JO "••> ! > .>> - y > >» > >> : > > 3* :» O > > .> ^ v^^P ■*' *> > ->"> > > j* y » :> >>* >V> j»> " ■^> :»_>§ ^j*> j>-2» ^>^»j> ?i v^-^fc^.'-i-a^ft. ^8?1I EEC K »i> 'lX> ."5«9C3> >-lX>C?* ;^3»^> » 3>: ' »• > J> > I"' » > i> >■< ^ - '- » i> > > >• . ^ ^j Xi9 V> _> » v; rA>- «% >^ <■>>- >^^QZQ^£ZOZOwZCQZZZCZZZ-^ r................... .... ;*', Surgeon General's Office &~ N n/U~l^... -^OOOQGClGaOr^ \ JJr^t <£ss;tg. VARIATIONS OF PITCH PERCUSSION AND RESPIRATORY SOUNDS, APPLICATION TO PHYSICAL DIAGNOSIS. By AUSTIN FLINT, M.D. OF BUFFALO, N. Y. " Happy am I in my own estimation, if I have thrown any light, in this Memoir, upon any clinical qut =• tiontiontiortions, and especially if I have stimulated the zeal of our young practitioners for the diagnostic studies which conconconconstitute, in my mind, one of the most beautiful parts of our art/ Am.'.v, On Dinaatt of the lleart. REPRINTED, FOR PRIVATE DISTRIBUTION, THE TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION, 1852. t\ zzmz ' '•v.. / STEAM PRESS, JEWF.TT, THOMAS & CO. 1S52. .ANNEX W8B F623o 1852. ON VARIATIONS OF PITCH PERCUSSION AND RESPIRATORY SOUNDS, AND THEIR APPLICATION TO PHYSICAL DIAGNOSIS. Very little attention has hitherto been paid to variations in the pitch of sounds heard in the practice of percussion and pulmonary auscultation. The sibilant and sonorous rales of bronchitis, it is true, are distinguished from each other chiefly by a contrast in pitch, but, as respects the remainder of the physical signs pertaining to pulmonary disease, they appear not to have been much studied in this aspect, and even the facts that have arrested notice do not seem to have been applied, save in a very limited degree, to physical diagnosis. By most writers on physical exploration, pitch modifica- tions, except* in the sibilant and sonorous rales, are not recognized, no allu- sion whatever being made to them. In the second edition of the able and comprehensive work by Dr. Walshe, of London, recently republished in this country, the subject is noticed more distinctly than by any other author with whose writings I am acquainted. Dr. Walshe enumerates among the ele- ments involved in the different modifications of respiratory sounds in health and disease, variations in pitch; he also mentions several important facts with respect to these variations. But he apparently loses sight of their practical applications, making no reference to them in connection with the diagnosis of individual thoracic diseases. Barth and Roger state, as briefly as possible, the fact that the bronchial respiration is higher in pitch than the cavernous. * The vocal sign aec/ophony should perhaps also be excepted. 4 PRIZE ESSAY. But, in general, as just remarked, nothing is to be found relating to this subject in standard treatises* on percussion and auscultation. "What facts are disclosed by the study of percussion and respiratory sounds, in health and disease, with reference to variations of pitch ? How far are these facts available in diagnosis? The latter question is much the more important of the two; or, rather, the importance of the first question depends mainly upon that which belongs to the second. The subject of physical exploration has already suffered from over-refinement. To be practically available in the hands of all intelligent practitioners, the art must be simpli- fied as much as possible. New distinctions, unless obviously tending to en- large or facilitate our means of diagnosis by physical signs, were they not only true, but ever so interesting to those whose attention is specially direct- ed to this department of medicine, would be of questionable utility, so far as they serve to render the pursuit more complicated and difficult. In pro- posing, therefore, to submit the results of my observations and experience, thus far, in answer to the foregoing inquiries, I am influenced by the belief that, considered in this point of view, the physical signs of pulmonary affec- tions admit of being enlarged in their application to diagnosis, and rendered more readily available for practical purposes. A single additional remark by way of introduction: the pitch modifications of sound, as before intimated, opening afield of study in physical exploration as yet but little cultivated, and to which, so far as relates especially to auscultation, my attention has but recently been directed, propriety and prudence dictate, not only caution in making deductions from a number of data somewhat limited, but a certain amount of distrust in a kind of observation in which the liability to error can- not be at once fully estimated. In view of these considerations, the conclu- sions which I shall present are advanced as propositions to be confirmed by further researches, the object of this paper being, in a great measure, to invite the investigations of others in the same direction. The subject naturally resolves itself into the study of — First, percussion sounds; and, second, the pulmonary sounds disclosed by auscultation. SECTION I. ON ATTENTION TO PITCH OF SOUND IN THE PRACTICE OF PERCUSSION. It is hardly necessary to gather recorded data with reference to the varia- tions of pitch of percussion sounds, since observations can be so easily made, * In connection with this statement, it is proper to give the bibliography to which it applies. The works consulted are as follows: — Laennec, edited by Forbes; Walshe on the Heart and Lungs; Hughes's Physical VARIATIONS OF PITCH IN PERCUSSION, ETC. 5 and repeated, to any extent, by every one. I shall, therefore, give my expe- rience under this head briefly, and in a general way, i. e., without citing particular cases. The use of the term pitch, as applied to percussion sounds', may be questioned, and questionable. Whether it be correctly applicable, in a musical sense, to these sounds, or to those of auscultation, I shall not stop to inquire. It suffices if the idea it conveys be intelligible, and if it de- note an appreciable distinction. A percussion sound elicited from the chest, if not entirely flat, has a certain amount of resonance. This resonance may differ in degree; in other words, the sound is more or less clear, or dull. A peculiar quality of tone arises from the fact that the chest contains air in vesicles, and hence the sound may be distinguished as the vesicular reso- nance. Percussion sounds present, occasionally, deviations from this vesicu- lar quality; an example the most familiar being the change occasioned by the presence of air between the pleural surfaces, or in a large excavation, constituting what is known as tympanitic resonance. Now, in addition to these classes of variations, the resonance on percussion in different parts of the chest, in morbid conditions, present a disparity analogous to, if not iden- tical with that which constitutes the distinction called high or low in com- paring musical tones — in other words, a disparity in pitch. This kind of disparity is recognized by directing attention to, and comparing the sounds elicited from different regions, just as is done with reference to musical notes in determining whether they are relatively higher or lower in key. The faculty of distinguishing discords, in other words a musical ear as it is called, doubtless assists this discrimination, and it is probably true that the ability to detect a slight variation will correspond with the delicacy with which devia- tions from the harmony of musical tones are appreciated. What pathological significance belongs to the fact of a variation in the pitch of resonance? The practical importance of the subject depends, of course, on the answer to this question. The question leads to the enuncia- tion of the following law: An elevation of pitch always accompanies dimi- nution of resonance in consequence of pulmonary consolidation. In other words, dullness of resonance is never present without the pitch being raised. This proposition is to be verified by observations which may be readily made. Diagnosis of the Lungs and Heart; Barth and Roger's Practical Treatise on Ausculta- tion ; Gerhard on Diseases of the Chest; Prize Dissertations on Physical Exploration, by Drs. Holmes, Bell, and Haxall; Blakiston on Diseases of the Chest; Latham on Auscultation and Semeiology ; Swett on Diseases of the Chest, edition of 1852; Bow- ditch's Young Stethoscopist; Lawson's Lectures^ in the Western Lancet. 6 PRIZE ESSAY. Cases of tuberculous deposit, with marked disparity of resonance at the sum- mit of the chest on one side, will furnish examples, and such cases are suffi- ciently numerous. But the law may be tested in the healthy subject. The precordial region presents well-marked dullness compared with the corres- ponding region on the right side. The percussion sound in the former situ- ation will answer as a type of resonance, modified by an increased proportion of solid material incident to tuberculous or other disease. A practical advantage of attention to pitch, in employing percussion, con- sists, thus, in its confirming the existence of dullness. It furnishes additional evidence thereof, and adds positiveness to the conclusion, when the mere diminution of resonance might not be with certainty determinable. To the musical ear, more especially if skilled in discriminating musical tones, a dis- parity in pitch is more quickly, as well as more clearly distinguished. It is far easier to appreciate a contrast in this point of view, than to determine a slight, or moderate preponderance of resonance in the percussion sound on one side of the chest. I have frequently illustrated this in teaching physical exploration. A person just essaying to distinguish relative dullness of reso- nance on percussion often fails in its recognition, even when it is pretty strongly marked. He is unable to perceive a difference which is sufficiently apparent to the practiced percussor. Under these circumstances, I have fre- quently inquired if the learner were able to sing, or play on any musical instrument. If he replied in the affirmative, I requested him to compare the sounds on the two sides of the chest as if they were musical notes, with refer- ence to pitch, and the disparity then became immediately manifest. If I am misled with respect to the assistance to be derived in this way, by the results of my own experience, the error involves a kind of self-deception which it is very easy to impart, for many to whom I have pointed out this method of determining dullness, have assured me that they have found it of great utility in practice. By directing attention to the pitch, an intelligent student, with some musical powers and cultivation, will become an expert in appreciating a slight dullness sooner than he can attain to proficiency in the manipulating tact of percussion. Another practical advantage, certainly equal to, if not greater than the foregoing, is derived from the fact that a distinct disparity of pitch may be apparent, in some instances, when a disparity in the amount of resonance is inappreciable. The correctness of this statement my observations lead me not to doubt. Others, however, are to be satisfied by the evidence of their own perceptions. This fact is, stated by Dr. Bowditch in his work entitled the Young Stethoscopist, and I do not recollect meeting with a similar VARIATIONS OF PITCH IN PERCUSSION, ETC. 1 statement by any other writer. He says, " A difference of note or of pitch be- tween two corresponding parts is not uncommon, when there is no real flatness in either. It occurs in cases in which the lung is not by any means imper- vious to air. Sometimes in the early stages of phthisis, and in pneumonia in its early or latest stages:" (page 60, second edition.) In another place, he remarks: " Any degree of dullness, even the slightest difference of note or of pitch, if confined to the upper part of the chest, between the portions equidistant from the spine or sternum, augments my suspicion of the exist- ence of tubercles:" (page 88, ibid.) To measure the exact amount of mere resonance, so as to make an accurate comparison of two sounds that differ but slightly in this respect, it must be evident on a little reflection, is not easy. The truth probably is, that the difference in pitch is perceived when a slight disparity exists which is ordinarily called dullness. And this leads me here to remark, it is not to be supposed that practical chest explorers have not been accustomed to be guided by pitch modifications of sound. Variations in this respect have been perceived without recognition, if this antithesis be allowable. The disparity has been apparent, but attributed solely to diminished resonance or dullness. This remark will be found to apply equally to respiratory, or to percussion sounds. This, however, does not prove that the practice of physical exploration will not be materially aided by directing the attention to the variations in pitch as such. A contrast in percussion sounds in many of the diseases of the chest is sufficiently obvious, requiring no special delicacy of discrimination. This is the case in pleuritis with effusion, in the second stage of pneumonitis, and in phthisis when the tuberculous deposit is abundant. Attention to pitch, under these circumstances, may be said, with truth, not to be of much importance. A flat, and a notably dull sound are readily enough discovered. It is in connection with the diagnosis of the early stage of tuberculosis that the point under consideration is particularly important. Of the importance of the diagnosis of the disease in this stage it is not necessary to speak. In view of the employment of means to arrest the further progress of tuberculization, and the fair prospect, in many instances, of effecting that object, there is per- haps no end in practical medicine more desirable than to determine positively the presence of tubercle before the disease has made much progress. Any addition to our means of giving precision to the diagnosis of incipient phthisis is a valuable contribution, not only to our science, but to our art, inasmuch as the prospect of saving or prolonging life is greater in proportion as the affection is earlier recognized. A disparity at the summit of the chest, however slight, is a sign to which 8 PRIZE ESSAY. great weight should be attached in deciding on tbe presence of tubercle. Practical auscultators generally will concur in the statement above quoted from the treatise by Dr. Bowditch, relative to this point. If, therefore, by attention to the pitch of resonance, we are better able to appreciate a slight shade of difference, or to recognize its existence with greater certainty, there can be no question concerning the service thereby rendered to physical exploration. It is hardly necessary to say, that the usefulness of the means of early diag- nosis in phthisis is to be regarded in both a positive and negative aspect. In other words, it is quite as important to be able to exclude tuberculosis, by the absence of physical signs, as to determine its existence by the presence of these signs, and, hence, improvements in physical exploration have practical relations of equal value, in either direction. Another advantage to be derived from attention to pitch consists in the facility of developing a disparity in situations in which but little resonance can be elicited, owing to the intervention of bone, muscle, and fat between the integument and walls of the chest. A late writer on diseases of the chest says, that the mammary region in females " is of no value in per- cussion."* The same author farther states that, "posteriorly, no advantage can be derived from percussion; the muscles are too thick about the shoulders to admit of a decided advantage even in cases in which the pulmonary con- densation is much greater than in incipient phthisis." These statements are to me surprising. A disparity of pitch is frequently very apparent in the scapular region, both above and below the spine, in cases of tuberculosis, and I have met with it here when it was not marked in the infra-clavicular region. I have demonstrated this fact repeatedly during the short period that has elapsed since the publication of the work from which the above extracts are taken. To dispense with the information from percussion sounds over the scapulae would considerably impair the diagnostic resources in incipient phthisis. The thickness of the muscular coating in other parts of the chest, and even the mamma of the female, do not prevent a comparison of sounds with reference to pitch; but, for reasons obvious enough to the pathologist, the comparison in these situations is less important in diagnosis, save in dis- eases in which the coarsest exploration would suffice to develop flatness, as in pneumonitis and pleurisy. Another advantage relates to the diagnosis of heart diseases. Percussing from the clavicle, the acromial angle, and the axilla, in a direction toward the site of the heart, the points at which there is a distinct modification of pitch * A Treatise on Diseases of the Chest, by John A. Swett, M. D., 1852, pp. 17 and 258. VARIATIONS OF PITCH IN PERCUSSION, ETC. 9 will mark the limits of the organ in these directions, while the point of im- pulse, if perceptible, will give the lower boundary. This method, thus, will be found useful in determining the degree of enlargement in hypertrophy and dilatation, and the amount of effusion in pericarditis. The significance of variations in pitch, as of other points of disparity, in the diagnosis of thoracic diseases, of course, is predicated on the equality of both sides of the chest, in this respect, in health. Does this equality exist? I cannot answer this question quite so explicitly as I could desire. Pitch modifications will necessarily result from causes which at the same time occa- sion obvious dullness, such as spinal curvatures, former pleurisies, arrested tuberculous deposit, &c. These causes, and others, moreover, may occasion, in some instances, a disparity in pitch, when the changes are not sufficient to produce obvious dullness. Comparison in pitch affording a more delicate means of discovering a slight deviation from the symmetry of the two sides, it is not improbable that healthy chests may be less uniformly equal in this particular than with respect to a marked diminution of resonance on one side. The examination of a large number of individuals presumed to be free from pulmonary disease would alone afford the data for answering the above ques- tion positively. I have frequently examined chests, at the summit more par- ticularly, with reference to this point, but without recording the results. Within a few days I have noted observations in twenty-two persons. In all save three, the pitch was equal in the infra-clavicular region, to which atten- tion was more particularly directed. In onet there was elevation of pitch on the right side, apparently owing to greater development of the muscles on this side. In another,, the same disparity existed, the same explanation not beino- so obvious. There was no reason to suspect disease of the lungs in this latter instance. The patient was a young female in perfect health. In the third instance, the percussion sounds were clear and equal at the summit anteriorly, but over the right scapula there existed evident dullness compared with the sound over the left scapula. This person was a mechanic, and the muscular mass in the interscapular space was notably thicker on the right side. It is undoubtedly desirable that examinations of this kind should be multiplied. In practicing percussion with a view to pitch, observance of the rules which are familiar to every practical auscultator is peculiarly important; I allude to the position of the patient, care to strike successively on the two sides at corresponding points, and with an equal force, &c. Tact in eliciting a loud distinct sound is desirable. A smart stroke is frequently more effective for this object than a light feeble blow, not, however, using sufficient force to 10 PRIZE ESSAY. occasion pain. The only pleximeter and percussor with which I have any prac- tical acquaintance are the fingers. It has often occurred to me that other instruments might in some instances be more satisfactory, but I have nothing to say on this topic from my own experience. SECTION II. ON ATTENTION TO THE PITCH OF SOUND IN THE PRACTICE OF AUSCULTATION. My attention has been directed to the variations in the pitch of respiratory sounds more recently, than to those belonging to percussion. It is for a few months only that I have made the former objects of study. During this time, as leisure and opportunities have permitted, I have been accustomed to note observations on the different cases of thoracic disease coming under my notice; and the views which I shall submit in this section will consist of deductions from the data thus collected. Considering the novelty of tbe subject, as well as its importance, I have thought it best to present, not only the conclusions based on what data I have gathered, but a transcript of the data themselves. As an appendix to this section, therefore, I shall give a brief synopsis of the observations which have been made in cases of disease, amounting to over forty in number. A larger collection of data for general- ization is undoubtedly to be desired; but it is to be borne in mind that the aim of this memoir is by no means to exhaust, but rather to open the subject, as one claiming attention, with a view to its practical application to physical diagnosis. I would here repeat that what I shall advance as the results of observations made up to this time, I wish to be considered in the light of propositions to be confirmed, enlarged, and perhaps corrected by continued investigations. As already intimated, to be able to estimate fully the liabil- ity to error of observation in a new field of study like this, may require the fruits of a longer experience. I am led to make this remark the more, in consequence of being sensible that a facility in distinguishing pitch variations in the respiratory sounds is much increased by practice. After what I have said, it is but justice to myself to add that, in making the observations I have noted, I have spared no effort to render them reliable. The point of departure for the study of pitch modifications, as of other physical signs of disease, is the examination of the chest in health. The first inquiry, therefore, in presenting this branch of the subject, will be, what vari- ations in pitch belong to healthy respiration? To this question I will devote a distinct division of this section, VARIATIONS OF PITCH IN PERCUSSION, ETC. 11 VARIATIONS IN THE PITCH OF SOUNDS IN HEALTHY RESPIRATION. With a view to the study of the variations to be found in a healthy chest I have noted the results of physical explorations, more or less complete, of twenty-seven individuals, presumed to be entirely free from any thoracic dis- ease. This number of observations, although too few to settle the numerical ratio of the occurrence of particular phenomena, will probably suffice for the present object, which is merely to determine some general principles to serve as the basis of the study of morbid deviations. Of these twenty-seven individuals twenty-one were males, and six females. The ages were various, all, with a single exception, being above childhood, and none being advanced in life. The majority were young persons from twenty to thirty years of age. The normal respiratory sounds are resolvable into three divisions, according to the parts of the pulmonary apparatus whence they emanate, viz., the tra- chea, the bronchi, and the vesicles. Named from these their anatomical relations, they are the tracheal, the bronchial, and the vesicular. The char- acter of pitch belonging to the sounds produced in these three situations may be considered under distinct heads. 1. Tracheal Sounds. — On placing the stethoscope over the trachea, the respiratory sounds are found to be notably high in pitch. The development, that is to say the loudness of the sounds, in ordinary respiration, varies con- siderably in different persons. In some persons they are quite intense, in others feeble, and even indistinct until the persons are requested to breathe forcibly, when they become much increased. The relative altitude of pitch is immediately perceived on comparing the tracheal sounds with the vesicu- lar respiration heard on listening over the chest. Two sounds are heard uniformly in this situation, viz., the sounds of inspiration and expiration. An interval occurs between these two sounds. The inspiratory is relatively shorter than the expiratory sound. The sound of expiration is higher in pitch than that of inspiration. These results have been uniform in all the observations that I have made. 2. Bronchial Sounds. — Explorations for the bronchial respiration wer^ made anteriorly near the claviculo-sternal junction, and, in a smaller portion of the cases, in the interscapular space posteriorly. Of twenty-three exami- nations in the former of these situations, the bronchial sound was appreciable in twenty, and not discoverable in the remaining three instances. Of four- teen examinations in the latter situation, i. e., the interscapular space, it was 12 PRIZE ESSAY. appreciable in all but one instance. As respects the two situations, in some cases, the sounds were more developed posteriorly than anteriorly, and in other cases the reverse. There was considerable difference in different cases in the degree of development, or intensity of the sounds. In several, no sound was discernible during ordinary respiration, but it became apparent on increasing the force and quickness of the respiratory movements. The pitch of the bronchial sounds is high, probably not much below that of the tracheal sounds, but it did not occur to me to compare the two with reference to pitch, until I began to write on the subject. The point has not much importance. The elevation of the pitch of the bronchial, compared with the vesicular murmur, is to be borne in mind. A comparison of the former, as heard in the interscapular space, and near the sternum anteriorly, with the latter as heard over other parts of the chest, showed, in every instance, a distinct and notable disparity. Other interesting points of distinction pertain to the bronchial sounds. Recollecting the relations, in size and length, of the two primary bronchi to each other, the inquiry arises, if the bronchial respiration heard in corres- ponding situations on both sides of the chest, before and behind, is uniformly equal in intensity and pitch ? With respect to intensity or loudness, of thir- teen examinations it was thought to be somewhat more developed on the left side mfour cases, on the right side in five, and in four cases no difference in this particular was apparent. As regards pitch, the result was different. Of twenty examinations, the pitch is noted to have been distinctly higher on the right side m fifteen, no difference being appreciable in the remainingy?z/e cases. This disparity in pitch between the two sides was not observed in all instances, both anteriorly and posteriorly. Excluding seven instances in which it is merely noted that the pitch was higher on the right side, without specifying whether before or behind, the notations in the remainder of the cases are as follows: 1. No disparity in front, but notably higher on the right side behind. 2. Higher on the right side before and behind. 3. The same. 4. The same. 5. Higher on the right side behindr where the bron- chial sound is alone heard. 6. Slightly higher on the right side in frontf no difference being appreciable behind. 7. Higher on the right side before and behind. 8. The same. The existence of a disparity in the bronchial sounds of the right and left side, attributable to the difference in size and length of the bronchial divisions of the trachea, has been pointed out by Dr. Gerhard, of Philadelphia, but the fact has not been recognized by all auscultators. Dr. Stokes, on the con- trary,, has taught that a disparity frequently exists, but that the bronchial VARIATIONS OF PITCH IN PERCUSSION, ETC. 13 character is apt to be more apparent on the left than on the right side. Dr. Gerhard speaks of the respiration being more blowing or tubular on the right side. If my observations are correct, both Dr. Gerhard and Dr. Stokes may be right, the discrepancy arising from confounding different elements which enter into the bronchial respiration. It is occasionally more developed, that is to say, louder on the left than on the right side. So far Dr. Stokes is cor- rect, but in a very large majority of persons the pitch is higher on the right side, while this relative elevation never obtains on the left; and, as the pitch is one of the most prominent of the elements of the bronchial respiration, the foregoing results accord with the fact pointed out by Dr. Gerhard. The observations of these two distinguished writers are thus apparently not reallv inconsistent with each other. In degree, or loudness, the normal bronchial respiration presents in differ- ent individuals great variations. In this point of view, it has no uniformity. It is never intense, and, in some persons, is quite faint, requiring a forcible respiration to develop it sufficiently to study its characters; and it is not appreciable in all persons. In a certain proportion of the cases in which the normal bronchial respir- ation is heard, not uniformly, a sound of expiration is appreciable. Of thir- teen instances in which the inspiratory sound was present, a sound of expira- tion also existed, the latter being absent in four. The sound of inspiration may be heard behind and not in front, or on the right side and not on the left. The facts with respect to these variations contained in the few obser- vations I have noted are as follows: Of the above thirteen instances, in six the sound of expiration was perceived only on the right side, either in front or behind, and in seven it was appreciable behind, and not in front. The sound of expiration appeared to be higher in pitch than the sound of inspiration, in every instance in which attention was directed to this point* This fact is noted in nine observations, an exception thereto not being noted in any. Thus, in this trait the normal bronchial respiration resembles the tracheal. In every instance in which attention was directed to the succession of the sounds of inspiration and expiration, an interval between was observed. Thi* feature belongs to the bronchial, in common with the tracheal respiration. It will thus be noticed that, in the more important of the elements of the tracheal and bronchial sounds, they are similar. They both want a distinct- ive quality which will be seen to characterize the vesicular respiration. They are both high in pitch, in this respect probably not differing much from each other. The inspiratory sound in both is short. The expiration in each is 14 PFIZE ESSAY. higher in pitch than the inspiration; the difference with respect to this point between the tracheal and bronchial respiration being that in the latter an ex- piratory sound is heard in a certain proportion of cases only, while it is uni- formly heard in the former. In each, an interval occurs between the sounds of inspiration and expiration. The characters distinguishing the two kinds of respiration consist in the greater intensity of the tracheal sounds, the uni- formity with which they are heard in different persons, and the constant presence of an expiratory sound. 3. Vesicidar Respiration. —- The vesicular respiration, as is well known, differs from the tracheal and bronchial in having a peculiar quality, not capa- ble of being very definitely expressed by language, but which is readily enough appreciated by the practiced ear. The terms breezy and expansive, perhaps, approach as near a definition as can be done by words. This quality of sound is sui generis, and familiarity with it is very necessary to the practical auscultator. The peculiarity alluded to may be characterized as, par excellence, the vesicular quality. I shall have occasion to refer to it hereafter by this title. In what other particulars does the vesicular respiration differ from the two varieties already noticed ? The difference in pitch is striking. The pitch is uniformly and notably lower than that of the tracheal or bronchial respiration. This was true of all the cases examined with reference to healthy variations. As a point of difference, it is one to which, in connection with the subject of this memoir, special attention is desired. An expiratory sound is appreciable in a less number of instances than is the case with the bronchial respiration. Of nineteen examinations with ref- erence to this point, the expiration was heard in nine. The pitch of the expiratory sound, when it is heard, compared with that of the inspiration, is another point of special interest in the present inquiries. Of eight observa- tions in which the facts relating to this comparison were noted, the pitch of the expiration was lower in all but two instances. In these two instances, the pitch of expiration was higher in the right infra-clavicular region toward the sternum, no expiratory sound being appreciable, in either instance, except in the situation first mentioned. So far as these examinations go, then, the rule is, that the sound of expiration in vesicular respiration is lower in pitch than the sound of inspiration, with occasional exceptions* at the summit of *.The sound of expiration is oftener heard when the vesicular sounds are exaggerated VARIATIONS OF PITCH IN PERCUSSION, ETC. 15 the chest on the right side toward the sternum. This rule, without the ex- ceptions, is stated by Dr. Walshe in the last edition of this work on the heart and lungs. Aside from the foregoing differences, the duration of the inspiratory sound, in the vesicular respiration, is longer than in the tracheal or bronchial. The expiratory sound on the other hand, is as notably shorter; and when a sound of expiration is appreciable, it is nearly or quite continuous with the sound of inspiration. The latter statement I give on the authority of others, and my own unrecorded experience, not having taken pains to note the facts relating to the point in the healthy observations made with reference to the subject under consideration.* There are some other variations in pitch which are of practical interest. The pitch of vesicular respiration at the upper part of the chest is higher than at the lower. This I have noted in eleven observa- tions, which were all that have been made relative to this point. The pitch does not appear to be sensibly raised by increasing the force of the respira- tory movements. It seems to remain the same in ordinary and forced respir- ation. This I have noted in eight observations, being all that were made relative to the point. The vesicular respiration has a sensibly higher pitch at the summit of the right than of the left chest, in a large proportion of indi- viduals. Of fifteen examinations relative to this point, the disparity just noted was found to be more or less marked in eleven instances, no difference between the two sides being apparent in the remaining four. The practical bearing of the several facts stated in this paragraph on physical exploration in disease will be at once obvious. In conclusion, while the tracheal and bronchial sounds were found to be essentially the same in character, the circumstances distinguishing each from the other being rather incidental than intrinsic, the vesicular respiration, on the other hand, contrasted with the two former, exhibits some striking points of dissimilarity. It has that inexpressible peculiarity distinguished as the vesicular quality. The inspiratory sound is lower in pitch. The expiratory sound, when heard, save in a limited situation, is lower than the sound of inspiration, the reverse of this being true of the tracheal and bronchial sounds. in supplementary respiration. In the clinical observations of cases of pneumonitis, the presence of a sound of expiration on the healthy side, and the lowness of pitch compared. with the sound of inspiration, are noted in several instances. See Appendix, First Series. Cases of Pneumonitis. * The continuousness of the expiration with the inspiration is noted in several of the clinical observations, in which the lungs pi one side were free from disease. See Appendix, First Series. — Cases of Pneumonitis. 16 PRIZE ESSAY. Distinctive features less prominent, but important, are the greater length of the inspiratory sound, the shortness of the sound of expiration, the continuity of these two sounds, and the fact that in a large proportion of cases the sound •of inspiration alone is appreciable. VARIATIONS OF PITCH IN RESPIRATORY SOUNDS IN CASES OF DISEASE. In treating of morbid variations, it will be most convenient to consider. under separate heads, the different diseases in which they have been studied. The divisions will then correspond with those of the clinical observations given in the Appendix to this memoir. Pneumonitis. — The present inquiry respecting pitch variations of sound has no reference to rales. The crepitant rale in the first stage of pneumonitis frequently drowns other sounds. The modifications which relate to the present subject are incident to the solidification belonging to the second stage of the disease. More or less crepitation, as is well known, may continue into this stage, being heard at the end of the inspiratory act. Under these cir- cumstances, enough of the respiratory sound may be heard, before it is lost in the crepitation, for the pitch to be compared with that of the respiratory sound on the healthy side. The observations pertaining to pneumonitis, among those which I have collected, amount to twelve. This number might have been increased since my attention has been directed to this subject, but it is probably sufficient for the present object. In each of these observations, the pitch of respiration was notably high, presenting a striking contrast, in this respect, with the respiration on the healthy side. The disparity, as I have noted in one of the observations, is sometimes as obvious as between a fife and German flute. Of these twelve observations, an expiratory sound was more or less developed in eight instances. In tivo, a sound of expiration was not appreciable; in one instance, it was appreciable, but too feeble for its characters to be studied, and in one instance the fact as to the presence or absence of the expiratorv •smnd is not noted. The pitch of the sound of expiration was higher than t'.iat of inspiration in every instance in which attention was directed to this point, save one. In the excepted instance, the observation was made in an early stage of the disease; the crepitant rale persisting, the expiratory sound was feeble, and the fact of its being lower is stated somewhat distrustfully. The expression is, it appears to be l^wer in pitch. The correctness of this .observation seems to me open to doubt, for, as I have had occasion to notice, VARIATIONS OF PITCH IN PERCUSSION, ETC. 17 there is a liability to err in estimating the pitch of a faint sound of respira- tion. Its feebleness may, without due attention, give rise to the impression that it is lower in pitch. With this doubtful exception, the elevation of the, pitch of expiration over that of inspiration was uniform, wherever the expira- tory sound was sufficiently appreciable to study its characters. Aside from what relates to the above pitch modifications, the facts noted with respect to other characters are as follows: The inspiration was short- ened in every instance in which attention was directed to this point This is noted mfive observations. An interval was observable between the sounds of inspiration and expiration in all the observations containing information on this point: viz., in six. The expiration was prolonged whenever attention was directed to this point. It is noted in five observations. The characters, then, belonging to the respiratory sounds incident to pul- monary solidification in pneumonitis, are, elevation of the pitch of both inspiration and expiration; a higher pitch of expiration than of inspiration, whenever the former is heard, almost if not quite uniformly; a shortened inspiratory sound; a prolonged sound of expiration; and an interval between the sounds of inspiration and expiration. The respiration in the second stage of pneumonitis, as is well known, is sometimes characterized as tubular, and sometimes as bronchial. As con- trasted with the vesicular respiration, the first term is certainly significant. The sound may also, with great propriety, be called bronchial, for, on com- paring the several points just mentioned with the different elements entering into the normal tracheal and bronchial sounds, more especially the latter, it is perceived that they are essentially identical. The bronchial respiration in pneumonitis is neither more nor less than the bronchial respiration heard in the healthy chest in certain situations. One of the chief points of difference between the normal bronchial and tracheal sounds, it has been seen, is the greater intensity of the latter. The respiratory sounds in pneumonitis vary considerably, in different cases, in degree. The intensity appears to be a contingent, rather than an intrinsic element. In some instances, the devel- opment of sound is fully equal to that heard over the trachea, and it may be even louder than is the tracheal respiration in some individuals. This com- parison of the respiration in pneumonitis with the tracheal and bronchial sounds would naturally enough lead to inquiries respecting the physical phi- losophy of the identity in their characters. Such inquiries, however, are en- tirely foreign to my present purpose. To contrast the respiration of pneu- monitis with the normal vesicular murmur would be to repeat the points of inference already noticed in connection with the variations incident to health. 2 18 PRIZE ESSAY. The disparity is, of course, based on the same circumstances as that between the tracheal and bronchial, and the vesicular sounds. Pleurilis. — The observations relating to pleuritis were made but in three cases. So far as these cases go, they show that, when considerable effusion exists, the sound over the compressed lung is high in pitch, presenting, also, more or less of the other characters belonging to the bronchial respiration. After the fluid has been removed nearly, or quite, by absorption, more or less pleuritic adhesions limiting the expansibility of the affected side, the respiratory sound, having resumed the vesicular quality, is relatively feeble when compared with the sound on the other side which is exaggerated, but a disparity in pitch may not be appreciable. If, however, the quantity of effusion has been large, so as to have distended greatly the chest, and led to considerable contraction after the absorption is effected, then, in connection with some permanent dullness on percussion over the affected side, the pitch of respiration may be higher than on the other side, although the vesicular quality and other characters of the vesicular respiration are resumed. For the exemplification of these statements the reader is referred to the Appendix, Second Series of Observations. Gangrenous Excavation, and Pneumothorax with Perforation. — I have had an opportunity of observing, since my attention has been directed to this subject, the respiratory sounds in but one instance of gangrenous excavation, and one of pneumothorax, both occurring in the same case. Over, or near the site of the gangrenous excavation, which was consider- able in size, the sound was noted to be non-vesicular, and low in pitdi; as respects the latter, presenting a striking contrast with the sound heard at the -.mimit of the chest, in the same case, where the lung was solidified by com- pression. Over the latter, the sound was equally non-vesicular, but high in pitch. The entrance of air into the pleural cavity through a perforation of about the size of a goose-quill occasioned a sound, non-vesicular, and low in pitch. For a brief account of the case, together with the autopsical appearances^ the reader is referred to the Appendix. Tuberculosis. — The physical signs incident to tuberculosis have relation not merely to the presence of the morbid deposit, but to its amount, and the stage of the affection. The study of the disease, with reference to the prin- ciples of diagnosis, thus presents itself under somewhat different aspects. VARIATIONS OF PITCH IN PERCUSSION, ETC. 19 During the past two months, I have recorded observations, with respect to variations in the pitch of respiration, in twenty-five cases of tuberculosis. I propose to examine the results of these observations under four heads, con- forming to the distribution of the cases into four groups in the Appendix to this memoir. Following this arrangement, I shall consider, first, the obser- vations in cases in which the tuberculous deposit was supposed to be small in amount; second, when the quantity of the deposit was comparatively abun- dant; third, when the disease had proceeded to the stage of excavation; and fourth, when the affection appeared to have been arrested. I. Observations in Cases of Small Tuberculous Deposit. — Pleven of the cases fall under this subdivision. In each of these cases, the pitch of respiration was found to be higher over the site of the tuberculous deposit, as determined by relative dullness on percussion. In order to test the reality of this variation, and ascertain whether the perceptions might not be influ- enced by preconceptions, in several of the cases included in this and the next subdivision, auscultation with reference to the pitch was practiced prior to percussion, or any other examination of the chest. In every instance, the pitch modification indicated the side on which relative dullness on percussion was afterward found to exist. I have frequently caused this experiment to be made by several young gentlemen, medical students, who have accom- panied me in my hospital visits, and with uniform success. That is to say, the difference in the pitch of respiration furnished a ready criterion of the existence, or greater abundance of the deposit on one side, before resorting to percussion or other signs. In some of the observations, the mere fact of elevation of pitch on one side is stated. I was at first satisfied with simply ascertaining this fact, without attending particularly to the expiration, or other points. In several of the eases, however, the observations were more comprehensive. It is noted that the sound of expiration was appreciable in six cases, and inappreciable in two; in three of the observations, nothing being stated on this point. The expiration is stated to have been prolonged in four cases. In five cases, the expiration was thought to be either equal to, or higher in pitch than the inspiration: or, to be exact, in three of these five cases it was thought to be higher; in the other two, it is stated to have been as high, if not higher. In some cases the vesicular quality was obviously impaired, in connection with the elevation of pitch; but in other cases, disparity in this respect was 20 PRIZE ESSAY. not obvious. So, with regard to development or intensity of sound, it was sometimes diminished, but not invariably. To determine the presence of a small amount of tuberculous deposit, in other words, the diagnosis of incipient phthisis, is frequently one of the most difficult problems in practical medicine. Certainly, the employment of phy- sical exploration with reference to this point requires as much accuracy, care and skill as in any of its applications. Several of the auscultatory signs which have more or less importance as indicating the presence of tubercle, are only occasionally present, and the evidence furnished by them is circum- stantial, rather than positive. This remark applies to the signs denoting cir- cumscribed bronchitis, pneumonitis, or pleurisy, in proximity to the morbid deposit; the sibilant or mucous idles at the summit of the chest; the crepi- tant rale, or friction sound, heard in the same situation. Other signs which are doubtless of importance in this connection, must be regarded as some- what equivocal, such as the jerking respiration, and a prolonged expiration. The most direct and constant of the signs incident to a small tuberculous de- posit is the modification known as the rude, sometimes called the harsh or rough respiration. This modification has relation to the present subject, while, to consider the other signs referred to, in this connection, would be irrelevant. For the novice in the study and practice of physical exploration, the rude respiration is generally, of all the signs, the one most difficult to be appre- hended. There is probably, no sign which causes the teacher or writer more embarrassment in his efforts to explain clearly. Take, for example, the de- scription by Dr. Hughes, author of a very lucid treatise on physical diagnosis. Speaking of the rude, compared with the vesicular respiration, he says, it "is the forte of the same note, but on a loose and jarring string;" and, again, contrasting it with the normal vesicular murmur, he says, " In the one, the same soft breeze passes through a greater number of trees; in the other, the breeze is increased to a moderate gale." Not only is there a singular indefi- niteness in the idea conveyed by this language, but the analogies selected for illustration are defective in correctness. The note is not the same in rude, as in normal respiration, and the comparison to the gale is calculated to give the erroneous impression that the rude respiration is necessarily louder than the normal, which is so far from being true, that it may be in a notable de- cree less developed; the intensity being a variable element, having nothimr to do with the distinctive character of the sign. The truth is, these terms rude, rough, and harsh, are unfortunate; they are not only inexpressive, but tend rather to mislead in the apprehension of the modification referred to. VARIATIONS OF PITCH IN PERCUSSION, ETC. 21 The sound is not intrinsically rude, or rough, or harsh. Even a well-marked bronchial respiration, to which the sound under consideration is an approxi- mation, can hardly be said to have the qualities indicated by these terms. The bronchial respiration is not very unlike in character the endocardial sound, which is characterized as a soft bellows murmur. Whatever appro- priateness the designation has, is based chiefly on the fact that, in the rude respiration, the peculiar expansive, breezy attribute of the vesicular respira- tion, which has been referred to as the vesicular quality, is more or less impaired. To form a correct idea of the modification usually termed rude, &c, it must be analytically decomposed, and the nature of its elements determined. It is an approximation to the bronchial respiration. It exhibits an incipient development of the character distinguishing the bronchial from the vesicular respiration. One of the most striking of these characters is the change in pitch. The pitch is raised. The vesicular quality is diminished; hence it approaches to a tubular or blowing respiration. The inspiration may be somewhat shortened, and occasionally a sound of expiration becomes devel- oped and prolonged, constituting an important rhythmical variation. By attention to these several points, much will be gained in practically recogniz- ing the modification; but it is not easy to find a satisfactory title to be sub- stituted for the names generally in use. Of tbe several elements mentioned here, as in the case of the bronchial respiration, it seems to me the pitcii modification is the most striking, and the most readily appreciated, while it is probably the most constant. The expiration deserves to be distinctly noticed. Considerable importance has been attached to a prolonged expiration, since its occurrence was pointed out as a frequent sign of early tuberculization, by James Jackson, the younger, of Boston, Mass. The best practical authorities have recognized this sign as a valuable contribution to the art of physical exploration. It is not, how- ever, a constant modification. Its absence, therefore, does not furnish ground for the conclusion that tubercle does not exist. Moreover, it may exist as a normal peculiarity, and consequently alone it is not perfectly reliable. In the few instances among the cases I have collected in which a prolonged expiration was present, and the pitch noted, it was found to be higher, or as bioh as the sound of inspiration. Now, in health, over the greater part of thl chest, if a sound of expiration be appreciable, it is found to be distinctly lower in pitch than the sound of inspiration. May it not be that the eleva- tion of pitch in expiration has a diagnostic value fully as great, or even greater than when the inspiration is thus modified ? May it not be that, in 22 PRIZE ESSAY. some cases in which the inspiration is not sensibly raised in pitch, the expira- tion may exhibit a change in this respect, and thus the latter furnish a more delicate sign of the presence of the disease ? These are interesting, and pos- sibly important questions, which are to be satisfactorily answered only by an accumulation of observations. It occurs to me here to remark (what would have been more appropriate in connection with pneumonitis,) that the observations of Jackson and others have showed the expiration to become earliest, and in the most striking de- gree changed, in the development of the bronchial respiration. This fact would lead to the presumption that, in the modification generally known as the rude respiration, the change would be first and most distinctly declared, in the expiration. The expiration in the development of bronchial respira- tion is said first to exhibit the bronchial character. Although not hitherto recognized as such, I can have little doubt that the change thus noticed con- sists chiefly in the elevation of pitch. This produces a more striking change in the expiration than in the inspiration, because the change is really greater in amount. The expiration in health is lower in pitch, while in the bronchial it is higher than the inspiration. The degree of modification is, therefore, greater than in the case of the inspiratory sound. In conclusion, it is highly important to bear in mind that the pitch of respiration at the summit of the right chest is frequently higher than on the left side, and that this may, or may not coexist with a greater development and prolongation of the sound of expiration on the right side. The practical inference is that these modifications, when present on the right side, are, in themselves, less significant than when they occur on the left side, and, in the former situation, are to be less confidently relied upon, especially in the absence of marked rational evidences of tuberculous disease. II. Observations in Cases in ivhich the Tuberculous Deposit was abun- dant.— The cases arranged under this head are comparatively few in num- ber, amounting to but five. In each of these cases, on the side in which the tuberculous deposit was most abundant, as declared by the relative dull- ness on percussion, and other signs, the respiratory sound was found to be haher in pitch than on the side in which the morbid product was less in amount. In three of the cases, the disparity in the pitch of respiration is simply noted in general terms. In the fourth observation, it is stated that there existed a prolonged expiration, with an interval between the sounds of inspiration and expiration. The expiratory sound, however, was so feeble that its pitch was not ascertained.. VARIATIONS OF PITCH IN PERCUSSION, ETC. 2-i In the fifth observation, an expiratory sound is stated to have been pre- sent, higher in pitch than the inspiration, with an interval between the two sounds. So far as these observations go, they lead to the conclusion that the respi- ratory sound over the site of an abundant tuberculous deposit, when it is appreciable, or not obscured by rades, will be found to be elevated in pitch, and presenting more or less of the other characters distinguishing the bronchial respiration. III. Observations in Cases of Tubercle advanced to the Stage of Exca- vation.— The cases coming under this head are of special interest, having reference to the study of the variations in the pitch of respiration occasioned by the presence of a cavity or of cavities within the chest. It has been seen already, in the single case of perforation of the lung and gangrenous cavity, presented in another division, that cavernous respiration, under these circum- stances, was low in pitch. This was true in all the cases of tuberculous excavation embraced in this subdivision. The cases studied with reference to the cavernous respiration are seven in number. In one of these cases, how- ever, the existence of cavities which had been predicated on physical signs, was disproved by post-mortem examination. This case is included in the series for convenience, and serves to illustrate certain points in diagnosis which are to be carefully attended to, in order to avoid an erroneous conclusion. Of the i-femaining six cases, in two, autopsical examinations were made, show- ing the existence of cavities, and their situation with reference to the parts of the chest where the physical signs of excavation had been determined, as noted in the recorded observation before death. The dissection, in both in- stances, was made at my request, by Dr. John C. Dalton, Jr., to whom I am indebted for reports of the morbid appearances. The attention of the reader is particularly invited to the eases which include autopsies. (See Observa- tions 1 and 3, under same head in Appendix.) In the four cases without autopsies, the existence of excavations, and their particular situations, are not, of course, demonstrated. The evidence consists of the physical signs, and other facts, pertaining to the histories. So far as the observations go, they show, as already remarked, that the pitch of the cavernous respiration is low, contrasting in this respect strongly with the high-pitched bronchial respiration. This is not claimed as a newly discovered fact. It is stated by Dr. Walshe, in the last edition of his treatise on diseases of the lungs and heart; and is implied in the language used by ]3arth and Roger. It is not, however, dwelt upon by either with much em- 24 PRIZE ESSAY. phasis, and, if I am not mistaken, it does not generally receive, with practical auscultators, attention as a diagnostic criterion.* The pitch of the expiration, when it enters into the cavernous respiration, does not appear to have attracted notice. In the cases I have observed, in which the sound of expiration was appreciable, the pitch was lower than that of inspiration. This forms a striking feature distinguishing the caver- nous from the bronchial respiration. In the latter, as has been seen, tbe sound of expiration, when appreciable, is higher, or at least equal in pitch to the sound of inspiration. The cavernous sound is, of course, devoid of what has frequently been referred to as the vesicular quality of normal respiration. This point is gen- erally noted in the observations. It is a point important to be borne in mind in determining the presence of a cavernous respiration; else the vesicular murmur, with its low pitch of inspiration, followed by a still lower expira- tion, may be thought to denote an excavation. Obs. 7 (see Appendix) illus- trates the liability to error incident, in part, to not observing sufficiently this precaution. The following elements, then, combine to form the cavernous respiration: A blowing sound, that is to say, a sound in which the vesicular quality is absent; a low pitch compared with that of the bronchial sound; an expira- tion, if present, lower in pitch than the inspiration. Keeping in view these characters, it is probably easy, in most instances in which there are cavities of any considerable size, to determine, with precision, their particular situations, by ascertaining the limits circumscribing the space over which a well-marked cavernous respiration is found to be present. We are assisted in defining the boundaries of these spaces by the fact that exca- vations are generally surrounded by tuberculous consolidation which will be likely to raise the pitch, and thus exhibit the cavernous sound in stronger contrast. If, however, this were not true in any instance, but, on tbe con- trary, supposing a cavity to be surrounded with lung giving a vesicular sound, we can generally satisfy ourselves of the lowness of pitch (having already satisfied ourselves of the non-vesicular character of the sound in ques- tion,) by comparing it with the normal bronchial respiration heard at the- sterno-clavicular junction, or with the tracheal respiration. A cavity at the apex of the lung will be more readily discovered by the respiration if it be * For example, in a treatise on disease of the chest, issued during the present year, I find the following statement: "A naturally cavernous respiration exists over the trachee. and larynx," VARIATIONS OF PITCH IN PERCUSSION, ETC. 25 anteriorly and superficially situated. It is hardly necessary to add that it must be more or less empty, and communicate more or less freely with the bronchial tubes. To ascertain the pitch and other characters, also, the respiration in the surrounding lung must be free from r&les. Tuberculous excavations, as is well known, generally coexist with a greater or less amount of crude tuberculous deposit. In cases, therefore, which pre- sent the physical signs of cavities, we have a high-pitched non-vesicular sound, i. e., the bronchial respiration, more or less, over parts of the chest, at its summit, in which the cavernous variations are absent. The observations in the cases of tubercle advanced to excavation furnish illustrations of this fact. In searching for the sites of cavities, the stethoscope is obviously preferable, since it enables us to circumscribe better the source of sounds. In immedi- ate auscultation, the sounds are received from a wider circuit. The character of the respiration, as heard by the latter method, will depend on the predom- inance of excavations or solidification within a certain distance of the part to which the ear is applied. If a large cavity exists, or several cavities, although the intervening tissue be solidified so as to give dullness on percussion, the pitch of respiration may be lower than on the other side in which the tuber- culous disease is less advanced. There, the combination of a low, non-vesi- cular respiration, with dullness on percussion, affords presumptive evidence of the stage of excavation. This is illustrated by Obs. 1. See Appendix. The importance of attention to the pitch variations in determining the presence of the cavernous respiration is enhanced by the fact that other phy- sical signs of excavations are inconstant and unreliable. A tympanitic reso- nance on percussion cannot be depended on. It may be absent although cavities exist, and may be present without excavations. The cracked pot variety is rarely discoverable, and may be due to the expulsion of air from the bronchial tubes or other morbid conditions. Pectoriloquy, which was regarded by Laennec, as a pathognomonic sign, is not only frequently absent, but does not possess that distinctive significance attributed to it by the illus- trious founder of auscultation. Between pectoriloquy and intense broncho- phony there is no intrinsic difference. In other words, pectoriloquy is but a variety of bronchophony, and may occur not only in cases with excavations, but when the lung between a bronchial tube and the ear is in a state of solidi- fication from tubercle or effused fibrin. For this statement I have the au- thority of Dr. Walshe. But, if it be substantiated by a sufficient number of observations that a cavernous respiration is uniformly low in pitch, with a sound of expiration lower than the inspiration, these traits, taken in connec- tion with its blowing or non-vesicular character, will suffice for its recognition, 26 PRIZE ESSAY. and consequently, not only for the diagnosis of the stage of excavation, but the localization of the cavity, the estimation of size, &c. IV. Arrested Tubercle. — During the time I have been engaged in mak- ing observations with reference to the present subject, two cases have fallen ander my notice in which the tuberculous disease appeared to have been arrested; in other words, the morbid product had not continued to accumu- late, nor had the primary deposit advanced through the processes of soften- ing and excavation. The cases have not any special importance in connection with the subject of this memoir. I have given them under a distinct head in the Appendix, because they are distinguished from the other cases by the fact of the disease having ceased to make progress. In this point of view, the cases are not without interest. In the first case, the disease was declared a year previous, and some cough and expectoration still remain. In the second case, the rational symptoms marking the period of the tuberculous deposit occurred several years ago, and the patient is entirely free from any symptoms of pulmonary disorder. In both instances, the disease has left permanent evidence of slight injury to the lung on one side, consisting of disparity of resonance on percussion, and an elevation of the pitch of respiration. The arrest of tubercular disease is doubtless much more frequent than has been heretofore recognized; and with the views now entertained by the most intelligent practitioners respecting the pathology of tubercle, and the proper ends of treatment, there is reason to hope that cases of this kind will become more numerous. As one of the causes of a lasting disparity between the two sides of the chest in the physical signs developed by percussion and aus- cultation, this is to be borne in mind in the examination of patients with reference to existing pulmonary affections. In the practice of auscultation with the view to pitch variations, the same rule of course obtains which is applicable to physical exploration in general, viz., the sounds of the two sides of the chest, in corresponding situations, are to be listened to in succession, and compared with each other, always recol- lecting to make due allowance for certain natural deviations which are deter- mined by observations made on persons in health, and also, as just remarked, bearing in mind the changes incident to pre-existing disease. That the respir- atory sounds may present strongly-marked variations in pitch will be readily understood, if it be observed for a moment how easy it is to breathe audibly with the mouth in unison with musical notes, and even in this way to hum a VARIATIONS OF PITCH IN PERCUSSION, ETC. 27 tune. Almost any one who has any fondness* for music is practically famil- iar with this. Or, as an illustration, let the pitch of sound be observed when different words or letters are whispered, after the ingenious method of repre- senting the variations in pitch of the bellows murmur of the heart, suggested by Bouillaud and Hope. The letters R, S, and the syllable who, thus exhibit quite different degrees of altitude in pitch. It is easy to distinguish the dif- ference in pitch among endocardial sounds. There is no greater difficulty in appreciating variations in this respect in pulmonary sounds. A musical ear is doubtless an advantage, as also some musical cultivation; but neither is absolutely essential. A medical student who has been accustomed to follow me in my examinations, and who is unable to distinguish one tune from another, finds no difficulty in recognizing the pitch variations in respiration, and in several instances has made and noted observations by himself which have corresponded with mine. The practice of comparing the pitch of respir- atory sounds doubtless leads to an increased facility in directing the attention to, and clearly perceiving variations. This I have found in my short experience, since I have been particularly interested in the subject. In conclusion, the more important practical deductions submitted in this section are recapitulated in the following summary. These deductions, I would again repeat, are submitted as propositions to be confirmed, enlarged, or corrected, by further investigations: 1. In the second stage of pneumonitis, the inspiratory sound is high in pitch, followed by an expiratory sound, which is frequently, if not generally hioher in pitch than the sound of inspiration; these traits being found in conjunction with more or less of the other characters which belong to the bronchial respiration. 2. In cases of small tuberculous deposit, or incipient phthisis, the most striking modification of the respiratory sound is the elevation of pitch. This elevation of pitch is an important element of what is generally known as the rude, rough, or harsh respiration. If an expiratory sound be appreciable under these circumstances, it may be as high, or higher in pitch, than the sound of inspiration, and the variation of pitch in the former is greater, inas- much as the pitch of expiration in the normal murmur is lower than that of inspiration. Elevation of the pitch of expiration, therefore, may be found to * The pitch of a respiratory sound may be readily imitated by modulating, with the lips, breath sounds in the mouth. I have sometimes found this useful in comparing the pitch of sound in the two sides of the chest. 28 PRIZE ESSAY. be valuable as a sign of incipient phthisis in some cases in which the variation in the inspiration is not marked. 3. If the tuberculous deposit be more abundant, the pitch of respiration is in a more marked degree elevated. The expiratory sound, if appreciable, will be likely to be as high, or higher in pitch than the sound of inspiration. More or less of the other characters of the bronchial respiration are at the same time present. 4. In pleurisy with effusion, the pitch of respiratory sound is elevated, in conjunction with more or less of the characters of the bronchial respiration, over the parts of the chest lying above the compressed lung. In cases of large effusion, after its complete removal by absorption, the affected side may continue to present a variation in pitch, the symmetry of the two sides being permanently impaired, in this respect, after the vesicular quality of respiration is regained. 5. In cases in which tubercle has advanced to the stage of excavation, the site of a cavity of considerable size is indicated by a blowing sound, low in pitch, with an expiratory sound (if appreciable) lower in pitch than the sound of inspiration. These traits constitute the elements of the cavernous respira- tion, and the cavernous respiration is the most constant and reliable of the signs of an excavation. If the cavity be very large, or there are several cavities, the respiration may be modified to such an extent that, on immediate auscultation, over the whole summit of the chest, it may present the cavernous characters. This may be the case while dullness on percussion shows the existence of more or less solidification in connection with the cavities. The coexistence of relative dullness on percussion, and a low-pitched blowing respiration, denotes the predominance of excavation. The cavernous respiration may also be present in cases of excavation from circumscribed gangrene, and in pneumothorax with perforation. 6. In arrested phthisis, the traces of the disease may be manifested by a permanent variation in the pitch of respiration, in connection with more or less dullness on percussion at the summit of the chest on either side; APPENDIX. CLINICAL OBSEEYATIONS. The following account of clinical observations embraces a synopsis of the characters of respiratory sounds relating to the subject of the foregoing essay, as noted at the time the examinations in the cases severally were made. Aside from these, details pertaining to the histories of the cases will be introduced, only so far as they seem to be important with reference to the diagnosis, the stage' of disease, or the appearances found after death. The object will be to condense as much as practicable, with due regard to the points just mentioned. For convenience of reference, the observations are distributed into different nosological groups; cases of each disease forming a distinct series. The classification of the observations corresponds with the arrangement of subjects in the foregoing essay, so that reference from either to the other may be easily made. FIRST SERIES.—'PNEUMONITIS. Observation I.— Dec. 30, 1851. Hospital patient. Pneumonitis affecting lower lobe of right lung. Second stage of the disease. Loud tubular respi- ration over the site of the solidified lung. Pitch of respiration notably high. Q0St 2.— Jan. 27,1852. Wm. Hasmer. Hospital patient. Disease of seven days' standing. Flatness on percussion over the lower third of chest, posteriorly, on the left side. The respiratory sound is bronchial or tubular, the inspiration somewhat shortened; a prolonged expiration is present, with an interval between the sounds of inspiration and expiration. Over the in- ferior third of the right side, posteriorly, the respiration is vesicular, supple- mentary, without any sound of expiration. The pitch of sound on the left side, compared with the right, is in a marked degree high, the contrast nearly as striking as betwean the sound of the fife and German flute. Obs. 3.— Jan. 29. George Young. Hospital patient. Has been confined to bed four davs. Dulness on percussion exists over the inferior third of the left chest. Over this portion the respiratory sound is notably higher in pitch than over the corresponding region of the right side. The inspiration is somewhat shortened. There is a faint but prolonged expiration, and an interval between the two sounds. Obs. 4.— Jan. 30. Mary Gaball. Hospital patient. Disease occurring 30 APPENDIX. as a complication of continued fever, third day after taking to the bed. Pneumonitis confined to lower lobe of the right lung. Inferior third of right chest, jDOsteriorly, flat on percussion. The pitch of respiration over this region is notably higher than on the corresponding region of the left side. The expiration is somewhat prolonged, and higher in pitch than the inspiration. A short interval between inspiration and expiration. Obs. 5.— Wm. Wrick. Hospital patient. Disease affecting upper and middle lobes of the right lung. Respiration on the right side, posteriorly7, bronchial; the pitch high, inspiration shortened, and the expiration prolonged. The pitch of the expiration is notably higher than that of inspiration. An- teriorly, the respiratory sounds on the right side too feeble to determine the pitch, &c. On the 9th of February, the respiratory sound on the right side anteriorly sufficiently developed to study characters. It is bronchial, higher in pitch than on the left side; expiration prolonged; inspiration shortened, and an interval between the two sounds. The pitch is distinctly higher than on the left side. On the left side the respiration is supplementary. A faint sound of expiration is appreciable, continuous with the sound of inspiration, and apparently lower in pitch than the inspiratory sound. Obs. 6.— Feb. 10. Catharine Finn. Hospital patient. Disease affecting middle lobe of right lung. In first stage. Crepitant rale in mammary and axillary regions. The crepitation obscures the recognition of pitch. On the left side the respiration is supplementary. An expiratory sound is present on this side, continuous with the sound of inspiration, and notably lower in pitch than the inspiratory sound. Feb. 11. Crepitant rale still heard in mammary region of right side. Posteriorly, over the middle third of the right side, there exists moderate relative dulness on percussion. A feeble crepitant rale is heard in this region, but not enough to obscure the pitch of respiration, which is notably higher than over the corresponding region on the left side. The expiratory sound, over the middle third of the right chest, posteriorly, is feeble, and appears to be lower in pitch than the sound of inspiration. Obs. 7.— Feb. 12. Michael Russell. Hospital patient. Eighth day of disease. Posteriorly, over middle and lower thirds of right chest, flatness on percussion. In these regions respiration notably higher in pitch than over the corresponding situation on the left side. The sound of respiration is too feeble to determine the pitch. Obs. 8.— Feb. 12. Philip -------. Hospital patient. Disease of a week's standing. Marked dulness on percussion over the lower and middle thirds posteriorly. Respiratory sound in these regions, in ordinary respira- tion scarcely appreciable; on forcible respiration more developed, without an appreciable sound of expiration. The inspiration is higher in pitch than on the left side. On the left side the inspiration is followed by a continuous sound of expiration, which is lower in pitch than the sound of inspiration. Obs. 9.— Feb. 12. James Whalen. Hospital patient. Disease affecting the upper and middle lobes of right lung, of nine days' standing. Flatness on percussion exists over the upper and middle thirds anteriorly, and over the whole side posteriorly. Percussion over the lower third anteriorly, on the right side, elicits clear resonance. Anteriorly, over the upper and middle thirds, a crepitant rale is heard at the end of the inspiratory act. APPENDIX. 31 Over the right side, posteriorly, the respiratory sound is notably high in pitch, and quite intense over the whole side. The sound of expiration is prolonged to an equality, in duration, with the inspiration, and there is an interval between the two sounds. The expiratory sound is higher in pitch than the inspiratory. This is the more marked the higher up the chest the ear is applied. Obs. 10.— Feb, 13. Jane McNolty. Hospital patient. Disease occur- ring as a complication of typhus, having taken to bed six days ago. Marked relative dulness on percussion exists over the middle third of left side, poste- riorly, and in the axillary region of same side. Over the inferior third, anteriorly and posteriorly, a gastric tympanitic resonance is transmitted. The crepitant rale is heard in the axillary region at the end of the inspiration. Over the middle third, the inspiratory sound is moderately loud, with no appreciable sound of expiration. It is somewhat shorter than the sound of inspiration over the corresponding region of the right side. It has less of the vesicular quality, and is notably higher in pitch. In the latter respect the disparity between the two sides is most marked. A faint crepitant rale is heard at the inferior portion of the right chest posteriorly. Obs. 11.— Feb. 13. John Jarry. Hospital patient. Disease of a week's standing. Marked relative dulness on percussion exists over the lower third of right chest posteriorly, and distinct bronchophony. No rales observed. The respiratory sound on both sides quite feeble. Over the lower third of right side the pitch is notably higher than over the corresponding region of the left side. It is notably higher than over the superior portion of the chest on the same side. The inspiratory sound over the lower third of right side is relatively shorter in duration. There is a sound of expiration obviously higher in pitch than the sound of inspiration, with an interval between the two sounds. On the left side there is a short, continuous sound of expiration, which is obviously lower in pitch than the sound of inspiration. Remarks.— In this case, two medical students,* who had been present at previous examinations of patients, and were accustomed to verify the results of my observations, were requested to explore and compare the relative pitch of respiration on the two sides, and the relative pitch of the inspiration and expiration on both sides. Without being acquainted with the result of each other's exploration, or of mine, the conclusions in the three instances were found to be the same. The foregoing statement is noted in connection with the observation. Obs. 12.— Feb. 19. Fitz Morris, Hospital patient. Fourth day of disease. Disease seated in the lower lobe of right lung. Crepitant rale was apparent yesterday, and is now heard at lower part of chest posteriorly. Bronchophony over these regions. The respiratory sound is loud, non-ves- icular, on high pitch compared with the sound on the left side. An expira- tory sound is heard, higher in pitch than the sound of inspiration, with an interval between the two sounds. On the left side, no sound of expiration Js appreciable. * Mr. J. R. Smith and Mr. Charles Ap. A. Bowen. 32 APPENDIX. SECOND SERIES.— PLEURITIS. This series will embrace but three cases; in two of which, the patients were laboring under the subacute form of the disease, with in one case considerable, and in the other large effusion. In the remaining case, the patient had recovered from chronic pleurisy, and the variations, were, therefore, those incident to the permanent changes left by the disease. Obs. 1.— Jan. 4. Conrad Reushling, Hospital patient. Chronic pleu- ritis affecting the left side. The lower and middle thirds of this side, anteriorly, are flat, and the upper third relatively dull on percussion. Poste- riorly, lower third flat, and the upper and middle thirds dull. Over the upper and middle thirds, posteriorly, respiration is feeble, and no sound of expiration appreciable. Over the right side the respiration is supplementary. The pitch of sound on the left side, posteriorly, is notably high. This, aside from feebleness, is the most striking point of disparity on comparing with the left side. Anteriorly, over the right chest, no sound of respiration appreciable, except just below clavicle, and here the pitch was obscured by dry crackling, Feb. 1. Up to this date, the patient progressively improved, and had become sufficiently restored to be discharged from the hosjutal. On the left side, at the summit, there is now slight dulness on percussion; at the inferior portion, the dulness is greater. The left chest is one half an inch less in circumference than the right. The left shoulder is somewhat depressed. The left side expands less at the summit than the right. The respiratory sound, on the right side, is exaggerated, supplementary. On the left it is relatively feeble. In both sides, the respiratory sound has the vesicular quality, a feeble sound of expiration being appreciable, and the duration of the respiratory sounds being apparently equal. After careful examination, I cannot satisfy myself of a disparity of pitch between the two sides. Remarks.— The following remarks were appended at the time of the last observation. This case affords an opportunity of comparing an exaggerated, with a relatively diminished vesicular sound. The physical and rational signs show that the patient has labored under subacute pleurisy, from which he has nearly recovered. There is slight condensation of the left lung from compression, and less expansibility from pleuritic adhesions. Here are two opposing circumstances as respects their probable influence on the respiration. The defective expansibility might be expected to occasion a pitch of sound somewhat lower than that on the right side, the respiration in the latter being, at the same time, exaggerated. On the other hand, the condensation would be expected to elevate the pitch. These apparently conflicting circumstances serve to antagonize each other, the fact being that the respira- tory sound at the summit of the chest on both sides is not far from equal. It may be inferred from this case that exaggeration of the vesicular murmur does not tend, in a marked degree, to elevate, nor, on the other hand, a feeble vesicular murmur to lower, the pitch of sound. APPENDIX. 33 Obs. 2.— Feb. 8. Ortinann. Hospital patient. The effusion, in this case, was large, compressing the lung into a small space at the'upper and posterior part of the chest. The disease was in the right side. No respiratory sound is to be heard save in the clavicular, post-clavicular, supra-spinous, and inter- scapular regions. Over the supra-spinous, and interscapular regions, the sound is feeble, non-vesicular; the expiration louder and higher in pitch than the inspiration. The inspiration is shortened, the expiration prolonged, with an interval between Ihe two sounds. On the left side, in the corresponding regions, the respiratory sound is supplementary. A sound of expiration is heard, which is about one-fourth the length of the inspiration. The sound of expiration follows that of the inspiration without any appreciable interval. In pitch, the expiration on this side is distinctly lower than the inspiration. -•x In pitch, the inspiration, as well as expiration, is higher on the right than on the left side; but this is more especially marked in the expiration. Obs. 3.— Feb. 10. Eliza Moore. This patient, eighteen months ago, had subacute pleurisy of the left side. The chest, on this side, was greatly- distended, the heart being dislocated, so that its pulsations were seen and felt to the right of the sternum. She has remained in hospital up to this present time, but is now quite well, and has been employed as a domestic, performing hard labor, such as washing, scrubbing floors, «^ ~ rc'<~< __ £<.< ; >,