iiMiWil  III  1  II  ml  BaraBtU, 
sHi-iaadlaBBblj  -iiBijiip  a*!!  rradrui.  Tlwf  aia 
fiiuoJtj  •>•  a  Wrt*  pncUc*.  Iibtb  bfMi  iBiad  V  ■ 
lABff ip*>taa».  BBi  «Mi*  fr*a  I1|a  Ib  wliaw  l«*4h- 
l«  ibnuaalB  haw  llitnrt  fw  luar  r»n.  lad 
fta*  mihsal  pnU.    taariXnn  JIkL  JoarMl  mitf 


I  MaalUimM  tn^c**  la  Iba  pncdc*  of  ib»a 


;>rl»l<i 
Xak  JfalOUr,  Xi- 


I  fb*  b»k  bbJ  lad  Ub  anN — »  Bn^iaal 

tloqaval   ff*T^aBd<r,  adJ   4  tbfno^b 

IT-    Tba  haiA  1B  bdl  Iw^lv  7«an  oM,  bat 

I  ■>  ■■lb  af  prtdaial  b?  lb*  pralkHbn 

■  aflar  adlUaa  baa  bota  ddaaBdid,  aad 

I  tmth  Ib  SB  Ilia  cabia  b7  aa.    Wa  nM»- 

r  SAMS  AttTBOR. 


ft 


ON  THE  NATURE,  SIGNS.  AND  TREATMENT  OF  CIllI-DREb 
FKVKB.  In  a  &rr»a  tt  Lallan  »ddt***ad  Id  Iha  Sla4a«l«  of  hit  Clut-  In  vne  baoiIiinD* 
octan)  vatooM  of  BW  fagc*,  anf*  tMh.    ft  M.    ■' 


ffRJTRCnn.L  [FLEETWOOD),  St.  D.,  3t.  R.  I.  A.  - 

ON  THK  DISEASES    OF  WOMEN;    iwluaing  tliosw!  of  Prcffnancr 

*Bd  Cblldbad.    A  E*v  ABarican  nlilioD.  rtTii«4  hji  tb»  Antbnr    With  Nnlwan-I  AiMUiiini, 
bj  IX  Fu<Ki*  C>f>oi>,  U.  D..  Bulknr  oi  ■'  A  Ptastioal  Tnalua  un  tba  llboBHi  u(  CbU> 
WKb  aamBTOD*  illartratiasfl.      In  <att  largo  a&d  tundjaiba  ^atavo  toliuca  of  746 
eiln  rlotli,  M  OS;  )«alh*i,  (1  00. 

t'rvm  I**  A-lJter'l  Frrfan. 
Ib  niriairisg  Ibli  aJittoa.  >t  tb«  i*>|iutt  ot  k;  Amatwan  pnbluhan,  I  ha**  IsiarUd  aeratal 
B«K  HcUoBaaiid  ebapttr*.  aoil  I  ban  adilad.  [  MIbt*.  all  tba  iarannBllan  wa  ha**  darirail  rrom 
faoant  raaaarabaa ;  in  aiblUi-m  to  wblah  Iha  fflbli-bam  hav*  baon  ffirlanaia  Bnangti  to  Aa^ora  tba 
aarrioas  tt  an  abia  and  bi^hl;  iiie«m*d  (dHar  In  \ti.  I'oii'lja. 

At  isiriium*  »(  all  Ihai  U  iBuvalk  IbLi  J*r*rl-  jii— M  Jay.  Tu  Pr.  CarapBiiu  Ibon. air  i>*  pr«> 
Baal  tt  Ba^cliK.  tbi  b«b  bafuia  ■•  h  I>abBi»  Iha  IhWm  daart/  >>>1>bl-d  fol  ■npl'lr>'UC  Ibiim  •nib  aa 
CUI**t  aad  Bk<n4  vajkabla  Ja  tba  lo^'.i'b  laodm^a*. ,  fr«ai  a  da«bl4miiB»~<ba  uii]*if  qi«ai  %tf  vlilcb  da- 
— BaMta  IMI^al  n-<M  wmltf  iDi-itH  bia  oan-f.  t.^'-tAj  \\.\'«\t,'\riy  u»- 

ll  wa«  iHfl  td  J>r  Catloe]|.r.  la  lalbtr  lb*  acal-  -  wa*ad  *tlh  IbadLMata*  vrwiminfi,  (rtnEiJi  T^tT  lilah 
IMvd  Ibdt*  flvDi  itvti-t  TarlnHA  Biturca.  aa^  ndaE*  aa  BBBBIhvrlt*  apvn  ibia  iiilorrt.  W^Hqurdbrlaef 
IWv  loB  nnaPBl  \y^n  Tbtthp  hjtt  4<)il4>  lalib  &  fbapartrriir  ll  u  nnr  L>f  ihp  mi^al  ii^friil  irblrh  bM 
tBBTVtIj'  baad  \a  ibc  a^Jaud  avtr  lirfora  v*;  la  Ua«#lCroiatba  piT*t>*«  ofaajr  far>.  Ti>aU>ibf  a 
Vblcb.  t#  Iba  laaallaD''  bla  ava  aalebilra  tilwarTa-  ll»  vim  TK-MbnindaJl^JEi  \  %i%i  will  1>«  fonnil  IV  ba 
lio«,1>rbu  aidMl  Iba vlaiva '>^  all  UrlUab  ui4  bir-.  iftTalaabUEn  ib**|itLlaaiaaalaaub«Ha«  bd J^tliaa 
ai!a;fl  wr11»r»  af  aaf  aal*;  IbBVC^nn^uBtnatom-  «•*  pi>fDp'n>Ili'ii>  v.irli  4^f  r"(Vrai>j<«  lo  tb«i(vallA*d 
plaUfotia.alllbaii>bii<>«BBii*aibaamb)i>MBiiba    »n«IU»Bs(.— OEaiiinB  Xtit  AaUiwL 

^r  ras 8AXS  tcrmn.  '^.^'  ... , 

Ii  ESSAYS  ON    THE   PURRPERAT,   FKVTIR,  APTD   OTHER   DI8- 
I          BJ.'IXS  PKDirt.IAn  TO  WOHKX,     PalarUd  rmn  lb*  writlnKa  of  llrUitli  Aurhnn  j^rarl- 
I         ooa  la  Ibe  «I<ms  oI  iba  EighMaotb  CniIwj.    In  SB*  aaal  oetaia  Tutuina  of  abMI  dlB 
I          PtM,  aiUa  olotb.     SI  iO. 
^nO\VN  aSAAC  BAKBR).  M.  D.  .,.,   ..^.^     , ..,,  /"^ 

ON  SOME  DISEASES  OF  WOMEN  ADMiTTTSO  OFStTROICAIi 
TBKAIUKKT.    Wllb  bawUoiB*  illwuMianii.     Oa*  ralan*Or».,  •>!»  tIMb,  pp,  ITS. 


«0. 

Aa  iBponiBI  additm  to  abalalilisl  IMatblaHk 
na  sptniln  aiiii—tliiria  and  aualrlTauv  «blcb 
Mr-  VaowK  JBiertMv,*ibIbtinofhprBrll^>^u1i^ 
a&d  abili.aB4  mrrli  tba  laraAil  BBaailna  i^rtttf 


Wa  baaa  DD  hrtMEBIloa  lura^inmniiit^nf  I  hit  bank 
la  lha  laratu)  aOMfioa  of  all  lai^tnia  wba  nab* 
(iiBBl*«iinp1(lBUapanv(lMi  MaJr  a"!!  |>n(tt«. 
~VvliU&  Quiiffirl^ /nurHOl. 


lllilwi:t.i,'«i-«»<^irii,Tl«B*Tt»i!OST7rKni»- 
>!««■  riccu«n  m  whmzit    ntiiimtf^  br 

Ohbb  AtMaed  has  HaaslMl  aad  Prtnu  rnttka. 
Tbhd  AaifrlcaB.  fruB  lha  TMrd  aa4  rairlwl  Lon- 
dao  (dKiaai.     la  asa  saura  Taian*.  aiifa  dnih, 

of  >»  rat».   K  an. 
BioBi  OX  TUX  cDSaTncncsAi.  tcxAruuiT 

0»  rUlALR  DiaUin  Isoe*  BMt  njwl  ttaa, 
T«l(«(k*>tn  tlol)>,arab«BlSMf^M.   II  ftt. 


ncwxist  TmsiTim  ox  the  msuso  t  rt 

NALU.  Wllb  !I1a->n.ll'>o>.  Elaaaail.  KdlUvs, 
wlih  tba  AuEhof'i  1b«i  lnipr«<^(naitla  aiirl  flarrac* 
tl'>ot.  Jn  ^4iB  ihuvl*  v^amB  <>f  AM  pafaa,  WllA 
plllia.  nln  cIMb,  Vi  «<. 
COI^MBIlT  bR  l/rtRRRAK  TTIR  MRBltM  IV 
rRMJkLK*.  TraMtiwd  hr  ('  l»,Mun(.JI  p.  ito- 
•asd  <dnl4a.     la  aa*  rai.  an,  ailiaiMh,  vllb 


M 


Ilistrar  0.  Vka'u  Pifni-icATtOMft— (i>i*(ra*!«  o/  Womm). 


JffODOB  [HUGH  U).  U.D. 

0>"  DISKASESPErrLIAIlTO  WOMEN;  i.l. 

''   or  lh«  I'UrtK.     With  <>(1|[iniil  i1lili(i>i.l»nt.     In  naf  ti»iiiii:i.: . 
Beuly  V)a  lAgoi,  *ilr*  b\<Ml     i3  Tt, 

COSTBStS. 

PABT  I-  nifRA«lia  or  tnniT«TI01l.— CtM^CII  I.  S«roil»  Irr^lilinH,  mn!  !(•  rIDnHSM»(«- 
IT.  Irrital-ln  Utsrot — Oulupliuntluut.  III.  LiHiul  £/iu|iIunit  irf  I<i;1>l-T'  llliiiu.  IV.  Lvi«l 
SjBijiloTni  of  Imlabit  Ulrfui.  V.  Qongrkl  Sjmfrtnm"  of  Imintil''  l«:«-«>r»  Vf  Qrntnt 
8)7ii|>luina  uf  Irtltabl*  I'Urui — KnAix  Iadu*ni?«<  of  Ctrflhnt  mH  f<Ti[DKl  tnililinn,    VII.  Pr«- 

5r<H  aail  TfirmiDaliDni  of  Irritable  L'twni       VIII.  Cnn>«  uid  I'ltaolnKT  af  IfiIuIiI*  PImmh^ 
X.  Tmatmiiit  of  IrritnH'  ttUnn— 1t>inu*al  or  Puilitlion  nf  Ihr  Oann'.      X.   Trv>l»*Dl  rf 
[>    IrritnMi.'  I'lrroi — to  Dtninlih  or  Dutidf  111*  Hurtild  InlUililUty.     XI.  TrHboKiI  nl  Irrtulil* 
UUcu" — n>'iilill»l  lij  Mrnttruot  Diionien  cuiil   lnfliinii0»llanl.      XII.    Trnklmral  of  IrrtUbta 
Clwat  Cuinpliskiiil  wUh  Si,>eundiiry  nnd  Kj-in|iilhrtlr  Sj-ajit^-iju. 
Fart  II-    1>'«i'i.,i('kiiieiiti  or  TUB  Uteudb  — Cn  irxin  I.    I>iipbu>qinMil  of  lh«  Ultiu.    T1> 
OftiUM  Mill  l))rnip(«eii  nf  I>itpliiHiii*ai  of  tb*  Uwrua.     lit.  Dlncnoiii  of  DiiplwviDaat  nf  ifa* 
UUnw     IV.  Tr«al»«Bl  of  lJu|ilK*nKnl  of  tli*  Uisrui.     V.  TiMlnflul.  tt'joUnueJ— InlatuJ 
BaplKirUn.    VI,  tViMtmmt.  cnntiiiaoj.-tivrar  PofulM.    Til.  TrMliuenl.  oontiaotd.    VUL 
TrvHTnrnt  at  CoMplloationt  t-f  I>!>iil wncn  U. 
tPART  lit.  DitKiiti  or  itEuinaK.  — Caumn  1.  a«Dflr>l  ud  LomI  B*d»Uan.     11.  S*dsUoa 
[i   of  Ulviiu.     111.  Diasdvcia  anil  TnalBHii. 


LKCTURES  O.V  THE  DISKASES  OP  tVOMP-N.  Second  Americiui, 

ttrm  th*  Kcond  I/aDd«D  odUloii.    >Ib  ■«■>■  mat  nlMo  Totuntrf  kbonl  UD  ^tii,  txtn 
olulh.    U  2i. 

Vtt  hKf*  1^ii>  pmba'ltit.l.  In  iHU  tprltftHaf  i««lBn<L    nn  m^rv  r  -'n  «4t^'**'^^  anqt^ttf  vb^ 

I  ^  rUUlvu^lMlM  Ja,  JIM 


lfaiTfPinBU*4V»u]  ■/•■4m  nuivauHfcruil  wjdi  iff 41^1(40, 
IVaai  UWUMh  KKd  »B>1rklcl>  numl  bll.  rr..ih  Itm 
laddh  nkJiiiM-  to  vlileb  iho  vkf]i-»iki  n^Mcu  htwr 

ANllMf  opI^  virrt  foPK  to  rKoniubTi'l  ib'  >»i]i]tika  lu 


b^fe  Mt'teL  fuM^  bi  pi«t1r>c  TlUii I'  t  ri.fl'.li-.- 
IjfHtlcSl    ClltncUI  IhlU  UlO  (nr 

iMalaHiiawithlbontadrglkraL -> 

■kll«B.»4  *n  nrMlalrda  boI  kiiu<  uf  tu}  uil.ar 
Wark  (»(u  wUlati  Ub  fBIiil'lBB.  to  kUK  |nB<>lleik 

^r  j-j/fi  SAUS  AVTwiK.  — ^ 

JLN  ENQUIRY  INTO  TRK  PATROLOarCAL  rMPORTANCK  OP 
Vt-OERATIOK  OF  TUB  03  UTIUtl.    In  mti  nau  ««Ur«  Toloma,  uln  «1oUi.    <1  St. 


rwitr  "r"' 

al»'l^  II:  r    •!. 

Wo  mnn  IT>*  BOihnf  dbt  mx^l  ikBBMfix  ■&« 

T*M«raoU£ll  l»'  IflilfBrfi^'"'  ^-  '■- -  •'*..r.l.  ■-  .1.  n>, 
TAtU4UJ«  UvBE^a*  U**i'  111* 

jpitpblc  dl4(]Dii  fta4  <r'i  bJI 

ijiprtfot  Ihi'iiiwlf**— !-'  --  . ,    :-  --..■ 

Iltitt  Jnnllj  t^i'Uinil  ■  tUoitti  VMtl fl 

hnra  f^ilro**  of  hivinv  t#«A  rBrafnltf  ro)a*4.  Ch4 
ti  vMI  ntthr  I'  lb*  kiDe  It  tw  kllH*r  BblBlBM 
—au^  JfmL  4*v.  •Tour. 


\  gnfp^oy  [SIR  JAMEfi  v.).  3f.D. 

'     CLINICAL  LECTURES  OV  THE  DISEASES  OP  WOMEN.   With 

BinaaF«i»  UlanlHUsDa,   In  oni  liiLndiivma  optsTe  TOtan*  ofM^r  &nn  |«|:m.  Mtr*  rlnth     t4> 
'  Th»  prlnclpBl  topliM  •mirMvil  ia  tba  L«Idh«  an  TBaUo-VaxIiul  Fi^'"''-  i'-n--f  •.<  •><-^ '  imi^ 
Tnslnnil  of  CiminoniB  bf  CBUfliai,  Djrmi'na.riliau.  AmanarrhsB,  1  t^ 

of  III*  V*^«.  Vqlrilli,  Cabh*  of  I>uth  sn^F  SiiriiLcBl  OptrMkni.  ^<.  >A 

Dal*Bt,  Om-ojTMKria.  [V1ti<>  f^illtilXii,  IV1kii<  tl*-aiblJiii««,  ^iirllmn  Trri'^nf^,  <^rnl-\l\  UropO, 
Ovuiulomy.  CibuIuoIhib.  UitsBtni  vf  llie  i'lill U|>liiu  Tubw,  P<icv|m(«I  MmiB,  Kok  InnltlivB  uid 
Stiftt-IstalallvD  of  Ui«  Ulariu,  JUi.  ^.  , , 


jDEfr.VKr  lirKXRV),  .V.  F>.  ■        .1 

A    PRACTICAL    TREATISE    OK    bTFLAjIMATION    OP    THB 
nXEnUE.  ITS  ORKVIX  aSU  AVmtlDMm.  nM.niMM<iiiMM»*Mim«ta*bU> 

•Hfo.   l>lilb  AmiiioBB,  fc««  Ibaburlii  BadnriMdlaallahUMA.    b>  ok*  iwiUrB  tolam* 

of  about  mo  fofSt.  BiIrB  clolli,     f^  T5.     (Ktn'Hi/f  /•)■•<.) 
Prtrmlil  Aillhaf^l   Prtfai<*. 

DariBK  (ha  jiMt  Mo  7«iBn,  (hi*  rrvldon  of  forinor  labnn  bBi  IwM  107  brtoelr*)  •nnwilm.  aaJ 
,  Id  IW  prtwBt  ilBt*  lh»  woik  nu^r  b*  anorldornil  (o  •mbod;  Uii  maUinj  •iprlBBM  «f  ika  m^ 
t  ytan  I  butt  daToIod  to  tti<  ilBilf  uf  utsiiuo  AinatB. 

Iiid«*d,  111'  'Hl^m  TiiLiimp  \*  fi  r«pl0l«  vlLh  iii&>r- 
ltt*t)4>o,  ['»  lU  »ji]jf*rtit(':4Up'tr0d^]oll>(I'<Lik^l*,  lb«l 

rkpb  Vk*  rfloQlrM  fur  iti*  ni?l  flvwrlpit^u  ^^f  *I{  Vttui 
kaw  koiwj  ■((h  ntiiJ  in  tht  AIhom  unilrn^'iii' 
I  tf^trvlBB  If  v«  bail  Bot  tMwB  do  laTarn*!  bx  itia  t,a- 

nr  rnK  saxb  aptuob.  ■ 

J.KEVIE\V  OF  TUE  rRESE>'T  STATF-  OF  UTERISR  PATHO- 
tOOT.    Id  an*  iubU  caUvu  i«Uv*.  •&>.n.c\aUi.    iO  wait. 


I 
I 


tititl.  To#li*olI  "'  ' 
..nnnliM  of  lb-  !■.■ 
— J>t>UU  Jtitl.  rm*. 


■-11 
•J 


.*f*  u  ir.*  fiv* 


Hbmkt  C.  L»a,'b  PoBLicATioKB — ( 4fi(ftw(/l[ry> 


jjonaE  [fivaii  /..).  a.  n..  ,  * 

THK   PRISCIPI.es  AND   PRACTIOI!  OP   OltSTliTRICf;.     !ll«»- 

tnltid  irlth  Ui^  lith<<|!n>phl«  |>l>l»  tontaiTtiiK  no*  hiiDiJnd  ■■)•)  (fl^-BluT  G^am  frsta 
qvoifto  T«liiiii*  «f  MO  doabla-eclonuinl  F*E^<  '(rongl j  boond  tn  «iU«  ciltrth,  %H.    tLM» 

Pros  tiii  Aitiimr'i  PiiarAck. 
"  InSiMMtcRd  b;  ihcsft  motiTn.  iku  author  b&i,  in  tlii»  volnmr.  endcaTorrd  to  pmcnt 
I  Bot  fliiQplf  hi*  own  opiniwnH,  bul  oIm  tlioM  or  the  nicat  ditlin^auhnl  anikoTitiaii  in 
'the  protcKuon;  lo  (but  tl  mA/  be  cotuiilervtl  a  ilige*l  of  th«  thcor;  ftnd  practice  of 
'  OhBtoific*  nt  thp  present  pMifld." 

In  ovrjiikK  oat  tkit  (lanffn,  th*  unpl*  id^*  KlTanUd  t>y  the  iDiut«  fbrn  hM  «iiith}«(1  lb*  maihfrr 
10  (ntor  Ihirouehlf  into  all  drCail*,  aiiil  In  vnnbiiilng  Ibt  ih*1I*  of  bb  long  (il^eilaDH  knJ  IIU'I/ 
'Wltb  Ik*  UaebiRfti  of  other  •U*linfii>(li>4  nullinn,  hrnuingt  fill  to  tJhti  Ui  ll>t  prMtlli-mvi  iib«t- 
'  *ir<r  Maiml  uiil  awiolnaH  mny  bo  miuirnl  In  duubldj]  cut*  uiil  •iiiftrc*odr<. 

A  dlMlagatlhlng  fMliir*  nf  ihv  work  if  thi>  profnirDHB  of  iu  illnilrtlinni.  Tbt  lilbojiTBi>b)ii 
.'  |ibtM  >n  wl  Arigin»l»  viil,  lu  &q»ut*  tlirir  Aconracj',  llin^  hmv*  b«»n  oopiitd  (mm  |ih4rtuf{nkfib«  tkkfrn 
I  •■pnittlj  for  tbfi  pnrpote,  Bpudvf  Ibtn.  A  f cr^  foil  fcrtH  r^  tnnni  lug*  on  wof-j  will  bit  found 
vnmMma  Ihrouith  Ibr  Uit.  to  tbat  all  tbo  dalsili  itlirn  hjr  t1w  *q1bci  mn  inptj  alnri'tatfO  brtho 
p  Wlull  Mill  III »  It  iai>]>  be  luldod  IhM  no  paint  ur  ri).<D<iiii  hux  bcEimiaieJ  lu  rtn-Xui  tlic  luFchanlod 
^MtMUtooiif  thrwprk  io'TfTrmpfrtworlbjof  Ibr  cbanctsr  iiii'ltBUiFi<ribttt«r)>in;£.i  Itronlain*. 
'  *■*  Eirniimtn*  •>(  ths  |Jittc«  anil  MUtpma  aiU  bs  fofvardcd  toaaj  addn**  tT»»  b^  oaij  «b 
,  HOtlpt  of  (U  CfBU  in  porCug*  ilawpi. 


Til"  ir»fV  ,':.-'         Mt  trrnti^iiiLiif  iiiOFr  tlirtm  a 

'  iilTipl*  prf  Likfllfiirsr  rL<i>«  Ja  Ltr  lif' 

parlin^m  o^        '       .       i'  ji  dianirihtrtx  mfrv  :h»q  la 
vrjjuLrf  t'-rALi-^j  LIU  uj  iJ^iVfj'    LI  IbJq  Ike.  4  ijOf- 

pajlft  'if  Clti'IirJ^iT;  lie*  )tD«  tluifj  III  Ollbr^d;  lu  b 
■In^T"  Vij]nCT>'<  (in*  whr.Jr  •ci^lLJVHELt  trf  ol  DlijInLrtft. 
An  alab'f'aLt  IvkI  I»  ■'>j<rl>1n44l  vitti  t«nmii  AniJ  m* 
'  ««*d  pi<li>rt»lUJij>trA[iLtUh.  t'l  lUtt  iii-fw<  t<r  pf'^Qilj'^ 
La  1«n  gmlafi  u(  bb'av^aiaf^- — 4m-  Mt^-  Timt^ 
•tpl.  .\1WL 
Wj  ihimlJ  Ilka  (e  *iiatr»  lb*  nnaladat  nf  Ihla 

fVCVirnlpI  w<vrt,  l>qt  arr«B4^  hlUEhl*  mvlfw  «K«Di]eit 
bf^kTOd  4fir  llull"d  •!*".  W*  r4nnil  tantlnAf^  Ehl> 
I  Botii-if  wtltanl  mfcriiuj  lo  lb«  flf^U^QE  Qrilth  iif  Eh* 
►flffc.  tA  tyf^KTopUyH  it  DoE  It*  Ijt  <lif*]l<^.  lU* 
fa|>«r  1*  tikp*Tlcf  (1  vIjkL  1*  Dvtia!  ly  kOoiilvtl  l>;  <Mir 

bgokjL     Tb« 'iicnvjiij*  hfi'i    nif.i'.T  >T'i''   -I'l *i 

btAOUTatly  "iT9Ti«4.     n  ,     .    - 

f*r  tlii>rlclrjAtii7,  i-nil  1- 
•blaliiiatlMo  li'ilirH  T. 
CMM>r«  Ual.  Jivrful.  Iki.  IMl 

lll*T«r>  latiivp»(<»'lr*>>d*''«aEiltr'l1i»lr*trd. 

•nd  II  niEril  ti>  Ei.i>  likptLfs  niuik*  walk'  ol  cnal 

«<i«r»1rlrjiiEii     I'f  Ejbfl  AEfiPf1<*ti  wurlf*  i>ri  Ibfl  •Tilijoct 

F  lUi  d(»d>dl]:('»liuLW«fit>^.  KtitVonr..  Ore-  'H 


Miidn'a  1 

crfJii  uEi^ruc.iLoD-  9tptj  tuple  i4  friblirtrBicil  rqtri>l 
faLlT,  TJth  vLpwi  fif  tb*  aoUnr  ar*  'nnirifJithtalTf. 
«lii1  ^'ficiMlj  »ui'^    TbvfutH^if fiid^ 

*intrHni*7  <if  iibtfr^ic  nrEnplEntU'^Ei  '      imta- 

—Cblnta  JImL  /M<nb>j,  Asf,  IKL 

>fAT«*Tfm*  ihta  wa  have  bad  at  our  JJ"TO«l  iAA«a 
W'  -    '  '  grraiairt  i.f  Dt  llDiIt*  !•  ntnaMFf 

l"  II  1>  EluiloabMdlT  bf  fif  Eha  nnu 

L»fi-.  .  .   ..lEn,  lEtd  r-arnfuTtj'  fianifinvd  Ir«jt1i*n 

i>b  lEii*  iif  iEii'4tiif*andpra*Ti»i>r*Ilnirtrlr«  wJiL'l)  ha* 
•T9r  bi»  iBflrd  tram  lbs  Auarlfao  prsia-— Jtot^li 
Vnf.sadavrff.  Jmrmal,  lalj.  lUI- 

W*  bar*  trtt  IT.  Bodft'*  b««t  mth  ktmI  plfy 

■uiY.  ifid  bib««  iniieli  ■atltlbfltlpo  ill  vkfirr^vlnt  niiF 

,     ...,^-.,.1-11.  ,  ..'  I.  ,.  ,  -|..,i-       111- ...I.  M(My 

■      Tim 
I  llio 

1....1J 1" -I   i-r.-t    ...-.,,1.-   .. -■   ., n.in. 

mnaWiaa  a1  whJ£a  liv  baa  nrrtTpdi  pirliiE,  wn  ItLali. 
MBolwiTtU' Is  iHofcii  III*),  la  bfiaain  ti  l>ui.  iii* 
danrtiiH  »t  Kvaafa  «>••  ttaa  liu  uiudtr  imlitd. 


AN  KXPOSITION  OF  THE  SIGNS  AND  SYHPTOMri  OF  PRRfl- 

KANOV,  W,ih»iiiiool>HTl'iip«nn«f«1)j»"U*nE>Bf«l«l«iE,h  Jll'lwtferj  Fr->m  ^^n  imionil 
anil  'EiUrKAil  KucIexIi  nlillon.  Wlih  tna  ri'^ulilla  «o)nr«d  plUM,  and  n<tnE>irnna  ■ood'OaU. 
In  00*  TtTj  baoiXiuaio  otU'o  volnct  id  (imtIj  AOO  fag«,  »i>n  «lolh.    |S  Tt. 


Jf 


rRINCIPLKS  ANIt  rr.ACTICK  OF  OBSTETIllCS.  faj.;  imluding 
th*  TtvalTEiKEl  (■!  Chroaii  I Daammitlion  nl  ih*  Corili  and  R»dy  of  lb«  tllaiaa  nonildarad 
un  traquTnl  »afr«[  At<'ntifli>.     With  abvEit  on*  hOTidnd  llliulralliini  <•!>  *»od.     In  ana 


TTLsn  SMITH  o-t  riBTimiTioji.  uuTnE  mm. 
ciPiiSH  mi)  rR.timcH  or  oiiiimHicK    la 

an*  ruril  lliUE'-  fulutDs,  diUa  <loEb,  ul  ICDivfot 

noiiT-B  BTimw  OF  MiDwinxr.  wiib  wetn 

aad  AddlOiaal   ninMnaiBt.     Ittimi   Anvrican 


'illlU'a.   ODaro1i}EaaKtavi>,«irnclf^b,  I31f 

DBWKM-H  coHi-BiinKNSivB  sVTLM  nr  xti>- 

WlrKltr.  Illaalralld  hjr  *«a*lnui>1  cun  and 
rnaii?  •nifhtlEirv.  Tvalftik  •il^Mnu,  iHlV  Ih*  aa- 
till' t  laai  Uipr*T(«aw  and  eMifrUuuK.  la  a*a 
MlaTa*otaa«.*Un<lMk,ot««iva«K.  •nW'- 


tt 


IlENiiT  C.  Lka'8  Pt;ni.iCATio!ts— (Afti/iri/irry).  ^ 


DAJISBOTITAM  (FRAXCIS  II.).  M.D. 


<\  v 


>■  ■.."('.    -^  ■.>\ 


w 


THK  PRINC3PLK8  ANU  PBACTrOE  OP  0Bf5TETRlC  MEDI- 
CINE AND  SIJUQltHV,  ill  rcr««Do<  l«  lU  ProoiM nf  PMiaritioii.  A  no  utd  tnTtrnd 
tJIllin,  thoouKlil/  nTiHi)  hj  th«  naUxir.  Wllk  •>bUUaD«  bj  W.  V  KcAiiie.  MP., 
rnifwnr  uf  OUlatrieiy  4«.,  la  lb*  Jt-OBrMii  tbdiul.  C*1I«(*.  Pliil»d*l|ilil>.  Id  an*  Ur^* 
•nil  tiaajktui*  LmpciiU  otUva  Tolane  at  UD  pafM.  •trangly  haiiDil  la  lH>Ui*i,  <rltb  tiir>c<t 
biindi;  nilh  fiilj'fonr  bMiitifnl  jiUtat.  knd  ninm^ai  w«od-«aU  In  Ih4  Mil.  ronUiininj  iu 
ftU  DMrljr  200  lftrx>  aiKl  bMOIltat  IlKtir**.     (T  00. 


1I7 
It  ftll  hf  Dftil  la  KniviT.  ud  Uh  priictllaati  vlU  tii< 

li,  A^  h  l4L*<ik  DrfrrprociM.  ■ur|Pi'«it  ^y  jiou4  oilier.— 
AbrAHmiK, 

Th4  Dliirm^ter  khd  rn^ti  nf  Dr.  TUmthoHiitn'a 
Wi*Ht  ■»  H  «*IJ  kuovD  hud  Ihoniif Iklj  c4C*b(i']>f«<1, 
UtH  *cDiiiMi1 1«  mBMiii*acT  uid  fviil«  >aH*'*>*"±>. 
Till'  LilTiBrniiLLtiiv  i*UlcK*n  DDa«rya«  Ami  adDnnhU. 
mFVfli44filr<l  tu  (bt  >t]^ho4t  nKJlt  91  trt.  Wn  ruirtol 
too  Iit4h1)'n»iiiiiiisiii]  ib«  wtrl  IS  «iit  tttian.~-S. 
iauti  Mtd.  ind  Snrg.  /oiir*al, 


.!:•   sbil* 


M  Ihf  •Uilnul,  *•*  Ult-bunt 

Whflii  irc  «Ii  l-i  mind  lb*  IMI  w>  aallHWMit  tt 
aiqnirinfa  kBuwIldiBariM*  Hbjfd.  nnuovi  >•■ 
<'ii¥r  Ilia  aisilKiil  ar  lb*  imwl  Alj  lb>  aVi  ■biiii 
iM.  <tirk  wiU  ■(oN  Uib— ^iK  y«f.  «/  IW  JM. 


fillers  [CHART^BS  D.).  M.  D., 

lalt'g  l>r<i/Wor  «/  OM'(''aa.  fts .  tn  WW  /^r(n  JlidUal  OiOttt,  ntlifUfHi. 

OBSTKTRirS:  THK  SOIKXOE  ANT>  THE  ART.    Fourth  oaiUoST 

r*vj'*d  jiD<l  iinjTruvfiil-     WiEh  otm  htimlri"!   aa/l  iwnlj'ninfi  lUujrtmtfnEm      I&  ua*  tkf«dll- 
Mly  printed  «cUto  voIqdm  at  700  Urff*  l^itfvr     Kitr*  cTotb,  $6  00  ^  iMkChtfr.  H  *<■- 


ftkitvr  cor  PH4«rt*  bvtl 


utf  like  rnftivr«4l  titvit  aC  rli« 


■Melt  babudivTMAl  Mttlfr-anrl  Ultnl^r 


in 


1* 


D4>i  nnlT^in-^fmttof  m4i.n7y<«Mnf  p»iDf(n  fail 


MWndtd  uki  9it JnUACd  vi(h  Eiirab^tiu  ii><«lVa«l  lit*- 


ric«,  tn'l  hrfl  baI I *n«tl    Lii  '  '  '   '<yifrt 


t-ON  THE  THKORY  AND  PRACTrCE  OF  MimVIFERT.    A  new 

Aiuarliion  Triim  Hid  iutitih  r«ti«pj  bdc[  anlArit**!  LonfTon  #i1ttlim,  ITiih  nq^na  oiut  arliluifia* 
br  I>.  FnUK'i*  Coxna.  U  [>.,  tuUiur  at  B  "frutlml  rrsAilia  on  ihn  tRHoin  t^  Cbtl> 
drna,"  ia.  Wilh  iinAliumlml  and  DJa*(j't4i]T  mas(rnll4ti».  la  mu  nrrkaBdMoitorMtS 
TBlDOM  of  utulj  TUU  tuja  pac*f.     ^xtn  dolh,  |4  00  i  IcMhsr,  $i  40. 

tD>ilK|il)[iKl>ii<il«iiI>rdbnriUto  UiewaiiUaf  Iba  srnAMlaa  to  lbs  CbEM  SUUa,  ih>  •dllor 

hai^ailsaTunid  In  inanl  nviylhtnn  thM  hia  «KfivrlniM  Euui  ihoBO  him  '  <   'ti« 

Ainvrlnn  tlDdent.  Inelndlng  a  Intft  bntnbdr  ■>(  illutlnlianf.     Wilh   i  ..r, 

b*  hu  uUail.  in  (h«  Tnnn  nl  no  ipinndtx.  ■oma  cbapUf*  fmpi  ■  Hub  '  •nd 

Nuniai,"  itcmtly  <MU*d  bjr  Dr.  CliiucliiU.  bolif*iB|[  tbat  Ibv  ilaUili  llinv  ;  i>  liardly 

fUl  tu  in'tiTt  qf  uvMiti^  tn  Iho  Junior  practilloner.     Th«  mull  of  ill  Ihci.-  ib«i  lb* 

wVii  0««  '■Diiiaini  falbf  <ioa4iiJr  Inur*  nutlsr  Uwn  Iha  lut  Ammsm  fditmn.  mm  »aulj  ••»■ 
bsU  DUTo  llluiiiMluai^  u  Uml,  btitwltiialaiidtDS  tb(  iwa  of  ■  uubUh  Uf*,  lb*  toImm  Mntblai 
klmoti.  MO  buudcol  ptgtt  nor*  ihan  Iwfvrc. 

No  pfToTi  bErt  betTi  ifatrvU  Ut  Mcur*  nn  tniprovaintiit  in  th^  DKOhilllMM  «ix*riilinn  of  lk»  ««tk 
viqual  to  l.hiit  Kb>oh  Iho  l«Kl  hu  reofrtwdn  uid  iba  folaom  li  confldmUj  Tirt«c.ii1«l  M  ona  of  bb« 
buidioii»*l  Xhtkl  hiu  Ibu*  far  bf*D  liaSd  livfvrn  lh«  Amvricui  pmrHMioD.  wtiil*  Ihr  vhj  Wv  priM 
Bl  wblcb  11  li  aSond  ibould  tfian  tar  It  k  |il«co  Iu  snrj  IwUm^oam  Ul  aa  «i«t7  «flM  tebla. 

TbHn  AdAllnna  raiidH  tha  i"rV  •till  mair  om- 

!ilHt««i>d  »«*prab^^  EhLQ  9T*r;  mA  tntJi  ilic  *jif<*i' 
*|il  «tl4  La  vbkh  tiff  imlilla^ara  bat*  vnaputvd 
l&i>  a^iilou  III  CkiiltMlU  va  aaa  eiBimiad  II  to  Ift* 

|lM((-»l<ii;  ■ItbflHl  (wCjlillll/  sell  plHlttt*- — t'l«' 
rf/in»f<  J^4i'^, 

r»»  w..iki  ua  IM»  liniBfh  of  naaioal  Klanra  ata 
fluaJ  1.1  Ik  f^t^rthlalj  aoaa  axcal  IE.  wbMbtr  la  rafmnl 

10  II FT  inr  rir4*:if*,  ftD4  infln*  rnwri  U  laaopapi*.! 

f--  -   '     '■    ■  III  Ira  atintllraf  larOrtniiLlr'Ti,  aitl 

11  .r'luniU  A  mofi  rtLiialilf.  wprti  fj.i 
Id'  L''  .'  ■  '  '  ■^"tnl.  o»  [aflnivf.  all  -^  Irlkim  »lll 
Aii4  ku  ii  I  hit  ihiiTrntUoa  wblr^  thoT  *^  *«Kbl0.— 

Tb*  iiri^ni  IcivIIm  Ii  Ttij  mnrh  mTariarT  and 
amjiIMnf  t^jrgsd  lbs  pnrlmi  *AIMa>.MihonA«( 


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hka  W4>d  Mil*!?  vttl^h  AonMIx  ^rvU  •■  '-<A. 

Aa  «i4id«ji*Ilufi  i't  i|»t  Will  .ft  c-«i'  h"V 

tUw  M'«  UB  lA4  Ubn  ill  Ih4  IflUl^  L  >«^ 

««ib   Uion   b«««««ATX  l«  lit*  4b<bi'  i '-«• 

»Bt*«iihBrofiH*f*rin*rtJlii  r-  ■  ■  *ir 

«r(i*rt()a>.iDCf4  «Bik  omavm  f ■   in 

mwi  U  lb*  unmiLBt  vi  Mal-r^tt  v4'>  1    n»a  b*ia 

Tl^rird  U  ai  bclUf  Wil-bA^li  fi*t  Mo#*af*,  or  v^i^ 
of  ffi|*rM)»  fen4  tlAlj  te  lbs  praiiiHg  f»y^in# 
ibKnUON    U«hD«l^Mw*u4*«rtcb«f«7»BAMl 


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Hkn&y  C.  Lea^»  PVBl 


(Surety). 


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fJSOSS  {SAMUEL  P.).  M.D., 
C_A  STSTRM  OF  ^URtiKRY:  Pathdlogtoal^  DJl«noAtk,  Therftp^utic, 

€if  }lUOpB£«»,  ftnngly  boiuiil  in  iHtbrr,  mith  ralsod  bandj-     $16  00, 

)  c«Dlinu44  bvor.  iboivQ  bjr  thv  cxbfiuftion  of  iui^dwIto  Iftrg*  e4itlao*  •f  tbii  fr«t  wnrk, 
Fthatit'bMsiicnfsratljiiJirpl^v'l^^v^iit  Mtlir  Ara«nc»n  pnMtitii>iion  and  itvlcuU.    Tboiigh 
'  I  4v#r  til  irvAJH  b4¥«  al]fc|j**d  jiiricTB  tU  AiaI  publivjktiou,  U  hi'  Hlrciidy  ivMubvil  iii  foujtk  a 
vkkle  the  ouv  of  iha  uidior  la  it.9  rtrixioti  »jvd  oorrvctlon  hsj  k^i^t  U  in  k  t^oDituitlj^  tm-tf 
.  ■hope.     Ft  th«  Qt*  «r  ■  rlni^i   thauirb  ver^  IfiblH  tjpi,  an  onuiahllj  LurK"  vnvDDt  nf 
rll  cundontHi  in  U*  po^i.  Ibc  two  voWtdtt  conlnlnln^  lu  mm^b  a»  Fuui   uf  five  oMinazj 
«.     Tliif,  rombiDtl  iriLb  t.bi?  moft  iMirvfiiJ  iu«i-hnniiia]  ottcKtivii,  uid  iUT4fy  <turub)«  binding, 
fiad«vi  il  oTi*  (jf  lh«  clwi|>«Kt  vurkji  ^ceipjiblu  to  tbt  pfufcwIbQ.     Kv«rj  nulfjitDC  iiTO)Hiri>r  bvlim^cing 
'  !•  lb*  daioAin  nf  lurgor;  1«  Ireal^i  ia  detiiilt  s</  (but  Ifaa  itudvat  vbo  poHUVU  tbu  work  m*j  b# 
'  1 W  b^T*  in  it,  A  vurififliil  librarj- 


BfiKC  Inbf  rwniKln  ih"  nrnul  *■.lnlInT.^^px1T•  imrfc 

*ot  part  MinoiTli^&fl— Ai*Jflfl  XrrifAiF 

/aumuf.  Sfiirrfi  21  X^H. 

CfimmrHf  ft  irltli  mripii  fif  our  rhmdnnl 

ha  [i>k>n«  rtf  RrLdhflnn,  t1it1i«r.  F^ri^MOUt 

aatbbT.  4nid  \\  tha  pn>-4intiDirricfl,  Jit  %  vr^krli,  rum- 
(Ntr*  )□  felmnit  *T*ry  i1«La][.  na  rnKTrnr  hnir  lutuar* 
o(  irtifin^,  JiD"!  T'Hilir^r-] Df  aip't  i»^jp<t  Voi>"'i)  in  ■ 

;  bBfk*  "tn^  Aim  bu  li«mn  la  *nLhTaC'  iSn  wh*)!"  Lt»' 

ni>4*f^  b*  h^K  kiT>1  bti  word-  f  1  la  «  wurk  vkttli 
Vt  MA  iVo«l  faBtl^InniE  J"  iV4;H^inin''nil  in  diit  IjrfLrLr*  n, 

U  l>  a^a  EbA  aLttTiM  uF  nut  ii\fT%ry.'-Oittt*MS»  JftrL 
rnarnnf  ftfifUbbfir,  IH&^- 

hl^bl  J  I'rLitd.  Thil  11  wouM  (hi  IdU  for  »■  ^o  >f"-Alc  (□ 

CH  i>r  (liu  frort,  — '-Um^n    Jf^^fnti   /nrunol, 

W«  ^kJlj  1o4orv  the  fHVnrmhtv  rtti^mn]»n4»tlna 
^vauid*vk*p  QftllrinUa  fln(  tprMnaf*-— ^I'liA 

Tb«  Doai  »piplcc«  wark  tb»I  h^t  ;rnt  Tb«d»I  from 
Hb*  prcA  va  thu  >clap«a  adeI  pncUm  vf  tu/jfi^rj. — 
U*mai"7\  CanaL 

T^ia  •7»laB  of  *«rtAry  l*.  w«  prtJkct,  dmUHit  Ut 
takv  A  firwnuiuliiic  iruaiQun  ift  Dvr  auti^rAi  lJ(«ra- 
cai*,  tad  W  EJ^n  crnwAin<  j;li>tf  vf  tfaH  aalhvr  ■  wall 
annrd  ttno,  Aa  an  ;tii;Eii>rtTf  f>n  gfinf>rat  mir^lril 
«illO««l>»  ttiti  wurk   \i  iiiiig  ro  ufciiry  «  iirprmloFChl 

tlasB,  nifi  AOl^  al  boma,  bm  abroAil.  W^  h^vc  uu 
■idiVloQ  la  pnaobBflla^  it  vubant  h  rUnl  lu  ctm 
lanxaftC^And  4i|»l  to  (fie  heal  fjiLniua  of  ALir^i-r^  Id 
Aay  tAufi^v- — ^-  I",  Jf(^^  J'lur'ial 

Jii>X  tmtf  hf  Ur  U>b  boai  toiiulsook  uq  lliK  Hqlijacr. 
AA  •  wb'^Li),  wt^Lln  Hi<f  n^t-h  -^1  Alnn'lnkn  Pluilaliti^ 
bat  dbi  ifLitli  9W\  bt  if4Ui)i  iiEi^rii  tLnQ  wor  Ilha^y 
h>  ba  r*ai>ti«il  io  miij   rt'ii^MM  ai  fc  bTfth  jiOtburllf 

Tfaa  ■rt>rtr  umatna  ■twfiS1ri«.  mtnar  kihI  Tnijot. 
«9«nUta  ADd  tfla^bQBllfi,  inchiULii^  intinqtirsTiun  a.nd 
ACUMlQallna.  vonorebl  t1lv*a*e«^  khA  ucr<r]iif'  inbu^fti- 
laClaa*  aad  A^DtiLilvua,     |i  la  a  4«<jm|itv1«  Tlicaauriia 


MikDvr  thLlI  qnl  iwaV  In  tula  for  uf^al  tbfi)r  jHlre.^ 
JVon  ^gnrUcr^  Jffil.  Pnt*.  Jui.  iJ.iM. 

Otv-bll  *bgrv  »*  fun/,  »"  tlhJ  tbund  pnuUoil  1^ 
fl^rniKTtfqi  «'iDVBjad  Id  jtliilii  lanciiafK      Thli  b^nlr  It 

arrr>  bu^  a  irirrk  w)i}<b,  w>j]la  r<irr  Unrrly  indvbipd 
lu  tba^iMi.  hiuft  alrvfi^  cUim  on  (jin  cmrita'iti  i>ril«« 
faiurMiiraurfiuaiaaV"DM— li'JlnAbP]jb  Jr*4lVoiir»ai, 
Jan    1^3. 

i  ^UbfiD  al  the  vurk  )■  ■ufld'<Dl  lo  ahow  l1iat  tb*  , 
nuU^-^r  abtl  i^oZiUihor  hato  4|4irniL  d"  latoi  Ln  m*kln^  ^ 

tU)ii«1  In  anj  tuiiarr/ — S^.  Zri>uia  Jtfur  cind  j^Lirtf. 
Jofirnai.  Aptil.  IW)1 

Tha  EMtII  nitpnrlnnllf  ii  nuw  olT#!-Dd  jjurli^  ODt 
f-hlur1at  litis  tu  r«r]d«r.  i>r  nLbnr  i^  jnitona  iab4  ir 
covntand  Ibla  frual  AmarlUD  imTli  oq  f<or^oT-  -^ 
Tpou  UjIi  [ait  4»1Et]on  «  gr^i  aiennqt  of  trbor  IiM 
t»f<>r>  tEVfBdud,1ti0Cib  Itf  all  oiLort  racvv^  LhoHlbDr 
iFiD  wurk  vra*  rri^^ribicl  fn  ][■  iiri'vioqii  •i[kEU>a>  >■  an 
fall  a.]Ld  euntiiMn  ■>  lo  bn  Htj<i)j  f^^^^An  tt  Unprw^ 
mrnt  Kvf^rj  abapier  bu  t>«oik  laiiHJ.  Ibo  («xiaTij(' 
im^nTtir  hj  □darlj'  iwit  huaJrcd  iKitv.  a.]t4  it  cua- 
aidHfiiMH  iiuuiNitEtf  viHicJiiot'  JiiTt  bfn  larjmdaw^^ 
Kiny  [t^Tiloit*  ImvQ  I^'D  auUrvfr  ff-^ff!(Hiii,  and  thti'- 
^^iifi-Mi^  iaaAir  iir  iJw  nxi  %Tt  prLnrjpalijr  irl  a  pra^ 
tltal  <;LkaT:LHnr-  Tlil-  fljimpmhrnnU*  IkjmU^  opna 
amYt'jr  bu  nndTgnno  r^rM^jat  taJi  <<nLarMaiDnli, 
kAiplui  Ph«  «P«lh  Lbvprntrawvl  Ihavrt^bd  airl«b« 
t(  rnr^Ff,  ao  iha(  vhoarar  !■  In  puaubuumi  df  ibla 
Wkifk  maj'eoaBiEU  11^  pupv  upon  any  ivji^n  ambrapfd 
irlLfild  ibn  vopr  flf  iijr  ^pparrrnfiT,  art4  rr>il  t^tlxHtd 
t[i4l  ir*  i^kftiEuR  II  fully  up  [it  iIik  fir<«*Qiii  alapdari 
of  *fiT-gl«(L  kautfloflK*',  Ji  |p  i.[i>fi  ■!>  fj]]n|>r^1tnQ'dv4 
Ihai  il  tn*f  inilhinJly  b*  «aM  ro  ^rnl'mf*  nil  ihil  la  ' 
ai^lnAlly  fciiLiwji,  LI44I  l"  fixity  ,.f  4„y  cihiifl  lo  Lb* 
illaj|ijo«l>  LuO  UuhCtutfuE  uT  inEirk-il  liLH'Hori  und  mfgI- 
dvDia.  Whanvar  lltuvbnliDiiivtil  biacJaaruAi^la  tb* 
HEilrJtvL,  QTHikkp  TtnltnT  nr  mnrn  imi^nit  jin  jmvjirunl  II 
l«  HOI  iraatlftf  ^  in  H,\*rt^jftfl  tlirn  ir^»fk  iacmluBbUf 
tiL^iiui. — Bttjfftltf  Kill.  JtttratiH^  l>«a  Iiof- 

A  iiftom  nf  ■tipjiprj'  hMcIi  *"  [hint  iinrlfaTIM  In 
Aur  IfDifiiAffr^  aoil  (ffhTcli  will  ImIaIIMv  uundale  bi*  - 
liaBw  ^llli  intflu^  #«laarT.  lud  ^lutL  Lb  uitruikkq- 
Ion,  irDljanoH  tbaTaifltoT  thnwork  Jt  thai,  irbl[4>iba 
pr pruning  nnrgnfln  irlM  AqiL  all  '.ImE  ht  rrtq^i^rx*  in  )|^ 
It  !<  %t  th4  auDf  liftL^  r^DO  of  ihr  ir}*n\  laluiiMemH' 
tL>t4  vhlcJi  Fan  bfl  pul  ibfO  IIlv  haDi)>  of  The  tlq-^vbt 
Ki«0kib^  lakniitr  1b«  prtbdpUi  nnd  prantlOfi  uf  Ihla 
bribob  of  the  prnJ'p'^oa  wblfh  ht?  4*^a\^ti»*  iiLb**- 
-lueqllrlufull*"-,— rAaffna.  dwVonrK,,  JTi^r^' 

^r  TBS  .-^A^E  ACTUOir  .      , /,:■/,,/      , 

^A   PRACTICAL    TREATISE    ON   THB    TtlSBASRS,  INJURIES, 

^B         AXI>  MALKOKMATIUNS  OF  TUK  TRINaRY  ULADDBR,  TDI  PROitTATB  OLANt>. 

^^K       ud  niihtj-faur  ill uilnl inns.    In  un*  UrE*  Mul  itr?  bsndMnM  (wUito  luliua*.  uf  oiBtsina.^ 
^^F      bamlMil  pog"-  wilr*  clolli.     M  UO-  4 

Wliqsr«r  vlll  VfEiii*  LTlp  tk>1  nfn-)iiu1  <>^  t-Aluabla  i  cnu*  wMtk  «■  m4k«  ftnr  1d*i  pntcavlou  i»  b*  lit 

■j/rtf 


Willi  u,  Ihal  tJipr«  i»  i>4  wifc  la  (ho  KoAlikh  Ijan- 


CjSIl— X  r  Journal  i!f  Jirautn*. 


Tim  SAMK  Al'TKoa 

rUACTIOAL 
AlJl- PASSAGES, 
pp.  4t».     %t  Ii. 


TKK.VTISR    ON    FOTtKION    BOOIFS    IN   THE 
Id  00^  bMilaani*  ootaTU  Tolaaa,   *il»  «1otb,   with  illalUKiloiit. 


SB 


Hfemr  O.^KA'i  PDBUCATI0S9 — (fiuf^itn/)^  ' 


THE  ScrENOE  AN1>  ART  OF  SURGHKT;  being  a  TrtutUie  m  Snr- 

gical  Injurior,  DI**«h*,  anil  OptnOost-     N>w  asl  icn[*nTeil  AmnitrBS.  (Wis  (k«  f«caa<l 
tnT^r/vi  «Dd  ^tr^Uf  r«v1ml  LonHua  «d1tton.     UltMlraiMl  villi  omv  Tftar  Ii«oclfo4  wond 
«ii|ini*ici|^.     In  ono  Inrj^  *n<l  h.in'l-omn  nrUTO  valame  or  1000  cIcmIj'  prlntod  fae™  •  *Ui» 
'^   elotli,  t»^  iFittiir,  laboit  t«ai.  f  T. 

ta  !<»  It  but  ipualnc  Mtlt*  InUtl)' •■"^hr  ■(!(•  | 
nirili     ll  atfhttnttMMtlfvmtrtiff.  IMr  iuivmV 

--  ■■- ■'    -■■■-i-moiUiM    M  tRDftal  k  lllglHr  I 

'  il>ki>;K  *a>ai(M7.  Ikai)  ihl>  , 


I  luc  tJ'^*»w  lawMt^ai  CDlPJ■^l■^n^  «ho«  Ihf  w&i*  of 

I,..  , I    .1  ,.        U'    l^...l,..„  .    I.  -    ...,,-.    ....  -.,.. 


•14*  Inak  llllin   In  <)■•  rfUtlUaiHC  lUd  UlS  UllddSI. 

]  — 0hM'*  Qf-'-'lir'ti. 

din*  ■  iBrr  wli>lr>1il«  i-ntUail  t1*v  of  U*  ul- 

W*  rmxoJBiniJ  11  u  lb«  b«al  etittwiidliua  af  uu- 
§crj  La  oar  lAKjia*^— <L>A4Co4  /dSHAl- 

li  14.  v«  ttilnli.  Eh*  innvi  THjnftli]*  praiiil««l  nmrt 
on  ■UMrr  l&41llaWlir4.lP7lh  f>.r  I'lUhx  febJj  *ld  prtt^ 


In  fiilnt.1*  ct  jiMollcal  il*(mlt  tnj  Irenr^mllj  it 

illtiilmlii.  "   ..         .     n  ■>•  MnH*  an*  *<iai»lal*(«a*  I 
ur  JjKQtH  ,,-j  *uil«4  I*  Lb*  ir*ai«  vf  balk 

•i*>I*ui*-  .  .  .. .-  UuB  aayaf  m|»aJ«mMri. 

Alter  Mn/sl  aud  ti««MBt  rniaat*  vf  Erloh«a'a 

ctLlmL/B* 


llflu  at  ll-    flia  >r;llLiir'«  tlylii  u  * 


■'Va. 


t-lilnA    liiiri.  In  a  vuluEUP  ul  alKinl  liail    jpL, 

Tlji  IliDlOd  iliof  wo  hara  ■■)  nilew  ibli  ltiii-inr*4    D»ni>l*tl  br  ir.»id-ciiu,  tn  (icmhiI  vhu  i- 
atUllaa  or  a  vqru.  lb»  Bral  1*taf  «r  vhlv^  w  pFtaril    ifipt'^i*.  (I'D  loutt  full  aod  im<iij<UI*  ■ju'I' 
a*  OB*  af  Ih*  'nrr  k**^  If  n9t  lb*  bnal  Ull-tmn)!   of  '  llag  nil  lb*  •UlijMI  |4  wljck  II  tmaU  la  iL*  Ka^U*^  . 
■urffj  wiih  Kblth  **  **ro  ■iiuIaM.  pprmlti  na  |  lBD(ua(a— vu*  JThl  oaal  tfar^,  Jmrmitl. 


MJLLER  {JAilBS). 
pniNCIPLKS  OF  SUROERY.    Fourth  American,  Ttota  iLc  Uuni  uad 

t««  hiudnd  aod  foftj  Uli]4U>tiOQ«  od  wod,  citr*  c'ckLh,     $i  Ty 


£"■ 


rWX  fUXE  AUTtlOK. 


TUB  PRACTICE  OP  STTRfiKKV.    Fourth  American,  from  ihe  Iwt 

Bdlnbunth  editien-     Ravixd  b^  tb«  A.niiiT>t>iia  adltor.     Ulntimto^  hy  Itifaa  hutnd  aoU 
aiiiT.fuur  tngnrtop  *«  auad.    ta  «s«  Ian*  (>9ta*B  Tslom*  d(  dwIt  TOT  lacx^  •■•*» 

elotb.     fsr». 

laatJJ'iiB  ih*l  i*u  f«biiBM  baaa  vm  Btda  h  ,  ir<|iiinid.    The  ■mbur  Uaa  mlBantlj  Mn>It>1«  f**- 
LUd  »n  t-MEiif^lfn  la  u  *h»rl  a  Uma  aa  ik#    0«a[.  *Ail  ««]i-isAiiiii*4  otaa.  irhn  kamn  avvOj 

alliim"  »>.<  lh>  "^TMIlic"  of  Knrfargr  bT  bli.  i  ■ii*i  bnii  laHctnt  Bbo«t  aa<  ouaitj  b«r  ta  lUh  ti. 

mior.  at  11  ilihljr  utf1iG4  iha  (DpnlaUma  uajr  hkita  i  — OMutv  JMf«J  JiaMrria-. 


pIHRIE  [  WILLIAM).  F.  R.  S.  E., 
THE  PRINCIFLES  AND  FRArxiCK  OF  SURGERY.    F^HunI  U 

J»uy  Neili..  Mb..  I'fCtt^r  vt  eiKjcnj  in  tbe  IVnni.  MMloal  Colttfv,  S^rcHO  la  Iba 
pannayliadw  llnipital.  Jka.  In  on*  wr/ babilMna  ooUfo  Tolima  ttltO  i>WM,  wili  lit 
111  ml  ration  F,  ««tra  riolk.    (A  Ti. 

WakHv  at  uvoOimargltid  «»rb  I'C  »M»Ml>lt  I  at  vkai*  iBblaaUaraaaivaaBnllyardi 
FMMi  •Wrtlalbcn  la  ••>  Muli  ibauiy  u»l  kiiHiiw.  |  —n*  ttlMiuTaiii. 


•a^L 


*ffAROEXT  (P.  W.),  M.  /). 


0>'  UANnAGIXC.  AND  OTHER  OPERATIONS  OF  MINOR  StTl- 
,''-..  QBKY.  !l«iaUli<ii].«iih'aBaildiUoiiaJ*ba((«tiiit  MI]lu.rrSaii;di7.  i>aah4>lM«wnMl 
'1      IXmo.  ToliB*,<>rn4ail]-<aupiw«,iri(liU}lT*>ii|.«iiU.    KiiracUit,  fi  ». 

Ifii'iiiilliiilj  ti  III  (ciI  Taliinlilr  til  all  nfm- 

b«t*  *r  <b*  jimrMriaa. — iMea^  Ktdieol  Jtianfiup, 
U»i.  I  Ml. 


Tb*  vnrr  bvtl  maanal  ftf  Minor  ttargar/  wa  h*a« 
aata.— JVu/ili>  M<A.  Joiritt. 


Wa  rnrdli]lj'....t.....-..i   11  I.  . 
1IWTIinrr«^1  411). 1. 

to  l^4^  •ur<<<«q  III 

IT*  DJI  lUILa/  fviu -   ^ 

Kril.  Am.  /vwaul,  Uar.  iB«i. 


KALOAiaSrs  OPKBATIVK  tHIROERy     vnih  BB-I 

■t*r«ii*  llIii>mitH}D>  oa  *atid.     la  ait  liaatMta* 

omroTi.ian',  tnri<loih.'a(  aiMtV  (Mff.  M  SO. 

rSKBT'S  OPhB.tTJ  ve  !<t'KOF.Br.    In  otn  T*tY  html- 

^ni«  fvUVii  y'i1nni'\  ^Trraalilb.  of  DT«f^U4  jiatf^ 

i  WRbAbiiullOa  vuod^illa.    vu> 


ruA'i'i  -i.iiK'ilrij.  rmn  It*  ihirilai.i  •i'i'(-l 

!>'  ..1  Mn  »••■ 

■  ■     i>»ibm.tt 


I 


—  TMak 

MoncCT,  ^H 


IIembv  C  Lba's  PcBi^OATioxa— (Sur?eiT(>. 


TUE  PttlNCiTLES  AND  PRACTICE  OP  MOPEllX  SlTROBRr. 

A  OFirukd  r«itb«|  AiD«rtfiui,  Tmin  thvii^lilb  mUt-jt^  Mid  inptnTtd  |'<  i^     TTIv*> 


Tn  Mr.  riroln'*  ho«*.  Ih<^b  <voiLTiitib(  <^tj  •«** 
tiiiv"  «Ifcliiirjp4l  III"  Iviuk  nn-<  i  . 

Mir  iiiftt  ihTB  •«"--  I'  »- 

■[flo4,  aod  bf  H^ihf   '- .-: -     -.  .     --    <^.       -.-^•- 

W^MbH  v«  Tiflv  Drulll'*  Burcrr  m  «  xuldv  l" 


ihf-< 


1   ran  at  t'i  jr.nhi-anr  milk  M. 
iil,L  ouodaB*  >* 


Ti 

[■Ml* 

A  [•]it-|Pk>.»k  irhlrh  tin  (VOQlul  «!'•  "F  I*-  f  f*n^' 
*!h^|]  III  b'^li  GailibJ  fcu*!  AnitTttv  If  ■  -il  «« 

'T  (ht  tinnUi^l,      r  rif   i^iHi'i  qf 


■  .M« 


[TIAMILTOS  {FRANK  II.).  M.D.,  ' 

A  rUACTIOAL  TREATISE   ON    FRACTURES  AND   DISLOCA- 

of777pi«c«,  itilb2V4UlaitnCE0Tu<citrit<:Iolh,  t^  ^y      (.Vint  rAii/y>f 
The  demand  vhkh  hu  n  imvlLly  rxbnnrUd  lvr«>  Xnrf^  vWtiatn  o€  ihU  Wnrk  iho««  Ibjtl  i^. 
IfWJlbur  hitii  ^nf^'prl^'l  tii  fuftpljing  b  vhbI,  Rtll  bj  iho  pnifMUDn  kl  l«r|ps  of  aii  *ibkii*X4t#  irv^tiHi 
t  ftfrv|ii«iiL  Luii  LfoubLrH>uk4  diwM  v(  «ccUDato.    Th*  unnnkiaou*  roicv  «f  the  iLftiToalDii,  BbfiHuJ 
I  v«|l  M  »i  hoiDfi.  hill  pr^nouni^Dd  It  th"  ini>it  rf-niitli^lii  Kork  (<»  irhieh  Lh*  wrpton  cbd  r«leF  for 
tfnfamMlon  rf*p«ctinj;  «lt  i|el4l!>  of  <be  ir\f<jfct.      In  Ihu  pm^vinitltin  of  Ihtii  dw  Mitfon,  tli4 
IftVlbOr  bM  wilolooiJr  fWdoitrtrrf  i^  render  i|  wofthj  «  pontliiuftnoo  of  the  fafor  wblnh  b**  btaa 
|ft«c(fM«1  to  II,  And  lh«  vtiwri^C"  nf  tbr  rw^ni  tr^r  liftJ  afforded  &  lirg«  Kmoimt  uf  uiaUrUJ  wbleli 
*  I  hM  aMfht  lo  lom  lA  ibo  bttit  prfte(l«ftl  siocounL 

,Th«TVlBBff  VpfiiM  nt  !•  (■•■  »T  II  irLLliKivag^r 
|voapd«d  pftifltftliu)  ilie  b««i  Ava  buiiltoM  htvit  «■  < 
Itbaml^eli  kfl  lb*  Gafllab  li.Diruftni^  at*  Ici  «>>ri  1u 
t^lrmitl  ■  rwrit^atUi  Drnfl^vi  ihtc  la  aMr  ft>r  Any 
1  fink.  *niiiir  i-r  ■aiamlvL'ka  gr  aralMlVD-— JVit'i^Vi^yi 
L  Jfof  ii4Cl  Jf-r^.  AumaL 

FfLPm  1^4  gr«>t  Ubm  *44  i'U4  bHlowM  uixia  ti» 

Mbonuh  «oi1  vUbvtiiia  mvavcm  (■■'   ""<  -'h  'i^^i   iv 

I  jtrrna  lt*vf  tp»*-n  falJy  r^.||*^j1       i  ■ 
"^  inhJ*lf«>(npM(t^J1u|ii1«lt1'tii  I. II  I,-   -.1 

Maa  Id  lh«  Eactl*h  l^cifiu^pt.     It  ii  cut  nnr  in- 
«>  lnj  pfmm  ADjrtblu^  lik«  «  ffrrDul  uvuijwit^- 


(Ilia  «ii>rl(;  M  Amo  V4ikM  HrrT  ^*  f^r  t<A^m4  Ihs 

ijf  iJlD  f«f  I  11l>I    II    t*ilUl  kt    b«k  |blll[4r  Elf  •UlM'Tt>J'ri|[4l1oili 

In  h*  iniiwii:  hcoi|iT  afii  Cnr  mly  «*«,      T*  RbMrr, 
Tbit  1«  h  *fttUftblv  ntuirltj.  <nrT«^r^of 

rn,..E    iTHl'i'irUnf    ..fl.*lr.,|,-     -  „  --InTMrn*, 


f.(7 


CRUSG  (T  a).  F./t.S. 
A  PRACTICAL  TREATISE  OX    t>lSKASB«   OK  TUB   TESTIS, 

«l>KltM  \TIC  fOHD,  AS!)  BCBOTl.'M.  SorouA  amoiioio,  rrom  llie  •«..rrf  1.T..I  nlntpid 
Kn^.iib  ftlilloQ.  Ilk  ono  h4u<l*«Aa«  octavo  vulu^^.  ixtm  ^J^th,  wilh  iium«faua  llluttr^ 
tiuui.     r^  42p.     tS  «0. 


^ARWELL  {RlCaAKD).  F.K.C.S.,  ' 

A  TREATISE  ON  1>ISE.\.«ES  OK  THE  JOINTS.    Illu^traUfa  wllh 

mfrraiingtnn  nuud.     In  unf  nij  liaiflKoiii*  (Krlaro  ■oluda  of  abuut  tiOO  piipH,  •'tlretldlh. 


,  stoviRit  fLinirAL  i.Ri?TOBn  ftir  svtnMT 

■  1  «!.  ir*,,  »W  1^. :  .■Inih,  II  n 
OnOPM  IW  TUB  STRIllTTDHl  AXlt  IMBIUB*  op 

(lujiNtinl  •**,  tKTn  tiJik,  wTili  ITT  Dnm  «a  ts 


l"«tr^i^r  'ir  »o»iimt.    la  on*  tr'j  !•'(«  a«la*»' 
Oiiiiuji'H  iH'TTiTTrrBt  As:>  fit*mir»;  (If  piR- 
aaiiH,ibDall>]OUpit«>,l*u*i«,tdiwk>«Kkik*»ttn 


30 


HXNRT  C.  lilA's  PumJCA-noW* — (.f.ir^T.ry). 


rroyxtiKK  {joshph).  f.  r.  x. 

THE  DJSKASES  OF  TKR  EAR:  th«r  NaUin-,  DiagnwU,  nml  TnmU 

m^nt,     With  <■»«  hmki1rv<l  ^nmrliixt  on  voDtl,     Second  AnjrrlM*  v<U4ktt>     Is  od«  twj 
haTS'**MflfIv  prkiil^l  '-fll^to  v<4*irTi#  ^f  l-IO  fag*l  j   rilri  cU'th,  %i. 

r?r«.  \n  irhif  I. 

1u    l>i"   "1"*l    '     ■ 


1-      iM,  ■.    iimn     Wo  n*f  ««- 

Mm  vlll  okM«t«  bi-«n}DOi|  H>*  upyrabta  of  lavAlml 
*el««f*,— lAWlfffi  JMtoal  Aolcw. 


Tb"  vothn  Htwu  lUTrd  tt  ll.«<^i]ivt  <if  cur  hmM*^ 

w4Eh  i-n>«>  4ni1  Jnwieifv-'ll  !■  bf  fhf  Il>>  M>l»t4  B^ 
irlbaHffU  la  Xh*  nn  aM  ffllcw*  o<  •■■••'r  1*  <W 


A  HANDY-BOOK  OF  OPHTHALMIC  SURCEKY,  for  the  uw  of 
Pnelitiqnan.  Wfib  nnnsmu*  illualrBtloo*.  In  and  nr;  hAnd*«««  MUio  taIubs,  «Mm 
ektb.    11  90     (JVvir  BM'Vf  1 

"  In  Brittnic  Ibm  p(|[*>  II  hit*  b*tii  uur  ftim  la  brFtif  th>  i-rifielelM  •■4  ffrndlr*  tf  modern 
opblbnlmk  iitgtrj  irlthiD  B  imnU  oompuu.  to  lupply  ibd  wnnU  h  lh«  bofj  ft^ltUoavf,  «bo 
may  barn  o*<lh«<  liint  bot  appurliinil]'  In  rind  Dm  innuaixBkli  Matrlbsllant  Uul  u^blWIaU 
WBignj  utd  MiicD&c  baT«  n««l<ttl  aUUlii  (bo  Imi  Oft«*ii  yoin. 

"Id  dtaoHbioK  ■ymctnini.  ««  hni"  limlivd  oniitlvtf  lo  lbO(°  irbicb  ar*  «M*nliil  kt  lb*  rcwf* 
•Mnvitef  dil*UB  ;  In  oauclblng  apf«iilt»iit,  JUi.,  la  Ihois  •Ittsll*  iihlsli  w***Ma(lal  t*t  lu  Irtut' 


JVXES  (T.  WHARTON],  F.R.S.. 
THE  PRINCIPLES  ANI>  PKACTICE  OF  OPIITHALSnO  MEDI- 

OINR  ANI>  SUROKHT.  1!'ilb  dob  bnaJnil  ud  nHOlOMi  illiuUaliaM.  Tbu4  tu4  im. 
vIibU  Aioarloiui.  with  Adilllloiu  trom  tbc  icooiiil  Iivndon  aiUUvD.  In  •«•  h«iiiUi«>  ntttn* 
<n/tvmt  ot  i!>i  pAfti,  cxira  olodi'    43  li. 

W«Vaoviprii"ivfifl(nliWfif<^'aUiM<ib'a*ii>#Hin{hnril  1  It  la  ab(Et*4ltfai  p4«tl(Kl  rMaWv*  t>a  ib«  »«ilNA 
«f  luriiruiill-m  In  IhcHiiiTtuinpua^  wf  H|>nlBllr  (n- 1  and  •iiiitloJ  ili>M>rt^r  (■•••r<L  aad  !•  irtU  ■4iyl|i 
mainttiililxbiHibwLbi  AaiulMjik|<lcltii>Hl  iiw- 1  U  iha  bmi*  boih  4'  ilixladMi  ltd  pciaUHaK 


d[«*l  ■tiulaal.— ^'-Ki  >VnnM(H  J 


I  (,■«!•  lift.  JM. 


A  I'ltAOTlOAL  TKEATiSK  ON  DlSKASf^S  AND  IXJURIES  OP 

THK  iCVB  Tairhlvb  Li  pi(iDi«i  un  Aiialuial»l  I  nt  rod  net  ran  aiplsnalarr  nf  ■  Hwlwiaul 
BTCtlnn  nf  Iba  Ilurnun  Kjfball.  hjr  TnnHM  WniKtus  Jnoiu.  P.  R  S.  Fiani  *i*  (ourtk 
TCTiMil  and  VD]ai|{eil  litindan  ailillon.  Wilb  SoU«  sud  Addjifun*  hj  AnauKLL  Uasawa, 
U.  I>^,  i*urK*Dii  lo  WlUtBMpiUl,  4a.  A«.  lu  noa  nrj  lars*4Qd  KaodaMMOcuiv  tatam« 
of  IbJT  |>*Ko<.  ciuaelulb,  wttb  plato*  and  aanwrviu  wogd-oala.    %t  M. 


JLfORLASIi  (TT.  W.).  JH.D. 


DISEASES  OP  THE  ritlXARY  OROANS;  a  Compendium  of  Ihelr 

INifnoitf.  Patholoin'.  nod  TiaaUauL      With  UluniallaD).     Is-***  laig*  abd  baadaOB* 
aoUva  i-aluua  nC  nbout  MD  !■«[«.  txlrB  Cl»lta,     91  60. 


mnnaaa«bnlr.i«v4aarfV»nE(Hrad  9r,  MafUb4'«  ' 
wnpaadloa  m  a  Ttrj  dnIniblasildUlaD  ig  Lht  library 


Mmif  MHlwaloraiiFfiaal  ttaallMHiir 
Kw  Mul  -Cftfr.  Kntnr,  IprU,  IkM. 


mmt 


AmTON{T.  J.) 


rin-.MATIONS 


OF 

liian. 


ON  THE  mSEASBS.  INJURIES.  AND  M 

Tnr  RKCTTM  ANn  ASUS,  vtllb  rfoiMtung  Habitual  < 

from  Iba  faurih  anr!  a(ilArjc*d  Londnn  ai-lilinn,     VTHb  banil -  .-iLi^nv.      la  ua^  t*sj 

btaulllullji  iirlnLed  aota'u  vuiams  «(  about  ^00  V*V-     M  31>'     (Jutl  limtJ.) 
Wa  lan  r«<<inin'4il  Uila  mluiD*  ol  Mr  Atbloa'a  tn  i     TUa  ilion  partoil  nbtA  hu  'lafaad  •*•••  IVa  ap' 

■••-■•      pmriuM  of  iha  rorinsr  AaarWia  ir*"afc  aad  laa 


IVf  trruMtf'il  InriD^  a*fufiU^nkdjI4M  IliaUlvitdatall' 
tt  III*  paiNiliify  auil  imini'ni  <,r  >lii<«i<t>  oonoKlaJ 
■  LilMlx^rftitiirn  -^CimfUi  Hi- 1  J-^vm  ,  Uarr^K  IMC. 
Tbia  la  a  nr*aA4  tnwini^j  r«tkM4«4UI'>s  c<i>b* 
«f  lb*  igoM  ToiMtil*  anatBl  iivaii*aa  1I14I  iht  phy- 
aba*ali  '  ■    ■ ' 


«I«Md  aod  an  rjiaaa  aaa 

{«nm<Mr,  Jaa.  IMH. 


il>  LLbtarj  — l^t«j|ai 


[ii>Eaanina  vOtl^iDt  |'ul>lUW4  lb  Ea^a4.  tvaLa*! 
aifiicta  vnaa  c0ira(  Um  Bnli«  lal  *(  ikaai*. 
1oiaba4  af  aaj  ftfcuiaaadall^a  *a  oar  fiatl  W  a  ba^a 
a1rH4f  aabTMablr  kaiva  li' uur  ■•hk 
JIM  omI  «afv  /owX  Ju  1),  IHC 


I 

■ 


IIevrt  C.  Lea's  PoBtiCATioifa — (SleJical  Jurisprudence,  Sc). 


\YLOR  {ALFRED  S.),  M.D.. 
MEDICAL  JUIUSPRUUKNCK-    Sixtli  American,  fVora  tbo  eighth 

ftiiJ  r*Ti*nl  Liindno  •riUioB-  WUh  Xutn  ftnd  RaTDrvnof*  1a  AfUBtknn  Dteit^op*.  1>>  CtK- 
iri:]iT  U,  PcsbOftH,  of  rhc  P^nlnikri^hm  iLnr.  la  out  tatgv  optavo  T'^Iumt  uf  JIi)  poeVi 
Hir*  cliith.  $4  fiO  ;  1#jahor,  $5  :jO.  ( AVio  RmJ^A 
Ctmvi'lar-hMe  ndiililriin*  b!%v%  beep  mldv  bj  the  cilTtor  to  lhl>  eil]t1<>ii,  cDnipr|'^i>^  !<i>ino  ImpArlaiit 
fl«Ctfoni  ffom  Ibi^mthor's  Inrovr  work,  "  Thfl  Piiiiflipl^*  nnd  Pr*f>tiii#  <ff  M*JS<jrtl  JurifpEmfrno*/' 
%t  ffW  t*  rafflftnot*  lu  AnflriAb-D  law  nmt  |ir»t^tip-  Tbo  aottt  of  the  furin«r  cJ^tor,  tfr-  Uf^fU- 
borfiB.  bave  1tk«vl»e  hnn  roUined.  and  the  «bo!a  is  prcannL^d  u  fulL<r  woirii;  W  tDaintain  tba 
ttittiniTBvb^d  |ii>Eitii]a  itfaieh  th«  wtirk  bu  aei]iiind  aji  a  Ifiailutj;  Ivxt-b^xtk  abd  authnrH.Y  on  Ilia 
mbjret- 


W<>h  ta  aat  fatlftcuB  f*r  r*ftn,  aaJ  ihr  prvPAni  •41' 

day.  ^ti  ilir  I'miUnr  (inivluca  uf  EuMl4;][i4  >»k  wLioli 
I*  uvftlM.  tiif>  Aiitnikva  vd^tur.  Vi-  Kiirt*fai->rii«v  EtM 
^Mte  JiL*  iIiLlT  v^  lb"  triE,  kfihI^  npLin  (hri  vik^li^p  wi 
cmtEEul  but  <Hhfiiilplhr  rTii*  ?4*lacnv  (Qn  bQ>l  and  rl^b«4l 
tmTl>iuE]  BiP4liv«l  j4rt>Liiiid«adaia  vur  UbKu^fK— 

TbttwaaBtMlDQ  1i>  (hi  pfofbv»1f>fl  nf  ft  Qcwanif  tn- 
fr«VM  fldltJua  of  1h1*  vflll-ttiiuvn  uml  di«Brt«d1r 
ptifit*t  vofk  ^dDf'i  bn  InoKwl  npi-n  oihrinrlxn  iEiaei 
«*a  tuttjifcl  '^f  «iii>cn»toUiniii.  'njflbi>f>W  hu  thaox 
■a«rlEa.    Ji  La  liri<^-  II  f»  rMTiiL^rrbflLiirq  ;  Li  itcat*  fu  a 

{HftHiC  Uin  rtu  lif  prc4CitTvH]  Lf>  il'p  iTr'«ij(lun  4jf  lb« 

e/alvtaa.  unJ  Tb»  <i>iiiiTt>iBmcM  i.f  Uie  Wijfli  In  *h. 

Ayf<vJjirlaJ-t  ibon^Ti  iii>c  Tpr^  |''rp^i>4tiL  o^tJM  aail  ff^ 
liirBDMi  %'i  rivi<ui  Aiuvnfaa»Ht,  U/  Pf.  tJarutiura^. 

^^C^^Al^  JIf'iI.  J'titf. 

Vta*"!!  bnrd'ruj'lbal  Ihln  Wi>r1(  In  ituJbi  h«^pDd 
|W  p«>  "t  «FlU<f»ra.  ai»4l  (hut  »ll  vr<  hivA  tn  do  I*  it 
cvacT«rulaT4  iks  prolW«alvD  dd  b^tlut:  H*  «HLDinu» 
Main  UJd  bvfqra  (bam.  In  IMHI,  In  ■  iJhitnLLaHEj  r*- 


hftrtj  (utiL[:l<!riiL'«  w|lb  lUit  jt^uaral  vnrd^ft  of  ibd 
t«-b  (irtifon-LoQa.  uiAdlwl  And  tf^n^  In  l^vor  *t(  tblfl 
jbtml'nM"  Iri'jttLiii,  whL'^b.  tLk»  ;Jin  ^a''  Jcitt  ibBii' 
liuDi^J,  ftUlj^iUi^  phol^J  la  Ike  mkaukl  f«r(u.  i*  rt^Ux 
1h*  molt  vUb^r*!*  iror^  aa  Ihaaubjvci  tbiLuur  lil*- 
ratiim  ifo«**D4i,  uid  hUJ  aiaqij*n1loniibJ  )■  httiH  lit 
grttnti'l  »  tbt  tUndiH  of  mt-JifAl  j4rU|-rad»ae*  La 
ibl«  r<iiiiilry  to  l^ibK  u  It  »ball  bv  ki.-j^|  hj  lit  tulMor 
frtc^JUipTirrrCy  uIpTl>  Lb*  igark  *»  t[  m'»  Lb.— I'Aijfrtl- 
Ith'intl  Pt'rftffn  MMtiot-Vftintrffiml  lifvi*tij, 

tTlLbuiilfnftt*Tia]|ftnflr*aAtai((b*bDllf  of  lMin«t 
■diulrablc  W4>ffc,  wAhiLVB  u  aweJiLlnd  iFPiafbr  ofoBit 
uploib*  pn^wwl  da-r,  with  nM  •rf*"  TiiinoT<ti1  and 
TWr  nfioj  anw  AUoMrnTim  bld^J.  Tbl»  U  a  wor^ 
Wall  wutlby  Iho  bl^U  |iuai1ku  of  Tt*  aiilbxr,  mad  a 
rHlrrttpn-^iLEailn  and  vivaqiil  ot  lb*  aiKln  of  Fnm^ 
hi':  (u^flMii*  In  IbU  «itdDlrv.  aitnind  in  nnnn,  we*mi* 
lu'n  tP*tT,  Jh  [bp  vr>rlfl,  fi^atralo  tb1«aTor/<«b*0lar 
tnLk  (LAdirp^OD  i  cloto  roTtMoa,  and  aauj'  ueir  vajeq 
■bd  <»ii-'TVriiJni]pt  hatt  bwia  Ad4*d:  ^f  li^o  w*mv  Him 
i\f^  p<xiniMLVci  rhar>^  bat-'  S-mi  ma^o  Ifiivn**  ou- 
04lk'kl  rnr,  Tl  wi-iin1  b*  h  iratT*  nf  Hmn  ^f>  atlfmpt 
■B7  ilv^rrif  tU'it  iff  {1>4«  vorlr.  wMvb  ihuti  Sh»«  Atntid 
llA  W'4j'  I4>  Etin  bjir^kaliir^f  of  alu'Vi  *trrf  |>r>f  rtflnn^f 
1albi«  lliirdLhm^  Lho^i*  ivbo  ban  II  nni  >^o1l|'|  po^ 
k^»  kL  f<i?iliirUb,  Thirn  l«  i,o  i".i»rr  U*-^»il  rf^rk  ^>f 
rvfkrduitu  ua  (lift  or  uij  eabJeot-'Jfttjdua  Jffifinii 
Aaeuie- 


W/,V6V>0W  [FOnnKS],  M.I>.,  D.C.L.,^c- 


ON  OBSCFRR   niSKASKS  OP  TIIK  BKAIN  AND   DTSORPKHS 

OP  TUB  MlTJIl;  tbcU  IncSplenl  Symptonir,  PathoEouy.  I)lft^o»i»,  Troatniftiit,  and  Pti>- 
ph;la«Ia.  SoccH'I  Aiucrioan,  ffum  ibv  Lbfrd  and  tvTt»pd  En/Mvh  p>][ikoii>  In  oov  banUaifai* 
oolavo  Tolumo  of  ncarJj  60O  imk^vp,  axlrft  elulb-     $t  3^-     (Jiue  Ittutd.) 

StlMHAKY  OK  CoSTKKTH, 

Cvai'TRa  I.  Iiilrc'1iiptton---TI.  HorbU  Pb^oooK^na  of  Itil«J1if(triea— TIL  Ptoioonltor?  Syiop- 
^  |md«  of  InaAftHy — tV,  Cufufufion*  of  PailcnU  after  Kccurerj— V^  8U1«  of  iba  Mii>a  durisjt 
ita««t«r5 — VI-  AhonaloUB  and  Slaakvil  A&alioai  of  the  Mind — VIT  £latfe  of  Cod*c1oiiiu««^- 
Tin.  £U«a  i>r  Eiiill»li»ii'1X-  SiH^  of  Maplal  UD|ifi^^um^\-  t^taga  of  AherrMioti'Xi.  Im- 
lidnaoDtof  MiDd — XII  M<^rbtd  Phpnompna  of  AUeiiTkon — ^XllI  Mortrid  tnt^iLOmena  «f  Mcmciry 
^-XEV,  Aiml*  iKH^vrdorx  fjf  MeibHT^^XV-  Chrvnia  A9«:lir>iis  nf  Maiti»fir— XVI,  Perveftiofi  ana 
EtallaHofi  of  Utfm<>rr — XVlf  Pfyoholoijy  and  Pathology  of  Memory— >X VI 1L  Uurhii!  Phe»u- 
men»  nf  M'tti-it^^XlA,  Morbiil  PheiioniHoa  of  ^itecfh— XX,  )lr>ibL<f  rhflnomena  of  ^enialior^— 
XXL  Horbid  Pbifiii-irueaA  of  the  Spveta)  ^enfoi'— XXLI.  Murbid  pbi^noioena  nt  W-'um.  Haarinr, 
Tm(»i  Toiiph^  and  Sfti'll'-XXin-  Mrirbid  Pbeoptnmi*  ^f  i*»*flp  and  I'r*jifliUi;— XXIV  AiorlfrJ 
FbeDOTiifliia  of  Ur^ATuc  unii  Kuitltltre  Llf^XXV.  Qotteml  Prlitvl^loi  of  Potbvb^cj,  DJa|;uoii^ 
TreatiDeDl.  ahd  I'ftjphjJiiiJtf-  , 

oar  cbavlcTtuD  ihalK  Ulonf  iliuv  «'» iiiii>ortaBt  aaj 

hranltfiillf  tvrltl'a  4  voJnma  btn  tuo<4  fftitn  ihe 
Urllk^li  lu^dlcfrl  pfeaa.  T^e  deU^l*  vi  Ibe  luaEiAife- 
mtiDi  of  roEiBrniiil  uuaei  <if  luaitlty  aero  utAt\y  la- 
t4r*B(  IhijHH  who  hnvB  miidv  ic^iUl  Ji-*-ib<p  ib'^f 
ApKUi  hUiLliri  \>i\\  t)r.  Vp'lutlhiir'i  jitB.4|FVlj  eKputL' 
titta  "T  iTkO  4.'iirly  ■> JU|-1  um,  hiid  Ll>  ^rvptiLr  J<7ct£|>' 
Uwn*  vf  lltd  iE]*id}uu>  aJi^fltua  uf  ;fir.jijpiiE  Juaau^iy, 
t(Ntii(bir  HVTh  bL>  indtrlou*  ^bia^TJitl^hiii  ni>  ibd  iital- 
raenl  of  dlan'ilAr'  it  (bi«  nilndt  ^bLUi^i],  k*  cr^irol,  b* 
ia'<:fQliy  tludTtd  by  all  wliu  Lave  uudvttaWa  iba 
rtfipoij'jlilllllvi  tA  mvdldiU  preclin  -^DnlUn  itvtUnl 

[r  ft  tbe  Boel  lalnreaUQAaa  vellaa  valuikbla  book 
ihaE  w«  hare  hoq  Inr  a  ivbx  limn  II  1i  tnt^y  fa4<i' 
naltnf  — ^^m.  JoW-  Jfrri.  Arifufvf, 

Pr  WLatlnw't  work  viit  odd^rubiedlj  iKcopy  aa 
aulqae  poaii^oD  \n  Ihe  ui4ditv-p<7fbuJi>i(lra1  ItleJa' 
tar*  of  Khit  eoaatry.^/iQmli'ii  HlTarf.  Anwu. 


Of  UiB  iii"r'LEi  ef  Dr.  Wlntle*'*  IreUlnelhe  prr^flfr 
alog  Uah  ■u^ri'nUf  ]  ndjvd-  Jl  b4*  lakra  lu  {iIum  in 
yh*  frnL[  rank  inf  rli"  norUh  Dpu^i  lliQ  «pr<cla]  ilvpart- 
m«ai  vf  prh<'Tl4>iil  jQi'it^dut  |o  tihk'b  U  i^iraiua— 
CJiufiann/^  J^vrtt'i/  i^  J/nf  ir(n.,  >lari;li.  l*M. 

|ll«an  I*i1-*rg<1lng  vnliimn  Ihal  will  amply  npaf 
for  a  rarvrni  renj^Al  by  all  leloEllecal  rvadvrt.-^ 
QhUraffo  Jfrvf   KAriMtPiT.  Fab-  IVUD. 

A  vork  wMch,  llkn  lb*  prhatfnt.  «1M  1»n|rttyald 
Iko  pn>tlEl<'Q«T  it  ff*tffn|«1ii«  and  atrnltw  ilir>  fir«l 
iMldloi^  »i|ra(K«a  of  etrebral  aiJ  idaiiuI  dlac«*e,  !• 
Ofloof  Ibbaaea  practteal  «aJiie,anddaaiiitiila  rttTOPal 
•tiaacloa  and  dlhoial  ela^ly  an  (h*  i>ar|'>f  all  *b4 
kvva  aiabtacM  Iha  medttal  profMafoa,  and  bive 
tbareby  aadariakea  mpoiixlbiikket  ta  wiitcb  ib* 
valfkr*  and  bapplnvaa  of  lodlrldxiBlii  nnd  fainULoA 
ai«  tarfely  VoauUed.  WethAlL  Iherefore  flvi>4  \\\\> 
brief  abd  QenMartlv  vorr  nBparf^rl  poiIh  of  l>r. 
Wlbiilii«'a  fnat  aad  eUaalcal  Wart  bjr  vifnuLof 


3S 


UtSKT  CIiKA'a  PcBUOATwiia.. 


•%  \i 


IKDKX  TO    CATALOGUE. 


AM*B<)  Sl«xu]'a  Haadbuot  tt  ChDnliuf 
AIIm'*  Dluiii't;  iTid  tVirt'nl  AnUsiaM 
AAier1M>i  ^'"^                .    '.:    .     <!  Ad^vniH 
AMl«mln*i  '  I  llnrscr 

Ai>U«ia«A  LI -  . 

blAldfilnil  ^TJ  th''  l^lifuE     .  .  ,  , 

BrlBloD  '>o  t>ip  sr.jDbBcih 

BlHtai'f  V'xllFil  I>|UBM|(  . 

ltU<l*ll  irn  >'ni-r<<r  IM  trglKd  KIUM 
BarvnII  «•  ik*  JMau 
VnlavBiht  I^maTIIiaiai 
,  BnaH  <M«Brr' '"  !><••■•«  r^  t>»  Hlrni 

BhSftM'  r  ■'■  ,;  ,.  T-    V.  '     ^ 

BOItlii-  r> 

[IffVDir  .  v 

BnD40  *lfcTjLir-inrmn[r^ 

Himllo'i  (Hlntnl  IiHUim  on  «or«»>t . 
Bmwh  •>■  lli«  fartlMl  IHM»m  «[  Wubib 

Biukloi  ua  BrrarliItU     . 
BqcliaUJ  «(id  Tuk«  on  tbi^aJtjr 

j  Buntletik  Oft  V*u<r««t   . 
Cafaskv'*  Hiimo  I'fa^tlolqfr    . 
'  Cupavur't  I^mptntiTv  fb^^lpLif^ 
Ciiiymi*  «*  III*  Kiwiuoui* 
,Q*f»UU'  <■■  tbana  ud  AlHMrs'Alcutiul 
Cuwt'aSf  uiiKla  .r  Mtwtla  Mwlte*  . 
h'Qfarlitlaoa  aJift  liftlllih'a  tiltftaamUrty 
tUiureblli'i  '7>i»iii  til  Mi4«(r*i7  . 
CbarrLUi  uri  iH«D44<*af  na»t«a 
'CkaKhlU  i>B  i>l»-<»  vl  CbU4nB 

SiiNblli  Ml  rostpgni  yvnr 
raif*  n  !■•»'• 

OtlMlat  4a  ru*n  aa  Fasalta,  b;  IM«« 
CaadlnaD  Pit—  of  ChlMwa     . 
OtopsryiB.  B  )  taelDfHDalSnrt'i'r   • 
Cespar  pir  A.  f.)  on  iln  T«iJ>,  He. 
CarllBC  on  Dlmuo  ..r  IJ»  T.-(l(  . 

ItalEflq'K  llnTnun  l*1ij«1tlo(7  ,         ■        , 
I>-  7iii£l>  "H  l^).t-L.i,'r  'Xil     . 
l).-SMri1i>-l>iBar  XklHlCtr 

brtwaf>4oi]  jiL>'.'«'  ur  r^^tnJi^ 

Dpwt^v  911  E'|AtMi4»  «r  CllUdFeD 

nielmn'a  PrMllMaf  HadtMoi) 
,  J>niUl^a  K^idftn  tlat^rf 

B«a(ll>aiiV  UndiiAl  nicilsiiKT 
.  ]>aBsti»ii^  Ilnra4q  Vtiy^wlo^ 

DviftW'ii  >Mi  s--  ((■.>..>rit<* 

Dagili  ■N>I  Kiioli  Hr-tiei 

■lla  -  ■  r,  »r  Timmn. 

M<b>^L.  ■    ,       ■■■       -  -■■iiKj 

Tliat  (in  lU^pLrUur/  i^t^ih  -       , 

niol  on  111"  l\'\n  .        .       . 

^[Di'4  PruiiTt  «r  Moi^Telap  - 

tvwa'-'t  MemtaUiry  C%^ltif 
,  JlKk  Da  Knul  AOmUaa 

CaMau'i  MaJlaBlCliriaUitr 

OiliMa'a  Suriwj 

'  Sluc*'>  I^ii]iu]n«l(al  ItliloliQ',  b;  talOj 

Qrviani'*  WflrtninC*  ftrrh*-ii»l«lrr 

OfhT'*  Annt.iinjr      .        ,        ,        .       . 

CIHAlh'*  IK   kl  CnlTfr^At  FvririDlil'J  - 
idrlOlh'i  l-l  W.t  tltniml  on  Inn  niiiod,  t - 

Ghfu^b  Irnnir^  Or^o^ 


'tiMfl 


OfH*  00  Triivi^n  *'..., Ill 
Oroa'iPiln'  ' 
Oiv«'»  Vuf'  ■ 
Bal>fr«boft   '  ' 

Harr^ann  (111 

ITiiW.'ii'"  ti 

lfo<1|v  -in  t^'uineii 

Hijd(-'»  ()lp.I->[lr«  .         .         ,         , 

Kgllanil'ii  MMllrai  Nntraantf  KariHileBi 
I  ItoraerV  Aualvnr  and  Hlaiolon^ 
I  Vii(l<a  oa  Aaantlallaa  and  finfatiB 


-  lud  I'rutam 

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3-V'itaA  MartVlnil  l^ibnliiKlol  Annliii*/ 

inn**  (ir.  lUndtlnK)  oa  Kitroua  DtwNsn 
■  »rt«'  Pbfmi,l.«T 

Kaai^t^a  ('litnLulT«cbaolD«f      .         .         ^         . 

Li:ip<niniki1  anil  Wht«on 'jii  fpfrraKorrkitt  . 

Li  lI'i^lLr  I'l'  T^ltiiv  l>Tr*  ,         .         . 

I  La  KtfGb^  i-n  P\i'-br,inniK  Aa 

lAUrfDO-  and  Vi'.in'>  i>^b1faa]m>eflarf««T 
I  lMjm4k  (in  u<-rL«aJ  otivtn'ailca 
I  t/ibrntiiia'a  rf^jalDlaclral  Chaifflairj,  i  tvla 
'  I^hnina'aChatiltar  ■'b}*l>Un> . 
'  Iindltin'a  Mansal  aF  KxwMBaUwt 
I  [^^fina-tn  ^■'••r  ,         .         ,         , 

I  MarJii^'kfra^^ral  Anilovij 
\  Valil&fcTTfVi»1<^r4tlTv6anErTy.by  ttrtflan  . 
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ftori-lrs'i  Hal   Ui.llfa  and  TlirnMllia,  abMJ(*d 

^halE]  and  SJia^i^^j.'*  Aiial.-uiT,  pj  J.''d  f 
lEk'T-'u  la  .Jib  1  nanrj  ]hL*r«v*n* 
kirair'HilbHiai  (iq  l^armrltii^n  . 

': ':i '  '"-■MO      .        .        .        .        . 

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I  ttlia'pflj  AaJ  VdUu  a  Analtuaj,  by  balij     , 
I  Blmiia'i  Gaoaral  PUbolacr    .... 


nrr-a  Aa*la»:(al  Alia* 
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^a  L'uaaiH  of  It' Diaia 

SI1I14  .  lUT.iH.ijilIa        ... 
'  ^Jttirnin  Aillima  , 

1 •'•  >'>.ri»il  nr  OllaMalMadlMva. 

<i  Jmii^i  Bdaaaa   . 
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.ii*<i**« 
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WiliW  PO  Ibt  I. Ill  ;• 
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Wil>i>u'i  I'MoauD  Uiacaxa  -£  ika  ll^'a 
Wllwa'*  llaaril»*«  •>(  CalaaMoa  U*«;aloa 
Wl^aaaai  Itaall^rBi'* 
Wila»a  va  flivrinalurrbaa 
Wiaalvw  *u  llialn  aad  ] 


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