1 THE MEDICAL EXAMINER. NEW SERIES. Enlarged from 24 to 72 Octavo Pages Monthly, WITHOUT ANY INCREASE OF PRICE. LINDSAY & BLAKISTON, PHILADELPHIA, PUBLISH THE MEDICAL EXAMINER, AND RECORD OF MEDICAL SCIENCE, EDITED BY ROBERT M. HUSTON, M. D., &c, &c. Published monthly, each number containing 72 handsomely printed octavo pages, the year commencing with January. OPINIONS OF THE PRESS. The Examiner is one of our cotemporaries whose time of appearance we expect with pleasure. It is spirited but courteous; independent and frank in the expression of its opinions, by which it sometimes provokes an angry retort; but its tone is elevated, and its criticisms generally just. Its reputation has been steadily growing since its establishment, and it gives promise of taking a permanent place among the medical periodicals of the country. — Western Journ. of Med. and Surf. Medical Examiner.—This Journal, edited by Professor Huston, has been greatly enlarged and improved. It is one of the best Medical Journals of our country, and deserves, as it no doubt will receive, the patronage of the profession.— Western Lancet. TERMS: Three Dollars per annum, or two copies for Five Dollars when paid in advance. 2 MACKINTOSH'S PRACTICE OF MEDICINE, A NEW AND IMPROVED EDITION. THE PRINCIPLES OF PATHOLOGY AND PRACTICE OF MEDICINE, BY JOHN MACKINTOSH, M. D., &c. FOURTH AMERICAN, FROM THE LAST LONDON EDITION. With Notes and Additions, BY SAMUEL GEORGE MORTON, M. D., &c. In one volume, 8vo. HARRIS'S PRINCIPLES AND PRACTICE OF DENTAL SURGERY, REVISED, IMPROVED, AND GREATLY ENLARGED. THE PRINCIPLES AND PRACTICE OF DENTAL SURGERY, ILLUSTRATED BY Numerous well executed Wood Engravings. BY CHAPIN A. HARRIS, M. D., D. D. S„ PROFESSOR OF PRACTICAL DENTISTRY AND DENTAL PATHOLOGY IN THE BALTI MORE COLLEGE OF DENTAL SURGERY; EDITOR OF THE BALTIMORE JOURNAL OF DENTAL SCIENCE, ETC., ETC. In one volume, royal octavo. 3 MEIG'S VELPEAU'S MIDWIFERY. Third Edition Revised, with Additions by Wm. Harris, M. D. VELPEAU'S ELEMENTARY TREATISE ON MIDWIFERY TRANSLATED WITH NOTES, BY CHARLES D. MEIGS, M. D., LECTURER ON MIDWIFERY IN THE JEFFERSON MEDICAL COLLEGE, &C, &C. THIRD AMERICAN EDITION, WITH NOTES AND ADDITIONS, BY WILLIAM HARRIS, M. D., LECTURER ON MIDWIFERY, &C, &C. In one volume, 8vo. HOPE'S PATHOLOGICAL ANATOMY. With 260 Coloured Illustrations. THE PRINCIPLES OF PATHOLOGICAL. ANATOMY: ADAPTED TO Forbes, tweedie, conolly, and dunglison'S cyclopedia of practical medicine and andral's elements, Illustrated l>y 5860 Beautifully Coloured Figures. BY J. HOPE, M.D., F.R.S., AUTHOR OF DISEASES OF THE HEART, ETC. EDITED BY L. M. L A W S O N, M. D., Prof, of General and Pathological Anatomy in the Transylvania University. 4 THE atauM&v Asm awnuuhi8» INCLUDING THE FCETAL AND PULMONARY CIRCULATION, WITH 10 COLOURED ILLUSTRATIONS. BY J. M. ALLEN, M.D., LECTURER ON ANATOMY IN THE PHILADELPHIA MEDICAL ASSOCIATION, AND DEMONSTRATOR OF ANATOMY IN THE JEFFERSON MEDICAL SCHOOL, ETC. In one volume. This volume is intended for both the Practising Physician and Student, and will be found useful in illustrating the situation of all the arteries together, with an exhibition of the surgical relations of the more important ones, and the general circulation of the blood through the body. A MANUAL OF AUSCULTATION AND PERCUSSION, BY M. J^ARTH, Agrege to the Faculty of Medicine of Paris, Sec., Sec. AND M. HENRY ROGER, Physician to the Bureau Central of the Parisian Hospitals, Sec, Sec. TRANSLATED, WITH ADDITIONS, BY FRANCIS G. SMITH, M. D., Lecturer on Physiology in the Philadelphia Medical Association, Sec., Sec. LINDSAY & BLAKISTON, N. W. CORNER OP FOURTH AND CHESTNUT STREETS. 1845. Entered, according to Act of Congress, in the year 1845, by LINDSAY & BLAKISTON, in the Clerk's Office of the District Court of the Eastern District of Pennsylvania. WB3 3 Griggs & Co., Printers. PREFACE. This little work, which is respectfully offered to the practitioner and student, is a translation of the Resume of the second Edition of Barth and Roger's work on Auscultation, with the addition of a new treatise on Percussion, by the same Authors, and such matter from the body of the work and other sources, as the Translator thought might prove useful. The tables which are inserted, are modifications of those of Dr. Walshe, adapted to suit the text, and the whole is intended as a short manual of the most important diseases o£ the chest and abdomen, and their method of diagnosis by physical signs. F. G. S. 291 Spruce St. CONTENTS. Page Bubbling or Mucous Rale, . . .37 Vibrating Rale, . . . .36 Rales, ..... 35 4. Alterations by Abnormal Sounds, , ib. Friction Sounds, . . . ib. Amphoric Respiration, . . .34 Cavernous Respiration, * . .33 Harsh Respiration, . . . ib. Bronchial or Tubal Respiration, . . 32 3. Alterations of Character, . . 31 2. Alterations of Rhythm, . . 30 Feeble Respiration, . . ib. Absent Respiration, . . .29 1. Alterations of Intensity, . . ib. Strong or Puerile Respiration, . . ib. Alterations of Respiratory Murmur, . . 28 Respiratory Murmur, . . .27 Auscultation of the Respiratory Apparatus, . 24 Division, . . . . .23 General Rules, . . . .14 Auscultation, . . . .13 VI CONTENTS. Page Crepitant Rale, . . . .37 Sub-Crepitant Rale, . . . 40 Cavernous Rale, . . . .41 Auscultation of the Voice, . . .43 Exaggerated Resonance, . . . ib. Bronchophony, . . , .44 iEgophony, .... ib. Pectoriloquy, . . . .45' Amphoric Voice, . . . . ib. Auscultation of the Cough, . . .46 Bronchial Cough, . . . . ib. Cavernous Cough, . . . .47 Amphoric Cough, . . . . ib. Metallic Tinkling . . . . ib. Thoracic Fluctuation, . . .48 Auscultation of the Larynx, . . ib. Tables on Auscultation, . . .51 Auscultation of the Circulatory Apparatus, . 61 Of the Heart, . . . . ib. Physiological Phenomena, . . . ib. Pathological Phenomena . . . 63 1. Alterations of seat, . . .64 2. " of Intensity and Extent, . ib. 3. " of Rhythm, . . 65 4. « of Character, . . 67 5. Abnormal Sounds, . . .68 Blowing Sounds, . . . ib. Rasping, Sawing, or Filing Sounds, . 74 Musical Sounds, . . . .75 VII CONTENTS. Page Friction Sounds, . . . .77 Auscultation of the Large Vessels, . . 78 Aortic Sounds, . . . .79 Vascular Sounds, . . . .81 Auscultation of the abdomen, . . 84 " of the Head, . . .86 " of the Extremities, . . 88 Obstetrical Auscultation, . . ib. Uterine Souffle, .... 89 Sounds produced by movements of Foetus, . ib. Sounds of Foetal Heart, . . .90 Percussion ; Historical Notice, . . 95 General Rules, . . . .97 Division, ..... 106 Percussion of the Chest, . . ib. Pulmonary Apparatus; Special Rules, . 107 Physiological Phenomena, . . . 108 Pathological Phenomena, . . .111 Increase of Resonance, . . .112 Clear Sound, . . . . ib. Tympanitic Sound, .... 115 Diminution of Resonance, . . .117 Obscure Sound, . . . . ib. Dull Sound, . . . .119 Cracked-pot Sound, . . . 122 Tables on Percussion, . . . 124 Circulatory Apparatus; Heart and Great Vessels, 126 Particular Rules, . . . . ib. Physiological Phenomena, . . . 127 VIII CONTENTS. Page Pathological Phenomena, . . . 128 Excessive Resonance, . . ib. Dulness, . . . . .129 Percussion of the Abdomen; Particular Rules, 131 Physiological Phenomena, . .132 Pathological Phenomena, . . . 135 Liver, (Hepatic Sound,) . . . 136 Gall Bladder, . . . .138 Spleen, . . . . .139 Stomach, (Stomachal Sound,) . . 141 Intestines, (Intestinal, Tympanitic, and Hydroaeric Sound,) . . . 143 Kidney, . . . . .148 Bladder, 149 Uterus, . . . . .150 Uterine Appendages, . . . 153 Peritoneum and Abdomen generally, . 154 Percussion of the Head, Neck, and Extremities, 157 Auscultation and Percussion combined. . 159 PART I. AUSCULTATION. By the term Auscultation, is meant the act of listening, and it is termed pulmonary, cardiac, abdominal, Src, according as it is applied to the lungs, heart, or abdomen. , Its direct object is the appreciation of certain sounds produced either by the movements of the organs themselves, contained in the different cavities mentioned, or else transmitted by these organs from others in their neighbourhood in which they are actually produced. Before attempting to apply auscultation to the detection of morbid phenomena in the chest, the student should make himself perfectly familiar with those of the physiological or normal condition. To do this—he should select a healthy individual and apply his ear to the different regions of the thorax, 2 14 AUSCULTATION. and note carefully the peculiarities of sound occurring in each. It is, perhaps, better to commence with immediate auscultation; that is, the direct application of the ear itself to the walls of the chest, it is much easier, and seems to be a sort of initiatory step to the use of the stethoscope. After having made himself acquainted with the healthy sound, he may proceed to the investigation of those occurring in disease, bearing in mind the following GENERAL RULES. There are some general rules necessary to be observed in auscultation, in order that its results may be at the same time more available and clearly recognised. Some of these relate to the patient, others to the physician. Rules in relation to the Patient. A. The part to be ausculted should be bare, or covered by a thin, soft garment, in order that the stethoscope may be accurately applied without producing any friction, and that the sounds may be readily transmitted to the ear: thick clothing, and particularly those of woollen stuns, prevent our hearing the respiratory murmurs at all, except in the case of children, in whom respiration is naturally very noisy, and silken stuffs arc prejudicial, from the rustling sound they produce. It is better then 15 AUSCULTATION". to leave nothing upon the chest but the shirt, or to cover the thorax with a towel, which will prevent the patient taking cold. B. The patient should be in a convenient position, varying according to the disease, and the region to be examined. Rules to be observed by the Practitioner. A. The practitioner should generally place himself on the side he is about to examine; sometimes it is better to pass to the opposite side, to the right, for instance, in ausculting the sounds of the heart. Generally, he may explore both sides of the thoracic cavity without changing his position. In cases, however, where the results of his examination appear doubtful, he should place himself on the right and left, successively, and auscult. Whatever position he assumes, he should auscult the anterior region with one ear, and the posterior with the other, habituating himself early to use either indifferently. B. Auscultation may be immediate or mediate, that is, it may be practised with the naked ear, or with the stethoscope. Laennec attached too much importance to the use of this instrument; for the merit of auscultation does not reside in the stethoscope, and the instrument adds nothing to the excellence of the method. The results are identical, whether 16 AUSCULTATION. we study the acoustic phenomena which are taking place in the living subject, by the direct application of the ear, or by the interposition of a conducting body. It is not necessary to proscribe, or adopt, exclusively, either method; both have their advantages, and our choice should depend on many different circumstances. The ear perceives sounds over a greater extent, because all the parts of the head, which come into contact with the chest, then become conducting media. But immediate auscultation cannot be of constant and general application. Feelings of delicacy would prevent the physician placing his head upon the anterior parts of the chest of the female. In some parts, as the axilla, the supra- and sub-clavicular, and the supra-spinous regions, the groin, &c, the ear is with difficulty applied in an accurate manner, particularly in very thin persons. In dirty persons, too, covered with perspiration, &c, feelings of disgust would render immediate auscultation almost impracticable, this inconvenience disappears, in part, however, by placing a towel between the ear and the thoracic walls. With the stethoscope, besides that it is not always at hand, the amount of the sounds heard is less; but, it has the advantage of being applicable to parts where the ear cannot be applied without difficulty. It circumscribes sounds better, and marks limits with more precision; but the same end may be obtained by a well-trained ear. 17 AUSCULTATION. Briefly; both mediate and immediate auscultation have their advantages. They should be employed alternately by the physician who seeks to establish the most just and complete diagnosis, in order that he may prescribe the most rational and efficacious treatment. The choice to be made between the two will vary, 1st, according to individuals. —The stethoscope is almost inapplicable to children, who are alarmed by it; it is preferable in women, but with men, its use is a matter of indifference; 2d, according to position. —In the posterior parts of the dicst the ear is inorc accurately applied to the walls; anteriorly, there is hardly a choice between them. Over depressed regions, the stethoscope is used almost exclusively; it alone is employed in the auscultation of some organs, as the larynx, trachea, abdominal aorta, &c; 3d, according to the nature of the sounds: —in the perception of certain resonant phenomena, sometimes the stethoscope has the preference, at others, the ear; the former is more convenient in circumscribed alterations, as in pulmonary apoplexy, or cavities; the latter, in diseases, whose extent is greater, as bronchitis or pleurisy. The form of the stethoscope, and the wood of which it is made, are not of so much importance as Laennec believed; from the moment in which it is looked upon, not as an ear-trumpet, but as an instrument, which, in some cases, is more convenient than 2* 18 AUSCULTATION. the ear itself, the better will it fulfil its object, convenience, and the more useful will it be. The original cylinder has been generally abandoned, and the stethoscopes of Louis or Piorry substituted for it. These instruments are composed of a hollow cylinder of cedar or ebony, from six to seven inches long, by one to two at its base, of a narrower diameter in the superior three-fourths, and terminating above by a round plate of ivory perpendicular to its axis, on which the ear may rest. This plate may be of the same wood as the tube, and the stethoscope thus constructed of a single piece, is that which we prefer. This instrument has been subjected to numerous modifications; Piorry himself, wishing to perfect it, substituted metal for wood, in order to diminish the dimensions of the cylinder; some have invented elbowed stethoscopes to enable them to auscult patients in every position without disturbing them, and in case of necessity to auscult one's self. Others have substituted a projecting extremity in place of the horizontal plate, to be introduced into the tube of the ear. M. Landouzy has proposed a stethoscope having numerous branches, to allow several to auscult at the same time. All these seeming improvements, and many others, which we have passed over in silence, have more inconveniences than advantages, and we believe the stethoscope, above described, sufficient for all purposes. 19 AUSCULTATION. If the ear is preferred in ausculting, it should be accurately applied, in order that it may follow the movements of expansion and contraction of the thorax, without friction of the surfaces in contact. If the stethoscope is employed, it should be held as a pen, and placed perpendicularly upon the region to be ausculted, taking as a resting point, a uniform surface to which it may be accurately adapted ; then holding it by the pectoral end with the fingers, (which should remain immoveable,) the pavilion of the ear should be applied to the horizontal plate of the instrument : if the exterior air find its way, either between the skin and the stethoscope, or between the latter and the ear, it will produce sounds w r hich will mask those of the air-passages. Care should be taken to press moderately: too violent pressure, at the same time that it is prejudicial to the hearing, will be painful to the patient, and may increase some of the symptoms, such as dyspnoea, pain, &c, and sometimes may even alter the sonorous phenomena. We should never fail to auscult both sides comparatively ; comparison alone may enable us to distinguish alterations otherwise hardly perceptible, and which might have escaped our notice: by giving us the healthy region as a type, it places in relief the slightest modification presented by the diseased points. It is almost unnecessary to add, that the physician requires profound silence around him ; that he should 20 AUSCULTATION. listen for a sufficient time, and so collect his thoughts as to be completely isolated from the external world, concentrating them upon the pathological interpretation of the sounds which meet his ear. With exercise he may accustom himself, not only, not to hear sounds which are occurring around him, but even to select from amongst many morbid phenomena that on which his attention should be mainly fixed. These precepts being known, let us place the student at the bed-side of a patient: What time shall he select for auscultation? where commence his examination, and how far conduct it ? what precautions shall he take, in order to arrive most quickly and surely at an acquaintance with the acoustic phenomena? Finally, how judge most accurately of their value ? In general, he must pass from the simple to the compound, and, in the examination of physical signs, it is well to commence with those whose appreciation is easiest. Thus, in exploring the chest, it is natural to examine first, its conformation and movements, and to define accurately the degree of resonance of its walls. Then he will enter upon auscultation with the chance of losing less time in unprofitable research. He will proceed precisely as though the patient were unable to reply to him: if, on the contrary, he can obtain information from him, he must gather it previously, as it will assist him in his examination ; it will prevent unnecessary fatigue in the application of 21 AUSCULTATION. different physical methods, and conduct him more directly to the object of his search, by designating the apparatus or portion of apparatus which he ought first to explore. For instance, if he is about to examine the chest, the seat of pain, when any exists, will indicate the side on which he may expect to find acoustic phenomena. Let us now suppose his ear applied to the left side of the thorax; if he has but little experience, how shall he judge of the nature of the sounds heard ? They may take place in the oesophagus or stomach, in the circulatory system, or the organs of respiration; in the latter case, they may depend on resonance of the voice, cough, or respiration alone. The signs furnished by the voice and cough are so intimately connected with the acts themselves, that they are easily recognised : it remains then, only to decide whether the sounds belong to the air-passages, the heart, or the superior part of the digestive tract. Those of the oesophagus and stomach have a peculiar character, and are a species of gurgling caused by the displacement of gas : to distinguish then whether the phenomena belong to circulation or respiration, he must examine whether the sound occurs sixty or eighty times, or only from sixteen to twenty times in a minute; the distinction will generally be easy. But this phenomenon, whether the effect of the action of the heart or lungs, may only occur at intervals, and then this rule is no longer applicable: under 22 AUSCULTATION. these circumstances, he should satisfy himself whether it is immediately dependent upon the movements of respiration, or the heart, whether it is synchronous with the expansion of the chest, or the pulsations of the radial artery. If it be connected with the act of respiration, he should examine in what respect it diners from the normal respiratory murmur, either in force, rhythm, or character, or whether it constitutes one of those abnormal sounds known by the name of rhonchi; whether the rhonchus is dry or humid, the bubbles manifest only in respiration, or in both inspiration and expiration, what is their size, number, &c. He will thus by degrees succeed in recognising the sound he seeks; but as many rhonchi, the subcrepitant for example, are manifest in a variety of diseases, the physician should not be satisfied to establish a definite diagnosis from a single acoustic fact; he should study their shades of difference, intensity, seat, and extent; he should seek further information from other stethoscopic phenomena, take into account the accompanying physical signs, the local and general functional symptoms, the circumstances under which the morbid accidents are developed, their progress, and finally all the physiological and pathological conditions relating to the subject. It is only by the union and attentive comparison of these different elements, that he can establish the basis of a correct diagnosis. AUSCULTATION. 23 DIVISION. Auscultation may be applied to the chest, neck, abdomen, head, and extremities. In the four sections corresponding to this division, we will treat successively of the different physiological and morbid phenomena, furnished by the principal apparatus of the economy.—(B. & R.,) Tr. 24 CHAPTER I. AUSCULTATION OF THE RESPIRATORY APPARATUS. Auscultation of the respiratory apparatus tised upon the thorax, or the laryngotracheal tube; its object is to study three orders of phenomena, furnished by the respiratory murmur, voice and cough. PARTICULAR RULES FOR THE AUSCULTATION OF THE RESPIRATORY APPARATUS. When we wish to examine the modifications of the respiratory sound, the patient should be placed in different positions, according to the parts of the thorax to be explored:—In the examination of the anterior part, lie may be, either standing with his arms hanging by his side, or seated in a chair, or in bed; but the dorsal decubitus is preferable, as the chest is then more firmly fixed.—In that of ihe posterior part, if the patient is standing, or seated on a chair, or, what is better, sitting up in bed, he should cross his arms and bend his head slightly forward. Sometimes, when very weak, he may lie either upon his face, or side. —In any case, the muscles should be moderately tense and the position of the body 25 AUSCULTATION. symmetrical; the shoulders should be of the same height, the head held erect, or somewhat inclined, either before or backwards; at other times it may be turned alternately towards the right or left, always being careful that the change be the same on both sides, and a precisely similar position assumed. In the examination of the lateral parts, the patient should lie on the opposite side to that examined; or he may be directed to clasp his hands over his head, retaining, in other respects, the position before described. In some rare cases, he should be placed on his hands and knees, as, for instance, when it is necessary to determine whether a liquid in the pleura changes its position with that of the patient. The patient should breathe naturally, that is to say, on the one hand, without exaggerated effort, or making a noise with his mouth, and, on the other, without holding his breath, two extremes into which he is apt to fall, either through fear, ignorance, or from the idea that something extraordinary is demanded of him. The observer also,«that he may not be deceived by a false appearance of cither too strong or too feeble respiration, should always be careful to remark the precise natural condition of the respiration.—It is sometimes necessary for the patient to hurry these movements, or increase their fulness, in order that the more rapid passage of air, or its more complete penetration into the cells of the lung, may make 3 26 AUSCULTATION. manifest the otherwise indistinct murmurs. Manyindividuals cannot breathe as they are directed; they must then be told to cough during auscultation; each act will be preceded and followed by a full inspiration, during which the acoustic phenomena will be more striking. The same end is sometimes attained, by causing the patient to speak, or to read several sentences in succession. In children, also, it is very difficult to obtain a spontaneous exaggeration of the respiratory movements; in them cough will be much more easily provoked. But, except in these particular instances, which demand, so to speak, an exaggeration of respiration, we must endeavour to preserve as regular and natural a condition as possible, because violent efforts may increase the intensity of the pain, or alter the true character of the sounds. The practitioner should choose the most comfortable position; if he is in a constrained posture, it will be impossible for him to keep his ear accurately in contact with the different regions of the thorax ; and if his head is too low, the afllux of blood to it will dull his sense of hearing. The choice between the ear and the stethoscope will be decided by the considerations mentioned in the preceding general rules. " Both sides of the chest must be submitted to precisely the same examination—conducted precisely in the same way—auscultation should never be considered complete until the entire chest has been 27 AUSCULTATION. examined; it is often in some or other situation, where the symptoms would least have taught us to look for disease, that auscultation proves its existence. In acute affections, auscultation should be repeated twice, at least, in the twenty-four hours."* — Tr. ARTICLE I. RESPIRATORY MURMUR. I. Normal Respiration. If the ear is applied to the chest of a healthy man during respiration, a gentle murmur is heard, analogous to that produced by a person in a quiet sleep, or heaving a deep sigh: this is the natural respiratory sound, or the vesicular murmur. It is composed of two different sounds, soft and distinct, to the ear—that of inspiration, which is more intense and prolonged, and that of expiration. The vesicular murmur is stronger in those parts which correspond to greater thickness of the lung, and it is rather more rude towards the root of the bronchial tubes. Normal bronchial respiration —Is equal in corresponding points on both sides, and, in some persons, rather more intense at the summit of the right lung.—It is more noisy when the respiration is deep and rapid, and its strength is likewise increased in * Walshe on Diseases of the Lungs, p. 4G. 1843. 28 AUSCULTATION. children (¦puerile respiration ;) it is, on the contrary, more feeble in many old persons. In general, it is more intense, in proportion as the chest is larger, and its walls thinner. II. Alterations of the Respiratory Murmur. These may be divided into four classes: —1. Al- terations of Intensity; 2. of Rhythm; 3. of Character; 4. Alterations by Abnormal Sounds. 1. Alterations of Intensity. Considered in this point of view, respiration may be strong, feeble, or absent. A. Strong or puerile respiration. —This consists in a more intense vesicular murmur than in the normal condition, with the preservation of its soft and distinct character. It announces less a lesion of the pulmonary organs at the point where it is heard, than disease of a more or less distant portion, the healthy parts making up for the inaction of those affected. B. Feeble respiration. —This is characterized by a diminution in the normal strength of the vesicular murmur, sometimes preserving its natural softness, at others, becoming more rude. It depends either upon the sound being transmitted less perfectly to the ear, or produced with less intensity. In the first case, it may be owing to pleuritic effusions, to thick false membranes deposited upon the pleura, or to tumours which remove the lung from 29 AUSCULTATION". the walls of the chest. In the second, it may be caused by pleurodynia; contraction of the larynx; partial obstruction of one or more of the bronchial ramifications by a collection of mucus, or by a foreign body; the contraction of their cavity; or the compression of their walls by tumours. We meet with it also in pulmonary emphysema, and in the first stages of phthisis. Of all the diseases which we have just enumerated, and which reveal themselves frequently by feeble respiration, tubercles, pulmonary emphysema, and liquid effusions into the cavity of the pleura, being by far the most common, (bronchitis, also a common disease, being readily distinguished by its peculiar rhonchi,) the student, on noting this sign, ought to fix his attention upon them almost exclusively.—If the feebleness of the vesicular murmur coincide with increased resonance of the thorax, there is emphysema present; if, with dulness, there are tubercles, or pleuritic effusion. —If the feeble respiration, accompanied by dulness on percussion, is confined to the summit of the lung, there are most probably tubercles; if it is circumscribed, at the lower portion, there is rather pleuritic effusion; if it exists at the both lungs, there are almost certainly tubercles on both sides; if at the base, there is a double pleurisy, or a double hydrothorax. C. Absent respiration. —We say that the respiration is absent, when the car, applied to the chest, 3* 30 AUSCULTATION. hears absolutely nothing; the vesicular murmur is wanting, and is replaced by no sound: there is complete silence. Absent respiration depends on the same condition of things as feeble respiration, and it announces, consequently, the same diseases, with this difference, that it indicates more decided anatomical lesions. — But the entire absence of the respiratory murmur being, almost without exception, a symptom of emphysema and tubercles; —the diseases of the larynx manifesting themselves by peculiar phenomena,— the obliteration of the bronchi, their obstruction by foreign bodies, as well as pneumothorax without perforation, &c, being affections, rare in comparison with liquid effusions into the pleura—it follows, that absent respiration is a sign of very great value, and a common indication of these effusions; and as pleurisy is more frequently single, and hydrothorax double, it. follows, that well marked absence of the respiratory murmur, on one side of the chest, announces almost with certainty a pleurisy with effusion. 2. Alterations of Rhythm. Respiration altered in its rhythm may be slow, (as from twelve to seven per minute,) as in many of the diseases of the cerebro-spinal apparatus; or frequent, (from thirty to eighty,) as in a great number of the thoracic or abdominal affections, —sometimes it is jerking, in asthma, pleurodynia, incipient phthisis, 31 AUSCULTATION. chronic pleurisy with adhesions, fyc. Sometimes it is long, sometimes short; finally, there is sometimes a prolonged expiration, and, then, the respiratory sound is almost always more rude. Of these different alterations, the last is the only one of importance as a diagnostic. We may say that the prolonged expiration is a symptom of only tiro diseases: pulmonary emphysema, or tubercles, in the first stage of their development. In some cases, it is the first, or only stcthoscopic sign of phthisis.* 3. Alterations of Character. A. Harsh respiration. —This presents variable de- * The late Dr. Jackson of Boston, gave a different account of the physical cause of prolonged expiration, from that which has been introduced into the tables on auscultation. According to this writer, as long as fie pulmonary tissue retains its flexibility and normal permeability, the respiratory sound is composed of that caused by the passage of the air through the bronchi, and that by its entrance into the pulmonary vesicles, and as the latter predominates, it alone is heard. But in proportion as tubercular infiltration takes place, the number of vesicles and the vesicular expansion diminishes, and the sound produced by the air in traversing the bronchi, remaining the same, it prevails more and more every day, and, finally, as that of the vesicles decreases, is alone perceived. Now, if to this, we add the fact, that as the lungs become infiltrated and denser in structure, their power of conducting sound is increased at the same time that their contractility is diminished, we can sec not only how the expiratory sound may be more dis. tinctly heard, but also increased in length by the slow contraction of the lung.—TV. 32 AUSCULTATION. grees of intensity, hardness, and dryness, and these alterations may occur in both expiration and inspiration, or in one alone. We meet with it in emphysema of the lungs, in incipient phthisis, in fact, in every case where there is pulmonary induration, (as melanosis, chronic pneumonia, &c.) —Of all these diseases, roughness of the respiratory murmur occurs most frequently in emphysema and phthisis. If this roughness be joined to dryness, in connexion with prominence, and exaggerated resonance of the thorax, it indicates •pulmonary emphysema. —If it be accompanied with a prolonged sound of expiration, and confined to the summit of the chest, with resonance of the voice and dulness on percussion, we may readily diagnosticate the presence of crude tubercles. B. Bronchial or tubal respiration. —(Bronchial or tubal blowing sound.) —Bronchial respiration, which is distinguished by an increase in intensity and an elevation of tone, may be very well imitated by blowing through the hand, rounded into the form of a tube, or through a stethoscope ; the greater the force and rapidity with which we blow, the more it resembles the tubal sound. Bronchial respiration, when slightly marked, differs but little from harsh respiration, of which it is but the exaggeration. When it is well marked, it has a decidedly tubal quality, which serves to 33 AUSCULTATION. distinguish it from cavernous respiration, which has generally a peculiarly hollow character. Bronchial respiration may be heard in a great many affections of the pleura, bronchi, and lungs especially —such as inflammatory hepatization, large accumulation of tubercular matter, extensive pulmonary apoplexies, &c, liquid effusions into the pleura, different tumours compressing the lung, and, lastly, the uniform dilatation of the bronchi, with induration of the surrounding tissue. Of all these diseases, the most common are phthisis pulmonalis, pleurisy, and pneumonia. When bronchial respiration is slightly marked, confined to the summit of the thorax, and supervening in the course of a chronic affection, it may be attributed to the presence of crude tubercles in the parenchyma of the lungs. When the souffle is more intense, and shows itself in an acute affection of the chest, we must suspect either pleurisy or pneumonia; if it is proportioned neither to the intensity or extent of the dulness of the thorax, it will rather be an indication of pleuritic effusion; if, on the contrary, it is intense, decidedly tubal, and perceived throughout the whole extent of the dulness, there is reason to believe the existence of pulmonary hepatization. C. Cavernous respiration. — (Cavernous souffle or blowing sound.) —This resembles the sound produced by blowing into a hollow vessel: and may be imitated by breathing with violence into the two hands, disposed so as to form a cavity. Its common seat is 34 AUSCULTATION. at the summit of the chest. It announces either elliptical dilatation of a bronchus or the existence of a cavity properly so called. But from the rarity of dilatations of the bronchi, and pulmonary excavations following abscess, gangrene, &c, compared with the frequency of phthisis, we may conclude, that nine times out of ten, cavernous respiration will indicate a cavity resulting from the softening of tubercles. D. Amphoric respiration. —This is of a resonant and metallic quality, and may be very well imitated by blowing into a large empty pitcher, or into a decanter with vibrating walls. It is accompanied nearly always by metallic tinkling. When amphoric respiration is well marked, it indicates almost infallibly pneumothorax, with pulmonary fistula. When ill-defined, it may announce the same disease, but may also be the symptom of a large cavity which is nearly always tuberculous. 4. Alterations by Abnormal Sounds. Abnormal sounds are of two kinds: rhonchi and friction sounds. 1. Friction Sounds. Pleuritic friction sound. —The two reflections of the pleura, which in the healthy state, glide silently one upon the other in the movements of the lungs, rub upon each other with a perceptible noise when certain pathological conditions occur. The pleuritic 35 AUSCULTATION. friction sound, which is very analogous to the rattling of parchment more or less dry, is ordinarily of a jerking character, and made up as it were of a number of successive cracklings. It presents varieties of rudeness and intensity, which have given rise to the division into soft or grazing, and hard or scraping friction sounds ; when very decided, it is perceptible to the hand applied to the chest; sometimes the patient himself can perceive it. In order that this sound may be produced, it is necessary that the pleurae, or at least one of them, should present asperities, and glide one upon the other, in the movements of elevation and depression of the ribs : these rough points depend almost always on the presence of false membranes deposited upon the surfaces of the pleurae. We meet the pleuritic friction sound in pleurisy, in occasional cases of tubercles of the pleura without adhesions, in some other organic alterations of this membrane, and very rarely in some varieties of pulmonary emphysema. But most frequently this phenomenon indicates a pleurisy which is improving. If it were heard exclusively at the summit of the chest, we might suspect tubercular pleurisy. 2. Rales, Rhonchi, or Rattles. Rales are abnormal sounds, which, being formed by the movements of the air through the air-passages, mingle themselves with the respiratory murmur, and 36 AUSCULTATION. either obscure or entirely replace it. We divide them into two groups: one called dry or vibrating, because they consist of varying tones; the other humid or bubbling, because they are caused by bubbles of air passing through a liquid. 1. Vibrating rales. —Under this head are included the two principal varieties of sonorous rales: the acute or sibilant, and the grave or deep-toned. The first consists of a whistling sound more or less acute; the second is characterized by a deeper, musical sound, resembling either the snoring of a person asleep, or rather, the sound of a bass string rubbed with the finger. Oftentimes they occur together, at others, they alternate, and one takes the place of the other. The sonorous rale may be heard in a great many diseases, such as inflammations or catarrhs of the bronchi, whether acute or chronic, in pulmonary emphysema, and in the compression of the air tubes by tumours obstructing their passage, all different morbid conditions, yet having one common element by which they may be recognised, viz : the momentary or permanent contraction of one point or other of the air-passages. In consequence of the frequency of bronchial catarrhs, and the comparative zwfrequency of the other morbid conditions, in which sonorousness or sibilance manifest themselves, the sonorous rale announces almost certainly an inflammatory or catarrhal condition of the bronchi.* * (It is likewise heard in asthma, in which the constricted con- AUSCULTATION. 37 2. Bubbling or mucous rales. —This division includes the crepitant, sub-crepitant, and cavernous rales. A. Crepitant rale. —The crepitant or vesicular rhonchus gives to the ear the sensation of a fine, dry crackling sound, analogous to that produced by the decrepitation of salt in a basin by gentle heat, or that occasioned by pressing a thin layer of healthy lung between the fingers. These bubbles, which are perceived only in inspiration, are very small, very numerous, of equal size, and rather dry. Their favourite seat is at the posterior and inferior part of the chest, on either side. The crepitant rale is witnessed in pneumonia, in certain forms of pulmonary congestion, in asthma and apoplexy of the lung* dition of the bronchial tubes also gives rise to the same variety of rhonchus.— Tr.) * The following ingenious account of the physical cause of this rhonchus has been given by Dr. E. A. Cirr, of Canandaigua, N. Y., in the Amer. Jour. Med. Sciences, No. VIII. N. S. The sound in question is described as resembling that produced by rubbing a lock of hair between the thumb and ringer when held near the ear, or that produced by the crackling of fine salt when thrown upon burning coals. Dr. Copland compares it to the crepitation produced by distending a piece of lung with air after it had been compressed; and thinks it arises from the diminished calibre of the minute bronchi, owing to interstitial effusion, and admixture of respired air, with the secreted or effused fluids in the tubes and air cells. It is generally supposed by auscultators, that this sound is caused by the bursting of extremely small bubbles of mucus in the air vesicles and smallest bronchi. Indeed, the later 4 38 AUSCULTATION. In consequence of the extreme frequency of inflammation of the lung, contrasted with the comparative writers upon this subject class it among what they denominate hullar rales, and M. Raciborski in particular, makes it depend on the crackling of the bursting bubbles, occasioned by the dry and viscid state of the mucus of which they are composed. M. Beau, who has made some very interesting and valuable observations on auscultation, dissents from the opinion commonly entertained respecting the cause of this sound, and suggests, whether, if we consider that it is not at all modified after a fit of coughing, and also that it is distinctly perceptible in many cases of pneumonia before any expectoration takes place, it docs not more probably depend on the f riction of the pulmonary vesicles, which, like the pleura, pericardium, and synovial membranes, are probably somewhat dried (dessechees) by the existing inflammatory action. Admitting that the considerations adduced by M. Beau appear to constitute a sound objection to the commonly received opinion on this subject, we may still be allowed to inquire if the views which ho has offered as a substitute are not equally unsatisfactory. If the sound in question were produced by the bursting of minute bubbles of mucus, it ought, like the mucous and sub-mucous rales, to continue through expiration, since it is here that the bullar rales are most distinct. But every practical auscultator is aware, that while the rale crepitant continues uniform quite to the end of inspiration, it is suddenly and entirely suspended at the commencement of expiration. That the bullar rales should be heard most distinctly during expiration, will appear very obvious when we consider the admirable arrangement provided for clearing the air passages of the bronchial secretions, and preventing them as well as all foreign matters inhaled from gravitating towards the air vesicles. From the experiments of Sir C. Bell, and others, it is evident that the transverse bronchial muscles act in opposition to 1 lie elasticity of the cartilaginous rings which enter into the formation 39 AUSCULTATION. rareness of (edema and apoplexy, the crepitant rhonchus, particularly when its characteristics are well of the bronchial tubes, and that during inspiration, these muscles are relaxed so as to allow the air passages to expand to their full extent. The effect of this simple arrangement is to allow the air a free passage to the air vesicles, without disturbing the mucus with which these passages arc lubricated, but during expiration these muscles arc called into action, the calibre of the tubes is diminished, the air is consequently expelled with greater violence, the secretions occupying a greater proportion of the calibre of the tubes arc pushed forwards till they accumulate in the larynx, causing sufficient irritation to provoke a powerful expulsive effort, or cough, and are thrown off. Where the secretions are abundant, as in the later stages of pneumonia and bronchitis, the free passage of the air is partially obstructed, and more especially during expiration, when the tubes are most contracted. These secretions are consequently thrown into agitation, the air mingling with them, forms numerous bubbles, the bursting of which gives rise to the louder bullar rales. But a very different state of things exists in the early stage of pneumonia, where the crepitant rale is heard. I believe M. Beau, and Dr. Williams, are quite correct in supposing that tiie bronchial membranes are somewhat dried by the existing inflammatory action, since one of the most manifest changes, observed during the early stages of pneumonia, is a suspension of the aqueous exhalation from the bronchial membranes. Now, the suspension of this function necessarily leaves the mucus with which the air passages are lubricated in so thick and tenacious a condition, that these membranes are glued together whenever they come in contact. The pulmonary tissue being more or less compressed by the descent of the ribs, and the rising of the diaphragm during expiration, the bronchial membranes are to a greater or less extent forced into direct contact. The capillary congestion and interstitial effusion, which arc among the essential elements of pneumonia, must greatly increase the volume of the 40 AUSCULTATION. defined, is almost a pathognomonic sign of pneumonia at the period of engorgemen t. B. Sub-crepitant rale—(mucous, humid and bronchial. —The sub-crepitant rale may be justly compared to the sound which is produced by blowing with a pipe into soap-suds. The varying size of the bubbles has given rise to the distinction into fine, medium, and large sub-crepitant. The number of bubbles and their characters are equally variable. This rale accompanies both inspi- diseased lung, and consequently augment the compression of the pulmonary tissue, and facilitate the adhesion or gluing together of the bronchial vesicles. Now, during every inspiration the air rushing into and distending these vesicles, necessarily overcomes these cohesions, and would not the separating of these membranes, thus glued together by tenacious mucus, naturally produce precisely such sounds as constitute the crepitant rale of pneumonia ? If this view of the phenomena be correct, it is not strange, that " distending a piece of lung with air after it has been compressed" should give rise to a similar rale. A great variety of experiments might be here introduced to illustrate this view of the phenomena. One of the most simple is that of moistening the thumb and finger with very thick paste, or mucilage of gum Arabic, and alternately pinching them together, and separating them when held near the car. Hy repeating and modifying this simple experiment, sounds may be produced so perfectly imitating the crepitant rale of pneumonia, that I am persuaded no one who will take the trouble to try it will doubt this explanation of its cause. The same explanation of the physical cause of this rale had also been given by Professor Mitchell, of the Jefferson Medical College, some time previously to the appearance of this article.— Tr. 41 AUSCULTATION. ration and expiration, and its most common seat is the inferior and posterior part of the chest on both sides. The sub-crepitant rale may be recognised in a great number of diseases, such as bronchitis in the second stage, the different varieties of catarrh of the pulmonary mucous membranes, dilatation of the bronchi with excessive secretion, certain forms of congestion and pulmonary apoplexy, and phthisis at the commencement of the softening of the tubercles. The most frequent of all these affections are bronchitis and tubercles in the commencement of the stage of softening: the presence of the sub-crepitant rale ought to lead us to suspect the existence of these two diseases particularly, and the knowledge of the favourite seat of the rhonchus will guide us in our diagnosis. If the bubbles are very numerous at the base of the lungs, and diminish in proportion as the ear of the observer approaches the top of the chest, the existence of bronchitis is almost certain; if, on the contrary, they are absent, or very few in number at the base of the thorax, and are heard higher up, particularly on one side, becoming more and more numerous as the auscultator rises, we ought to diagnosticate tubercles in a state of softening. C. Cavernous rale, (gurgling.)—This rale is caused by bubbles, less numerous, large, irregular in size, and joined with cavernous respiration ; it is this mixture which gives it its distinctive character. It is perceived both in inspiration and expiration, and is 4* 42 AUSCULTATION. ordinarily confined to the summit of one or both lungs.—Sometimes the rhonchus, although situated at the upper part of the chest, has smaller bubbles and a clearer tone, without any admixture of cavernous respiration: this is the cavemulous rale. The cavernous rhonchus announces either the presence of a cavity in the lung, communicating with the bronchi, or an elliptical dilatation of the bronchi.—If it is accompanied by cavernous voice, and has its seat at the summit of the lung, it will be an almost certain indication of the existence of a tubercular cavity. Appendix. There arc still some abnormal sounds, not so well characterized however, more rarely recognised, and whose value has been determined with less precision: these are cracklings, plaintive tones, or at times something analogous to the dull flapping of a valve; at other times may be heard a rustling sound, (Fournet.) These phenomena have appeared to us to be due to the presence of tubercular excavations, with the exception of the rustling and crackling sounds, which we meet with only in the commencement of pulmonary phthisis. 43 AUSCULTATION. ARTICLE II AUSCULTATION OF THE VOICE When we auscult the larynx of a man while he is speaking, the vocal sound is transmitted with distinctness through the stethoscope, and strikes forcibly upon the ear. Along the trachea this resonance is rather less grave and intense, and over the chest we hear only a confused humming sound.—The natural resonance of the voice, which represents exactly all the varieties of the voice itself, is the more intense, in proportion as the latter is stronger and more sonorous, as we listen nearer the great bronchial tubes, and as the chest is wider and the walls thinner. It is equal in corresponding points on both sides of the chest, but is rather more marked towards the top of the right lung, on account of the greater diameter of the principal bronchus. In the pathological condition sometimes the vocal resonance is only exaggerated, at others, it undergoes, in addition, modifications of its nature, and the voice becomes bronchial, tremulous, cavernous, or amphoric. A. Exaggerated resonance of the voice, or slight bronchophony, is characterized by a rather stronger resonance of the voice than natural, not, however, to the extent of the bronchial voice, (true bronchophony.) It usually accompanies similar, but less marked and less extensive alterations. 44 AUSCULTATION. B. The bronchial voice, or bronchophony, is a much stronger resonance than the natural; it is remarkable for its intensity, its extent, its fixedness, and its permanence. It usually accompanies bronchial respiration. We may meet with it in dilatation of the bronchi, in pleurisy, and particularly in induration of the lungs. But in consequence of the infrequency of dilatation of the bronchi, it is almost always pulmonary induration that is determined by the presence of bronchophony; but, of all the diseases in which the density of the lung is increased, pneumonia and tubercles are by far the most common. The characteristics of bronchophony being more complete in pneumonia than in tubercles, it is better marked in the first disease than in the second; it only exists in some cases of pleurisy, and if then it is decided and extended, we may suspect that the pleuritic effusion is complicated with pneumonia or tubercular induration. C. The tremulous or bleating voice, (mgophony,) is a peculiar vocal resonance which assumes a shriller tone and becomes trembling and jerking. It sounds as if the patient were speaking with a piece of metal placed between his teeth and lips, (resembling the voice of the puppet Punch.) It is heard generally on one side, in the lower half of the sub-spinal space, and when it occupies a more extensive surface, it is still most strongly marked in this point; it may change its position in the different postures of the 45 AUSCULTATION. patient. It coincides almost always with weakness or absence of the vesicular murmur at the base of the chest. True a?gophony announces a pleuritic effusion, which is, in nearly every case, serous.—If it is perceived on one side only, accompanied by fever, there is pleurisy; if on both sides, without fever, and with general dropsy, there is a hydrothorax. If it appears in the course of an inflammation of the pulmonary parenchyma, and more particularly if it changes its position with that of the patient, it indicates a pleuro-pneumonia. D. Cavernous voice. (Pectoriloquy.) We call that a cavernous voice, in which the vocal vibrations seem concentrated into a hollow space, whose walls reflect them back to the ear, more or less distinctly articulated —It is in general confined to the upper part of the chest, and coincides either with the cavernous rale, or more frequently with cavernous respiration. The cavernous voice, like the cavernous souffle, indicates the existence of an elliptical dilatation of the bronchi, or a tubercular, purulent, apoplectic, or gangrenous excavation. From the rareness of these elliptical bronchial dilatations and pulmonary excavations, independent of phthisis, compared with the frequency of cavities in phthisical subjects, we may conclude that, nine times out of ten, cavernous voice indicates a tubercular excavation. E. Amphoric voice is characterized by a resonance very much resembling the metallic and cavernous 46 AUSCULTATION. humming produced by speaking across the mouth of a large pitcher three-fourths empty. —It coincides usually with amphoric respiration, and, like it, announces pneumothorax, or, more rarely, a large pulmonary cavity. ARTICLE III. AUSCULTATION OF THE COUGH. When the ear is applied to the chest of a healthy man when he is coughing, we perceive a dull and confused sound, accompanied by a succussion which shakes the pectoral cavity. This phenomenon, composed of impulsion and sound, is the more perceptible as it occurs nearer the ear, in the large bronchial tubes, or as the patient coughs with more or less violence. When we listen upon the larynx and the trachea, and, in an individual with a narrow chest, at the root of the bronchi, the cough has a cavernous character and produces the sensation of the rapid passage of air through a tube. In the pathological condition, the cough presents special characters: it is bronchial, tubal, cavernous, and amphoric. When the cough is tubal, the ear experiences the sensation produced by a column of air passing with much noise, violence, and rapidity, through a tube having solid walls.—It manifests itself under the AUSCULTATION. 47 same circumstances as bronchial respiration, and is a decided symptom of pulmonary hepatization. The cavernous cough consists in a stronger and much hollower resonance than the normal. It is accompanied by an impulse against the ear which is quite distinctive. It is one of the most positive signs of the existence of a cavity in the lungs. The amphoric cough is characterized by a well marked metallic resonance; when heard in connexion with the amphoric respiration and voice, it announces the existence of a pneumo-hydrothorax, or a large pulmonary cavity. Metallic Tinkling. We give this name to a slight silvery sound, single or multiple, resembling the sound produced by pouring grains of sand into a large metallic vessel. It accompanies both respiration and voice, but is generally more manifest during cough. It announces the existence, either of a very large pulmonary cavity, a pneumothorax, or hydro-pneumothorax, with or without fistulous perforation of the bronchi. In consequence, however, of the rareness of cavities sufficiently large to give rise to a perceptible metallic tinkling, this phenomenon,when well marked, is almost always indicative of pneumothorax.—As gaseous effusions of the pleura rarely exist without a collection of fluid or pulmonary perforation, if the tinkling be produced in a constant and evident man- 48 AUSCULTATION. ner, both by respiration and voice, it is almost a pathognomonic sign of hydro-pneumothorax, with fistulous communication of the pleura and bronchi. Thoracic Fluctuation. In the physiological condition, succussion does not produce any sound in the chest; but when there is an effusion of liquid and air into the cavity of the pleura, the collision of these fluids, produced by succussion of the trunk or the spontaneous movements of the patient, causes the ear to perceive a plashing sound exactly like that produced by shaking a decanter half filled with water; this phenomenon is sometimes so well marked, that it may be heard at some distance from the patient: it nearly always accompanies amphoric respiration and metallic tinkling, and like them, indicates the existence oipneumohydrothorax, or a very large pulmonary cavity half filled with liquid. ARTICLE IV. AUSCULTATION OF THE LARYNX. In the healthy condition of the larynx, the respiratory sound has a hollow and cavernous tone, the vocal resonance is at its maximum, and the cough gives the sensation of the rapid passage of air through a hollow space. In the pathological condition, the AUSCULTATION. 49 laryngeal respiratory murmur is harsher, or more rasping, as, for instance, in acute or chronic laryngitis, or else it is replaced by a whistling sound, as in spasm or aidema of the glottis, in stridulous laryngitis, in some cases of foreign bodies in, and compression of, the trachea; or by a sonorous tone, as in the case of laryngeal ulceration with thickened edges, and obstruction to the passage of the air; or again, by a snoring sound, as in simple or stridulous laryngitis, ulcerations, laryngeal vegetations, fyc, —a sound which has frequently a metallic tone in croup. In some circumstances, the ear perceives a laryngeal cavernous rale, as, for example, when the trachea and larynx are filled with mucus, this rale may be more circumscribed and confine itself to the presence of the mucus upon an ulceration, or around a foreign body arrested in the ventricles, &c. Finally, in some rare cases, we hear a tremulous or vibrating sound, which announces the existence of croup with floating false membranes. There is another sign, that is met with in a great many diseases of the larynx, that may be established, it is true, by auscultation of the chest, but which ought to be mentioned here : it is the diminution, or complete obliteration of the vesicular murmur. This phenomenon accompanies every alteration which offers an evident obstacle to the introduction of air into the air passages, whether it obstruct or narrow the diameter of the tubes, (as swelling, inflammation, vegetations, accidental products, foreign bodies, &c.,) whether it compresses them fiom with- 5 50 AUSCULTATION. out, (cancerous tumours, cysts, aneurisms, &c.,) or whether, finally, it produces more or less complete occlusion of the superior orifice of the air tube, (as hypertrophy of the tonsils, polypi of the nasal fossae falling upon the superior part of the larynx, &c.) END OP AUSCULTATION OF THE RESPIRATORY APPARATUS. TABLES. Tables exhibiting the physical cause and ordinary seat of the different physical signs, together with the names of the diseases in which they are observed. These Tables have been considerably modified from the original, not with the hope of improving them, but in order to adapt them to the text of MM. Barth and Roger. In the article, Prolonged Expiration, the physical cause has been given in the words of the Authors, as explained by them in the body of the work. In the text, a different explanation has been offered in a note by the Translator.— Tr. 52 AUSCULTATION. XTameoftheSign. Physical Cause of the Sign. Ordinary seat of the Sign. Diseases in uhich it is observed. Respiratory mur- Passage of air into the mi- Vesicular structure. In health, "is a gen,,e sigh^^ nuie air tcsicles. softi nejther dry nQf g b radlia| ,^ developed, composed of two sounds, the inspiratory and expiratory, inappreciai bly separated." (Williams and Clymer.) j Strong or puerile Increased rapidity of the pas- Variable, may occupy a part roh4tri , r , p ,, ,.„,,„„.... reSP,raU ° n - SSSSIStSK o-f t - healthy disease of a more or less dis tissue, ad J t .c effiiuon. tant portion. The healthy joining < Plmiri tie effusion Eed mak,ng UP th ° Se PartS ' Tnua'thoricic'^mour, Chronic consolidation. Rarefied by vesicular cm [ physema. 2. In healthy tissue, sudden- ( Spasmodic ly released from spasm. \ asthma. 3. In tissue af- ( "ypertrophy. fected with J Earliest stage of pneu' ( monia.—(Walshe.) | Feeble respiration. Otetroction to the entrance Variable may occupy part of. Pleuritic effusions. Thick false memor an entire lung. branes deposited on the pleura. Tumours which remove the lung from the walls of the chest. Pleurodynia. Contraction of the larynx. Partial obstruc tion of one or more of the bronchial ramifications. Contraction of their AUSCULTATION. 53 cavity, or compression of their walls by tumours. Pulmonary emphysema, and in the first stage ot phthisis. Spasmodic asthma. More or less occlusion of the superior orifice of the laryngeal tube by hypertrophy of the tonsils. Polypi of the nasal fossa:, falling upon the upper part of the larynx. Absent or suppress- Complete obstruction to the Variable, the part or whole of Same diseases as weak respiration, with ed respiration. entrance of air, or the inter- a lung. this difference, that it indicates more position of a fluid prevent- decided anatomical lesions, ing the transmission of the sound. Slow respiration. Retarded action of the respi- Whole lung. Diseases of the cerebro spinal apparatus, ratory muscles. w # Frequent respira- If the extent of the respiratory I Entire lung. Inflammation of the thoracic or abdo tion. movements is diminished, minal organs. Exaggerated activity the number is increased to ot circulation, supply the deficiency. l>e rangement of hcmatosis. Jerking respiration. Interference with the continu- Whole of one side, or infra- Asthma. Pleurodynia. Incipient pht hi - ous expansion of the ciiest. clavicular region alone. sis. Chronic pleurisy with adhesions, either from pain, or, under certain circumstances, from the presence of pleuritic adhesions. Harsh respiration. Condensation or rarefaction Summit of the chest in tuber- In vesicular emphysema. In incipient of the pulmonary substance, cnlar diseases. In other phthisis, in fact, in all cases where and dryness of the mucous cases, it is variable. there is pulmonary induration, as memembrane of the bronchial lanosis, cancerous infiltration, chronic tubes. pneumonia, &c. 54 AUSCULTATION. [ JVameoftkeSign. Physical Cause of the Sign. Ordinary seat of tke Sign. Diseases in which it is observed. I Prolonged expira. Ir i tt« Mtto condition the Generally at the summit of Pulmonary emphysema. Tubercles in ?L P^ e L n ? S" m tne luu S> s «™times over a the first of developo^u u " tended SUrface - tizalion ° f^ consequence only a short and feeble sound; but when morbid productions, as tubercles, are infiltrated into the pulmonary parenchyma, these bodies, produce prominences on the interior of the j final bronchial ramifications, and the air meets with obstacles in its egress, which increase the friction, and, hence, there results an increase in the force and duration of the expiratory sound. I B , r . 0 on Chial r I f!? ra ' Condenw, . ti f on of the pulino- Same as harsh respiration. Inflammatory hepatization Tuherrnli i tion, (including nary substance. „„,. al " , y luhercult' blowing and tubal zation of the lung. Pulmonary apo! varieties.) Pr y " L "l" 1(1 effusions into the pleura. Xumours compressing the lung. Dilatation of the bronchi with induration I °f the surrounding tissue. Cavernous respira- Passage of air into a dilated Summit of one or both? —— —— —— — tl0n - bronchus, or into a hollow lungs, C Tuberculous cavity. space in the interior of the Central portion. . . . Dilatation of the bronchi. " S " Any other part of the Iun<*. £ Cavity from abscess, sphacelus, soften- J >"g of cancer, pulmonary apoplexy. AUSCULTATION. 55 Amphoric respira- Passage of air into a large About the middle of the chest, Pneumothorax, with pulmonary fistula, tion. cavity, by a moderately wide to one side, and a little pos- Excavation of large size in the lung, opening from the air pas- teriorly. from tuberculous or other disease, as sages, above the level of any sphacelus, abscess, &c. liquid contained in the cavity. Soft or grazing fric- Slight asperities on the s ir- " Variable, not only in dirfe- In pleurisy, in the forming stage, and tion sound. face of the pleura?, which rent cases, but from day to in tubercles of the pleura, if heard at have lost their polish and day in the same subject. the summit of the chest, become dry. In the move- Sometimes at apex of lung." ments of respiration they rub upon each other. Hard or grating fric- Thick false membranes, with- "Where the cause is idio- t Period of plastic exudation, tion sound. out adhesions. pathic pleurisy, the central <.pi eur ; sv J Period of absorption with height, and inferior part of I or without contraction of the chest posteriorly, and ( the chest." laterally; where the cause is tuberculous pleurisy, sometimes at the summit. In cases of advanced emphysema, at the posterior inferior part of the chest (?)" Sibilant rhonchus. 1. " Presence of viscid mucus "Commonly, generally over Inflammation or catarrh of the bronchi, in, and modifying the form both sides of the chest, or in acute or chronic. Pulmonary emphyand caliber of, the bronchus other cases limited to some setna. Tumours pressing on the brontemporarily, and itself be- spot in particular, the site chi. coming the seat of vibration, of which is variable." which is transmitted to the tubes. 2. " Permanent alteration of J caliber of bronchi from ex- ternal pressure." 56 AUSCULTATION. JVame of the Sign. Physical Cause of the Sign. Ordinary seat of the Sign. Diseases in which it is observed. Sonorous rhonchus. ]. " Presence of viscid mucus Same as the sibilant. '• Same as the sibilant- the precise conin, and modifying the form damn of the diseases vary commonly and caliber of the bronchi, in the two cases however." and itself becoming the seat of vibration. 2. " Permanent alteration of caliber of bronchi from ex ternal pressure." | Crepitant rhonchus. Presence of viscid mucus in Varies, most commonly, at Pneumonia, in the stage of engorgement, the minute bronchial termi- the base of either lung. particularly in certain forms of palliations, the walls of which monary congestion, oedema, and apobeing in contact after expi- plexy of the lungs, ration, are forced apart by the entrance of the air in inspiration. Sub crepitant rhon- Bubbling of air through liquid Inferior and posterior parts Bronchitis in the second stage. Different chus. of variable consistence in of chest on both sides. Supe- varieties of catarrh of the pil. mucous minute bronchial tubes. rior part of lung on either mem., dilatation of the bronchi with side. excessive secretion. Certain forms of congestion and pulmonary apoplexy. And phthisis at the commencement of the period of softening. Dry Crackling rhon- "Wherever tubercle exists in " Unsoftened tubercle in moderate quancnus. the first stage; hence, in the tity." great majority of cases the summit of the lung anteriorly and posteriorly;— that is, primarily; it may appear secondarily, however, in a lower situation, when the 57 AUSCULTATION. disease has advanced to the second stage superiorly. It has not yet been detected as a primary condition in those rare cases, in which tuberculization commences interiorly." "Humid crackling Bubbling of air through liquid Summit of either lung. " Tubercles commencing to soften." rhonchus." of variable consistence in minute bronchial tubes. Cavernous rhonchus. Bubbling of air through liquid Summit of one or both lungs. Tuberculous excavation. contained in a hollow Si,ace Central part of lung. Extensive dilatation of bronchi. in the lungs, the bubbles are f Excavation from abscess, sphace.us, larger irregular in size, and communication of pus contained in less numerous than in the . . «„„_,-» J P'eura or elsewhere, with bronchi; last and joined with caver Indifferently in any part. . -j some destruction of substance atnou's respiration, tending. Softening of cancer. Pul|_ monary apoplexy. Cavemulous rhon- Bubbling of airthrough liquid. Summit of one or both lungs. Tuberculous excavation, chus. Smaller bubbles, clearer tone, without admixture of cavernous respiration. 1 "Weak vocal reso- Diminished conducting power Anterior surface of either Atrophous vesicular emphysema. Pneunance. of substance of lung, or pre- side (especially the left,) also mothorax.' sence of non-conducting me- the bases posteriorly, dium between the lung and the walls of the chest. 58 AUSCULTATION. JVame of the Sign. Physical Cause of the Sign. Ordinary seat of the Sign. Diseases in which it is observed. Exaggerated vocal _ " ~ resonance.or slight Bronchophony, is characterized by a rather stronger resonance of the voice than natural, not, however, to the extent of the bronchial voice. It I usually accompa'. nies similar, but j less marked, and less extensive alte- I rations. Bronchophony. 1. Unnatural density of the j At the summit. Tuberculous infiltrations pulmonary tissues surround- Base, commonly. In pneumonia, ing the bronchi, rendering Central h ight. In pleurisy with effusion them a better conductor of Variable. . S 1" ° l, PP Rr P art of c,lesI - ral| y- Atrophy of lung. Emphysema of lungs, or walls of chest. Emaciation of walls of chest. Pleurisy with effusion above the level of the liquid. (Pkod.-i ) Hernia of the lung without -ii vision of the integuments. ——— — —— __ __________ _________ _____________ Dilatation of the bronchi, (rare.) T na.'ce'' itiC rCS °" U " nat «/a"y abundant quan- Left infra-clavicular and ~ " \ Atronhou- na '- Le - flf a,r ««e subjacent mammary regions; also ax- Pulmonary emphysema. gS^^i,-, parts together with in- illary and infra-axillary on Pneumothorax. Ml>pert.ophous. creased tension of the walls. either side. Hydro-pneumolhorax. Diminution of reso- tion _of_ some sub_ All regions of the chest. Great muscular development, t,,,e, t ,ayer a. (Obscure sound.) and the walls of the che«t of tat, (when occurring under these cirwhich prevents the transmis-' aX?*? ¦[ be recos , nised f '™ sion of sound tnft fact of ,ta bei "g eo -" al cornssponding points on opposite sides.) Infiltration of the walls of the chest, ab scess in the thoracic walls. Pleurisy, in early stages, with slight effusions, or later, with plastic exudation, or retraction of the walls of the I chest; slight hydrothorax. PERCUSSION. 125 Diminution of reso- Increased density of the sub- All the regions of the chest 1 Pneumonia, acne anil chronic former 1 n»nce. jacent parts, and diminished but the bases and summits in all its singes. b. (Dull sound) with quantity of air in the corre- anteriorly and posteriorly. Tuberculous disease in all its stages, increased resist- spondn.g pulmonary tissue. more frequently than the Dilatation of the bronchi, ance of walls. central and lateral regions. Tumours of walls of chest, or pleura, cancer, melanosis, (rare ) Pleuritic effusion. Hydrot borax. Pulmonary apoplexy. Haemnihorax. Condensation of the lung from the effusion of serum, blood, or pus. Hydro-pneumolhorax, (lower pari of the chest.) Tubular character Any condition which brings Lower part of infra-clavicular (General (period of of sound. the larger bronchi unna- and upper part of mammary Pleuritic effusion. < retraction.) lurally near the surface, and regions; most frequently ob- f Partial. ' so within reach of percus- served on the left side. Accumulation of pus retained and lying 1 sinn; or the presence of a over bronchi. solid substance between Pneumonia (very rare.) those bronchi and ihe sur- Dilatation of bronchi. f ace - Tuberculous cavity of a small (rarely large) size. Chronic consolidation of lung. Cancerous mass around bronchi. Amphoric character. Antero superior part of chest Tuberculous cavity of large size, having on either side. walls generally and equally condensed. Cracked metal Sudden propul sion of air, Antero superior part of chest Tuberculous cavity of large size, wi h I sound. (forcibly expelled from a ca- on either side. anfractuous walls. and communicating (Cracked pot of B. vity) against the walls of freely with the bronchi; with thin and R.) the passages with which it and elastic walls, and containing air conies in contact. and liquids. Moveablenessofthe JMoveableness of the material Inferior regions of the chest. Pleurisy, especially at the period of gralinuiia of dulness causing the dull sound. vitating effusion, of sound. Hydroihorax. Hydru-pneumntliorTX. 11* 126 CHAPTER II. CIRCULATORY APPARATUS. PERCUSSION OF THE HEART AND GREAT VESSELS. I. Particular Rules. The majority of the rules we have laid down as applicable to percussion of the pulmonary apparatus, may be repeated here. In general, moderate percussion is sufficient to discover that portion of the heart which is in immediate contact with the walls of the chest; but in order that we may have a just idea of the real volume of this organ, and discover the part concealed under the anterior border of the lung, it is necessary that the percussion should be deep and practised with more force. It will be necessary also always to percuss first in the vertical direction, and then in the horizontal; often also it is useful to determine even more exactly the limits of the dulness in every direction ; and in order that we may have more accurate results, and be able to judge of the changes which may take place from day to day, it is advisable to mark them by lines upon the body. 127 PERCUSSION. II. Physiological Phenomena. In the normal condition the precordial region gives a dull sound, the degree and extent of which are by no means invariable. In fact, the heart being more or less covered by the anterior border of the left lung, necessarily gives rise to great variations in the pleximetrical results. However, according to the measurements generally admitted, the normal dulness of the precordial region extends about two inches in every direction. It begins, superiorly, about the fourth rib, and extends downwards as far as the sixth; it has its maximum about the centre of this region, and laterally it is blended by degrees with the pulmonary sound. Below, and on the left, it is replaced by the peculiar resonance of the stomach. Below, and towards the right side, it is often confounded with the dulness of the left border of the liver, which approaches or touches the heart, so that it is difficult to define exactly the limit which divides these two viscera. The dulness yielded by moderate percussion of the precordial region, does not give, (as before stated,) the real dimensions of the heart; it merely makes known the extent of surface in contact with the walls of the chest. Stronger and deeper percussion is necessary to discover the parts concealed by the lung, and the obscure sound then extends laterally, beyond the limits before mentioned, over a space 128 PERCUSSION. which varies in proportion to the different sizes of the heart in different ages and individuals. In regard to the great vessels arising from the heart, we have already seen that their presence behind the sternum slightly modifies the resonance of the chest; and according to the recent researches of Piorry* it will produce an obscure sound, quite distinct from the pulmonary resonance. This slight dulness extends over a space of from sixteen to twenty lines, near the base of the heart, at the point where the aorta and pulmonary artery are in contact with each other, and over not more than ten or twelve lines where the aorta rises alone behind the sternal wall. III. Pathological Phenomena. The dulness yielded by the precordial region in the natural condition, may, in a morbid state, be diminished in intensity and extent, and even give place to excessive resonance. But this phenomenon is nearly always due to emphysema of the internal edge of the lung which covers the anterior face of the heart; it more rarely accompanies atrophy of this viscus, which also allows the internal edges of the two lungs to approach each other. More rarely still, the excessive resonance depends directly upon a lesion of the central organ of the circulation, namely, * De l'examen plessimetrique dc l'aorte, etc., dans Arch. Gen. de Med., December, 1840. 129 PERCUSSION. the accumulation of gas in the cavity of the pericardium : in fact, pneumo-pericardium is an exceedingly rare affection. In some cases, no less rare, the sound by a hydroaeric tone announces the existence of a collection of liquid and gas in the cavity of the serous membrane. The modifications of resonance, which are influenced by pathological conditions of the central circulatory apparatus, consist much more frequently of an increase of the natural obscurity of the precordial region: this latter is converted into a dulness at the same time more decided and extensive, with a proportionate increase of resistance to the finger. These phenomena may depend either upon the presence of large clots in the cavities of the heart; more frequently upon eccentric hypertrophy of this organ, or upon liquid effusion into the pericardium composed of serosity with or without false membranes, (hydropericarditis, pericarditis,) with or without the mixture of a variable quantity of blood, (hemorrhagic pericarditis,) or again, by a combination of several of these morbid conditions. Some peculiar characteristics of the dulness will serve to establish the differential diagnosis between hypertrophy of the heart and hydro-pericardium. Thus in this latter affection, the superior or lateral boundaries of the dull sound may vary according to the position of the patient; for instance, when he is in a sitting position, the transverse diameter will exceed the vertical. 130 PERCUSSION. This important characteristic should also be noticed, that, in hydro-pericardium, the dulness very frequently comes on in a short time, and gradually increases in extent, —a progress and extent not observed in hypertrophy. We may remark also that, the space occupied by the dull sound is in proportion to the increase of volume of the heart, and may afford us a tolerably accurate measurement of it; we should recollect, however, that complication with pulmonary emphysema, so frequent in organic diseases of the circulatory apparatus, is an obstacle to the accuracy of this measurement. According to Corvisart and Piorry, the results furnished by percussion will enable us to extend the diagnosis still further, to distinguish dilatation of the heart with atrophy, from dilatation with hypertrophy of the walls, and to recognise the alterations of any of its cavities, &c. In some cases, a more or less decided and extensive dulness manifests itself in the course of the aorta; considered singly, this sign would be of no great value, since any variety of tumour situated behind the thoracic wall, and in the direction of this vessel, would manifest itself by the same diminution of natural resonance. However, an abnormal dulness in the region of the sternum may announce, sometimes before any other symptom, the existence of an aneurism of the ascending aorta, and the examination of the other concomitant phenomena will establish this first semeiotic datum. 131 PERCUSSION. SECTION II. PERCUSSION OF THE ABDOMEN. I. Particular Rules. In percussion of the abdomen, (which is generally performed upon the anterior walls,) the patient should lie upon his back in a symmetrical position, with his arms extended along his body ; the thighs a little elevated and bent slightly upon the trunk, in order that the abdominal parietes may be easily depressed, and thus brought near to the deep-seated organs. Moderate relaxation is the more necessary, as too great tension of the muscles has the effect of making them resisting, and rendering the sound furnished by the subjacent viseia more obscure. In the exploration of the lateral regions, the patient should lie on the opposite side to that about to be examined ; and in the exploration of the posterior regions, he should lie upon his belly, or be in a sitting posture, with the body bent forward. It is often necessary to incline the body either to the right or left, in order to observe whether change of position produces a shifting of the dulness: it is seldom necessary to place the patient upon his hands and knees for this purpose. As to the physician, he should stand on either side indifferently, and percuss in different directions, according to the organ to be explored. If, in the exa- 132 PERCUSSION. mination of the different regions of the abdomen, digital percussion has the advantage of being joined to palpation, the pleximeter, on the other hand, has that of being easily shifted around the abdominal viscera, in order to measure their circumference; and if in the examination of the chest the finger generally suffices, here the pleximeter should sometimes be employed in preference. It will be particularly useful if the belly is very sensitive, because the pressure of the pleximeter being uniformly distributed, and over a more extended surface, it will be much less painful. Percussion of the abdomen particularly, should be sometimes very superficial, and at others deep; and the pleximeter will serve a very useful purpose in depressing the abdominal walls, in order to study the sound of parts deeply seated in the abdomen. II. Physiological Phenomena. The various regions of the abdomen, considered in relation to its normal resonance, present very great differences, which are connected with the varying structure and density of the organs contained in its cavity. For the sake of accurate study, it is divided into three horizontal belts, which include its whole extent: 1st, the epigastric, right and left hypochondriac regions; 2d, the umbilical region, and the flanks, which correspond posteriorly with the loins ; 3d, the hypogastric, and right and left iliac regions. PERCUSSION. 133 At the epigastrium the sound is a little dull in the superior and right portion, varying in extent, in consequence of the presence of the left lobe of the liver, which encroaches more or less upon the epigastric region. In the remaining portion of this region, which is in relation with the stomach, we obtain a clear sound, (stomachal,) which becomes humoric if the stomach contains gases and liquids, and more or less obscure, if it is filled with alimentary substances. The right hypockondrium yields a dull sound, (hepatic,) which extends throughout it from the sixth or seventh rib, (five inches below the clavicle, according to Piorry,) to the edge of the false ribs, beyond which the intestinal resonance is established. This dulness which is rather less marked above, in consequence of the habitual interposition of a thin layer of the lung, is at its maximum in the middle of this region; lower down, as the liver diminishes in thickness, we lind, by deep percussion, the clear sound of the intestines, obscured by the hepatic dulness. In a horizontal direction, the dull sound extends towards the right as far as the posterior region, and towards the left, it ceases one or two inches beyond the median line, where it is replaced by the stomachal resonance. These limits give the exact measurement of the liver in every direction. It is even possible, by strong percussion, to make an 12 134 PERCUSSION. approximate estimate of its thickness, and it then becomes very easy to appreciate its size.* In the left hypockondrium which corresponds to the great extremity of the stomach, we obtain anteriorly a clear stomachal sound, more decided than that at the epigastrium; laterally and more posteriorly, this sound becomes dull, in consequence of the presence of the spleen at this point. The line of separation between the clear and the dull sound defines the inner limit of this viscus, and the inferior limit is determined by the line where the resistance to the finger gives place to a certain degree of elasticity, and the splenic dulness to the intestinal resonance, at least whenever the kidney is not in contact with the spleen. The umbilical region yields a more or less clear sound, which is due to the presence of a portion of the arch of the colon in its superior part, and to the small intestine in the remainder of its extent (intestinal sound.) Laterally, towards the lumbar region the sound still preserves a little of its clearness, in * A correct knowledge of the situation of the liver, in relation to the neighbouring organs, is of great importance in reference to the diagnosis of some of its structural lesions. It becomes highly useful in enabling us to understand how an enlarged liver may so interfere with the stomach as to interrupt its functions; how it may produce jaundice by impeding the flow of bile, dropsy of the abdomen by obstructing the return of the blood to the heart; and how abscesses, originally formed in the hepatic tissue, may burst into the surrounding organs. — (Tr.) 135 PERCUSSION. consequence of the presence of the ascending or descending portion of the colon; but more outwardly, and throughout the lumbar region, it gives place to a dull sound extending as far as the level of the kidneys which are covered by a thick muscular laver. In the hypogastrium, the presence of the lowest convolutions of the small intestine gives rise to a clear sound, if the bladder and uterus are empty. In the opposite condition, we obtain, in the lower portion, an invariable dulness circumscribed by a curved line convex superiorly, with humoric resonance at the boundary if it is the bladder which is distended, and immediately replaced by the clear sound, if it is the uterus which is developed by the product of conception. Finally, in the iliac regions, we perceive a clear sound, when the ccecum, or the iliac portion of the colon are distended by gases, a humoric sound if they contain gases and liquids, and a dull sound (stercoral) if they are filled with fasces. III. Pathological Phenomena. The sounds yielded by the different regions of the abdomen, present very numerous modifications in the pathological condition. They may be altered in their intensity and in their character, and be modified in their seat and limits, that is to say, be increased or diminished in extent, and undergo displacements 136 PERCUSSION. in different directions. Finally, abnormal sounds sometimes present themselves in different parts of the abdomen, which are not usually found there, and of which not even a trace exists in health. Let us study in succession the alterations of resonance in each of the abdominal viscera separately, and then those which may present themselves in the different regions of this cavity. Liver and gall-bladder. —The hepatic sound may change its position in the same manner as the liver itself without any alteration either in character or extent; these displacements, generally speaking, only take place in the vertical direction: the dulness may rise higher than in the natural condition, to such a degree, that its superior limits reach the fourth or even the third rib: we observe this in cases where the liver is pushed up in consequence of an extensive peritoneal effusion, or even in those of very considerable meteorism. It may equally be more or less depressed, below the inferior border of the false ribs, by extensive collections of liquid or gas in the left pleural cavity. In other circumstances, the hepatic sound occupies a more considerable space; its superior limit rises along the side of the chest; the inferior is at the same time depressed a little below the border of the ribs, and descends sometimes even to the crest and fossre of the ilium; often again, the dulness extends equally to the left, occupying the whole of the epigastrium and even reaching the hypo- PERCUSSION. 137 chondrium. We cannot fail then to recognise the increase in volume of this viscus, when the dimensions can be so readily measured by the extent of dulness on percussion, nor to judge of its shape by the relative increase of this dulness in the vertical or horizontal direction. But this increase in volume of the liver is concomitant of very different lesions: it may be due either to cancerous masses developed in its thickness, to the presence of one or more hydatid cysts, to fatty degeneration, or finally, to a recent sanguineous congestion, or a chronic hypertrophy without any other alteration of structure. In establishing the differential diagnosis, palpation often lends great assistance to the use of the pleximeter. In cases of cancer' or hydatid cysts, the parts of the liver which are accessible to touch, present more or less prominent inequalities, and its inferior border is often unequally thickened. When, on the contrary, it is due to simple hypertrophy, or fatty degeneration, the viscus usually retains its shape; the part which passes beyond the false ribs is smooth, and the inferior border remains thin and sharp. But in hypertrophy the liver is generally heavier and denser, whilst in the fatty condition it is usually lighter, and in the first case, the resistance to the finger, in percussing, is greater than in the second. It should be remembered also, that the fatty condition is met with almost exclusively in tubercular phthisis. In regard to the distinction be- 12* 138 PERCUSSION*. tween cancer and the acephalocystic cysts, the cancerous nature of the tumours will be recognised by their number, their small size, and their central depression ; accphalocysts might be suspected, if there were only a single tumour more prominent and more rounded, and there would be no doubt in the diagnosis, if we could establish by percussion a peculiar tremulousness, which will be spoken of hereafter. At other times, the hepatic sound occupies a more narrowed space; its dimensions are diminished in every direction, and the limits circumscribing it, approximate on all sides. Diminution of volume, such as is frequently observed in advanced cirrhosis, and much more rarely in simple atrophy, without other alteration of texture, cannot be mistaken from these characteristic signs. These results of percussion are the more valuable in these cases, because that, in ascites, so frequent a complication of the lesion before mentioned, the liver being pushed up and entirely concealed under the false ribs, has become entirely inaccessible to the touch. The gall-hia elder, which normally escapes detection by palpation and the use of the pleximeter, may become evident in cases of considerable distention by an accumulation of bile, serous liquid, or even numerous biliary concretions. In percussing transversely, in the direction of the inferior border of the liver, we may sometimes discover a more obscure sound, instead of the clear one of the intestines, which succeeds the hepatic dulness: 139 PERCUSSION. and if this particular dulness have its seat at that point of the abdomen which corresponds anatomically with the situation of the biliary reservoir, and if it may be delineated of an oval form, it is more than probable that it depends on distention of the gall-bladder. Spleen. —The foregoing considerations are equally applicable to the spleen. This viscus may be depressed below its normal position, by a liquid or gaseous effusion into the left pleural cavity, or pushed from below upwards by ascites, or extensive tympanitis. In the first case, palpation is sometimes sufficient to recognise the position and volume of the spleen; but in the second, percussion only can furnish certain results, and the changes in position of which we have just spoken, are revealed by analogous displacements of the splenic dulness, whilst in the usual seat of the viscus we discover a resonance foreign to it. The dulness of the region of the spleen is also susceptible of variation: generally but three inches and a half in extent in the vertical direction, by three inches only in width, (according to the researches of Piorry,) it may diminish or increase to a more or less considerable degree. Diminution in extent is most frequently caused by the distention of the stomach or intestines by gas, and then sometimes nearly the whole splenic region yields a clear sound. This diminution is, at other times, due to the small size of the spleen: and 140 PERCUSSION. if we can satisfy ourselves that it is owing neither to tension of the epigastrium or abdomen, nor to exaggerated tympanitic resonance, it may be attributed to atrophy of this viscus, such as is frequeutly met with, in individuals who fall into a state of extreme emaciation, from long-continued organic diseases. But the increase of volume in the spleen is an occurrence of much more importance. When the increase is slight, the viscus generally extends beyond the inferior border of the false ribs, and by judging of the volume of this portion of the spleen, by touch, we can form an approximate idea of its total dimensions: but percussion alone can give an exact notion of the portion concealed under the ribs, and thus concur in throwing light upon its real volume. But this is not all: even although hypertrophied, the organ may be pushed up in the same manner as the diaphragm, by gaseous distention of the belly, and, in this case, pleximetry is indispensable to determine its dimensions. The measure of its extent in height is more easy, and generally in hypertrophy, without organic lesion, the increase in width and thickness corresponds to that which takes place in a vertical direction. Now, the vertical dulness may rise five, six, or eight inches, and indicate corresponding dimensions in the volume of the spleen. This increase is frequently met with as a sequel to long-continued intermittent fevers; in some rare cases.it mav be even more 141 PERCUSSION". considerable, and this viscus has been seen to extend as high as twelve and fifteen inches, at the same time that it weighed eight, ten, or fifteen pounds, and even more. Increase in extent of the splenic dulness, so frequently concomitant of hypertrophy of the spleen, may also be met with in other alterations, such as cancers, hydatid cysts, &c. But these latter are very rare, and besides, in them, the shape of the viscus undergoes more or less evident changes. Let us add, in conclusion, that it is not always easy to decide whether a dull sound over the splenic region is really dependent upon the spleen; and that it may be difficult to determine its superior limit in cases of hepatization of the base of the left lung, or pleuritic effusion on the same side, as also, to define accurately its inferior limits in ascites; but percussion practised with different degrees of force, at the same time changing the position of the patient, will generally enable us to overcome these difficulties. Stomach. —The clear sound yielded by the stomach varies, even in a healthy individual, in extent and intensity, according as we explore the organ sooner or later after a meal, and in a state of vacuity or plentitude. At all times, the sound is generally moderately tympanitic: it occupies the left portion of the epigastrium, as well as the corresponding hypochondrium, and extends a little towards the more inferior regions of the abdomen. 142 PERCUSSION. As a consequence of different pathological conditions, the stomachal sound may become much more intense, assume a very decided tympanitic character, and extending further, may rise in the hypochondriac region as high as the fifth rib, occupy the entire epigastric region, and extend below the umbilicus. We may recognise by these characters, an enlargement of the stomach from distention by gas, as is frequently observed in cases of narrowing of the pylorus, (hydrogastric.) The sound frequently also assumes a humoric tone, which announces the simultaneous presence of liquids and gases collected in great quantity in the cavity of the stomach. At other times, on the contrary, the stomachal sound is much less decided than in the healthy condition, and confined to much narrower limits, when, for example, the stomach is shrunken, in consequence of chronic inflammations, or, more particularly, from poisoning by acids. Sometimes even there is a dull sound perceived over a certain space, principally at the epigastrium and the pyloric region. This dulness often depends upon the presence of the left lobe of a hypertrophied liver, or its prolongation in a transverse direction ; but it may also be caused by cancerous degeneration of the walls of the stomach, or an accumulation of blood in its cavity. In the first case (hypertrophy of the liver) the dulness is permanent, and by deep and forcible percussion we may discover the characteristic sound of PERCUSSION. 143 the stomach under the more or less thin lamina of the liver which covers it. When the dulness depends upon carcinomatous degeneration, it is usually confined to the pyloric region, where a moveable tumour may be made apparent by palpation, whilst the tympanitic sound again makes its appearance in the left hypochondrium. An accumulation of blood is recognised, on the contrary, by dulness supervening accidentally in the course of a chronic affection of the stomach, and during the simultaneous development of the general symptoms of hemorrhage. Finally, the stomachal sound, when displaced, may be found more or less removed from the seat occupied by it in the normal condition: thus, the stomach has been seen contained in hernial tumours of the linea alba, and even of the inguinal ring.* The production of a clear sound in them by percussion would reveal the presence of a portion of the digestive tube; and if, after having caused the patient to swallow a quantity of fluid, this resonance is suddenly changed to dulness, it would be incontestable proof that the stomach itself formed part of the hernia. Intestines. —The sound yielded by the abdomen may become duller in all the parts which correspond * See case related by Dr. Yvan, of Paris, in the Archives Generates, January, 1830, in which part of the stomach occupied the sac of a scrotal hernia.— Tr. 144 PERCUSSION. with the intestines, or only in a limited region in comparison with these viscera. Dulness extended over the whole intestinal region is often coincident with depression and retraction of the intestine, and then announces a state of vacuity of this tube, and contraction of its walls, as is seen in some cases of cancer of the stomach with constant vomiting;. Dulness confined to a portion of the intestine may be owing to very different pathological conditions. If its appearance in any part of the abdomen coincides with the general symptoms of hemorrhage, it will enable us to recognise the accumulation of a sanguineous liquid, and even cause us to suspect the source of the enter or rhagia. If its existence be proved in the right iliac fossa, occupying a definite extent, and there be at the same time prominence or tumefaction of this region, it would be a sign of intestinal obstruction, with accumulation of alvine matter and alimentary residua. In the left iliac fossa, it very frequently announces the presence of faeces collected near the end of the large intestine, in consequence of prolonged constipation. The dulness may also be due to carcinomatous degeneration of the walls of the intestine, or even to intestinal invagination. We are readily led to suspect the existence of one of these two lesions, if the dulness coincide with a tumour situated upon the course of the ilium. But cancerous tumours of the small intestine are very rare: the degeneration more frequently occupies 145 PERCUSSION. the colon, and the cancer may then be confounded with accumulation of faeces. Its most usual seat is the left iliac portion; and as it is also the point where fsecal matter most generally collects, there is often in both these morbid conditions a tumour perceptible to the touch, and hence the possibility of an error in diagnosis; this accumulation of stercoral matter may also be mistaken for any other tumour. But let liquids be injected into the colon, and percussion again practised after the injection has operated, then if the dulness disappears we will discover that it was produced by a stercoral tumour; and if, on the other hand, it still remains, we ought to suspect the existence of a tumour formed by degeneration of the walls of the intestine, or adhering to its surface. It will often be useful to associate these injections with the use of the pleximeter, not only to determine the presence and position of the large intestine, but also to diagnosticate many of its diseases : they serve, in fact, according to Piorry, to define more accurately the existence and seat of narrowing of the colon, accessible neither to the finger, nor to a bougie introduced into the rectum. If, for example, a small injection is given, the liquid cannot pass beyond the narrowing; and when, afterwards, percussion gives a dull sound below a certain point, and a clear one above it, there is reason to admit that the narrowing is seated at the point where resonance gives place to dulness. 13 146 PERCUSSION. The intestinal sound often becomes more intense, and entirely tympanitic. This modification is rarely confined to a small part of the abdomen, but generally occupies a large proportion of it. It announces the presence of a considerable quantity of gas in the belly. In an immense majority of cases, the elastic fluids are enclosed in the intestine, (intestinal pneumatosis,) and occasionally they are contained in the cavity of the peritoneum itself. In either case, the tympanitic sound is general; for the intestines when inflated with gas have a tendency to fill the cavity of the abdomen, which in peritoneal pneumatosis is always distended throughout, unless there be morbid adhesions. However, in meteorism, it is rare that the tympanitic sound is of the same intensity in all points; it is frequently more decided in the region of the colon, and the windings of the intestine may be traced through the abdominal walls. In true tympanites, on the contrary, the intestines are pushed up posteriorly, and the resonance is more uniform. Another characteristic will serve to distinguish these two species of pneumatosis: in intestinal meteorism the liver is forced up towards the thoracic cavity, but it rests in contact with the walls of the hypochondrium, where its presence is evidenced by the dulness peculiar to it, whilst, in tympanites, it is displaced at the same time upwards and backwards, and the exaggerated resonance extends even to the hepatic region. If the tympanitic resonance of the intestines asr 147 PERCUSSION. sumes the humoric character, it is an indication of the simultaneous presence of gas and liquids. Sometimes these fluids are enclosed in two contiguous cavities, and the humoric sound is then only obtained in the limits separating the dull sound of the one, and the clear sound of the other; if the liquid be confined to one viscus, as when the bladder is distended by urine and in contact with the intestines inflated with gas, it remains permanent in the same region ; on the contrary, it is subject to displacement if the liquid itself may be displaced, as is observed in ascites, where the effusion obeys the laws of gravity. Sometimes the liquids and gas are enclosed in the same cavity, and this occurs most generally in the intestine, as has been seen in the right iliac region in the majority of typhoid fevers; in this last case also, sudden pressure upon this point, causes us to hear and feel a gurgling which is not obtained when the two fluids occupy different cavities. Finally, the intestinal, as well as the gastric sound may be found in a point more or less remote from the seat to which they belong. These displacements are witnessed particularly in cases of hernia of the umbilical and inguinal region; and percussion, by revealing the resonance of these tumours, proves that they are formed by a portion of the digestive tube. When the hernia is not strangulated, we may sometimes satisfy ourselves, what portion of the intestine is displaced, by means of an injection by the 148 PERCUSSION. anus. If the clear sound be permanent, it is a sign that the small intestine is contained in the hernial sac; if the resonance be changed to dulness, it is a proof that it is produced by displacement of the large intestine. The Kidney. —The kidney is so deeply seated behind the anterior abdominal wall, and placed posteriorly and laterally beneath so thick a muscular layer, that it is very difficult to determine by percussion its exact seat and precise dimensions. Pleximetry only serves to throw light upon the diagnosis of some of its diseases, such as extensive hypertrophies, tuberculous or cancerous degenerations, multiple cysts, hydronephroses, or other alterations, with decided increase in volume: in these cases we perceive a greater and more extensive dulness in the flank and loins of the corresponding side. We have seen a case of this kind in which the dulness rose as high as the sixth rib, and descended as far as the iliac crest, and the kidney was found to have degenerated into an encephaloid mass of from twelve to fifteen inches in length. Percussion may also cause us to suspect either absence or atrophy of the kidney, or displacement of this viscus, if the region where it is generally found, yield less dulness and less resistance to the finger. We may know that it is due to the first of these alterations, if we cannot succeed in discovering any unusual tumour in the abdomen, and to the second, if we can establish the existence of a tumour having the 149 PERCUSSION. shape of the kidney, either in any point of the abdominal cavity, or especially near the sacro-vertebral angle, where we have several times found the organ of the urinary secretion. The Bladder.-—The bladder, situated low down in the lesser pelvis, is, when empty, separated from the anterior abdominal wall by the lower convolution of the digestion tube, and percussion of the hypogastrium yields only the clear sound of the intestine. It is otherwise when it is distended with urine: its fundus, then ascending in the abdomen, passes beyond the pubis; its anterior face is in contact with the abdominal wall at a varying height, and its presence is recognised by a dull sound, circumscribed above by a curved line, with the convexity uppermost. This phenomenon, which is very easily established, becomes a valuable sign of retention of urine and the extent of the dulness, whose superior limit rises sometimes as high as the umbilicus, affords us a measurement of the quantity of liquid accumulated in the bladder. This dulness suffices to distinguish retention of urine from suppression, and micturitions arising from over distention, from the dribbling of incontinence. It is equally sufficient to establish the diagnosis between tumefaction of the belly, due to the accumulation of urine in the bladder, and the development of the hypogastrium in cases of uterine pneumatosis. The distinction will be more difficult between retention of urine and other anatomical 13* 150 PERCUSSION. conditions, which also give rise to a dull sound, such as cysts, or other solid tumours of the hypogastrium, and particularly pregnancy and dropsy of the uterus. But, in the first case, percussion at the superior limit of the dulness will yield a humoric sound, which will not exist in dropsy of the womb, or in pregnancy, and which, still more evidently, will be wanting when the development of the uterus is dependent upon other pathological conditions, as solid tumours, for instance. Besides, under all these circumstances, the resistance to the finger will be greater than in the case of urinary tumour; and if cysts with very thin walls do not offer this resistance, and we can find a humoric sound at their limits, we must remember that they rarely occupy a median position, and that they scarcely ever have the symmetrical form of the distended bladder. As to ascites, which also gives rise to dulness in the hypogastric region, we cannot mistake it, from the very arrangement that the dull sound assumes, being circumscribed by a curved line with its concavity uppermost, and particularly by this marked characteristic, that it changes its position with that of the body. The Uterus. —In the normal condition and when it is empty, the womb, buried in the lower part of the hypogastrium, is inaccessible to touch, and completely concealed from percussion. But when it is normally developed by the presence of an em- 151 PERCUSSION. bryo, or pathologically by different morbid conditions, pleximetry will furnish valuable results for diagnosis. In pregnancy, percussion practised with care, will give (according to Piorry) a dull sound from the end of the second month, which is an indication of the development of the uterus. If this phenomenon is perceived before we can recognise the enlargement of the organ, by palpation at the hypogastrium, by ballottement, by touch, or by auscultation of the characteristic sounds of pregnancy, it will be a valuable sign at this period, which will add greatly to the probability of gestation. But this result, at so early a period, can only be obtained in exceptional cases. At a more advanced stage, in proportion as the uterus, increasing in size, passes the pubis and rises into the abdomen, we can easily establish by means of percussion at the hypogastrium, a dulness, circumscribed by a curved line convex superiorly, whose extent, form, and situation are in relation with the volume, configuration, and symmetrical or inclined position of the uterus. The characters of this dulness, no doubt, establish a strong presumption in favour of the existence of pregnancy; but it does not give any certainty, and will be insufficient to decide whether the development of the uterus is physiological or pathological, whether it is due to gestation, dropsy of the uterine cavity, or to any other morbid product, as a mole, fibrous body, &c. The presumption of preg- 152 PERCUSSION. nancy will be greater, if the dulness advances with the regularity and progress proper to this condition; but we are not always able to establish this ascent of dulness. and the semeiotic results of pleximetry are inferior to those furnished by auscultation at this period. But, according to Piorry, percussion may facilitate the diagnosis, and enable us to recognise pregnancy by several other characters of the dulness, such as its greater intensity with more marked resistance to the finger in certain points which correspond with the fcetus, and its diminished intensity with an obscure sense of fluctuation in the intermediate points; finally, its displacement by changes in position of the fcetus, characters which fail in the pathological conditions already cited. Pleximetry, in yielding similar results, is particularly useful in establishing the existence of pregnancy, in cases where we are unable to discover either the sound of the foetal heart, or the placental souffle by auscultation; and it may also, to a certain extent, aid in determining the position of the fcetus. In the morbid condition, it is likewise by a dull sound that lesions of the uterus nearly always manifest themselves, whatever be their seat. Thus, in cases of dropsy, slight internal hemorrhages, or fibrous bodies of great volume, percussion yields a dulness whose extent gives the degree of development of the womb, or the dimensions of the tumour. Some peculiar characteristics may serve, in addition, to give precision to the diagnosis: thus, 153 PERCUSSION. in dropsy or in internal hemorrhage, the dull sound is equal throughout, and without much resistance to the finger, and the space occupied by it is regularly ovoid, like the uterus itself, whilst in the case of fibrous bodies, there is not the same uniform intensity throughout: some parts of the organ offer a greater or less resistance to the finger, and the shape of the space occupied by the dulness, is, in addition, very irregularly rounded. It is in very rare circumstances that the uterus can yield a tympanitic sound; a slight accumulation of gas in its cavity is alone capable of producing this phenomenon. This fact, however, has been sometimes observed, and uterine tympanitis will be probable, if we can establish at the hypogastrium an oval swelling, yielding a clear sound, circumscribed in every direction, and unchanging in its position. In regard to the uterine appendages, the most common lesions, which are capable of modifying the resonance of the lower part of the abdomen, are cysts of the ovary and Fallopian tubes, giving rise to a dull sound ordinarily witnessed on one or the other side of the hypogastrium, and which rarely assume a symmetrical position in the median region. The dulness will be the more marked, and accompanied by a greater resistance, in proportion as the walls of these sacs are thicker, and the contents more consistent. The extent of this dulness, concurrently with palpation, will give the approximate 154 PERCUSSION. measure of the size of the tumours. As long as they are only of moderate dimensions, the cysts of the ovary and Fallopian tube cannot be confounded with ascites; but when they fill the whole abdominal cavity, the case is altered. We shall give hereafter the differential characteristics of the dull sound in both these diseases. Peritoneum and abdomen generally. —After having studied particularly the alterations of resonance proper to the principal viscera, it only remains now to describe those which may occupy the whole extent of this cavity, and those which, although localized, may be found indifferently in various regions of the abdomen. The whole belly may yield a much more obscure sound on percussion, in cases of serous infiltration of the abdominal icalls, and in those of obesity with thickening of the sub-cutaneous adipous layer, with fatty infiltration of the folds of the peritoneum, and of the deep-seated cellular tissue. Sometimes, also, the whole region which corresponds to the intestine, yields an obscure sound in chronic peritonitis, when iherc exist false membranes, thickened and infiltrated with tubercles, with or without tubercular degeneration of the mesenteric ganglia, and in these cases, palpation serves to perfect the indications of pleximetry. At other times, an abnormal dulness may be present at one point or other of the belly. It may be due either to a tumour developed in one of the 155 PERCUSSION. organs of which we have already spoken, or it may depend upon a circumscribed puriform collection in the serous cavity, upon an hydatid cyst, a cancer of the epiploon, or an abscess of the extra-peritoneal cellular tissue, as is frequently seen in the iliac fossa and in the lesser pelvis. The degree and extent of the dulness will commonly give the measurement of the density and size of these solid or liquid and its seat may sometimes enable us to discover that of the lesion; but, in general, the results of percussion are not sufficient for diagnosis, and in order to arrive at an accurate knowledge of the alterations, we must add to the pleximetric indications, the results furnished by palpation of the abdomen, and rectal or vaginal touch, and take into account equally the presence and progress of the concomitant symptoms. The diagnosis will be possible with the aid of percussion alone, when the dulness, instead of being confined to a circumscribed region of the abdomen, occupies the whole inferior portion, and particularly when, at the same time, it is susceptible of displacement, by changing the position of the patient. These characteristics are sufficient to enable us to recognise ascites. The presence of a liquid effusion into the peritoneum, will be still more certain, if we obtain a humoric sound in percussing upon the limits of the dulness, or if an evident fluctuation is perceived. There are some cases where the dulness occupies 156 PERCUSSION. the whole, or almost the whole, of the abdomen, which presents at the same time a very large size. We may then diagnosticate almost with certainty the existence of ascites, or extensive ovarian dropsy. The distinction will be established by the following characteristics : in encysted dropsy, the dulness occupies the most prominent region of the belly, whilst the clear sound is found at the sides, where the intestines are pushed back by the tumour. In ascites, on the contrary, the dull sound occupies all the inferior portions, whilst in the sub-umbilical region the presence of the intestines, which are pushed up towards the epigastrium and float upon the surface of the liquid, give rise to a tympanitic sound which contrasts with the dulness of the rest of the abdomen, from which it is separated by a curved line, concave superiorly. We may add that the fluctuation is much more decided in ascites than in encysted dropsy of the ovary. Besides the various modifications of resonance here described, there is one which is most frequently met with in the abdomen, but which may be found in very different regions of the body and extremities. It is a peculiar sound, or rather, a mixed phenomenon obtained by percussion, and resulting from the association of a kind of humoric sound with a vibratory thrill perceived by the hand, and designated by the name of the hydatic sound or vibration. This phenomenon, of which we may have a very accurate idea, by shaking an acephalocyst in the palm of the 157 PERCUSSION. hand, is actually dependent upon the existence of hydatids, and is produced by the oscillations of the vesicles in the pouch which encloses them. This thrill is not present in every hydatiferous tumour: its absence, therefore, does not prove that a spherical tumour in the region of the liver is not an acephalocystic cyst; but its presence constitutes a pathognomonic sign of this variety of disease. Percussion of the head, neck, spine, and extremities. Can we class among the facts of pleximetry the imaginary sound of a broken vessel that the cranium yields on percussion in cases of fracture, the peculiar sound rendered by a carious tooth when struck with a stylet, the dulness with fluctuation present in articulations which are the seat of hydarthrosis, &c. ? Percussion may have more real and useful applications in some cases of fistulous abscess containing gas or air; sometimes also, it will serve as a differential diagnosis between anasarca and emphysema of the cellular tissue, by manifesting in the first disease a notable dulness, and in the second, resonance accompanied by dry crepitation under pressure of the finger. Piorry has also proposed to percuss over the vertebral column, or the spinal regions, in order to recognise either aneurisms of the descending aorta, alterations or change in size of the vertebras, or abscesses developed in their neighbourhood, consecutively to 14 158 PERCUSSION. caries. In all these cases there is a dull sound yielded on- percussion, and the extent and form of this dulness indicate the size and shape of the alterations. Finally, Mr. Stokes, of Dublin, has advanced the opinion, that percussion may not be without advantage in the diagnosis of diseases of the larynx.* But Piorry, before him, had already published all his views upon this subject.f " Percussion of the larynx or the trachea can only be performed mediately. In order to practise it, wc must fix the trachea and larynx, by the assistance of the pleximeter, firmly held upon these tubes. In the normal condition, the finger discovers elasticity, and the ear resonance over the points which correspond to these organs. There are very few pathological conditions in which it will be otherwise, unless, there should be a tumour on the neck surrounding the trachea and larynx ; then we may make use of percussion to determine their seat. The presence of liquids in the ventricles of the larynx, followed by the penetration of air into the neighbouring cellular tissue, may be suspected, if percussion upon the neck discovers an unusual resonance in connexion with emphysema. In cases where a soft and dcpressible tumour is situated upon the larynx, we may judge of the depth at which it is seated, by that at which * A Treatise on the Diagnosis and Treatment of Diseases of the Chest. 1837. t Traite de Diagnostic, t. i., 412. PERCUSSION. 159 we obtain resonance, by pressing upon the tumour with the pleximeter, and then percussing." There are some circumstances in which we can use to advantage percussion and auscultation combined. Laennec has proposed the simultaneous employment of these two methods of examinations in certain cases of pneumothorax ;* it is generally resorted to, in order to manifest and more clearly demonstrate the hydatic sound. Cammann and Clark have gone further,f and attempted to generalize this mixed method; they have applied it to the exploration of the viscera of the chest and abdomen, and they affirm, that it is possible thus to bound in every direction the solid organs which are in contact with each other, as the heart and liver, or which are placed, the one before the other, as the lung and the heart, or even, again, those which are surrounded by different media, as the abdominal viscera in the ascitic liquid.J Any attempt at progress * " Wc may," says he, "estimate the extent and space occupied by the air, by ausculting and percussing, at the same time, in different points; we then hear a resonance similar to that of an empty cask, mixed occasionally with tinkling." Tom. i., p. 139. t A new mode of ascertaining the dimensions, form, and condition of internal organs by percussion and auscultation. July, 1840. Copied into the Archives, Gen. de Med. 1841. Vol. x., p. 225. t It appears that tlicse gentlemen proceed in the following manner: One of the observers applies his ear upon the extremity of a solid cylinder (of wood, cut in the direction of the fibres, six inches in length, by ten to twelve lines in diameter,) the 160 PERCUSSION. in semeiology ought not to be rejected, and on this ground, the researches of these New York physicians deserve the attention of practitioners; but we must remark, that this mixed method has the great disadvantage of demanding the simultaneous cooperation of two observers, and we are of the opinion, that the results of pleximetry and auscultation, as usually practised, are sufficient for all exigencies of diagnosis. other end of which rests on an intercostal space. The other observer percusses according' to the usual method, at one or two inches from the point with which the instrument is in contact. The sounds thus obtained arc perfectly transmitted by the solid stem, and they are perceived with extremely marked differences, in proportion to the differences of structure and material disposition of the organs examined. We regret that we have not been able to procure the original article of Messrs. Cammann and Clark, and consequently, that we cannot, as we would desire, repeat their experiments, and judge of their value by a full acquaintance with the subject. THE END.