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ON THE DIAGNOSIS
mi
DISEASES  OF THE  CHEST;
BASED UPON THE COMPARISON OF THEIR PHYSICAL
           AND GENERAL SIGNS.
        BY W. W. GERHARD, M. D.

PHYSICIAN TO THE BLOCKLEY HOSPITAL; LECTURER IN THE PHILADELPHIA
    MEDICAL ASSOCIATION; FELLOW OF THE PHILADELPHIA COLLEGE
       OF PHYSICIANS; MEMBER OF THE SOCIETE MEDIC ALE
           D'OBSERVATION, AND OF THE SOCIETE
              ANATOMIQUE OF PARIS, &C.
       piflatttlpliia:
KEY & BTDDLE, 23 MTNOR STRERT.
          1836. 
^■r\.YO
1935
Entered according to  Act of Congress, in the year 1835, by Key & Biddle, in the Clerk's
          Office of the District Court of the Eastern District of PennsylvaniA.
     Philadelphia:
Robert Wright. Printer,
   No. >.r> Minor Street 

TO
             P.  CH.  A.  LOUIS,

DOCTOR IN MEDICINE OF THE  FACULTIES OF PARIS AND ST.  PETERSBURG;
   MEMBIiR OF THE ROYAL ACADEMY OF MEDICINE, AND PERPETUAL PRE-
      SIDENT OF THE SOCIETE MEDICALE D'OBSERVATION DE PARIS,
                        &C. &C. &C.
                         AND TO


      SAMUEL  JACKSON,  M.D.,
PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE UNIVERSITY OF PENNSYL-
         VANIA ; PHYSICIAN TO THE BLOCKLEY HOSPITAL, &C,
FROM  THE  AUTHOR. 
 
PREFACE.
  The utility of physical exploration is  now so gene-
rally appreciated, that those physicians who have hith-
erto undervalued its aid, are in some measure obliged
to familiarize themselves with this means of investiga-
tion.
  In order to  acquire  the  requisite knowledge of the
physical signs, and  of their relation to each other, as
well as to the  general  symptoms,  it is, in the first
place, necessary to examine a well characterized ex-
ample of each sound, and to fix the recollection of it
as firmly as possible in the memory.  After the signs
have been learned, their relative importance  is to be
estimated,  and  they should then  be  compared with
the general symptoms of the disease.
   The object of this little work is to  facilitate such a
study of the physical  signs, and to render them more
generally useful,  by showing their intimate relation
with the ordinary symptoms.  It is, therefore, strictly
clinical, and embodies most of the facts relating  to
auscultation;  these  were always subjected to the per-
sonal observation  of the  author, unless the exception is 
X                    PREFACE.
expressly stated.   It was thought most expedient that
the work should be as concise as possible; but refer-
ence is made to those general signs  which are indis-
pensably necessary to a correct diagnosis.   A complete
history of  pectoral diseases  could not be attempted
within the limits of so short a treatise.
  The facts detailed in  the  work, are chiefly derived
from  Drs.  Laennec,  Louis,  and Andral.  I am also
indebted to the excellent treatise of Dr.  Williams, and
to  that of Dr. Hope, on  the diseases  of the heart.
Laennec had investigated  the signs of  diseases of the
lungs so minutely, that few new facts have since been
discovered, but some additions  have  been made  to
various points  connected with auscultation; a differ-
ent value has  been  affixed  upon various signs, and
they  have been more intimately connected together,
and with the general  history  of disease.
   Much valuable matter was derived from the private
instruction and public lectures  of  M. Louis, at the
Hopital de la  Pitie; almost the whole chapter  upon    /
the conformation of the chest, and numerous isolated,
but important facts,  were  obtained  from that  source.
The  original  matter  chiefly consists of an analysis of
the normal respiration on  the two sides of the chest;
a new classification  of the varieties of the bronchial
respiration; some facts relative to the  auscultation of
children; and  a concluding chapter, which is designed
to  facilitate  the  inquiries of those physicians who
are not yet familiar with physical examination. 
PREFACE.
XI
  The  last chapter is especially designed for those
physicians who are distant  from the large cities of
America, where a knowledge of physical investigation
is more general than it is thoughout the country.
The want of hospitals in small towns and villages,
renders it expedient to  adopt a mode of study, which is
less necessary in our larger cities, where the physical
means  of investigation are habitually practised.   In
Philadelphia they were introduced soon after the dis-
covery  of auscultation, by Professor Jackson, who has
since diffused  a taste for  exact physical  observation
amongst his numerous pupils.
Philadelphia, November, 1835. 
I 
CONTENTS.
Introductory Chapter,
                         CHAPTER II.
General Remarks on Exploration,......13
    Of the Conformation of the Chest,......14
                         CHAPTER III.
Of Percussion,        .     .    ,......18


                         CHAPTER IV.

Of Auscultation,..........26
    Of the Varieties of the Healthy Respiration,   ....   32
    Of the Alteration of the Respiratory Sounds produced by Disease,   35
    Of the Rhonchi and other Morbid Sounds,     ....   41
    Of the Auscultation of the Voice,......48
    Of the Alterations produced in the Resonance of the Voice by
      Disease of the Lungs,            .    .        •    •     .49


                         CHAPTER V.
Of the Cough and the Expectoration,      .....   55
    Of the Expectoration,........58


                         CHAPTER  VI.

On the Movement of the Thorax,                              63
        A* 
XIV
CONTENTS.
                        CHAPTER VII.
Bronchitis, or Pulmonary Catarrh,......65
    Varieties of Bronchitis,........67
    Dilatation of the Bronchi,.......72

                       CHAPTER VIII.
Emphysema of the Lungs,........74

                        CHAPTER IX.
On Pneumonia,..........'J
    Of the Varieties of Pneumonia,......88

                        CHAPTER X.
Gangrene of the Lungs,........94
    Metastatic Abscess of the Lungs,......100

                        CHAPTER XI.
Phthisis, or  Pulmonary Tubercles,......102
    Of the Physical Signs of Phthisis,......105
    Of the Expectoration in Pulmonary Consumption,    .    .     .  113
    Of the Varieties of Phthisis,.......115

                        CHAPTER XII.
Pulmonary Apoplexy, and OEdema of the Lungs,     .    .     .  123
    Pulmonary OZdema,      ........124

                       CHAPTER XIII.
Pleurisy,...........120
    Of the Functional Signs of Pleurisy,.....136
    Varieties of  Pleurisy,........M>.

                       CHAPTER XIV.
Pneumo-thorax,.........  140 
                        CONTENTS.                      XV

                       CHAPTER XV.
Tubercles of the Bronchial Glands,......146


                       CHAPTER XVI.
Of the Heart,..........149
                      CHAPTER XVII.
Inflammation of the Heart and its Membranes,      .    .    .  154
                      CHAPTER XVIII.
Diseases of the Valves of the Heart,.....162

Hypertrophy and Dilatation of the Heart,     ....  169
    Dilatation of the Heart,........171
                      CHAPTER XIX.
Of the Method of Acquiring a Knowledge of the Physical
      Signs,       ..........
    Of the Varieties of the Respiration,     .....
    Of the Rhonchi..........
    Of the Voice,..........
174
176
178
180 
 
ON THE DIAGNOSIS
                   OF


DISEASES  OF  THE  CHEST.
            INTRODUCTORY CHAPTER.

The diagnosis of diseases of the chest is derived from
a comparison of their functional and physical signs.
The functional signs or  symptoms, are the alterations
caused by the disease in the function of the lungs and
of other organs  of the body.  The physical signs are
the alterations in the texture and mode of action of the
thoracic viscera, which are  appreciable by our senses,
especially that of hearing.
  The above definition shows that these two varieties
of signs are not always very different from each other.
Some signs, as the mode and degree of dilatation of the
thorax, may be classed either as rational or as physical.
For practical purposes,  the physical signs should be
divided into—1.  Those derived from the  conformation
of the thorax.  2. Those from percussion.  3. Those
from auscultation.   The manner in which the respira-
      B 
10
ON THE DIAGNOSIS OF
tion is performed, and the characters of the expectora-
tion, may be regarded as an intermediate class.
   It will be readily conceived, that the indications of
the physical signs  are  much more precise than those
derived from the symptoms; since the former indicate
the physical state  of the pulmonary organs,  as their
density,  the liquid  or solid matter  infiltrated in their
tissue, and the nature of the bronchial secretion.  When
the physical signs are distinctly marked, we infer, with
absolute certainty, that there is a corresponding internal
lesion; the comparison  of the physical sign with the
symptoms, informs us what the nature of the lesion may
be.  If the investigation of the disease be at first limited
to the functional signs, we can, in a large majority of
cases, determine its nature—whether it be phthisis, pneu-
monia, &c; but the degree  of development,  and  the
extent of the lesion, can only be known from the phy-
sical signs.
   It is well known  that many diseases assume a latent
form: that is,  they  pass through their course without
their presence being indicated by the ordinary  symp-
toms.   Pneumonia, pleurisy, phthisis and other affec-
tions of the  chest, may  be  latent, and  can only  be  de-
tected by physical examination, which  explains the
local cause of the disease.  In such cases, the non-exist-
ence of the rational signs does not prove that the lungs
were  not diseased, but  it merely shows  that for some
reason the anatomical lesion was not accompanied with
the usual functional disturbance.   When the physical
signs  of these latent  diseases are as clear as they usually
are, the evidence is entirely sufficient for an accurate
diagnosis. 
DISEASES OF THE CHEST.
II
  On the other hand, there are cases of pulmonary dis-
ease in which the physical signs are obscure or doubt-
ful;  but the rational symptoms tolerably well marked.
This variety is produced by very deeply-seated lesions,
or slight alterations of the tissue in different parts of
the lungs.   It is also owing, in some cases, to great irri-
tability of constitution, giving rise to strongly marked
symptoms,  disproportioned to the  slight  anatomical
lesions.  This irritability of some individuals contrasts
with the comparative insensibility of others, in whom a
latent disease  may have disorganized a large portion of
the pulmonary tissue.
  When  the  symptoms  indicate a pulmonary disease,
have we a right to infer,  from the absence of the physi-
cal signs, that it does not exist?   Clearly not.   We can
only affirm that the disease is not far advanced, or there
would  be direct  proof  of the alteration of structure
of the lung.  A neglect of this precaution has thrown
great and unmerited discredit upon auscultation.   The
degree  of skill  possessed by physicians in the art of
auscultation, is necessarily various; but those most ex-
perienced, know that cases of disease do occur, in which
the  functional signs are tolerably marked before the
development of a palpable physical lesion.  It is pre-
cisely in cases of  this kind, that the counsel of a phy-
sician, who can assure his patient that the lungs are
but  little, if at all, diseased, is the most useful.   The
rules of hygeine, best adapted to the case, should from
that moment be rigidly enforced.
  The  preceding remarks  will, I think, clearly point
out the invaluable aid rendered by physical exploration,
in resolving a problem as complicated as a disease of
the chest sometimes becomes. 
12
ON THE DIAGNOSIS OF
   Diseases of the lungs may be recognized tolerably
 well by the rational  signs alone;  but it is as unwise in
 a physician to reject the aid of auscultation, as it would
 be in a surgeon to despise the use of the sound.  A
 moderate share of knowledge  enables a surgeon to de-
 termine, with great  probability, a particular disease of
 the urinary organs, from the description of the symp-
 toms, given by the patient himself.  Would he venture
 to prescribe, without passing a  sound into the urethra,
 to convert that probability into complete or nearly com-
 plete certainty?   The evidence derived from  ausculta-
 tion is quite as certain as that obtained by the surgical
 mode of exploration, and is equally useful in giving
 clear and precise knowledge of disease.

  Note.—To show that the absence of physical signs of  disease is only
valuable as negative evidence of the degree^ and not of the-existence of dis-
ease, I will mention one example.
  A gentleman was suddenly taken  in  August, 1834, with  haemoptysis,
after moderate muscular exertion.  The discharge of blood continued for
several days, with acute fever, slight cough, emaciation, &c, indicating the
occurrence of an acute form of phthisis.  The physical signs were limited
to a little alteration of the softness and fulness of the respiratory murmur
and a few bubbles of mucous rhonchus, when he was spitting  blood.   The
diagnosis was not, that the patient was free from consumption, but that the
disease was not sufficiently advanced to cause much alteration of the pulmo-
nary tissue, and, consequently, the physical signs were doubtful.  The phthisis
proved to be acute, and produced rapid emaciation, tuberculous cavities, and
death. 
DISEASES OF THE CHEST.
13
CHAPTER II.
  The physical exploration of the thorax consists in—
  1. Examination of the conformation of the chest, in-
cluding mensuration.
  2. Percussion directly upon the thoracic parieties, or
on a solid body, in contact with them, in order to ascer-
tain the degree of resonance yielded by each part.
  3. Auscultation, or the application of the ear to the
chest, or to an acoustic tube, interposed between the
thorax and the ear of the auscultator.
  Physical  exploration is  not confined  to these three
modes of investigation, although, as they admit of an
application  much more  extensive than the other  me-
thods, it is necessary to enter into  greater details rela-
tive to them.   Other physical signs are derived from
succussion, or agitation of the patient, in  such a way as
to communicate a slight shock to any liquid that may
be  contained within the pleura.  Some signs belong
partly  to  the  class of physical  and partly to that of
functional signs.  These are,  the thrill communicated
to the hand, placed upon the  thorax, while the patient
is speaking, and the more or  less perfect expansion of
the chest during the act of respiration.  The last men-
tioned signs are all of secondary importance. 
14
ON THE DIAGNOSIS OF
        OF THE CONFORMATION OF THE CHEST.
  The conformation of the thorax should be examined
in the following manner:
  The patient should stand or sit erect; the chest being
bare, or covered with a garment drawn closely over it.
The arms of the patient should hang by his side, and
the shoulders be thrown a little backwards.  The shape
of the  chest may then be  examined  by the observer,
who must place himself directly in front of the patient,
in as good a light as possible.
  The thorax, in healthy individuals, forms  an irregu-
lar  cone, the apex of which is upwards and truncated.
The cone is not regular, but presents on each  side a
plane, instead of a regularly rounded surface.  One of the
planes forms the anterior surface of the chest;  another
the posterior; and the two others, which are the shortest,
form the lateral parieties.   On each of these planes
several prominences and depressions exist naturally, in
healthy subjects; but in disease,  there  is frequently
increase or  diminution of  the natural inequalities, or
formation of others, which  did not exist in the state of
health.
  On the  anterior surface  of the chest, the following
inequalities are found:—Behind the clavicles, in sub-
jects who are neither very thin nor very  corpulent,
there are obvious depressions, the internal edge of them
being formed  by the sterno-mastoid  muscle.   These
depressions are necessarily a little more evident in thin
than in corpulent persons, and  are  sometimes extreme
in those who are reduced to the last degree of emacia-
tion.  In very fat subjects, there may be a prominence
instead of a depression, without corresponding disease 
               DISEASES OF THE CHEST.             15

of the lungs.   Unless the post-clavicular depressions be
different on the two sides of the thorax, it is therefore
very probable that they indicate no morbid state of the
lungs.   If one of the hollows be much deeper than the
other, we infer that the corresponding  portion of the
lung has become contracted,  and occupies less space
than in the natural  state; this depression is produced
by adhesions between  the two surfaces of the  pleura,
following inflammation of that membrane.  As  inflam-
mation  of the  pleura,  at the summit of the lungs, is
almost invariably produced by a deposit of tuberculous
matter in the pulmonary tissue, an important  sign is
thus derived from "the  increase of  a post-clavicular de-
pression.   If the lungs be distended from dilatation of
the vesicles, or if there be an effusion of liquid into the
pleura, the post-clavicular hollow  on the side affected
is nearly effaced, or  is  sometimes converted into a pro-
minence.   In patients of  moderate corpulency, there
are depressions below the clavicles^ corresponding to
those above  them;  they are increased  or  diminished
under  the same  circumstances  as the  post-clavicular
spaces, but from the unyielding nature of the bony walls
of the  chest, the difference between the two sides can-
not be so great.   The chest becomes gradually more
prominent from the clavicles  to the sixth or seventh
ribs; the swell is gradual, and is partly caused by the
pectoral muscles.   It is a little greater on the right than
the left side, except just over  the  region of the heart,
where  there is frequently tf very slight local  promi-
nence.   The prominence is increased by emphysema
of the lungs, or by effusions of liquid into the  thorax.
The increased prominence is most frequently observed
along the margin of the lung, which is the usual seat 
16
ON THE DIAGNOSIS OF
of emphysema.  When the pericardium is distended
by liquid, there is a very evident pyriform projection
in the region of the heart.  If the pleura be the seat of
the effusion, the dilatation is more extensive and more
equable.   A slighter  degree of prominence  usually
accompanies enlargement of the heart.   The  anterior
part of the chest offers deeper depressions  than usual,
when adhesion of the two surfaces of the pleura  has
succeeded to extensive inflammation of this  membrane;
the depression, in such cases, extends to  the whole sur-
face.  It is  local, when  adhesion of the pericardium
occurs after the absorption of large collections of liquid
contained in that sac.
  The posterior part of the chest offers  a more irregu-
lar plane than the anterior, on account of the situation
of the spinal column and the scapulae.   The surface is
flat between the  spine and  the scapulae,  and below
these bones is convex.   It is  less easy to recognize
partial depression^  or prominences at  the upper and
posterior part of the chest, than at the anterior surface.
The scapula,  and with it, the whole  shoulder rises,
when large effusions have taken place into the pleura,
and sinks again when adhesion has followed their ab-
sorption.  In emphysema, there is elevation  of both
shoulders, but it is  greatest on the side most affected.
There is, in cases of emphysema, a double cause for the
dilatation, arising partly from the habitual efforts made
during inspiration, and partly from the actual distension
of the vesicles.   The inferior  parts of the chest are
dilated to a very evident degree in emphysema, and
still more in pleuritic effusions, or pneumo-thorax.  The
affected side is not  dilated when the lung  is inflamed,
but there is sometimes  a slight enlargement of the 
               DISEASES OF THE CHEST.            17

sound one, frorrrthe great efforts made during respira-
tion.   The effusion of liquid occurring in pleurisy,
causes distension of the lowest parts of the chest.   Con-
traction succeeding a cured pleurisy, is also better seen
near the  base of  the  thorax, where  the false  mem-
branes are the most extensive, and the consequent ad-
hesions are strongest.   The axillae  which present the
most regular of the four planes, constituting the thorax,
are dilated or contracted under the same circumstances
as the posterior and inferior regions;  but  as their altera-
tions of conformation are less evident, it is not neces-
sary to enter into other details. In whatever part of the
chest the  dilatation or contraction may occur, they are
always more perceptible in the intercostal spaces than
at the  ribs.
   The conformation of the  thorax  varies to  a certain
extent, in the different  ages  of life.  In children, the
chest is more rounded than  in adults, the depressions
are scarcely perceptible, and the upper part of it is more
narrow.   The anterior  surface is much smaller,  and
the lower and posterior portion is proportionably more
developed than in advanced life.   In old age,  the ri-
gidity of  the ribs and their cartilages diminishes the
roundness of form, and renders the imperfect planes,
observed  in adults, much more evident.
   Mensuration of the thorax is performed by drawing
a cord around the chest,  upon a horizontal line,  and
measuring, on each side, the distance from  a spinous
process to the middle  of the sternum.   The difference
in the measurement of  the two sides, is most evident
just below the nipple.
       c 
18             ON THE DIAGNOSIS OF
                 CHAPTER III.


                  OF PERCUSSION.

  As the walls of the  thorax  form a firm and elastic
case,  which is filled by a  spongy tissue, containing
much air, it is evident that it must yield a hollow sound
when struck.  The sound must be more hollow when
the air is in large quantity, and less hollow when there
is less air and more solid or liquid matter.  Upon this
simple fact is based the art of percussion, which is one
of the most important means of physical exploration.
  This mode of examining the chest, invented by Aven-
brugger, and revived by Corvisart, has but recently
attracted the attention it deserves.  Laennec  relied so
much on his admirable skill in auscultation, unassisted
by other physical signs, that he was rather disposed to
undervalue them.   M. Piorry, the inventor of mediate
percussion  has applied this  mode of investigation to a
number of diseases, but he  does not  seem  perfectly
aware of the necessity of combining it with  accurate
auscultation.  Percussion,  as now practised  by that
class of physicians at Paris, who consider the art of
diagnosis as the solution of a problem by a comparison
of all its elements, is a necessary complement to auscul-
tation.  These two means of investigation are  perfectly
identical in their object, which is to ascertain the phy- 
DISEASES OF THE CHEST.
19
sical condition of the lungs.  Auscultation is, however,
of more extensive application, as it discloses alterations
of the bronchial tubes not distinguishable by percussion,
which can only indicate the  greater or less proportion
of air, compared with solid or liquid matter, in a given
portion of the thorax.
  Percussion shows the state of that portion of the lung
which is immediately beneath the part of  the thorax
struck by the fingers.  This fact may be easily verified
by a simple experiment.   If a vessel be half filled with
water, and be struck with the ends of the fingers, near
the level of the liquid, the sound will be hollow above
this level, and flat below it.  It must, however, be recol-
lected, that the sound near the line of division is partly
produced by air and partly by the liquid;  it therefore
has a mixed character  between the  clearness of the
gaseous resonance and the absolute flatness yielded by
a liquid.
   On percussing the thorax, the dull sound on the  line
of a liquid is limited to a very small space, not exceed-
ino- half an inch; elsewhere, anatomical demonstration
shows clearly that the sound  on percussion is in direct
accordance with the proportion of gas and  liquid or
solid matter.  The greater or less density of the solid
or liquid below the point percussed, causes a difference
in the resonance of the chest, which  is less easily ap-
preciated than the distinction between gas and liquid.
These minor shades can only be recognized by an ex-
perienced observer, whose ear is aided by the sense of
touch, or the degree of resistance given  to the fingers
by the body percussed.
   The practical application of percussion in the exami-
nation of the diseases of the lungs, is directed almost 
20
ON THE DIAGNOSIS OF
solely with a view of ascertaining the  quantity of air
in a given part of the chest.  If the air be more abun-
dant than natural, the percussion is more sonorous than
in a healthy chest;  if less air and more liquid or solid
matter be contained in the lungs, the percussion is less
sonorous.   As the more important diseases of the lungs
and heart are attended by alterations of the relative pro-
portions of air and denser bodies, the utility of percus-
sion, in ascertaining these lesions, must be obvious.
   When the results obtained by percussion are com-
pared with those of auscultation, the precise physical
state of the lungs is discovered.

   Of the manual performance of percussion.—Percus-
sion is mediate or immediate.   Immediate  percussion
requires the ends of the fingers,  or in some cases, their
palmar surface to be struck quickly upon the walls
of  the thorax.  This mode of percussion was  once
generally employed,  but is now  very properly and
universally abandoned, on account of the production of
less sound than may be obtained from mediate percus-
sion, the greater  pain caused to the patient, and the
absolute  impossibility of using this method  when the
cellular tissue is infiltrated with liquid  or loaded with
fat.  Mediate percussion was introduced by M. Piorry,
now physician to the Hotel Dieu, of Paris.   A dense
resisting body is placed in contact with the patient,
and held with  the  fingers of the left hand, while per-
cussion is made upon it with the right.   The body in-
terposed  between the fingers and the  skin is called a
pleximeter; it  may be a thin plate of ivory, leather, or
metal, or, what is generally the most  convenient, the
fore-finger  of the left hand.  An excellent pleximeter 
DISEASES OF THE CHEST.
21
is a piece of caoutchouc, or common gum elastic, about
a quarter of an  inch thick, and tolerably firm.  This
pleximeter is very elastic, gives a good full sound, and
prevents any pain being felt by the patient.
  The percussion should be made in such a manner as
to produce the greatest possible sound, without giving
pain.  These two requisites are perfectly compatible;
if percussion be  well made, it gives little or no pain; if
awkwardly, it is almost always painful, and frequently
mischievous.  When the fore-finger  of the left hand is
applied to the chest, the percussion may be made upon
its palmar or dorsal surface.  The sound is clearer, but
accompanied by a slight  clacking noise, when the dor-
sal surface is percussed; it is purer, more completely
hollow, and not less loud when the palmar face is struck.
The latter surface is  necessarily percussed when the
depressions above the clavicles are  examined; in that
case, the convex surface  of the finger is readily placed
in contact  with  the concavity of the  chest.  When the
anterior surface of the chest is percussed, it is almost
indifferent which surface of the finger is struck. When
the  back is examined, it is  most convenient to strike
upon the convex  surface of the finger.   Whether the
pleximeter be the index-finger, or a piece of caoutchouc,
the  fingers should strike against it in the same manner.
The four fingers of the right hand should be brought
into a line, and  the blow be given as quickly as possi-
ble, with  the ends of the fingers,  and  not with the
bulbs.   The motion should  be performed in the wrist
and in the metacarpal joint of the fingers, the arm being
perfectly passive, and much care should  be  taken to
withdraw the fingers immediately after they have touch- 
22
ON THE DIAGNOSIS OF
ed the pleximeter. *  It is frequently very convenient to
use the middle finger only in percussing, if the patient
be thin.   The tap is then extremely light, but gives  a
very perfect sound.
  It is usual  to percuss slightly the different parts of
the chest, before making a more careful examination to
ascertain  the  precise alteration  of  the  diseased parts.
The pleximeter must then be passed carefully from the
top to the bottom of the chest, percussing first on one
side, then on  the corresponding point of  the other, in
order to ascertain their relative sonorousness.  If the
finger be  the pleximeter, it should be applied in the in-
tercostal spaces.
  The  chest  is usually divided into several artificial
regions for facilitating the description of the sound ob-
tained on percussion.  Distinct names, derived  from
their anatomical characters, have been  given to these
regions—but some inconvenience results from this arti-
ficial arrangement.   The method pursued by M. Louis
is preferable.   He divides the chest into definite parts,
and when he  wishes to render his description very pre-
cise, he mentions the anatomical  relations.   The fol-
lowing  arrangement is chiefly based upon his practice:
The posterior part  of the chest is divided  into three
regions on each side.  The upper is beunded inferiorly
by  the spine of the scapula; the middle third extends
from the  upper  termination to three inches below it;
the lower third  includes  all the inferior part  of the
chest.  Each of these  divisions, when  necessary, may

  * Physicians unpractised  in percussion, are apt to commit two errors:—they
strike with the bulbs instead of the ends of the fingers, and allow them to
remain in contact with the  pleximeter, after they touch it.  This awkward
mode is painful to the patient, and gives imperfect results. 
DISEASES OF THE CHEST.
23
be subdivided into an internal and an external portion,
the inner margin of the scapula forming  the line of
division.  The axillae are each divided into two equal
portions, by a line passing  transversely through their
middle.  The anterior region of the chest is divided
into three nearly equal regions on each side; the upper
extending from the clavicle  to the third rib,  the middle
from the third to the sixth rib, and the third including
the space below it.   Each  of these regions, like those
of the back, may be divided into external and internal
parts.   Besides  these divisions, there are others more
strictly anatomical;  these are the post-clavicular and
the praecordial region.   The  former is the depression
immediately behind the clavicles; the latter  is the space
corresponding to the heart, extending from the left nip-
ple to the middle of the sternum', and from the base of
the chest obliquely to the junction of the sternum and
the fourth rib.
  The intensity of sound in each of these regions is in
proportion, first, to the greater or less pulmonary tissue;
secondly, to the distribution of the bronchial tubes; and
lastly, to the thickness of bone, muscle and cellular sub-
stance covering the  lung.  The sound on percussion
is, therefore, most sonorous in the axilla and the in-
ferior regions of the  chest.   It is a little less sonorous
below the clavicles, and still less resonant upon and be-
hind them.  The middle anterior region is more sono-
rous than the upper, if the patient be thin; less so, if
muscular.   The two superior  dorsal regions give a
comparatively obscure sound  at  the external portions,
where  a thick layer  of  muscle covers the scapula;  at
their internal portion, the percussion is more sonorous. 
24
ON THE DIAGNOSIS OF
The annexed cut, (No. 2,) shows these regions, and the
different degrees of sound afforded by each of them.

  Of the position of the patient when examined by per-
cussion.—This must vary according to his strength and
the degree of pain he may suffer.   In chronic diseases  l
which are not far advanced, the patient can easily place
himself in the most favourable position.   In acute affec-
tions, or in the advanced stages of phthisis, the position
of the patient cannot be changed  from the recumbent
posture; it frequently cannot even be altered from one
side to the  other.  The latter class of diseases may
almost always be recognized by such obvious physical
signs, that it is of little consequence in what position
the patient is examined.  When the anterior surface of
the chest is percussed, the patient should sit erect upon
a chair, the shoulders thrown a little backwards and the
arms hanging by the sides; the muscles and skin cover-
ing the chest are thus made tense,  and yield the loudest
sound.  In percussing the axilla, the arms of the patient
must be raised above his head.  When the back is ex-
amined, he may sit with his face towards the back of a
chair, or simply fold the arms upon  the chest and in-
cline his head forwards;  in either case, the skin is put
upon the stretch.
  In young children, percussion affords very important
signs, which are the more valuable from the compara-
tively little aid we can receive from the auscultation of
such patients.  It is best performed by tapping lightly
with a single finger along the back.  Very little result
can be obtained from percussing  them on the anterior
part of the chest, which is narrow and covered by a layer 
DISEASES OF THE CHEST.
25
of fat.  Besides, almost all the diseases of the lungs in
young children begin at the posterior margin or base.
  If the  child be an infant, it should be laid upon its
face, or supported, so that it may lean forwards and make
the skin of the back tense.
  Percussion is performed in the same manner in the
case of aged persons as in  that of young adults.
D 
26
ON THE DIAGNOSIS OF
                  CHAPTER IV.


                 OF AUSCULTATION.

  Auscultation is the art which relates to the discov-
ery and appreciation of the sounds produced in the dif-
ferent parts  of the body, in  health  or in disease.   In
other words, it is the application of the sense of hearing
to the investigation of diseased action.
  Any  organ which, in  a  healthy  or  morbid state,
yields an appreciable sound, may be examined by the
ear; but as the lungs and heart produce a much greater
variety of sounds than any  other viscera, auscultation
is chiefly applied to the examination of these organs.
When the ear is directly  applied to a part of the sur-
face of  the  body,  auscultation  is immediate.  When
an acoustic instrument, called a stethoscope, is used as
a conductor of sound, we employ the term mediate aus-
cultation.  The  stethoscope was exclusively used  by
Laennec, the discoverer of auscultation.  His attention
was first directed to the subject, from accidentally pla-
cing his ear upon  some paper rolled into a cylindrical
form, and then applying it to the chest of a patient af-
fected with a" disease of the heart.   The great distinct-
ness of the  sound induced Laennec to examine, by
means of the stethoscope, patients affected with various
diseases of the thoracic organs; and after the labour of 
DISEASES OF THE CHEST.
27
a few years, he was able to bring the art of auscultation
nearly to its present degree of perfection.
   Later observers are more  accustomed to immediate
auscultation, which has many advantages.  The sound
is more intense when the ear is applied directly to the
chest; the position  of the patient need  be less  con-
strained than is necessary for  the accurate adaptation
of the instrument;  the different regions of the chest
may be examined with greater rapidity, and, above all,
the sounds heard may be easily compared with each
other.   Immediate auscultation is  not practicable, for
obvious reasons, over the anterior part of the chest in
females, nor can the space in which the sound is heard
be as accurately circumscribed as with the stethoscope.
The reason last assigned, is of great importance in the
auscultation of the voice and of the praecordial region.
The auscultator should, therefore, not neglect the use
of the stethoscope, although, in the majority of cases,
the unassisted ear answers not  only as well, but better,
than if aided  by the cylinder.   When the stethoscope
is used, the results should generally be verified by im-
mediate auscultation.
   The best material for making stethoscopes, is some
of the lighter kinds of wood, of rather close grain;  none
answers the purpose  better than cedar;  the metals,
ivory and other substances, have been  tried, but they
were  all soon abandoned.   In its  simplest form, the
stethoscope is a cylinder of wood, eight to twelve inches
in length, about an inch in diameter, perforated in the
centre by a canal, one-fourth the diameter of the whole
instrument.  One end of the stethoscope is excavated
in a funnel or trumpet-shaped cavity, to collect the
sound  from  a larger surface.  The  excavated  end 
 28             ON THE DIAGNOSIS OF

is applied to the chest of the patient, but in auscul-
tation  of the heart, the hollow is first filled up by a
wooden plug, fitting accurately into it.  The length of
the stethoscopes now used is about eight inches; the
original dimensions of the  instrument are retained at
the excavated end, but it gradually diminishes in di-
ameter to the other extremity, upon which a flat piece
of ivory is attached, for the more  convenient applica-
tion of the ear.  The diameter of the central canal is
the same throughout its whole length.  The modifica-
tions  which  different  individuals  have made  in the
stethoscope, are very numerous, but  in  the  essential
parts  of its construction the instrument  remains the
same as when first used by Laennec.
  The application of the stethoscope demands some
care;  the extremity of the instrument must  be ex-
actly in contact with the chest, which must be perfectly
bared or covered by a thin and soft garment; the posi-
tion of the observer must be as unconstrained as possi-
ble, and his ear should be accurately placed upon the
instrument.  At first, the rustling of the patient's clothes,
or other external sounds, may be confounded with the
respiratory murmur; but this mistake can only occur to
a very inexperienced auscultator.
  The position of the  patient should be the same as
has been already indicated when treating of percussion.
If his strength should  not  be  sufficient for him to sit
up, he may be carefully placed first on one and  then
on the other side, in such a manner that the ear or the
stethoscope may be successively applied to  the different
parts of the chest.  If his prostration be very great, the
examination must be  confined to  the anterior  part of
the chest; in cases where  this occurs, the  signs are 
DISEASES OF THE CHEST.
29
usually very distinct.   In the early stages of consump-
tion, the patient should always be placed in the most
favourable position, and, if practicable, should be ex-
amined both with the stethoscope and by the direct
application of the ear to the chest, previously covered
by a soft garment.
   At first, the patient may breathe, as he does under
ordinary circumstances;  but afterwards, he should be
directed to  respire more quickly.   When the  respira-
tion has been  heard, we should direct the patient to
cough; and, lastly, the voice should be examined by the
stethoscope, which should also be used when we listen
to the sounds  of the heart.   A single examination is
never sufficient when the case is at all obscure; a variety
of circumstances may throw much doubt upon the
signs, which a subsequent auscultation may  remove.
The sounds vary according to the greater or less ex-
pectoration, the degree of fever and other circumstances
independent of the original lesion.
   The preceding remarks  show that I attach but lit-
tle importance to the kind of stethoscope which indi-
viduals may prefer.   The important point is to have a
 perfect knowledge of the sounds yielded by a healthy or
 a diseased  chest.  When this knowledge is  attained,
 they may be heard with  or  without the stethoscope,
 sometimes  better without  it, especially when a rapid
 examination is necessary.
   In  all cases, the physical exploration of the chest
 should be made as quietly as possible, and in such a
 manner as to avoid exciting the attention of the patient.

   Of the sounds produced by a healthy lung during the
 act  of respiration.—When the ear  is applied to the 
30
ON THE DIAGNOSIS OF
 chest of a person in good health, a faint rushing sound
 is heard during the act of inspiration.   When  this
 sound is carefully analyzed, it will be found to consist
 of two elements, more or less blended together.  The
 first element, or the blowing sound, is that produced by
 the air passing through the bronchial tubes.  It resem-
 bles the sound made  in  the mouth and fauces, when
 the air is quickly inhaled.   It is heard most distinctly
 at the  root of the lungs, over the trachea, and near the
 clavicles, especially the right.  The second sound is
 the soft murmur caused  by the expansion of the vesi-
 cles; it is the best characteristic of a healthy pulmonary
 tissue.  This sound is termed the vesicular murmur, or
 the vesicular respiration, from its anatomical seat.  It
 is best heard where the tissue of the lungs contains the
 greatest number of vesicles, and the smallest bronchial
 tubes—that is, at the base of the lungs, in the axilla, and
 at their anterior margin.
  The sound of expiration is much more feeble than
 that of the inspiration, and in a healthy subject is almost
 confined to the parts where the first  or blowing sound
 is heard.  It is short,  feeble, blowing, and does not re-
 semble the inspiratory murmur.
  The original seat of the blowing sound seems to be
 in the fauces and the nasal cavities, as may  be readily
 tested  by placing the ear near the mouth of a person
 who inspires strongly.  However faint the  inspiration
 may be, a  noise is produced in the mouth, but this
sound  does not in the least  resemble  the respiratory
murmur or the second sound.  The sound  of expira-
tion is produced very perfectly in the fauces, as may be
verified by  the experiment just mentioned.
  The blowing sound of inspiration and that of expira- 
DISEASES OF THE CHEST.
31
tion are partly conducted from the fauces into the chest,
and in part  originate in the  bronchial  tubes of large
caliber.  The physical  condition of the large bronchi
and of the cavities of  the mouth, is very analogous.
The resemblance is still closer when the  pulmonary
tissue loses its spongy structure and becomes indurated.
In this case, the sound of respiration, in the indurated
parts  of the lungs,  resembles very nearly  the sounds
produced in the  mouth;  sometimes  it  becomes much
louder.
   The vesicular  murmur is not heard except near the
vesicular structure of the lungs;  it cannot be produced
artificially, and does not resemble the sounds made by
the air passing through the fauces.   The cause of this
sound is probably the  rustling  of the  air  against  the
sides  of the vesicles, as it passes in to fill the vacuum
made  by the  elevation of the  ribs.   As the  pressure
necessary to  drive out the air from the vesicles is uni-
form, the air is gently expelled  from  them, and conse-
quently produces no sound until it reaches the bronchi.


   Note.—The distinction between the sounds produced  in tubes, such as
the fauces or large bronchi, and those originating in the vesicular structure
of the  lungs, may be exemplified by the following experiment:—Take a
stout gum elastic bag, into which a short tube is fitted, such as is used in
injection for hydrocele.  If the air be expelled from this bag, and the press-
ure be  suddenly removed from  it, its sudden dilatation produces a partial
vacuum, and as the external air rushes in to fill it, a loud sound is produced
by its passage through the tube.  An analogous sound is heard on expelling
the air by compressing the bag.  If this process be repeated, while the bag
is applied to the ear, the sound produced by the air, as it is forced in, is dis-
tinctly heard, but with the addition of a new element originating in the bag
and not in the tube. No sound is heard in the bag when the air is expelled
from it. If the sound produced by the dilatation of the pulmonary vesicles
could be substituted for that caused by the air passing into an unyielding
bag, we should have a perfect representation of the sounds of respiration. 
32
ON THE DIAGNOSIS OF
   OF THE VARIETIES OF THE HEALTHY RESPIRATION.
  (A)  Varieties dependant upon anatomical structure.—
I have already stated, that the respiration was more blow-
ing and less vesicular in those parts of the lungs in which
the bronchi were largest. The vesicular murmur is, how-
ever, always perceptible in every part of a healthy chest.
The respiration is most blowing at the inner part of
the scapula, in a space about two inches in length, be-
low the spine of the scapula, and in breadth extending
from that bone to the spine.  The largest bronchi cor-
respond in situation to this part of the chest.   The blow-
ing respiration is heard, but less distinctly, at the upper
posterior part of the right lung, and still more feebly at
the corresponding portion of the left.   On the anterior
part of the chest, the blowing respiration is confined to
the breadth  of about two inches at the summit of the
right lung.
  The blowing sound  of the respiration is not heard,
except in the portions of the lungs just described, when
the patient breathes moderately, but fully expands the
chest.  If he should drive the air forcibly through his
mouth, then the sounds always produced in the fauces
are so much  exaggerated,  that  they may be heard
throughout the whole extent of the thorax.
  The singular fact, that the respiration was always a
little blowing at the upper part of the right lung, and
not of the left, has been familiar to me for some years.
I have recently made a number of dissections of the
lungs, to ascertain whether this fact could be explained
by their  anatomical structure.   It will be seen, by  re-
ferring to the cut, No. 1, at the end of the work, that
the bronchi  distributed to the upper lobe of the right 
DISEASES OF THE CHEST.
33
lung, pass  nearly in a straight line from the trachea;
those proceeding to the left lung, make a much longer
circuit, in  consequence of the  curve made by the left
bronchium, as it passes beneath the aorta.  The length
of the principal bronchium, on the left side,  is two
inches and a-half; that of the right is less than an inch
and a-half, measured from the middle of the bifurca-
tion.   The caliber  of the bronchi, passing to the right
lobe, is nearly double that of those on the left.  There
are, therefore, three  circumstances which render the
respiration more blowing  on the right side—1. Proxi-
mity of its bronchial tubes to the trachea.   2. Their
straight course.   3. Their greater size.
   The vesicular murmur is heard, unmixed with the
blowing respiration in the other parts of the  thorax.
 In adults, it is  stronger on the anterior surface of the
 chest;  in  children, it is louder  at the back, which  is
 not covered by  thick muscles in early life.   The respi-
 ration, in most persons, is loudest towards the base of the
 thorax, where the thickness of the lung is greatest.  In
 the axilla, the  respiratory murmur is pure, and very
 distinct.   At the  praecordial region it  is distinct, but
 is rather more feeble than on the right side.
   (B) Varieties produced by the difference of age.—In
 children,  the  respiration  is  much stronger than  in
 adults; the difference is so considerable, that the respi-
 ration of  children is regarded as  a distinct variety, to
 which the name puerile respiration is commonly given.
 The greater loudness of the  respiration characterizes
 both the blowing and  the  vesicular  sounds, which,
 throughout the chest, are more mingled together than
 in  adults.  It  depends partly upon physical causes;
 that is, the  thinness of the parietes of the chest, and
        E 
34
ON THE DIAGNOSIS OF
the short distance between the fauces of the child and
the ear of the observer.   From the first of these causes,
the respiration  in thin persons resembles, to a certain
extent, that of  children.   Another  cause must  be the
greater activity of the function of respiration in early
life, when the number of inspirations is  nearly double
that of adults, and each  effort of breathing drives the
air forcibly into the lungs.
  In  old age,  the  respiration becomes  more feeble,
partly from enlargement of the vesicles and rigidity of the
walls of the chest, and in part from diminished activity
of the vital functions.   The diminution of force extends
to both the sounds, but is, perhaps, still more percepti-
ble in the blowing than in the vesicular sound.
  (C)  Varieties caused by the constitution of the pa-
tient.—The respiration of corpulent persons  is  more
feeble than that of thin ones, from the obstacle produced
by the interposition of the fat, which is a bad conduc-
tor  of sound.   Infiltration  of the cellular tissue, from
dropsy or other causes, produces a similar effect.  In
emaciated subjects, the distinctness of the respiratory
murmur is  very great, unless the function of respira-
tion be imperfectly performed.  In women, the respira-
tion  is heard more imperfectly beneath  the  mammae
than in other parts  of the chest, where it is generally
louder than in  men, and  approaches to the characters
of the puerile respiration.   Digestion or muscular exer-
tion both increase the loudness of  the vesicular sound.
The nervous excitement sometimes produced  in irrita-
ble persons  by an examination of the chest, also exag-
gerates the respiration, a circumstance to be recollected
when we examine patients of this character. 
DISEASES OF THE CHEST.
35
OF THE ALTERATION OF THE RESPIRATORY SOUNDS PRO-
                 DUCED BY DISEASE.
  1. Of the signs which consist in changes of the sounds
yielded  by  the  normal  respiration.—These changes
may be limited to an increase or diminution of the
sounds of respiration, without alteration  of the rela-
tive loudness of their elements; or the relative inten-
sity of these elements may be much changed from the
natural state.  In all the varieties of this class, we
shall discover the blowing or the vesicular sound, but
always more or less altered.                 t
   (A) Increase of the normal sounds ofrespiration.—-In
this variety, both the blowing  sound and  the  respira-
tory murmur are augmented.  Cases have been men-
tioned, in which this increase was occasioned by pecu-
liarities of temperament, or habit  of body, or by some
accidental circumstance  affecting the patient.  The
force of the respiration may also be increased by dis-
eases of the lungs.   When a portion of the pulmonary
parenchyma becomes impervious to the air, and inca-
pable of performing the function of respiration, the por-
tions  not diseased  act  with  increased  energy,  and,
therefore, render the sound of respiration louder.  This
is especially the case when one lung is compressed by
a pleuritic effusion.   A lung, which is  partially dis-
eased, may yield a  puerile respiration in its  healthy
 portions.   The same variety may occur  in bronchitis
 and in fever, though there is no alteration of the paren-
 chyma, but merely a lesion of the bronchial tubes im-
 peding the passage of the air.
   (B) Diminution of the  normal sounds.—The sound
 of respiration may become less loud than natural, from 
36
ON THE DIAGNOSIS OF
lesions occurring in parts external to the lungs, or from
alterations in the structure  of these  organs.   If  the
pleura contain a liquid, whether it be pus, blood or
water, the respiration becomes more feeble, in part from
the compression of the pulmonary  tissue, which pre-
vents the perfect dilatation of the air-cells; and partly
from the interposition of a stratum of liquid, which re-
moves the lung to  a greater distance from the  ear.
The respiration is constantly feeble in emphysema, the
feebleness extending  to both the blowing and the vesi-
cular sounds.  The same is frequently, but not invari-
ably, the case in bronchitis.   In phthisis, the respira-
tion is generally less  loud than natural, but the feeble-
ness  is usually attended with other alterations of the
respiratory sounds.
   (C) Increase of the blowing sound of respiration, with
feebleness or absence  of the respiratory murmur.—This
division includes the most important alterations of the
respiratory sounds; that is, the different varieties of the
bronchial, cavernous  and amphoric respiration.  I shall
describe them in order, beginning with the cases wThich
differ least from the characters of the normal respiration.
   (a) Imperfect bronchial  or rude respiration.—In this
variety, the blowing  inspiratory sound is more distinct
than usual,  and more prolonged; the vesicular mur-
mur is still heard, and is  usually more feeble  than in
a healthy lung; in some  cases it is louder, but has a
rougher sound.  The feebleness of  the vesicular respi-
ration arises partly from condensation of the tissue ob-
structing the passage of air into the vesicles, and partly
from the increased loudness of the blowing sound, by
which it is masked.   The vesicular sound is never en-
tirely destroyed in the rude respiration of which it is the 
              DISEASES OF THE CHEST.             37

distinctive character.  The expiration is still more blow-
ing and prolonged than the inspiration, and is more
marked if the lesion be  upon the  right side of the
chest than if  on the left;  in the first case, the natural
sounds of respiration are exaggerated, but in the second,
a new sound is produced.   Some care and experience
are necessary to discriminate between this  variety of
the respiration and that  which  exists in  the natural
state, at the upper part of the right lung.   The  best
differential mark,  when the lung is not diseased, is the
presence of a pure and decided vesicular respiration, a
little more feeble  than on the  left side,  but  similar in
character.   Though rude respiration be accompanied
with a  respiratory murmur, it is rougher than natural,
and the expiration is also  much more prolonged and
blowing.
   The rude respiration is heard in pleurisy, when the
 effusion is moderate; in the very earliest stage of pneu-
 monia, and near its termination;  almost always in the
 early stages of phthisis.  It is scarcely ever produced
 at the base or along the anterior margin of the lungs.
   (b) Bronchial  respiration.—The vesicular  murmur
 disappears when the  pulmonary  tissue  is perfectly
 indurated,  the blowing sounds are still   heard, but
 much more strongly than  in the natural state.   Both
 the inspiration  and  expiration become  more loud and
 more prolonged, but especially the latter.    The sensa-
 tion communicated to the ear is that of  the  air passing
 through solid tubes, and not through the spongy tissue
 of the lungs.  The bronchial respiration may be pro-
 duced by disease in any  part of the chest, except very
 near the base of the lungs, where the bronchial  tubes
 are too small for  the production of this sound, though 
38
ON THE DIAGNOSIS OF
 the pulmonary tissue should be indurated.   It may be
 well developed on the anterior part of the chest, in the
 upper half of both lungs, and in the upper two-thirds
 or three-fourths on the posterior part of the thorax, as
 well as in the upper half of the axilla.   If the lesion be
 on the right side of the chest, the bronchial respiration
 is more distinct than if it  be on the left.  Although the
 loudness  of the blowing  inspiration, and especially of
 the expiration, are always greater in the bronchial res-
 piration than  in the normal respiration, the essential
 character of the  morbid variety is the total absence of
 the vesicular murmur.  The loudness of the sound de-
 pends upon the  size and unobstructed  caliber of the
 bronchial tubes, and the  hardness of the matter with
 which the tissue of the lung is infiltrated.  The bron-
 chial  respiration is heard in the large majority of cases
 of pleurisy, in phthisis, when the bronchial tubes of
 large  or middle size are surrounded with masses of tu-
 bercular matter, and in pneumonia.
   (c)  Strong bronchial or tubal respiration.—This may,
 with  propriety,  be  separated from  the ordinary bron-
 chial  respiration, although  it is but  an exaggerated
 form.   It must be studied separately, because it forms
 an important link between the  variety last described,
 and the cavernous  respiration.  The  inspiration  and
 expiration are not only strongly blowing, without the
 least trace of  vesicular respiration, but they are both
 very loud, and resemble  the sound which would be
 produced  by some one  blowing strongly into the  ear.
 This character is best marked in the expiration.  The
 puff of air does not seem  to  proceed from a single
spot, but from a large extent of lung.  During the in-
spiration the sound seems diffused through a consider- 
DISEASES OF THE CHEST.
39
able portion of the pulmonary tissue, until it is gradu-
ally lost.  This variety of the bronchial respiration can
only be produced under very favourable circumstances;
the bronchi must be large, and the induration of the
pulmonary tissue so complete that no air can pass into '
the vesicles.  It  is scarcely ever observed, except in
pneumonia, when it is heard near the root of the lungs
in the larger bronchial  tubes, and in dilatation of the
bronchi.  It is remarkably loud  when the bronchial
tubes are dilated, at the same time that the pulmonary
tissue is indurated.
   (d)  Cavernous respiration.—The cavernous differs
from  the tubal respiration in being limited to a circum-
scribed portion of the lung, into which the air is heard
to pass, and from which it  is  forcibly expelled; some-
times it seems as if it were blown directly into the ear.
This  variety of the respiration is produced, as  its name
implies, by a cavity in the lung, which, in an immense
majority of cases, arises from the softening of tubercu-
lous  matter.  It  is  consequently most frequently ob-
served at the summit of the lungs, where tubercles are
usually deposited; if it  be caused by cavities, resulting
from pneumonia or gangrene of the lungs, the most com-
mon  point of origin is about the middle of the  posterior
part  of the thorax; that is, at  the  upper part of the
lower lobe of the lung.  A lesion which occasionally
gives rise to cavernous respiration, is  the dilatation of
the bronchial tubes, when  it  exists in a very marked
degree;  this  is,  however, a rare circumstance.   All
cavities do not give rise to an equally perfect cavernous
respiration; to produce  it  in the most marked degree,
the cavity should be about the size of a walnut, should
communicate freely with a large bronchial tube, and 
40
ON THE DIAGNOSIS OF
its walls should be firm and surrounded by an indu-
rated parenchyma.   When the cavity exceeds the size
of a walnut, the cavernous respiration is  a little less
loud, especially if the  pulmonary tissue around it be
still permeable to the air.   The large size, and the soft-
ness of the walls of the cavity, reflect and conduct the
sound imperfectly.   It is not always possible  to distin-
guish between the cavernous and the tubal respiration;
the physical  state giving rise to them, and  the sounds
themselves, are  sometimes so similar as to deceive  a
practiced ear, unless the progress of the case  has been
carefully watched.   When cavities are of very long
standing, the cavernous respiration may become less
distinct.  I believe this change  sometimes  arises from
the contraction of the bronchial tubes communicating
with the cavity, and  the  diminished hardness  of its
walls.
  (e) Amphoric  respiration.—As the air  passes into
cavities of very  large size,  it  produces a sound not un-
like  that caused by blowing  smartly into  a  glass  or
metallic  vessel.   The intensity of this sound varies;
sometimes  it is  very  similar to that just described;
at other times,  it is merely a slight whizzing  noise,
which may resemble, to a certain  extent,  the sibilant
rhonchus.  The expiration is never so loud as in bron-
chial respiration; it ceases entirely if the opening  be
small, as is frequently the case in pneumo-thorax.  Am-
phoric respiration is produced by large cavities, which
cannot reflect the sound as sharply as smaller ones;  it
is, therefore, usually a less distinct variety than the cav-
ernous  respiration, especially in  those cases in which
the  expiration is wanting.  The cavities  which give
rise to it are most frequently either the pleura, when a 
DISEASES OF THE CHEST.
41
fistulous opening has occurred between this membrane
and the bronchi; a gangrenous excavation, or one pro-
duced by softened tubercles.  In extremely rare cases
it  may be caused by a  cavity following pneumonia.
The same cavity, which at first may yield a well marked
cavernous respiration, will produce an amphoric sound
when much enlarged; and  as the latter is less easily
recognized than the former, cavities of very large extent
may be unnoticed,  particularly where the pulmonary
tissue around them remains  permeable to the air.  The
only sure means  of avoiding this error  is to examine
the patient carefully, and more than once.  There is
no probability of  mistaking  the case when the patient
has been long under the care of the physician, who
may then  easily trace its progress from cavernous to
amphoric  respiration.  It is hardly necessary to add,
that no trace of vesicular murmur can be detected in
the amphoric respiration.

      OF THE RHONCHI AND OTHER MORBID SOUNDS.
   The second class  of  alterations of the respiration
comprises the  accidental or adventitious  sounds  pro-
duced during the act of respiration.   The sounds are
of two classes:—1, Those produced directly by the pass-
age of the air through the bronchial  tubes or vesicles;
 and,  2, The sound produced by the dilatation and con-
traction of the lungs reacting upon the matter secreted
into the pleura.
   Of the sounds produced by the passage of the air
 through the bronchial tubes  or into the pulmonary vesi-
 c^.__These  sounds are termed rhonchi, or rales, a
 French word, equivalent to the  English rattles.  For
 several reasons, the word rhonchus is preferable to that
        F 
42
ON THE DIAGNOSIS OF
of rale, which, after the discovery of auscultation, was
very generally used in the English works  on the sub-
ject.  The rhonchi are of two kinds, humid  and dry;
they are either  produced by the air passing through a
liquid of different degrees of tenacity, and giving rise
to a succession of bubbles,  or they originate from the
thickening or other  alteration in the  structure of the
bronchial tubes.
   1. Of the humid rhonchi.—As these  sounds are pro-
duced by the air in its passage through a liquid, form-
ing bubbles of different sizes, they must vary according
to the tenacity of the -fluid, the size of the bronchial
tubes, and  the greater or less rapidity with which the
air is forced through the bronchi.  When the bubbles
are large and produced in a bronchial tube of large ca-
liber, or in a cavity  communicating freely  with the
bronchi, the rhonchus is either cavernous  or mucous.
When the liquid is contained in the smaller tubes, the
rhonchus is the subcrepitant; when its tenacity is great,
and  the rhonchus originates in the vesicles or smaller
bronchia, it is termed the crepitant.
   (A) Cavernous rhonchus, or gurgling.—This is the
loudest and most easily heard of all the humid rhonchi;
the air passes into a liquid of moderate tenacity, con-
tained in a cavity of a size varying from that of a small
almond to a large orange, or in some cases limited only
by the pleura and the thoracic  parietes.   The  gurg-
ling is not in exact proportion to the size of the cavity,
but varies  according to the quantity  of  liquid, the
greater or less condensation  of the surrounding pulmo-
nary tissue, the caliber of the bronchial tube opening
into the cavity, and its position above or below the sur-
face of the liquid.  The thickness  of the  pulmonary 
DISEASES OF THE CHEST.
43
tissue between the cavity and the ear, does not mate-
rially diminish the intensity of the sound.   The cha-
racter of this rhonchus is best described by the word
gurgling—the impression is exactly such as we should
suppose produced by agitation of a liquid and air in a
circumscribed cavity.  The gurgling is generally pre-
ceded by a dry mucous rhonchus, or crackling,  which
becomes more  liquid  and distinct as the cavity in-
creases.   The  cavernous rhonchus is always heard
where a cavity in the lungs, containing a liquid, com-
municates  with  the bronchi.   It occurs  by far  the
most frequently in cavities following the softening of
tuberculous matter, but  it is  sometimes produced by
dilated bronchi, or  by pneumonic abscess, or circum-
scribed gangrene.  When the gurgling is from a tu-
berculous cavity, it is heard most frequently and most
distinctly near the summit of the lungs; when it pro-
ceeds from a dilated bronchus, it is found near the root
of the lungs, between the shoulders; if from pneumo-
nia  or gangrene, the rhonchus is most frequent near
the  posterior and inferior part of the  thorax.   This
rhonchus is the surest means of diagnosticating cavities
in the lungs, because they almost always contain liquid,
but are  very frequently so  much obstructed that the
cavernous respiration is obscured.  The gurgling may
cease for a short period, from temporary obstruction of
the  tubes, but it may be readily reproduced by direct-
ing the  patient to  cough, which  will remove the im-
pediment.
   (B) Mucous rhonchus.—This is analogous in charac-
ter to  the cavernous; it is more  diffused,  but less in-
tense.  It is produced, like the gurgling, by the passage
of air through a liquid of little tenacity, but it must be 
44              ON THE DIAGNOSIS OF
 contained in the larger  bronchi, instead of a circum-
 scribed cavity.  The sound is rather that of a success-
 ion of bubbles than of a confused gurgling;  the bub-
 bles are not always of equal size; at times, they seem
 produced by a thinner liquid, which breaks quickly; at
 others, they are larger,  and approach more  nearly to
 the cavernous rhonchus.  When the liquid is chiefly
 contained in the bronchi, near  the  root of the lungs,
 the mucous rhonchus cannot be certainly distinguished
 from the cavernous;  the resemblance is most perfect
 when the  surrounding pulmonary tissue is indurated.
 There is scarcely a disease of the lungs in which the
 mucous rhonchus is not occasionally found; its presence
 may be presumed when the expectoration is abundant,
 and not  tenacious;  and,  if wanting for a short time, it
 may be easily heard again by making the patient cough.
 Mucous rhonchus is almost always heard in the second
 stage of pulmonary catarrh, when the expectoration
 has become abundant; its seat is the posterior and in-
 ferior part of the lungs.   In pneumonia, mucous  rhon-
 chus is often present after the termination of the crepi-
 tus ; in phthisis, this rhonchus  is very frequent, and
 varies according to the quantity  of liquid contained in
 the bronchi; it is most constant  when the tuberculous
 masses begin to soften, but it is then caused by  the
 secretion from the mucous membrane of the bronchi,
 rather than by the softened  tubercle which is  confined
 to the cavity, where it gives rise to the cavernous  rhon-
 chus.
  (C)  Crepitant rhonchus, or,  as it is often called,  moist
crepitant rhonchus.—This sound is  produced in the
small bronchial  ramifications, or, as some suppose, in
 the pulmonary vesicles; and  is caused by the passage 
DISEASES OF THE CHEST.
45
of the air through a very tenacious  liquid.   The bub-
bles are, therefore, much smaller,  and break with a
sharper noise than the mucous rhonchus.  It has been
compared to the sound caused by the crackling of salt
thrown upon hot coals, to  the  effervescence of cider,
and other analogous sounds, which do not perfectly re-
present the character of the rhonchus.   It is described
with some  difficulty, but when once heard, is always
recognized.   The crepitant rhonchus may occur in any
part of the lungs, but it is most frequent at the lower
and posterior part, and is heard chiefly during the in-
spiration.  Sometimes it can be traced from point to
point of the lungs, by the peculiar crackling  sound, like
that caused by igniting a train of moist powder.  The
crepitant rhonchus is peculiar to pneumonia; it occurs
in this disease, even when it arises from external vio-
lence, and the  expectoration is entirely wanting.  It
is, therefore,  probable  that this sound is  sometimes
caused by the dilatation of the inflamed vesicles, and
not by the liquid contained in them.  The  crepita-
tion is heard in  the early stages  of pneumonia, and
when the part of the lung first affected has passed to
 the stage of hepatization, it is usually surrounded by a
 belt of crepitant rhonchus, which extends with the pro-
 gress of the disease.
  °  (D) Sub-crepitant rhonchus.—-This variety is distin-
 guished from the preceding, by the larger size of the
 bubbles, made  by the air  passing through  the smaller
 bronchial tubes, and the greater quantity of liquid.   It
 resembles the crepitant rhonchus in the regular success-
 ion of the bubbles,  which  seem nearly of equal size,
 and  are not  so irregular  as they are  in the mucous
 rhonchus.   Its characters  are thus  intermediate be- 
46              ON THE DIAGNOSIS OF

tween those of the sounds just described, and it passes
into them  by such insensible gradations, that  it  is
sometimes impossible to determine when the one ends
and the other begins.  The sub-crepitant  rhonchus is
very frequent in catarrh, when it is usually heard
at the  base of the  lungs; in  lobular pneumonia,  in-
cluding the peripneumonia notha; in true  pneumonia,
when the disease is passing to resolution; in oedema of
the lungs, and in  other affections of these organs, accom-
panied by inflammation of the smaller bronchial tubes.
  2. Of the dry rhonchi.—These are  two  in number,
the sonorous,  and the sibilant; they are not produced
by the  passage of air through a liquid, but  by changes
in the caliber of the bronchial tubes from thickening of
the mucous membrane, or the accumulation of viscid
mucous upon its  surface.  The changes in  the respira-
tory sound  caused by diminution of the caliber of the
tubes, resemble the alterations of tone made by blow-
ing through  reeds of various  dimensions.  The dry
rhonchi are not confined to cases of inflammation of the
bronchi; they may be heard when there is  simple con-
gestion of the mucous  membrane.   Sometimes they
are heard singly, at  other times, mingled  together or
combined with the moist rhonchi.  They are signs of
secondary importance.
  (A)  Of the sonorous rhonchus.—This rhonchus resem-
bles the cooing  of a pigeon, or still  more  nearly the
sound of the bass-string of a violin.   It is  so peculiar,
that when once heard, it cannot readily be forgotten;  it'
is not produced in the smaller bronchi, but  is most dis-
tinct where these tubes are  largest.   It is  common to
the inspiration and the  expiration, but in a majority of
cases, it is most evident in the expiration, and on that 
DISEASES OF THE CHEST.
47
account is sometimes confounded with bronchial respi-
ration.  This mistake may be avoided by observing the
sharper and more musical  tone of the  sonorous rhon-
chus, the vesicular respiration which is  heard, either
at the same time with it, or alternately; and lastly, by
percussing the patient, when the clearness of the reson-
ance will  show that the respiration is masked  by the
sonorous rhonchus, but is not bronchial.   The sonorous
rhonchus  is  common  in those  stages of catarrh,  in
which the  bronchial mucous membrane  is congested,
while there is little secretion of liquid; it usually dis-
appears when  the liquid  rhonchi are  heard,  but  is
sometimes mingled with them.
   (B) Of the sibilant rhonchus.—This sound resembles
a low whistle, and, like the sonorous rhonchus, is heard
both in the inspiration and the  expiration.   It is con-
fined to the smaller bronchial  tubes, and  occurs  in
pulmonary catarrh, in emphysema, and in the bronchial
congestion, produced by typhus fever and  other dis-
eases.
   (C) Dry crepitant rhonchus.—This is a very rare and
unimportant sound; it occurs occasionally in emphy-
sema, when the distended vesicles or  the interlobular
tissue, inflated with air, are compressed against the
pleura during the act of inspiration.  It is a very feeble
rhonchus and resembles the crepitant in some respects,
but does not communicate the sensation of a liquid con-
tained in the bronchi.
   3.  There are  two  adventitious sounds not  classed
amongst the rhonchi.
   (A) The grating sound {bruit de frottement).—It is
caused by the friction of the two surfaces of the pleura,
lined with false membrane  upon each other, and is 
48
ON THE DIAGNOSIS OF
heard in the latter stages of pleurisy, when the more
liquid part of the effusion has been absorbed.   The
more solid portion, consisting of coagulable lymph, re-
mains, and forms two rough surfaces, which  chafe
against  each  other  at every act of respiration, and
give rise to a  peculiar creaking noise, like that  made
by rubbing together two  pieces of parchment or dry
leather.  The grating  sound is  heard at the lower
part of the chest, where the motion of the ribs is most
considerable and  the false membranes are  usually
thickest.  It is  heard both in inspiration  and expira-
tion, and, when  well marked, is attended with a pecu-
liar quivering of the chest, easily felt by the hand.
   (B) Metallic tinkling.—This is a rare sound, and  is
heard only in the pleura,  or a very large cavity in the
substance of the lung, following tubercles or gangrene.
It is produced by the fall of a drop of liquid from the
upper part of a cavity, upon the surface of a fluid con-
tained in it, which gives  rise to  a peculiar  tinkling
sound, a little similar to that produced by striking  a pin
against a glass vessel.   The sound is not permanent,
but when suspended, may be often  reproduced by  mak-
ing the patient cough.  The essential condition for its
production is a cavity of large size, containing both air
and liquid.

        OF THE  AUSCULTATION OF THE VOICE.
   When  a person  whose lungs  are  not  diseased,
speaks, a slight tremor is felt throughout the whole
chest, but no distinct sound is heard.  In certain  parts
of the chest, although  the distinct articulation of the
voice is lost, a confused resonance is quite perceptible.
These parts are the two fossae above the spines of the 
DISEASES OF THE CHEST.
49
scapulae, the upper half of the space included between
these bones and  the spine, and the depression imme-
diately  below the right clavicle.   The resonance is
greater  at the upper part of the right  than of the left
lung, for reasons stated in the description of the charac-
ters  of  the normal respiration.  It is  heard in these
parts of the thorax, because  the  voice is conducted
from the larynx and mouth, by the column of air con-
tained in the larger bronchial tubes.   The small  size
of the bronchial tubes in the inferior part of the lungs,
and  the spongy  texture of these  organs, prevent the
transmission of sound.   The resonance of the voice is
augmented by induration of the pulmonary tissue and
increased size of the bronchial tubes, which render the
lung a much better conductor of sound.

OF THE  ALTERATIONS PRODUCED  IN THE RESONANCE OF
         THE VOICE BY DISEASE OF THE LUNGS.
   1. Increased resonance.—The resonance of the voice
may be louder than natural, though the lungs are not
diseased.  If the patient be much emaciated, the reson-
ance is  very loud near the large bronchial tubes;  it is
greater when  he has a deep bass voice, than when the
voice is feeble.   When the lungs contain more solid
matter  than in  a healthy state, the resonance of the
voice is increased.  In the first degree of this increase,
the  words are confused, but the voice vibrates a little
more strongly beneath the ear than in health.   This
alteration is heard when  the rude respiration occurs,
and is produced by a similar physical state of the lung;
it is most distinct at the upper and posterior parts of
the  lungs, and is more frequent on the right than the
        G 
50
ON THE DIAGNOSIS OF
left side.  The same anatomical structure which causes
a slight degree of resonance in the right lung of healthy
subjects, gives rise to a considerable increase of sound
when it is but little diseased.
  2. Bronchophony is  a variety of resonance of the
voice, which is much louder and much more distinct
than is ever heard  in a healthy lung.  It is always
found when the respiration is bronchial, and varies in
intensity according as it is simple or tubal.   In the less
marked form, the voice is heard very plainly, but the
words are not distinct.  In  the  variety accompanying
the tubal respiration the voice is very loud, and some-
times the articulation is  quite distinct.   The  words
seem almost to  enter the ear, but are evidently diffused
through a considerable portion of the lung, and do not
come  from a single point.  The first degree of bron-
chophony is a very frequent and most  important sign
in the course of phthisis, and is usually heard in pleu-
risy, when the  effusion is considerable.  The tubal re-
sonance of the  voice is almost peculiar  to  pneumonia,
when it is very loud at the  posterior and middle parts
of the chest, where the bronchi are largest, and the in-
duration of  the lung is greatest.   Dilatation of the
bronchi will often give rise to a very loud resonance of
the voice, especially when  the surrounding tissue is
indurated.   In all cases, bronchophony is  a pheno-
menon  ever  existing with  the bronchial  respiration,
and heard most distinctly under circumstances which
are alike favourable to both, that is, large size of the
bronchial tubes and induration of  the surrounding
tissue.
   3. Pectoriloquy is the resonance  of the  voice yield- 
DISEASES OF THE CHEST.
51
ed by a cavity in the lung of moderate  size.   When
pectoriloquy is perfect, the voice seems to proceed from
the cavity and to enter the ear; when it is not perfect,
it resembles so closely the different varieties of bron-
chophony, #that no distinction can be made between the
two sounds.   It must be evident that a cavity will
yield nearly the same resonance of the voice as a large
bronchial tube, and if the bronchus pass through hard-
ened tissue, it may even give rise to  a more  perfect
resonance than a cavity not communicating very freely
with the external air, and surrounded by sound pul-
monary structure.   A cavity capable of yielding a per-
fect pectoriloquy, must be of moderate size, not exceed-
ing that of a small pullet's egg; it must be completely
emptied, and  its walls must  be indurated.  Although
the surrounding lung be hardened, and the cavity of
suitable size, it will not yield perfect pectoriloquy if it
be temporarily obstructed with liquid.  Pectoriloquy is
not one of the most important physical signs; it is rarely
perfect, and is not permanent, so that the presence of a
cavity may generally be detected more certainly by
the cavernous gurgling.
   4. Amphoric resonance of the voice.—Like the ampho-
ric respiration, this sound is not always easily recog-
nized when the progress of the disease has  not been
watched during its earlier periods.  The voice seems
more hollow,  more distant and more diffused, than in
pectoriloquy; sometimes it  has  a peculiar rumbling
sound.   It is scarcely possible to describe the amphoric
resonance, although it is unlike any of the sounds men-
tioned in the preceding paragraph.  Sometimes it re-
sembles the sound made by speaking in a glass tumbler, 
52
ON THE DIAGNOSIS OF
especially when it arises from a communication between
the pleura and the  bronchi.  But if it depend upon a
large tuberculous or gangrenous cavity, the tone is much
less sharp, and the resonance is sometimes quite obscure.
It ceases entirely when the bronchi are obstructed.
  5. Egophony.—When the voice is transmitted through
a layer of liquid contained in the cavity of the pleura,
it has a peculiar quivering intonation, resembling the
bleating  of a goat or the voice heard through a speak-
ing trumpet.  The sound is not often so loud  as it
usually is in bronchophony, unless  the lungs  be in-
durated at the same time that there is  a collection of
liquid in the pleura, when the -bronchophony is loud
and distinct, but has a peculiar vibrating tone, resem-
bling egophony.   The resonance of the voice is always
greater than natural in egophony, but while it  some-
times approaches the loud tone of bronchial resonance,
at other times it is like a faint whisper; in all cases the
essential character of the sound is its vibration.   The
quantity of liquid necessary for the production of this
sound, must be sufficient to interpose a layer of moder-
ate thickness between the  lungs and  the costal pleura;
but if the quantity  be so  considerable as to compress
the lungs against the spine, the resonance of the voice
ceases, because the air no  longer  passes into the bron-
chial tubes.   The usual seat of egophony is about two
inches above the base of the lungs; it is most distinct at
the  posterior part of the chest, but  varies as the posi-
tion of the patient changes the level  of the liquid.  It
is a useful sign in the diagnosis of pleurisy and hydro-
thorax; but as it is not constant and is confined to cer-
tain stages of these  diseases, it is always of secondary
value. 
DISEASES OF THE CHEST.
53
  6. Diminished resonance of the  voice.—When  the
quantity of air contained in the chest is so much in-
creased as to diminish the fitness of the lung as a con-
ductor of sound, the resonance of the  voice is  less
strong than in health.   The sound  is extremely feeble
in the parts of the lung  affected  with  emphysema.
When effusions of liquid into the pleura are so consi-
derable as to obliterate the spongy texture of the lung,
and flatten the bronchial tubes, the resonance of the
voice is entirely lost.  Infiltration of the walls of the
chest, or a large deposit of fat, must necessarily enfeeble
it;  but in a large majority of the diseases of the lungs,
the voice resounds more strongly than natural.
   Of the auscultation of the voice and cry of children.—
It is difficult to examine the voice of children; when
such an examination  is practicable, the signs do not
differ materially from those heard in adults.  The bron-
chophony is well marked in children older  than six or
seven years; it is  usually doubtful in those  that are
younger.
   Pectoriloquy is rare, partly because cavities are not
frequent, and  partly from the  copious mucous secre-
tions  which  obstruct  them.   Egophony  is distinct
when there is a pleuritic effusion.
   The cry of  children does not give  rise to the same
loud resonance in the chest as is caused by the voice.
 The cry is a sound produced in the larynx and nasal
 cavities, by the forcible expulsion  of the air from the
chest, and does not communicate a  distinct vibration to
the column of liquid contained in the bronchi.  There
is, however, some sound heard over those parts of the
 lungs which are hepatized, which is probably owing to 
54
ON THE DIAGNOSIS OF
the conducting power of the hardened tissue.   As the
cry of children is followed by a quick and full inspira-
tion, distending the vesicles to  the utmost, and repro-
ducing any rhonchi which may have been suspended,
it is useful to auscult them when crying, in order to
hear the  sounds caused by a perfect dilatation of the
air cells. 
DISEASES OF THE CHEST.
55
CHAPTER V.
      OF THE COUGH AND THE EXPECTORATION.

  The characters of the cough, and the appearance of
the liquid expectorated, are closely connected, and af-
ford valuable indications in the diagnosis of pulmonary
diseases.  The cough is, in itself, a useful symptom,
and serves to render the signs of auscultation more dis-
tinct, by removing the liquid accumulations which ob-
struct the bronchial  tubes.  It is, therefore, usual when
ausculting a patient, to request  him to cough before
concluding the examination.  There are several varie-
ties of cough, caused by different diseases of the chest,
and by the successive stages of the same affection.
   1.  Short, dry cough.—In the early stages of phthisis,
and in  some affections of the fauces, there  is a short,
dry cough, usually limited to a single effort, rarely ex-
ceeding two or three successive expirations.   When
this cough exists in the earlier stages of phthisis, it is
sometimes so slight that the patient  himself  is  not
aware of its existence, until  it is  pointed out  by his
physician.  When his attention  is directed to the fact,
the cough is often rendered more rare from  the efforts
of  the  patient  to suppress it.   This  variety  of  dry
cough,  which may either depend upon disease of the 
56              ON THE DIAGNOSIS OF

throat  or of the lungs, is not important in itself, but
becomes of value when combined with other signs.   In
febrile  affections, not immediately connected  with the
lungs, there is frequently a short, dry cough, not unlike
that of phthisis.  This symptomatic cough is especially
frequent in children, who are scarcely ever ill without
having more or less of it.  The short, dry cough, com-
mon in some chronic diseases, is owing, in a large pro-
portion of cases, to irritation about the fauces; but in
other instances no such cause can be detected.
  2. The  suppressed cough.—When  the  pleura is in-
flamed, the effort of coughing causes much pain, and is,
therefore, as far as possible, repressed by the voluntary
efforts  of  the  patient, who checks the motion of the
ribs.  The suppressed cough attends inflammation of
the pleura, whether it be simple or connected  with dis-
ease of the lungs.   It is  readily recognized by its ab-
rupt termination.  Another variety of suppressed cough
is  frequent in pertussis,  and other  affections of  the
chest, in which violent paroxysms of coughing occur;
the patient's fears  suppress the cough as long as pos-
sible.
  3. The sonorous  cough is loud and hoarse, but at the
same time dry.  It occurs in the  early stages of bron-
chitis, before  the secretion of liquid has commenced.
There  is a peculiar nervous  cough, which is  loud  and
shrill;  sometimes it is not unlike the crowing of a cock;
very frequently it may be heard at a distance.  This
variety of cough is usually attended with some uneasy
sensations at the larynx, and both physician and patient
are often led to suspect some important disease of  this
organ,  until the history of the case, and the negative 
DISEASES OF THE CHEST.
57
physical signs, show that there is probably no organic
disease.*
  4.  The laryngeal cough.—In affections of the larynx,
the cough has a peculiar character.  When the  mu-
cous membrane is thickened, and  the opening of the
glottis is of course diminished, the cough is stifled,  or
sometimes whistling;  it is never  loud  and sonorous.
Ulceration of the  larynx is  attended by a feeble but
hoarse cough, proportionate to the aphonia which exists
under such circumstances.
  5.  The loose mucous cough is marked by a loud sound,
with the rattling of a liquid passing through the fauces.
It is the usual cough of catarrh,  when there is copious
secretion of liquid into the bronchial tubes.  Other dis-
eases, in which the expectoration becomes abundant, as
phthisis and chronic bronchitis, are attended by the
loose cough.  It frequently is  heard in the third stage
of pneumonia, when there is pus  infiltrated  through
the lung.
  6.  The hollow cough of advanced consumption, when
the lungs contain  numerous cavities, is perfectly  indi-
cated by its name: it is almost characteristic of the pre-
sence of cavities in the lungs.
  7.  The spasmodic cough is most marked in pertussis,
when there  is spasm of the muscles of the chest and
larynx during the expiration, which is  followed  by a

  * I have seen two remarkable examples of the loud nervous  cough,
which was so sonorous that it might have  been heard through the whole
house. One of these patients died of another affection; his larynx was found
to be perfectly natural; the other patient  recovered, after the application of
a blister to the back of the neck. In both these cases, the absence of all
signs of organic lesion led to a suspicion of the true nature of the disease.
        H 
58
ON THE DIAGNOSIS OF
 noisy sonorous inspiration.  A similar variety is occa-
 sionally met with in other diseases of the lungs.  The
 asthmatic cough scarcely differs from the preceding;  it
 is frequent  in emphysema, when it occurs in  violent
 paroxysms  during the  convulsive  fits  of dyspnoea.
 They usually last until free expectoration commences.
   The varieties of cough might be greatly multiplied, but
 for practical purposes, the classification I have just given
 will be found sufficiently convenient.   All these differ-
 ent  forms are most marked  when  the disease of the
 lungs has not extended to a  very large portion of the
 parenchyma, in  which  case  the  excessive dyspnoea
 prevents the quick expiration which  constitutes the
 cough.  The diseases of the lungs sometimes run  their
 course almost without cough, especially in the  aged.
 In children it is always present, when the lungs are
 diseased, and it continues until a large portion of  their
 parenchyma has become  indurated.

              OF THE EXPECTORATION.
   The sputa may vary in quantity, colour, consistence,
 form and odour;  they may also contain foreign matters,
 as blood, pus, tuberculous and calcareous concretions.
 As the sputa are chiefly secreted by the mucous mem-
 brane lining the bronchial tubes, they indicate  its le-
 sions, which vary in the different diseases of the tubes,
 as well  as of the parenchyma.  Besides the secretion
 from the mucous membrane, the expectoration, in many
diseases of the lungs, arises in part from cavities formed
 in their substance.
  The secretion  of liquids into the bronchi  is necessa-
 rily independent of the will, but the expectoration is a 
DISEASES OF THE CHEST.
59
voluntary act.   It  is performed imperfectly when  a
person is averse to making the necessary muscular
effort, on account of the pain it may give him, or other
reasons;  there are no sputa when the feebleness of the
patient prevents his making an effort.  For  similar
reasons, children below the age of six years do  not ex-
pectorate ; they do so but rarely until the age of puber-
ty.   In very old people the expectoration is rare, and
not proportioned to the extent of the disease.
  When the sputa are  not copious, they are  chiefly
expectorated in the morning, on waking from sleep,
during which they accumulate in the bronchi.   When
the sputa are copious,  but  the expectoration  causes
pain, they are also retained in the  lungs until a par-
oxysm of coughing comes on, and they are discharged
in large quantities.
  Except in the cases above  mentioned, the sputa are
rarely wanting  during the whole course of a disease,
but they do not  usually assume their characteristic ap-
pearance until the disease is sufficiently advanced to be
recognized  by  the more  certain physical signs.  In
some exceptional cases the sputa are pathognomonic,
when the physical signs are doubtful, on account of the
remote situation of the lesion or the state of the sur-
rounding tissue.
  1. Of the quantity of the expectoration*—It is small
when it  does not exceed a wine-glassful in the twen-
ty-four hours;  moderate when from two to six fluid
ounces; large from six ounces to a pint, and very large
if more than a pint.   In descriptions of the sputa, it is
advisable to state the quantity.
  2. Of the colour.—The saliva and the mucus of the
bronchial tubes are transparent;  it may be more abund- 
60
ON THE DIAGNOSIS OF
 ant than usual.  A higher, or rather more prolonged,
 degree of inflammation of the bronchial mucous mem-
 brane, gives a whitish colour to the sputa, if the catarrh
 pass into resolution; or, if it assume a chronic form, the
 sputa are yellowish, and frequently of a greenish tinge,
 and altogether opaque.   In acute inflammations of the
 air-vesicles and of the minute bronchial tubes, the sputa
 are at first transparent and colourless, but soon become
 tinged of an orange hue, or they are rustr-coloured or of
 a bright scarlet colour.  In inflammations of the lungs,
 with great prostration, the sputa are brownish, of a ma-
 hogany colour, or like that of stewed prunes.
  3.  Consistence.—In general, the sputa, if colourless, are
 thin and very liquid, those that are yellow and opaque,
 are thick, and flow less easily.  The shining transparent
 sputa of pneumonia are more viscid than any other, are
 often heaped up in the centre of the cup,  and adhere
 strongly to its sides.  In one variety of chronic catarrh,
 and in some affections of the tonsils, the matter  expec-
 torated is very small  in  quantity, and  almost solid.
 The sputa frequently consists of two parts, one more
 solid, and the other nearly of the consistence of  water.
 If much air be mingled with the sputa,  they are light
 and frothy.
  4.  Form.—The  sputa generally run  together,  and
 form a mass which is nearly homogeneous:  they unite
 more  perfectly if they  are  nearly similar  to the  na-
 tural secretion of the bronchial tubes.   The viscid trans-
 parent sputa of pneumonia blend together perfectly
well;  the yellow expectoration of catarrh less perfectly,
a part  of the sputa  is in irregular shreds, intermixed
with a whiter liquid.  The form assumed by the ex-
pectoration in phthisis, is often  peculiar; a thin  liquid 
DISEASES OF THE CHEST.
61
forms the greater part of the mass, in which float irre-
gularly rounded masses, generally as large as a shilling,
with loose  cottony edges.  The sputa in gangrene of
the lungs,  and in the last stages of  phthisis, run to-
gether, and do not retain a peculiar form.
  5. Odour.—Transparent sputa are without decided
odour; the thick, yellow liquid has  generally a faint,
nauseous smell,  which  is very marked in cases of
phthisis.   Gangrene of the lungs is distinguished by a
peculiar fcetor, sometimes gangrenous, at other times
resembling the smell of moist plaster.  Occasionally,
a variety of chronic catarrh and of tuberculous phthisis,
in their  advanced stages, are attended with foetid ex-
pectoration.
   6.  Of the foreign matters mingled with the secretions
of the bronchial  tubes.—Pus is often  intermixed with
the mucus secreted in bronchitis, phthisis, and the lat-
ter stages of pneumonia, when the sputa are said to be
muco-purulent.  Sometimes a portion of the pus is un-
combined,  and sinks to the bottom of the mass.   Blood
may be intimately combined with the sputa, as it is in
pneumonia, when it  communicates a general rusty or
reddish tinge  to  them;  or it may be  mixed in streaks
with the mucus,  and still retain its  florid red  colour;
or, lastly, it may be unmixed with the bronchial secre-
tions, when it constitutes haemoptysis.  The tubercu-
lous matter may  sometimes, though rarely, be detected
in  the  sputa, under  the form of  minute yellowish
opaque  grains, not often exceeding the size of a pin's
head; this appearance coincides with the softening of
the tubercles.  Calcareous matter is sometimes, though
rarely, observed  when  the  tubercles are  dry and con- 
62
ON THE DIAGNOSIS OF
tain much of the  salts of lime.  Portions of gray or
dark pulmonary tissue have  also been expectorated
after separation from the  adjacent tissue.   In cases of
jaundice or pneumonia, complicated with disease of
the liver, the sputa may be tinged with bile.   I have
seen the expectoration composed almost entirely of pure
bile from a fistulous opening between the liver and the
lungs, following a wound of these organs. 
DISEASES OF THE CHEST.
63
CHAPTER VI.
         ON THE MOVEMENT OF THE THORAX.

  In health, the act of inspiration is performed partly
by the elevation of  the shoulders and ribs, and partly
by the depression of the diaphragm.  The passage of
the air through the  nostrils does not cause them to
dilate evidently.  When the respiration becomes diffi-
cult, the different muscles, whose action concurs in res-
piration, act irregularly, and much more forcibly than
in a state of health.  When there is dyspnoea, without
pain in any part of the thorax, all the muscles concern-
ed in respiration act with increased energy.   The nos-
trils dilate widely, the shoulders and ribs are forcibly
elevated, and the diaphragm depressed.  In acute dis-
eases, the degree of the dyspnoea is nearly commensu-
rate with the extent of the pulmonary affection.  In
chronic diseases, this is by no means the case.  There
are even some instances in which there is extreme
dyspnoea, but no appreciable lesion of the lungs.  When
there is acute pain  in the sides of the thorax, or at the
diaphragm, from inflammation of the serous membranes,
the parts of the chest nearest  to the inflamed pleura
move less than they do in a state of health.   The mo-
tion becomes free as soon as the pain subsides.   If effu-
sion of liquid occur into the pleura or the pericardium, 
64
ON THE DIAGNOSIS OF
the motion of the ribs at the corresponding part is im-
peded by the mechanical distension, though there be
no acute pain.  When the liquid is absorbed, and false
membranes unite the two surfaces of the  pleura, the
dilatation of the diseased side  is  always imperfect.
The diminished motion of the side of the chest, most af-
fected in phthisis, depends upon the adhesions produced
by the frequent inflammations of the pleura.
  The number of the- inspirations is generally from
twelve to sixteen in the minute; but when the lungs or
the pleura are much inflamed, the inspirations may in-
crease to thirty or forty;  and, when the disease is ex-
tremely violent, the number  may be as high as  sixty
or seventy.  This extreme frequency is most remarka-
ble  when all the serous membranes of the chest are in-
flamed at the same time.  In acute diseases, the frequency
of the inspirations is at first nearly proportioned to the
violence of the affections; when they have lasted a cer-
tain time, the patient seems to accommodate himself to
a diminished supply of air, and breathes less frequent-
ly.  The respiration of children affected with diseases
of the chest is very frequent, especially when the lobu-
lar pneumonia has extended to a large portion of both
lungs.  The irregularity and the morbid  slowness of
the  respiration more frequently indicate affections of
other  organs than the lungs.   When the extreme fre-
quency of the respiration in acute diseases has ceased,
the inspiration remains more hurried than usual; some-
times  it is performed in as short a time as the expiration
—after which a pause ensues.   In health, the time re-
quired for the inspiration is  twice  as long as that of
the  expiration, both in children and adults. 
DISEASES OF THE CHEST.
65
CHAPTER  VII.
       BRONCHITIS, OR PULMONARY CATARRH.

  Anatomical characters.—When the  mucous  mem-
brane of the  air tubes is inflamed, it is reddened and
thickened.  The secretion of mucus is diminished in
quantity, or  entirely  suppressed.  The dryness and
thickening of the bronchial mucous membrane form the
most  important characteristics  of the  first stage of
bronchitis.
  When bronchitis has reached the second stage, the
secretion of liquid recommences; it is at first thin and
watery, or whitish and semi-transparent.   It becomes
yellowish and opaque as the disease proceeds towards
resolution, when it also augments in quantity.   The
thickening of the  mucous membrane often gradually
ceases when  the  secretion of  liquid diminishes in
quantity.
  Physical signs.—Percussion, in this disease, gives no
certain results; the sonorousness of the chest is not sen-
sibly diminished, unless the inflammation has extended
to the smaller bronchial tubes, when there is sometimes,
but not always, a slight diminution of the sound.
  The respiration is  altered in bronchitis; when the
disease is in its earliest stage,  there is a diminution in
the intensity  of the respiratory murmur.   The  feeble-
       i 
66
ON THE DIAGNOSIS OF
ness of sound does not extend to the whole of a lung,
but is confined  to portions of one, or both, of these or-
gans.  It is usually most evident at the anterior margin
of the lungs, and varies during the progress of  the dis-
ease.  When the respiration is not enfeebled, it is often
stronger than natural, and has a peculiar roughness of
sound; but, as the vesicular murmur is still distinct, it
does not resemble the blowing or bronchial respiration.
  In not a few cases of bronchitis the respiration pre-
sents no other changes than those just mentioned; but
in a majority of patients, especially if the disease be
intense, the  dry or  moist  rhonchi are  heard.  The
sonorous rhonchus precedes the secretion of liquid.   It
is loudest near  the large bronchial tubes, and from its
great distinctness in  the expiration, may be easily con-
founded with bronchial respiration.  The sibilant rhon-
chus is less frequent, and is found at the anterior mar-
gin of the lungs, where the bronchi are of smaller size.
It is much more common in secondary than in idiopa-
thic catarrh.
  When the  disease is so far advanced that liquid is
secreted  into the air tubes, either the mucous or the
sub-crepitant rhonchus is heard.   They originate  at
the base  of the lungs,  or along their posterior margin,
rarely at the anterior surface.   When the rhonchus is
the coarse loose mucous, it is  easily recognized;  but a
fine sub-crepitus may be confounded with the crepitant
rhonchus of pneumonia.  It is the  more easy  to com-
mit this error from the seat of the sub-crepitant rale at
the base  of the lungs.
  Expectation.—In the  early stages  of acute catarrh
there is no expectoration.  When liquid is secreted into
the bronchial tubes, the sputa are thin and transparent, 
DISEASES OF THE CHEST.
67
but never tenacious and viscid, as in pneumonia.  They
usually run together, and flow  readily from the cup.
When the disease is farther advanced, the sputa are
yellowish, opaque, or only semi-transparent; they are
thicker than in the earlier stages, but not tenacious,
as in pneumonia.  The opacity  and  increased consist-
ence of the sputa indicate the approaching resolution
of the disease.
   Cough.—The cough of bronchitis is peculiar; at first
loud and hoarse, it  becomes loose and more frequent
when the expectoration  begins.  It does not resemble
the short dry cough of pneumonia or pleurisy, nor the
faint and rare cough of commencing phthisis.
   Rational signs or symptoms of bronchitis.—The de-
gree of fever, the prostration and the state of the diges-
tive functions,  vary to so great an extent in bronchitis,
that no general description  of them can be given.  In
the  slighter forms of disease, the  functions of other
organs than the lungs are scarcely impaired; in some
severe forms of disease, nearly all the organs participate
in the disturbance.

               VARIETIES OF BRONCHITIS.
   Epidemic bronchitis, or  influenza, differs from the
common form  in the greater intensity of the general
symptoms, compared with the slight cough and altera-
tion of the respiration.  The physical signs of epidemic
catarrh do not  differ from those already described.
   Chronic  bronchitis.—There  are  three  varieties  of
chronic bronchitis—one  is the chronic mucous catarrh;
another  the dry catarrh; and the third, the pituitous.
   1. Chronic mucous catarrh.—This form of the dis-
ease may occur at all ages of  life, but is most frequent 
68              ON THE DIAGNOSIS OF

in the aged.  Its physical signs are precisely similar to
those fomnd in the acute disease,  and the expectora-
tion returns its yellow, opaque, muco-purulent aspect.
The functional alterations are generally slight, but in
some rare cases the fever is considerable, and scarcely
differs from the hectic of consumption.
   2. Dry catarrh.—In this variety the sonorousness of
the chest is not  diminished, indeed it is often greater
than natural, from the complication with emphysema,
(q. v.)   The sonorous rhonchus is frequently heard in
the larger bronchial tubes, but less constantly than the
sibilant,  which  almost  always accompanies the dry
catarrh.   The frequency of the sibilant rhonchus is
supposed to depend upon the secretion of a small quan-
tity of mucus, which concretes and forms temporary
obstacles to the passage of  air through  the smaller
bronchi.  A more constant cause of it, is the partial
thickening of the bronchial mucous membrane.
   Pituitous catarrh, or  the variety which  is accom-
panied by an abundant secretion of thin  liquid, is more
rare than the dry catarrh.  The expectoration consists
of a glairy transparent  liquid, sometimes  mixed  with
whitish  mucous flocculi, and is extremely copious.  It
occurs most frequently in persons advanced in life, and
may last during a  long series of years.   The sound on
percussion is as great as in the other varieties, but the
respiration is partly  masked  by abundant and  very
liquid mucous rhonchus, sometimes passing into the
sub-crepitant.  The dry rhonchi are often heard at the
same time with the moist, forming a singular union of
sounds, which may,  however, be perfectly  well dis-
tinguished from each other.   This mixture of rhonchi
was sometimes  termed,  by  Laennec, the song of  all 
DISEASES OF THE CHEST.
69
birds (omnium avium cantus), from the  number  and
intermixture of the sounds.
  Spasmodic  catarrh, or whooping-cough.—Whooping-
cough differs essentially from the varieties of ordinary
catarrh which I have just enumerated; there is a new ele-
ment in the disease, which  does not exist in the ordinary
varieties of bronchitis: that is, the spasm of the glottis.
The forced expirations of the cough succeed each other
rapidly, and are followed  by a loud sonorous inspira-
tion, produced  not in the lungs, but the larynx.   The
cough continues  until a  free expectoration of thick
white glairy mucus terminates the paroxysm.  Chil-
dren who do not  expectorate, discharge the mucus by
the involuntary contraction of the muscles of the chest
or  by vomiting.   The  catarrhal  secretion precedes
the sonorous cough, but becomes more abundant as the
disease is fully formed.  At the earlier stages, and even
when the cough has become spasmodic, there is no
redness or  thickening of  the bronchial mucous mem-
brane.   The bronchi are filled  with whitish  mucus,
which accumulates in their smaller branches.   When
the disease has been of long duration, the bronchi are
thickened, reddened, and contain a  yellow muco-puru-
lent liquid.   In some cases there is induration of iso-
lated lobules of the lungs; but in general  lobular pneu-
monia is less frequent than it is in many diseases of
children.  A more common consequence  of whooping-
cough is dilatation of the bronchial tubes, which  very
constantly occurs when the paroxysms  are frequent,
and the  expectoration has become muco-purulent.
   The percussion is sonorous, unless the lungs  have
become  indurated: it then offers the usual changes ob-
served in the lobular pneumonia.   The  respiration is, 
70              ON THE DIAGNOSIS OF

in the early stages of the disease, expansive and pure
after each paroxysm of coughing, but is mingled with
much mucous rhonchus when the liquid has accumu-
lated in the bronchi.   The rhonchus  is first heard in
the lower parts of the chest near the base of the lungs.
  The respiration is  feeble, even when the  whooping
sound is loudest, although it may be heard in the chest;
it is evidently conducted from the fauces and larynx,
and becomes less loud in proportion  as the distance
from these parts is greater.
  In  advanced  cases  of whooping-cough, when the
paroxysms have become very frequent, the mucous
rhonchus  is loud and constant; its bubbles in some
parts  of the chest  are extremely large; in  others, so
small that the rhonchus passes into the sub-crepitant.
The dry rhonchi are often mingled with the moist;, the
sibilant rhonchus is more  frequent than the sonorous.
The  sounds heard  in whooping-cough  are,  therefore,
nearly similar to  those  presented by the pituitous
catarrh.
  When the mucous rhonchus is very loud and con-
stant it generally coincides with dilatation of the bron-
chi;  if these tubes  be much  enlarged, there is some-
times a well-marked gurgling.
  General remarks on the  diagnosis  of the different
varieties of bronchitis.—It will be evident from the pre-
ceding remarks,  that, besides the cough and expectora-
tion, the essential characters  of bronchitis are the na-
tural resonance in percussion, the feebleness and rough-
ness  of the respiration, with the moist and dry rhonchi.
The  distinction between the varieties of the disease de-
pends upon the quantity of the secretion, and in some
measure on its nature.  In the spasmodic catarrh, the 
               DISEASES OF THE CHEST.            71

peculiar  whooping noise, and the strictly paroxysmal
nature of the affection in its earlier stages, distinguish
it from the other forms.   Acute bronchitis differs from
pneumonia in the perfect sonorousness of the chest and
the absence  of fine crepitus, bronchial respiration or
acute pain.  Chronic catarrh sometimes simulates phthi-
sis, but the dull sound of the clavicular  regions,  the
rude  and afterwards the cavernous respiration, added
to the functional  signs, will scarcely leave roorn for
doubt.*
   Secondary bronchitis.—There are few diseases attend-
ed with fever in which there is not more or less catarrh
during some period of their course.   The intensity of
the secondary  bronchitis is not, however, equally great
in all febrile affections: it is  well marke'd in measles
and  typhus fever, but  comparatively slight in small-
pox and  scarlatina.  The seondary bronchitis does not
differ in its physical signs from the primary.  The
 bronchitis of children, whether primary or secondary,
presents  more abundant liquid rhonchi  than  that of
adults, from the very copious secretion of mucus, which
 is not expectorated, but accumulates in the bronchial
 tubes.  It is almost invariably present in all diseases of
 very  young subjects, and  seem's  to  constitute one of
 their necessary elements.   Catarrh  in itself is rarely
 fatal  in  children, but if it last  long  and cause much
 fever, lobular  pneumonia is very often developed and
 quickly proves fatal.
* See chapter on Pulmonary Consumption. 
72
ON THE DIAGNOSIS OF
             DILATATION OF THE BRONCHI.
   The dilatation of the bronchi may be  confined to a
small portion of one of the tubes: or it may extend to
the whole length of one or more bronchi: or, lastly, a
succession of dilatations may exist in a bronchus which
is of the usual caliber in the intervals between them.
Dilatation is one of the consequences of long continued
inflammation of the bronchial tubes; their membrane is
injected, thickened, and secretes an abundant mucous or
muco-purulent liquid; it is rare to find it thinner than
usual.   The bronchi of any part of the lungs may be di-
lated in chronic catarrh; this lesion is most frequent in
those of the upper lobe—but  in whooping-cough it is
more common in the lower lobe.  When the dilatations
are considerable,  especially if they extend  to several
tubes, the intervening pulmonary tissue  is indurated,
of a grayish-colour, not very unlike that of  the tuber-
culous infiltration.
   The dyspnoea in dilatation  of the bronchi is rarely
considerable, unless it be combined with emphysema.
The cough and the expectoration do not differ from
those of the chronic mucous catarrh.  The fever and
emaciation are generally slight, as are the other func-
tional alterations.  The  patients are  commonly  ad-
vanced in life.
   Diagnosis.—There is  but one affection with  which
dilatation of the bronchial tubes  can  be readily con-
founded—that is, pulmonary consumption.  The physi-
cal signs are  nearly identical  in the two  diseases, but
the more advanced age, and the few  general symptoms 
DISEASES OF THE CHEST.
73
of patients affected with dilatation, will generally dis-
tinguish them from consumptives.*
  The physical signs, indicating dilatation of the bron-
chi, are bronchial respiration, passing into the cavern-
ous, if the bronchus be very large, and dull sound on
percussion, from the  condensation of the tissue of  the
lungs; as the bronchus is generally filled with liquid,
there is either gurgling or  loud mucous rhonchus.
When the liquid has been expectorated, bronchophony
or pectoriloquy are heard, and are  sometimes as dis-
tinct-as in pulmonary phthisis.
  The two diseases just mentioned  are the most  fre-
quent causes of bronchial dilatation, but it is also  fre-
quent in pulmonary phthisis, when  the bronchi near
the cavities are very constantly dilated, and sometimes
contain tuberculous matter.   When the tubercles are
evacuated, the surface of the cavity is so  continuous
with the bronchial tubes, that it  would often be diffi-
cult to  decide upon the origin of the  cavity,  if there
we(re not tubercles scattered through the lungs.
   Obliteration of the bronchial tubes.—There are  no
signs, either  functional or physical, by which oblitera-
tion of the bronchial tubes  can  be recognized.   The
lesion is merely mentioned as an anatomical fact.

                     * See Phthisis.
K 
74              ON THE DIAGNOSIS OF
                 CHAPTER VIII.


            EMPHYSEMA OF  THE LUNGS.

  There are two varieties of emphysema.  One is the
vesicular,  consisting in dilatation of the  air vesicles;
the other is the interlobular emphysema,  so called be-
cause the air is effused in the cellular tissue between
the lobules of the lung.
   Vesicular emphysema.  Anatomical characters.—The
lung does not collapse when removed from the chest;
the dilated vesicles are distinctly visible, and vary in
size from that of a large grain of sand to a  grain of mil-
let : in rare cases  they may be much larger.   The dila-
ted vesicles vary from the size of a large grain  of sand
to that of an  egg; in ordinary cases, they are as large
as grains of millet.   The dilatation is not confined to
a particular  portion  of the  lungs, but  is  generally
most evident along their anterior margin, where the
vesicles are largest in the normal state.   The lung is
paler than  natural, and is light and spongy to the feel;
it yields a crepitating sound, if pressed.   These cha-
racters clearly show there is more air and less solid or
liquid in the lung than usual.
  Physical signs.—The  conformation of  the chest is
altered; the distention of the lung, which is increased by
the efforts  made by the patient in the act of respiration, 
DISEASES OF THE CHEST.
75
gives rise to permanent enlargement of the thorax.  The
dilatation is of two kinds—one is the rounded form given
to the thorax of emphysematous patients by the strong
efforts of respiration.  This general dilatation is not
confined to a portion of the chest near the  enlarged
vesicles, and  is, therefore, probably owing to the strong
efforts of inspiration, and to the imperfect expiration
characterizing the disease.   The second kind of dilata-
tion is local, and  consists in a moderate prominence of
the intercostal  spaces  at the  part nearest the dilated
vesicles, that are generally at the anterior margin of
the lungs  on each side  of the sternum.  The promi-
nence is gradual, and may be easily distinguished, by its
rounded or oval form, from those caused by effusions
of liquid into the pericardium.
   Percussion is more sonorous than natural over all the
dilated portions of the lung.  The increase of sound is
quite perceptible in cases where  the dilatation of the
vesicles is moderate; it is very great when the emphy-
sema is sufficient to cause a local prominence of the
chest.   The  percussion  is, of course,  most  sonorous
where the prominence is greatest.   The respiration is
invaribly feeble in cases of emphysema; the feebleness
extends over all affected parts of  the lungs, especially
where the chest is most  prominent.  Both the sounds
of the normal  respiration  are weak, but the alteration
is most perceptible in the vesicular murmur, because the
dilatation of the vesicles is most frequent in those parts
of the chest where no blowing sound is heard.  In ex-
treme cases, the respiration is completely lost;  no sound
can be  distinguished, though the thorax expands forci-
bly.  The dry sibilant rhonchus is frequently, but not
constantly, observed; it is produced beneath the dilated 
76              ON THE DIAGNOSIS OF

part of the thorax.   The sub-crepitant  depends upon
accidental complications of emphysema with catarrh,
and is limited to the inferior portion  of the chest.  The
dry crepitant rhonchus is very rare, and, when present,
is probably owing  to  interlobular emphysema.  The
resonance of the voice is diminished, and the pulsations
of the heart are heard less strongly than usual in the
affected lung.   The vibration of the voice, felt by ap-
plying the hand to the chest while the patient speaks,
is rather increased than lessened.
  Functional signs.—The dyspnoea is always consider-
able in emphysema.  In cases of moderate severity, the
patient is conscious that his breath is a little short when
he  ascends a  hill rapidly, or makes any violent exer-
tion;  in  extreme cases he  becomes breathless  upon
ascending a  few steps of  a staircase.  Besides the
slight, but  constant oppression upon taking exercise,
emphysematous patients are subject to violent parox-
ysms of dyspnoea, which frequently  occur without any
assignable cause, and  oblige the patient to sit erect or
even lean forwards: he is not able to  lie in any possi-
tion.  The muscles of respiration are all thrown into
violent action; the face of the patient is livid and swol-
len ; great anxiety and constriction are felt at the prae-
cordia, which continue until the paroxysm is relieved.
  The cough is dry and wheezing in emphysema, but
becomes  more loose towards the  end of a paroxysm,
when there is  a rather  copious expectoration of trans-
parent frothy liquid.  No other sputa are observed in
emphysema, unless  the disease should become compli-
cated with other lesions of the lungs.
  There are  no signs of disturbance of the general
functions in pure emphysema; nor does it  seem ma- 
DISEASES OF THE CHEST.
77
terially to shorten life, although it may cause intense
suffering. No age is totally exempted from emphysema,
but the disease is much more frequent  in persons past
the middle period of life than  in the young;  in chil-
dren it is very rare.
   Varieties  and complications.—The interlobular em-
physema consists in the extravasation of air  into the
cellular  tissue, beneath  the pleura and  between the
lobules.  It often complicates the ordinary variety, and
frequently occurs in other diseases of the lungs which
have been attended with much dyspnoea.  If a large
portion of the lung has become impervious to the air,
the vesicles in the healthy part are distended beyond
their natural limits, and constitute an  acute variety of
the disease, which is especially frequent in the lobular
pneumonia  of children.  Chronic bronchitis is often
complicated  with emphysema; in a  certain number of
cases, it seems to be the exciting cause of the latter
disease; in others, there is no evidence  of catarrh before
the emphysema  began.   Tuberculous consumption is
not very often connected with this lesion: the two dis-
eases seem, in some degree, to counteract  each other,
 and patients afflicted with the one are rarely attacked
 by the other.  They do occasionally occur  in the same
 individual, and  present symptoms depending on each
 disease.  If an emphysematous patient is taken with
 pneumonia, his dyspnoea becomes extreme, and the dis-
 ease is apt to terminate fatally.  Diseases of the heart
 are very commonly found at  the same time with em-
 physema, and necessarily increase the dyspnoea.
   Diagnosis.—The  chief signs upon  which  the diag-
 nosis  of emphysema  is based, are  the  dyspnoea, the
 altered conformation of the chest, the  very clear sound 
78
ON THE DIAGNOSIS OF
on  percussion, and  the feeble respiration.   None  of
the signs is found in simple chronic catarrh, except
moderate dyspnoea, and sometimes feeble respiration;
when the others appear, we may infer that emphysema
is taking place.  There can be no difficulty in distin-
guishing pneumonia or pleurisy;  but phthisis may be
confounded with emphysema, unless the chest be ex-
amined with care, when the signs of percussion and
auscultation will show the difference between the dis-
eases.   When  they  are  found in the  same  subject,
those of phthisis will be found at the top of the lungs;
those of emphysema, along their anterior margin; the
dyspnoea and paroxysms of cough indicate the latter,
while the nature of the expectoration  and the emacia-
tion correspond to the former disease.   Diseases of the
heart are distinguished from emphysema  by the local
signs, the oedema of the limbs and the greater func-
tional derangement; when they are found together, the
local signs of emphysema and the general symptoms of
diseases of the heart predominate. 
DISEASES OF THE CHEST.
79
CHAPTER IX.
                   ON PNEUMONIA.

  Anatomical characters.—Inflammation of the lungs
presents three distinct stages:
  1. First stage of pneumonia, or infiltration of the pul-
monary tissue with blood and  serum.  In the earliest
stage of inflammation of the lungs, as  in  that of the
other viscera, a greater quantity of liquid than usual is
contained in the organ.   If the lung  be incised, a red-
dish spumous serosity issues from it in abundance.  If
it be pressed between  the fingers, it is less soft and
yielding, but more friable than the healthy lung.  Its
colour is livid red externally:  it is of the  same tinge,
but  smooth upon its incised surface.  The bronchi,
in the inflamed  portion, are reddened, and contain a
whitish mucus.
  2. Second stage of pneumonia or hepatization—a term
given to it from the  singular resemblance  of the cut
surface of the lung to that  of the liver.  The pulmo-
nary tissue  is hard and resisting when  pressed, but
upon moderate increase of force, is broken into a red-'
dish pulp.  Its colour, externally, is reddish, and in its
interior it varies from a brick red to a dark  purple, and
presents a granulated aspect, as if it were elevated into
a multitude of small  points. The granulated appear- 
80              ON THE DIAGNOSIS OF

ance is most  distinct  when the lung  is torn.   The
liquid  exuding from it is  glutinous, whitish and red-
dish, but contains no bubbles of air.  . The bronchi are
of a deep red colour, frequently thickened, and contain
a viscid matter, which is often yellow  and puriform.
The redness of the bronchi extends to all the inflamed
part of the lung, but is most conspicuous in the smaller
tubes, which are often obstructed by the viscid  secre-
tions.   The larger bronchial tubes  are flattened, but
retain  their caliber undiminished.   These alterations
of the  lung  are owing to the deposit of lymph in the
pulmonary tissue, with which it is intimately combined.
It is not positively certain whether the lymph is origi-
nally secreted in the vesicles or in the cellular tissue
uniting them;  but it is probable  the secretion  occurs
simultaneously in  the air-cells and the surrounding
tissue.   The granulations  can  scarcely be formed by
any other part of the parenchyma, than the vesicles to
which  they are analogous in size and distribution.  On
the other hand, the phenomena of inflammation of other
parts of the body render it almost certain that the cel-
lular tissue largely participates, and that the smaller bron-
chial tubes are evidently inflamed.   When the disease
is near the surface of the lung, the pleura participates in
the inflammation.  In a large majority  of patients, the
hepatized lung gradually resumes its spongy texture,
without passing into the third stage.
  3. The third stage of pneumonia has received the
name of gray softening, purulent infiltration, and yel-
low hepatization.   The cellular tissue is infiltrated with
purulent  matter, which oozes  abundantly  from  the
lung, when  incised, especially if it be subjected to  a
slight  pressure. The  granular aspect of the lung is 
DISEASES OF THE CHEST.
81
gradually lost, as this stage begins; the lung afterwards
is  softened, and does not give a smooth surface, but
breaks away before the knife  into a pulp.  If the dis-
ease be still more  advanced, the cellular tissue is con-
verted into a  yellow purulent  liquid, and  may be
washed away by a gentle stream of water, leaving be-
hind it the vascular ramifications and bronchial tubes.
No  abscess follows, except in rare cases; the pus is
merely diffused throughout the cellular  tissue.  When
an abscess forms, the vessels may often  be distinguish-
ed in  the  midst of the  pus, which is  contained  in a
cavity lined by a  false membrane, as in other parts of
the body.  The third stage is sometimes called gray
softening, at others, gray hepatization, from the differ-
ent shades of colour; there is, however, no real differ-
ence in these cases, except in the more or less perfect
diffusion of the pus throughout the whole pulmonary
tissue.  In some subjects, the  purulent deposit occurs
a few days after the beginning of the disease;  in others,
after some  weeks duration.  The  bronchial  tubes, in
the third stage of pneumonia, are filled with a yellow
purulent or muco-purulent liquid, which often closely
resembles well formed pus.  The redness and thicken-
ing  of the mucous membrane do not diminish, and the
smaller bronchial tubes are completely  obstructed.
   Physical signs of pneumonia.—These vary according
to the different stages of the disease.   Percussion, in
the  early stages, is but little  altered, because the  lung
still contains air, although  it  is infiltrated with an un-
usual quantity of liquid, and, consequently,  the sound
on percussion  is a little  less  clear than if the vesicles
 were fully distended with air.  But  if the pneumonia
 is deep-seated, and not considerable, the diminution in
        L 
82
ON THE DIAGNOSIS OF
the resonance is not perceptible.  In the second stage,
or that  of hepatization, the percussion becomes per-
fectly dull, because no air is contained in the indurated
portion  of the  lung, and there can,  therefore, be  no
resonance; there is the greatest flatness where the walls
of the chest are thin,  and the hepatization complete,
that is,  at the lower part of the thorax, between the
angle of the scapula and the spine.  Although the re-
sonance  is not completely obscured  until  the pneu-
monia has reached the surface, and is of considerable
extent, there is a dull  sound, if there be an indurated
nucleus, of the  size of a walnut, though the  greater
part of  the  affected  lobe is still  permeable to the air.
The flatness limits accurately the extent of the hepatiza-
tion.   When  the disease  has advanced  to  the  third
stage, the flat sound is not diminished, because no air
is admitted  into the lung.   If it does not pass to this
stage, the lung gradually becomes permeable to the air,
and the  sound, from  flat, becomes dull, and finally
clear.  A slight degree of obscurity remains in the side
affected, for some weeks, and occasionally there is a
little permanent dulness.  The last mentioned pheno-
menon is probably due to  the formation of false mem-
branes  between the ribs and the lung.
   Of the respiration.—The characters of the respira-
tion, like those of  percussion, vary in  the  different
stages.   In the earliest stage of pneumonia, the respira-
 tion offers a crepitant rhonchus, and an obscure bron-
 chial or rude respiration.   These signs are either found
 at the same time, or one precedes the other.   In my own
 observations,  I have  found the rude respiration per-
 ceptible before the crepitus was heard.  In two cases
 of pneumonia, admitted into the Pennsylvania Hospital, 
DISEASES OF THE CHEST.
^3
last winter, at a very early period of the disease, rude
respiration was heard at least twenty-four hours before
the crepitus.  In other cases, the crepitus seems the
earliest alteration of the respiration.   This diversity
in the symptoms probably depends upon the seat  of
the-disease; if it commence at the root of the lungs,
near, the large bronchi, and at a little distance from the
surface, there will be rude respiration, even if the tissue
of the lungs be  very little condensed, while the crepi-
tant rhonchus, if it exist, is too distant to be heard.  In
the majority of cases, the crepitant rhonchus is found
at the same  time with rude or  bronchial respiration,
and as its characters are much  more easily defined than
those of the bronchial  respiration, it has almost exclu-
sively attracted the attention of physicians.
   In the  second  stage  of pneumonia, the crepitus
ceases, or is heard only when the  patient  respires
strongly, especially after  the effort of coughing.  The
crepitus may, in most cases, be reproduced by an effort
of coughing, either in the spot where the bronchial res-
piration is  strongest, or immediately around it, in the
part of the lung least inflamed.   The bronchial respi-
ration reaches its highest  degree of intensity in the
 second stage of pneumonia, when the lung is complete-
 ly indurated.   It  is  not every where equally  loud,
 although the hepatization may be complete throughout
 the lung.   The larger tubes always yield the most per-
 fect bronchial respiration; it is, therefore, loudest at the
 root of the lungs, where the large bronchi pass.  The
 hepatization usually begins near  the upper posterior
 part of  the lower lobe  of the  lung, and surrounds the
 larger tubes, before the rest of  the lungs are affected.
 The earliest and the most perfect bronchial respiration 
84
ON THE DIAGNOSIS OF
is, therefore, usually heard  between the spine and the
middle of the scapulae.   At the base of the lungs, where
the vesicles are much developed, and the bronchi are
small, bronchial respiration is less loud, and disappears
more quickly from the obliteration of the tubes, by
thickening of the mucous  membrane, and secretion of
viscid matter.   The bronchial respiration is more dis-
tinct in pneumonia than in  any other disease;  it is
generally  tubal at the root of the lungs, where  both
inspiration and expiration are so loud and blowing, that
pneumonia furnishes the type of this variety of the res-
piration.   Bronchial respiration is the most important
physical sign  of pneumonia; it  exists in every case in
which the disease is formed long enough before death,
to be recognized by auscultation.   M. Louis observed
it in all  the  cases  which  were  examined  by him, at
La Pitie; there was  not one, of  sixty to  eighty
cases of pneumonia which  I have witnessed within the  ?
last three years, which did  not present bronchial respi-
ration.  Laennec was disposed to undervalue bronchial
respiration in the  diagnosis of pneumonia, and to ex-
aggerate the  importance  of the crepitant rhonchus,
which had attracted his attention at an earlier period.
   Bronchophony  and  bronchial   resonance  of  the
cough necessarily  accompany  bronchial  respiration.
Bronchophony is most intense  where the respiration
is tubal, and  is, therefore,  loudest  at the  root of the
lungs.  It exists in a greater or less degree, wherever
bronchial respiration is produced;  and, like it, is  more
distinct in pneumonia than in any  other disease.   The
bronchophony of pneumonia sometimes has a peculiar
vibrating tone, from the complication of pleuritic  ef-
fusion. 
DISEASES OF THE CHEST.
85
  The third stage of pneumonia, or that of purulent
infiltration, offers the same flatness, on percussion, as
the second stage.  The tissue of the lung is infiltrated
with pus, instead of lymph, but remains equally im-
permeable to the air.   The vesicular murmur does not
return, but the bronchial respiration ceases, and is re-
placed by a loose sub-crepitous, or a mucous rhonchus.
The intensity of the rhonchus  varies according to the
quantity of liquid effused into the  lungs.  The bron-
chophony and bronchial respiration  do  not  entirely
disappear at the root of the lungs, when no traces of
them exist elsewhere.   The cough produces a  loose
mucous rhonchus, instead of the trains of dry crepitus.
   When an abscess is formed  in the  lung, which oc-
curs in some rare instances, a loose mucous gurgling and
cavernous respiration replace the bronchophony.   The
extent of the  gurgling corresponds to that of the ab-
 scess, but probably extends something  beyond it, and
 is  partly owing  to the liquid secretion in the larger
 bronchial tubes.   Abscess  in  the  lungs is  rare, and
 much caution must be used in not confounding  bron-
 chial respiration and  purulent infiltration of the lung,
 with signs of an abscess.   The vesicular respiration
 returns, in a great degree, after an abscess has  been
 cured; but it always remains feeble and less expansive
 than natural.
    As a large majority of cases of pneumonia go no
 farther  than the  second stage, they do not  offer the
 physical signs just detailed.   As  soon as the disease
 begins to yield, and the hepatized lung becomes per-
 meable to the  air, a loose  crepitant, or sub-crepitant
 rhonchus is  developed.  The  return of the  crepitant
 rhonchus is  of favourable omen, and indicates the ap- 
86
ON THE DIAGNOSIS OF
proach  of convalescence;  whence it is sometimes
called the crepitant rhonchus of recovery.  The bron-
chial respiration lasts longest at the root of the lung, but
becomes less acute, and gradually disappears,  as  the
vesicular murmur is heard, mixed  with sub-crepitant
rhonchus.  When the rhonchus has totally ceased, the
respiration remains feeble for several days in favour-
able cases, and for a longer period,  in those that have
been more severe.
  When the disease has gone on to the  stage of suppu-
ration, the crepitant rhonchus is not reproduced;  the
mucous rale disappears, and is gradually succeeded by a
feeble vesicular sound.  In a case  which I witnessed
last winter, in the short space of two days a distinct
vesicular murmur had  replaced the mucous rhonchus,
which had been heard  in the whole of one lobe.
  The expectoration, like the signs of  the respiration,
varies in the different stages of pneumonia.
  In the first  stage, the expectoration  consists of the
natural  mucus of the bronchial tubes, and  is  either
transparent or whitish.  As the disease advances, the
sputa become more tenacious, more transparent, and
flow less easily from the  cup; they are small in quan-
tity—generally from one  to  four fluid ounces.   The
peculiar viscidity of the sputa, their small quantity,
and the tenacity with  which  they adhere to the mu-
cous membrane, and when expectorated to the cup, are
characteristic of pneumonia.
  In the second stage, the sputa are semi-transparent,
and become still more viscid; at the same time, they
acquire a  peculiar rusty  colour.   This tint is  some-
times precisely similar to that of the rust of iron;  but
it may vary from orange to bright red.   The sputa are 
DISEASES OF THE CHEST.
87
not coloured in streaks or spots, but throughout their
whole mass;  the colour arises from an intimate combi-
nation of blood with the tenacious mucus.  When the
expectoration has assumed  the tint  described, it is ab-
solutely characteristic of pneumonia, and occurs in no
other disease.   The quantity of these sputa  is  very
small—not exceeding a  few ounces; they contain no
air, and run together at the bottom of the cup.   When
the disease passes from the second  stage towards reso-
lution, the sputa becomes more abundant, less viscous,
are yellowish, and  adhere less closely to the bronchial
membrane.  The patient, therefore, expectorates more
easily.
   The  sputa, in the third stage, assume various cha-
racters.   Most  commonly  they are yellowish,  either
 muco-puriform, or  purulent.  I  have seen them partly
 composed of a  muco-purulent matter,  and partly  of
 creamy homogeneous pus, which sank below the level
 of the rest of the liquid.   A rarer variety is the brown-
 ish liquid sputa, like the juice of prunes;  this forms a
 homogeneous, and rather thin liquid.  The yellowish
 sputa are of more favourable omen than the brown.
 When the disease, at last, terminates favourably, the
 sputa do not resume the viscid rusty aspect which they
 presented in the second stage, but  become less -yellow,
 and finally  consist simply of  whitish  mucus.  The
 sputa, in pneumonia,  are so well marked, that we may
 often recognize the disease, simply from  their inspec-
 tion.   It is, therefore, of high importance to become
 perfectly familiar  with their characters.
    The pain is slight  in pure pneumonia.  When the
 disease is confined to the central parts of the  lung, the
  patient rarely complains of acute suffering.   He expe- 
88
ON THE DIAGNOSIS OF
riences general uneasiness, and is oppressed in breath-
ing, without being able to designate the seat of his dis-
ease.   As soon as the pleura becomes inflamed, the pain
becomes acute, and is precisely similar to that of ordi-
nary pleurisy,  known  by the familiar but expressive
term, stitch in  the side.   As the pleura generally par-
ticipates in the inflammation from  the  beginning of
pneumonia, the pain in the side is usually one of the
first symptoms.  It disappears before the  expectoration
and the physical signs indicate complete resolution of
the disease.
   The frequency of the respiration  is  very great in
pneumonia; it  is scarcely ever less than twenty-four in
the minute, and varies from  that number to forty; or,
in extreme cases,  fifty or sixty.  It  is high, the ribs
nearly motionless, and chiefly performed by the dia-
phragm.   The  cough in pneumonia is short, dry and
suppressed, in the  early stages; loose and less painful
when expectoration becomes free, and the hepatization
passes to the third stage, or resolution begins.   The
fever and prostration of strength are greater than in
any other acute disease of the lungs.
   The decubitus is almost always dorsal.  When there
is much  oppression, it is  elevated; the patient cannot
lie upon  the side affected.

          OF THE VARIETIES OF PNEUMONIA.
   Age.—A marked change in the characters of inflam-
mation of the lungs, takes place at  the  period of the
second dentition.  Before the age of six years, the form
of disease, known  as idiopathic  pneumonia of adults,
does not  occur.  After that age, it becomes frequent,
and presents a series of symptoms, which is nearly in- 
DISEASES OF THE CHEST.
89
variable in patients of both sexes and all ages, except-
ing those far advanced in life*  The disease which
occurs in young children, is that variety called  lobu-
lar pneumonia, from the  manner  in which it ori-
ginates in isolated  lobules of the lung, which become
indurated, while the  intervening pulmonary tissue re-
mains permeable to the air.  The hardened lobules are
of a dark purple colour, smooth instead of being granu-
lated, and very firm.  The induration advances from
each of the points of origin, until a large portion of the
lungs is impervious to the air.  Death frequently does
not occur until three-fourths or two-thirds of the pul-
monary  parenchyma is hardened.   The  disease  is
almost always double, and  begins at the lower lobes of
both lungs, extending from them to the upper lobes,
 along the posterior margin of the thorax.  It is rarely
 complicated with pleurisy.   This variety almost always
 succeeds to chronic catarrhs, or  other diseases, as the
 exanthemata, &c.;  it,  therefore, has  not a definite
 duration.  There  is no expression of pain, no expecto-
 ration, and sometimes no cough; but the disease is in
 a great degree latent, and, notwithstanding its extreme
 frequency, is often  mistaken.   There  is not always a
 rhonchus, but where the disease succeeds to catarrh, a
 mucous, or sub-crepitant r*le is heard.  Bronchial res-
 piration is  never so distinct  in  this disease  as in
 idiopathic pneumonia, and scarcely ever becomes tubal;
 it is best heard at the root of the lungs.   At the base,
  * For a more particular account of this form of disease, the reader is re-
ferred to a paper published in the American Journal of Medical Sciences,
in the year 1834.
       M 
90              ON THE DIAGNOSIS OF

there is rarely heard any sound, either of vesicular ex-
pansion, rhonchus,  or bronchial respiration.   Bron-
chophony, in young children, scarcely  exists;  some-
thing like it is heard in the vibration produced by the
cry.  Percussion yields obscure results, when the lobu-
lar  induration is very limited; but by retaining a pre-
cise recollection of the  natural resonance of the  chest
of healthy children,  a slight degree of obscurity may
be recognized.   We have  not the means of verifying
the degree  of sound by the  comparison  of  the two
sides of the  chest; for the disease begins in both sides,
and advances with nearly equal rapidity.   If the chest,
along its posterior margin, sounds less  than it does in
the chests of healthy children, the sound is really dull,
although there is no difference between the two sides.
The progress of the  disease, from a number of isolated
points in both lungs, explains the early destruction of
all  respiratory sound.  The  hardened  lobules  press
upon the bronchi, and prevent the air from passing into
the tissue, which remains permeable.   The absence of
crepitus  is explained by the peculiar  secretions of the
bronchi; they  are never viscous and transparent, as
in ordinary  pneumonia, but consist of glairy, whitish
liquid.  This variety  of pulmonary  induration  does
not pass to purulent  secretion.
  Lobular pneumonia is not strictly confined to young
children; it occurs  as  a  secondary  lesion, in  many
febrile diseases; but  it passes more frequently to the
stage of suppuration, in older subjects.  The difficul-
ties in the diagnosis are similar to those just described;
but it is more easy  to  examine adults, and, therefore,
discover  slight  alterations  in the respiratory sounds. 
DISEASES OF THE CHEST.
91
 The sub-crepitant  rhonchus is, also, more  frequent in
 lobular pneumonia of  adults, than in that of young
 children.
   Pneumonia, in very old patients, offers some anoma-
 lies.   It is rarely accompanied with great derangement
 of the functions, and is very often latent.  Little cough,
 little or no expectoration, oppression, loss  of strength,
 and slight fever, are usually the only symptoms.  The
 physical signs are well  characterized, and are precisely
 similar to those already described, as common to all the
 usual forms of pneumonia.  An early physical explora-
 tion is the more necessary in these  cases, on account of
 the great  mortality of the disease, which destroys a
 large proportion of the aged.
   In all classes of  patients, the right lung is more fre-
 quently inflamed than the left, and the disease  com-
 monly begins at the upper part of the lower lobes.  The
' upper lobes  are more frequently affected  in the aged
 than in younger persons.
   Pneumonia is frequently consequent upon other dis-
 eases of the lungs,  especially phthisis and emphysema.
 Consumptive patients recover nearly as well as healthy
 subjects from attacks of  acute  inflammation of the
 lungs, unless the disease is far advanced, when it  often
 proves fatal.  The signs, such as unusually viscid
 sputa, pain in the side, crepitus and bronchial respiration
 in the lower  lobes,  are then added to the general  signs
 of phthisis, and the physical signs, which were already
 present at  the upper part of the lungs.  Emphysema
 causes great distress when  the lungs  are inflamed,
 from the extreme difficulty of the respiration, and not
 unfrequently aged  asthmatics perish from this compli- 
92
ON THE DIAGNOSIS OF
 cation.   The  signs of pneumonia, in such cases, are
 perfectly well marked.
   In almost every case of pneumonia, there is more or
 less inflammation of the pleura;  the  only exceptions
 are those rare cases in which the inflammation is limit-
 ed to the central parts  of the lung,  and the  lobular
 pneumonia of children.   As the  inflammation of the
 lungs seems to precede that of the pleura, and is in all
 cases a vastly more important lesion, it is now usual
 to consider the pleurisy as one of the secondary lesions
 of pneumonia, and not  to apply  to it a distinct term.
 The word pleuropneumonia is now little used.  When
 the disease of the pleura is very intense, the effusion of
 liquid may be nearly as  great as in ordinary pleurisy.*
 As a general rule, the inflammation of the lungs  and
 pleura are in inverse proportion.
   Diagnosis.—The discovery of auscultation, conjoined
 with the functional signs, which were already known,
have rendered the diagnosis  of pneumonia more sure
than that of any other  internal disease.  It  is, there-
fore, usually selected as the type of comparison amongst
acute affections.  If the case be  as  well  marked as
cases of pneumonia usually are, the succession of the
physical signs, detailed in the preceding pages, and the
characteristic sputa, with the pain and oppression, will
prevent the-possibility of error.   Even in cases where
the disease is of small extent, and  deeply seated, a rude
respiration near the root of the lungs,  some bubbles of
distant crepitus, and the  characteristic expectoration,
will rarely leave  room for doubt.   The lobular pneu-
* See chapter on that disease. 
DISEASES OF THE CHEST.
93
monia of young children is much less readily recog-
nized than  the pulmonary  inflammation of adults.
The signs of it have been already indicated; but when
the obscurity, on percussion, is not great, it is some-
times difficult to distinguish between this disease and
simple chronic bronchitis; especially in those cases in
which the disease  has  not been traced from its early
stages. 
94
ON THE DIAGNOSIS OF
                  CHAPTER X.


              GANGRENE OF THE LUNGS.

  The pulmonary tissue is not unfrequently affected
with gangrene.  A small portion of the lung may be
attacked; or the mortification may extend to the whole
of one lobe; or a considerable portion of the lower lobe
of each lung;  or, in rare cases, it may invade the whole
of one of these organs.
  When a portion of pulmonary tissue becomes gangre-
nous, its colour is greenish brown;  gradually deepening
to black, as the disease advances.    No line of demarca-
tion separates  the dead  from the  living part; but the
colour changes insensibly, from black to  dark red, as.
we pass from the softened sphacelated part to the firmer
tissue.   When the gangrene is circumscribed, an im-
perfect false membrane  may be  discovered.  I have
seen this membrane well developed in idiopathic  gan-
grene, but still more frequently in that variety  which
follows injuries, or surgical operations.
  The tissue of the lung becomes softened as the dis-
ease advances, and falls into a soft pulp, or liquid, with
a characteristic foetid odour.  The softened portion is
gradually discharged by expectoration, and a  cavity is
formed, corresponding to the extent  of the gangrene.
When the disease  has not  been  arrested,  the walls of 
DISEASES OF THE CHEST.
95
the cavity are formed of the softened pulmonary tissue,
with numerous shreds and filaments hanging from it.
The filaments are the blood-vessels, which resist mor-
tification longest.   It is not known what anatomical
appearances  follow  the cicatrization  of gangrenous
cavities; the analogy of the lesions render it probable
that they are similar to those consequent upon tuber-
culous excavations.—(See Note at end of Chapter.)
  The physical signs of  idiopathic gangrene are at
first limited  to a  mucous, or sub-crepitant rhonchus,
near the seat of the disease,  without alteration of the
resonance on percussion.  As the tissue of the lung is
softened, and a cavity forms, gurgling  replaces the
mucous rhonchus, and generally becomes very intense,
from the large size of the cavity, and  the quantity of
liquid constantly oozing from its walls.  No disease offers
a louder, and  more constant  gurgling,  than gangrene;
tuberculous cavities are rarely  as  large, and do not
secrete as much liquid.  When the expectoration of the
gangrenous lung occurs, cavernous respiration and pec-
toriloquy accompany the gurgling;  they vary with the
size of the cavity, and the more or less complete evacu-
ation of the sloughs.  The cavernous respiration is, in
such cases, loud, and perfectly distinct;  but the voice
wants the clear resonance given to it by the hard walls
of a tuberculous cavity.   Should the  cavity become
extremely large, the percussion  over it becomes  very
resonant;  in one case, I found it so loud as to make me
suspect that perforation of the pleura had taken place,
and, consequently,  extravasation of  air within  that
membrane.   The  gangrene had destroyed nearly the
whole of the left lower lobe, leaving a vast cavity, com-
municating freely with the bronchi.   In such cases, 
96
ON THE DIAGNOSIS OF
the resonance of the voice becomes amphoric;  the res-
piration assumes an analogous character, and is simi-
lar to that heard  in pneumothorax, and in very large
tuberculous cavities. •
   When gangrene of the lungs is cured, the gurgling
gradually becomes less intense, and is succeeded by a
mucous rhonchus, which finally ceases with the expec-
toration.  The bronchial respiration, and bronchophony,
diminish until there remains  merely a slight blowing
sound in inspiration, and expiration, with a feeble re-
spiratory murmur;  the  respiration never  regains its
original strength.*   It is probable that a cicatrix^.simi-
lar to those sometimes found  in  phthisical subjects, is
formed  after the case of gangrenous cavities; and as
the pulmonary tissue is  not reproduced, the  respira-
tory sounds  heard  near  the diseased points are con-
ducted  from the healthy tissue.
   The  percussion, in most cases of gangrene, becomes
obscure over the  affected part.   This arises from the
condensation  of the  surrounding pulmonary  tissue,
which is infiltrated with serosity.  In some cases, the
percussion is perfectly natural, until a large cavity is
formed, when it becomes more sonorous than  usual.
This phenomenon occurred in a  case already alluded
to; it  was found, on  dissection, that the  pulmonary
parenchyma, around the  cavity, was not indurated.
   The  expectoration furnishes the pathognomic sign of

  * I examined a patient  more than  a year after his recovery from well
marked gangrene of the lungs, and detected  the alterations described. In
another patient, the lower lobes of both lungs were gangrenous, and offered
a loud gurgling, with cavernous respiration.   The man left the  hospital,
perfectly cured, at the end of two or  three months; but the vesicular re-
mained extremely foeble in the points where the gurgling had been heard. 
DISEASES OF THE CHEST.
97
gangrene.  It is always foetid, but has not always the
odour of putrefaction; not unfrequently its  smell  re-
sembles that  of moist plaster.  The breath is equally
foetid with the expectoration.   The fcetor varies at dif-
ferent periods of the day.  It  is always increased when
paroxysms of coughing come  on, and the expectoration
becomes more copious.  The sputa are most frequently
greenish and yellowish; they are at  times of a dirty
ashen colour, and vary from these shades to a dark
brown, or blackish hue.  The changes in the appear-
ance of the sputa, from a dark to a lighter colour, and
the diminution in quantity, indicate  the  approach  of
convalescence.
  The cough is frequent and harassing when the gan-
grenous cavity is formed; it  comes on  in paroxysms,
which continue until the contents of the cavity are ex-
pectorated.   After copious expectoration, the  cough
ceases almost entirely, until the cavity fills again.
  There is much fever in most cases of gangrene of the
lungs; but it may be wanting in this, as in other pulmo-
nary affections.  The disease is then latent, and can
only be recognized by the physical signs, and the pecu-
liar odour of the sputa and breath.
  The dyspnoea is not great at the beginning of the
disease;  it only becomes considerable when a large
portion  of the  pulmonary tissue  is  attacked, and is
greatest  when  secondary pleurisy has  supervened.
The feebleness of the patient is much greater than the
extent of the disease would lead us to expect; indeed,
gangrene of the lungs is most frequently developed in
patients already weakened by previous disease.
  The last important symptom is the alteration of the
colour of the skin, which is, I believe, always found in
       N 
98
ON THE DIAGNOSIS OF
cases of extensive gangrene;  at least, I have always
observed it.  The skin is of a dirty yellow, or has a
bronzed aspect; it is shrunken, and less vascular than
usual.   The discolouration extends to all  the tissues
which are found after death—pale, and often greenish,
or livid.
  The prognosis  in gangrene of the lungs is always
doubtful; the mortality is  about  one in two patients.
The proportion of deaths was once thought  to be much
greater;  but more accurate observation has shown that
it is by no means so fatal a disease as was imagined.
  The diagnosis is  based  on the following physical
signs:  mucous rhonchus, gurgling, cavernous respira-
tion; when we add to these signs, the fcetor of the
sputa,  the colour of  the skin, and the great loss  of
strength, we are sure that no other disease can be con-
founded  with gangrene.  Phthisis is a chronic disease;
its  cavities  form slowly; the expectoration is rarely
foetid.   Pneumonia is distinguished  by the bronchial
respiration,  the crepitant rhonchus, the flat sound on
percussion, and the characteristic sputa.  The only dis-
ease with which gangrene could be confounded, is bron-
chitis ; some varieties of this affection are attended with
foetid sputa, and when they are secreted in large quan-
tities,  the mucous rhonchus caused  by them  may be
mistaken for gurgling.   It is difficult to distinguish gan-
grene of the lungs  from this variety of bronchitis,
which is well described by M. Andral.  The progress
of the disease can alone remove the obscurity.
    Of the varieties of gangrene of the lungs.—No age is
 exempt  from this disease.   I have witnessed it in chil-
 dren under  the age of two years,  and in patients far
 advanced  in life.  Children  dying  with  gangrenous 
DISEASES OF THE CHEST.
99
sore mouth, not unfrequently have circumscribed gan-
grene of the lungs; it  also occurs  in them as an idio-
pathic disease.  The lesion occurs most frequently in
the winter, but is  much more frequent in some years
than in others; sometimes there seems to be  an epi-
demic of gangrene of the lungs.  In a single winter, I
saw six cases of the disease at the Philadelphia Alms-
house, and the same year the disease  was extremely
common at Paris.
   Like other diseases of the parenchyma of the lungs,
gangrene seldom occurs without consecutive pleurisy.
This  complication materially increases the  pain and
dyspnoea, but diminishes  the chance of a fatal termi-
nation, which might otherwise happen from perforation
of the  pleura.  Tuberculous consumption  is rarely
complicated  with  gangrene;  when the latter disease
comes on, sloughing of the tuberculous cavities are pro-
duced, and the peculiar odour of gangrene is developed.
   Pneumonia is rarely followed by gangrene.  Authors
speak of gangrene as a termination of pneumonia, and
some have not considered gangrene of the lungs as a
distinct affection, but merely one of the varieties of the
pneumonia.   Mortification, undoubtedly, may follow
inflammation of the lungs, as well as of any other organ;
but if we carefully trace the history of cases of gan-
 grene,  we shall find that  few, if any, offer evidence of
 previous inflammation.  M. Louis considers the disease
 as entirely unconnected  with pneumonia,  and  says,
 he has found no  evidence of inflammation before the
 sputa and breath  became foetid.   The last three cases
 of gangrene which I have observed, were all  seen at
 an early period of the disease;  two died, and one re-
 covered.  In the dissections of those  who died, there 
100
ON THE DIAGNOSIS OF
was no hardening of the lung around the gangrenous
cavity; there was not, therefore, even secondary inflam-
mation.   Not one of the three cases offered crepitant
rhonchus, or bronchial respiration, or  viscid sputa, be-
fore the breath and expectoration became foetid.

         METASTATIC ABSCESS  OFJTHE  LUNGS.
  There  is a peculiar  lesion of the lungs, which fol-
lows  surgical operations,  suppurating wounds, and
phlebitis.   It was termed metastatic abscess, by Dance,
and bears some analogy both  to pneumonia and gan-
grene of the lungs.   The lesion  passes through the
following anatomical stages:
  In its earliest stage, a lobule of the lungs is of a dark
livid red, or purple colour; harder than the surround-
ing tissue, but easily crushed by moderate pressure.
If the disease be a little more  advanced, the hardened
part is dotted with purulent points, which are scattered
equally throughout it, and  a  yellow  puriform liquid
may be forced from it, by moderate pressure.  The pus
in the centre of the smaller abscesses resembles very
nearly yellow tubercles, and, like them, softens from the
centre towards the circumference.   At a still more ad-
vanced stage, the lobule is completely infiltrated with
pus, or a liquid of a strong gangrenous odour.   When
the lesion has reached  its last stage,  it is  surrounded
by a distinct false membrane.
   As the lesion always occurs near the surface of the
lungs, the pleura is very soon involved in the inflam-
mation, and the usual effusion of liquid is secreted into
its cavity.   The false membranes are  thickest near the
abscesses, which are most frequent near the base of the
lungs, though not confined to  any  one part of them. 
DISEASES OF THE CHEST.
101
   Signs of metastatic abscess.—These are a sub-crepi-
tant rhonchus at the posterior part of the lungs;  and,
should pleurisy be present, there are flatness  on per-
cussion, and egophonic resonance of the  voice.   No
other  signs indicate  the  presence of this lesion, and
even they may be wanting, if the affected lobules are
very small.  The  chills,  the  profuse sweats, and the
expectoration of viscid reddish sputa, afford  more cer-
tain evidence than the  physical signs.   The cough is
not very frequent, nor is there ever abundant expecto-
ration; the  dyspnoea is at times intense, and almost
always considerable.
   The diagnosis of this  lesion is usually easy, and is
the more certain from the circumstances under which
the disease  occurs.   If a patient who  has undergone
an important surgical  operation, or who  has a  large
suppurating surface,  be suddenly taken with a  chill,
cough, and the other signs described, there is no room
for doubting the development of a metastatic abscess.

   Note.—While this sheet was passing  through the press, I had occasion to
examine a cicatrized cavity, following gangrene of the lungs.  The patient
died of delirium tremens, complicated with fracture of  the  leg.  Nine years
before, he had a disease of the lungs, which lasted four months, with so much
foetor of the breatli, and expectoration, that no one could remain in the  room
with him.  The cavity was in the lower lobe of the left lung, about the
size of an almond, and lined with a delicate mucous membrane; the sur-
 rounding tissue was indurated. 
102
ON THE DIAGNOSIS OF
                 CHAPTER XI.


        PHTHISIS, OR PULMONARY TUBERCLES.

  The diagnosis  of pulmonary consumption is  more
complicated than that of any other disease of the lungs.
In its earliest stages, a most careful comparison of the
symptoms and  physical signs is  necessary to give a
probable degree  of accuracy;  but in the  advanced
stages of phthisis, the disease is recognized at a glance,
even by those who are not of the medical profession.
  Three stages are observed  in this disease:  they are
not altogether  arbitrary, but  are  based upon changes
occurring in the  tubercular matter, which is the ana-
tomical lesion constituting consumption.
  First stage of consumption.—The lungs of patients
dying in the earliest stages of consumption, offer tuber-
cles, under the  following forms:—1. Rounded miliary
granulations of a semi-transparent gray colour; the
largest not exceeding the size of  a millet seed, and so
hard as to resist considerable pressure.  These granu-
lations are usually, but not always, found in the  early
stages of consumption; when they are very numerous
in the  lungs, they are often found in other organs of
the body, especially the brain and spleen.  2. Tuber-
cles, properly so called, which are rounded bodies, of a
yellow, opaque colour, homogeneous, hard, and varying 
DISEASES OF THE CHEST.
103
in size from a grain of millet to that of a large pea.
3. The pulmonary tissue is in some subjects infiltrated
with tubercular matter, of a transparent, or yellowish
aspect, which fills its cells as water does a sponge, and
destroys the porous texture of the lungs, but leaves its
tissue entire.
   Second stage.—In this  period, the gray granulations
disappear, or are less numerous.  The  tubercles in-
crease in size, and as they become larger, press upon
each other so as to destroy their regular rounded form;
they thus gradually coalesce into masses of considerai-
ble size.  The infiltration of tuberculous matter chan-
ges less in its appearance  than the other forms of this
lesion; it rarely becomes perfectly yellow in  adults.
The pulmonary  tissue is necessarily more or less com-
pressed by the  development  of  the  tubercles;  it is
atrophied, and is gradually replaced by the morbid pro-
duct.   The vessels passing amongst the tubercles are
not obliterated at an early stage; they resist longer than
the other parts, and when completely surrounded, are
slowly obliterated, but ulceration of them is very rare.
The  bronchi can be traced  direotly  into the  morbid
substance; their  caliber  is then contracted, and their
 tissue is confounded with the tubercles.  The lung
 around the diseased part, at this stage, is rarely sound;
 it is hardened and shining, partly from the infiltrated
 gray  substance, and partly from induration,  which
 sometimes seems to depend upon chronic  inflamma-
 tion.   The bronchia are often reddened, and thickened
 near the masses of tubercles, but this is not  invariably
 the case.
   Third stage, or softening and evacuation of the. tuber- 
104
ON THE DIAGNOSIS OF
 culous matter.  When the tubercles have attained a
 moderate size, which rarely exceeds that of a large pea,
 they begin to soften at their centre.  The  progress of
 the softening continues from the centre to the circum-
 ference,  until it reaches a bronchial tube, terminating
 in the mass.   Ulceration takes place into the tube, and
 the tuberculous substance, as it becomes softer, is dis-
 charged  through it.   A cavity is necessarily produced
 by this  evacuation;  it is prevented from encroaching
 upon the adjacent tissue by a firm cartilaginous mem-
 brane, which is sometimes lined upon its internal side
 by a second membrane of less  firm  consistence  than
 the first, and secreted at a later period.   As each mass
 or cluster of tubercles passes into the softened state, after
 attaining a certain size, it is obvious that these cavities,
 by the successive  increase and  softening of surround-
 ing portions, will  tend to run into each  other; but as
 they cannot touch at all points on account of their sphe-
 rical shape, the communication  from  one to the other
 must take place through a small opening.  This opening
 is gradually  enlarged by ulceration, or  the softening
 of tubercles  forming the walls of the  cavities,  until
 they communicate freely with  each  other.  A small
portion of the pulmonary tissue, immediately surround-
ing the  vessels, usually resists  the ulceration longer
than the rest,  and forms a band or bridge, running from
one side  of the cavity to the other.  The disposition of
the tuberculous matter to soften and form cavities, is
the characteristic of the third stage, and  distinguishes
it, both by its anatomical and physical characters, from
the second.   The bronchi  communicating  with the
cavities are always red and inflamed, and consequently 
DISEASES OF THE CHEST.
105
secrete  much  mucus during  life.   The  pulmonary
tissue around them is more constantly indurated than in
the other stages.

         OF THE PHYSICAL SIGNS OF PHTHISIS.
  These necessarily vary with the  different stages of
the disease.   In the first stage, when there are but
few scattered tubercles, it  is impossible to ascertain
their existence by physical examination.   When  the
tubercles are more numerous and  larger, and the dis-
ease is fully formed, though it  should  not yet have
passed into the second stage, the physical signs become
evident.   Were the tubercles equally disseminated, as
actually occurs in some exceptional cases, the respira-
tion would be little affected by the  great dispersion of
a small  number of tubercles.  But as they are both
more numerous, and  are  developed  at an earlier stage
at the top  of the lungs, a small number will give rise
to considerable local  alteration of the respiration.   It
is, therefore, necessary to examine the summit of the
lungs with especial care, both by percussion and aus-
cultation.   Percussion must be made above, upon, and
immediately below each clavicle; in these places a very
slight deviation from the natural standard  may be de-
tected.   It should, however, be recollected,  that a very
small difference in favour of the left side does not in-
dicate induration  of  the  right lung, as the summit of
the left is  naturally a little  more sonorous.
   The alteration  of  the  respiratory sound is at first
limited  to a very  slight increase of the blowing noise
in both  inspiration and expiration; but especially the
latter, when it constitutes the rude  respiration.   It is
heard on the right side at an earlier period  than on the
       o 
106
ON THE DIAGNOSIS OF
 left, even if there be equally large accumulations of
 tubercles on both.  This anomaly is caused by the larger
 size and straighter course of the bronchial tubes passing
 into the summit of the right  lung.  The anatomical
 structure, which, in the  natural  state,  causes  a  very
 slight blowing sound on the right side, must exaggerate
 the blowing respiration produced by a moderate number
 of tubercles.  The sound in the right lung of a phthisi-
 cal patient  should not be regarded as morbid, unless
 the respiration is decidedly blowing; a slight difference,
 perceptible  by an accurate auscultator, does not neces-
 sarily indicate disease.  But if the respiration be more
 blowing, at  the summit of the left  than the right  side,
 there can be no reasonable doubt that the lung contains
 tuberculous matter.  The same peculiarity of structure
 which gives rise  to a rude respiration on the right side,
 produces a  greater resonance of the voice.   In the nor-
 mal  state the  difference is extremely  slight;  but if
 tubercles be deposited at the  summit of both  lungs,
 there will be heard a decided resonance of the voice at
 a much earlier period on the right than the left side.
  Percussion, in  the earlier stages of phthisis, is best
 performed on  the anterior part of the chest, because
 the lung is there  very near the surface.   Auscultation
 of the voice, and respiration, should be practised at the
 posterior part of the chest, especially above the spine
of the scapulae, and between this bone  and the spinal
 column, from the  summit of the lung to the fifth dorsal
vertebrae.  Tubercles are most frequently deposited at
the posterior margin of the lungs, where the bronchi
are largest;  and any alteration they may cause  in the
respiratory sounds, is, of  course, most easily detected
along the posterior part of the thorax. 
DISEASES OF THE CHEST.
107
  As the anatomical lesions characterizing  the  first
stage of phthisis pass insensibly into those of the
second, the same gradual transition is observed in the
physical signs.   When the  tubercles are collected  in
masses about the bronchial tubes, the alterations be-
come so evident, that  a very short  exploration of the
chest will render the case perfectly clear.  Percussion
near the clavicles  becomes  dull  on both sides, or  on
one only, as the tubercles may chance to be deposited.
In  ordinary cases it is dull on both sides, but more on
the one than on the other.   It is not very often per-
fectly flat, because  a small  portion of parenchyma  re-
mains permeable to the air.   The flatness is, also, well
marked at the upper  and posterior  part of the lungs,
notwithstanding the thick covering of muscle.
   The respiration, in  the  second stage, is decidedly
bronchial; the blowing sound is well developed, both
in  inspiration  and expiration;   the vesicular  sound
ceases entirely, or is barely heard.  The bronchial res-
piration is best heard at the posterior part of the lungs,
for the reasons already stated.  It does not in any place
 acquire the strong  characters of the tubal respiration of
 pneumonia, for the gradual deposit of tubercular matter
 tends to obliterate  the bronchi more perfectly than  the
 induration  of pneumonia,  and  does not  form  solid
 masses around  the largest tubes.  When  the respira-
 tion is bronchial at the summit of one lung, it is almost
 always rough  at the corresponding  part of the other,
 as tubercles are rarely confined to one of these organs.
 Some alteration of the respiration is often found towards
 the inferior parts of the lung, especially at its posterior
 portion, from deposits of tubercles, which, in this stage,
 are no longer  limited  to the summit.  In these situa- 
108
ON THE DIAGNOSIS OF
tions the respiration  may be rough, or puerile, but not
bronchial.  The  soft equable murmur of respiration
rarely continues,  even in the parts of the lung least
altered;  the  inspiration has a harsh sound, or it is
weaker on one side than on the other.  The alteration
of its rhythm and softness,  sometimes occurs in  the
earliest  stage of  phthisis,  when  it forms a valuable
sign; it is, however, much more frequent in the second
period.
  In the second stage of phthisis, different rhonchi are
often heard; they are the mucous and sub-crepitant, in
those parts where the bronchial respiration is most  dis-
tinct, and the dry rhonchi in various portions of the
lung.   The sign is  not very important,  as they  are
rarely permanent.
  The increased resonance  of the voice passes into
bronchophony when the bronchial respiration  is per-
fect.  It is never  as loud as the bronchophony of pneu-
monia, but is well characterized, and is an invaluable
sign.  It is best heard at the posterior part of the chest,
for reasons already assigned.
  A new sign of much importance is often observed
when the tubercles are in considerable number, and is
sometimes present at a very early period of the disease.
It is the  greater loudness of the sound of the heart, op-
posite to the tubercles, which serve as a better conduct-
ing medium than the spongy tissue of the lungs.  If
the tubercles are  most numerous in the right lung, the
pulsations of the heart are heard more distinctly there
than at the corresponding part of the left, and we then
infer, with great certainty, that the lungs are indurated.
Should the tubercles  be much more numerous in the
left lung, then  a careful  examination is  necessary to 
DISEASES OF THE CHEST.
109
ascertain the limits of the sound of the heart, and the
manner in which it ceases.  If the transition from the
left to the right side be very abrupt, it is probable that
there is disease of the left lung, and not of the  right;
for the sound of the heart is heard with gradually less
intensity, as the points of the chest are more and more
remote from it.  But if the left lung be much diseased,
the sound is nearly as loud  at its apex as it  is at the
praecordial region.*
   In the third stage of consumption, when the tuber-
cles are softening, the flatness, on percussion, is at least
as great as  in the second.  It may be more complete
from the hardening of the surrounding pulmonary tis-
sue, and its infiltration with tubercular matter.  When
the cavity is completely evacuated, the sound does not
become clear, unless its extent should be very great.
In such cases, a gaseous resonance is produced, but it
has  not the character of the healthy pulmonary sound;
it is more hollow, like that of an empty vessel, and if
the patient open his mouth, it often has a peculiar tone,
called bruit depot feU, or sound of a cracked pot.  The
name is very descriptive of the sound, which is most
distinct when the  cavity is  very near the ribs.  The
bronchial respiration passes into  the cavernous  as the
cavity becomes  complete,  but perfect cavernous respi-
ration is not heard until  the walls  of the cavity are
hardened, and  its communication with the bronchi is
large.   It disappears at  times, when  there is much li-
quid in the cavity, but is  reproduced after free expec-
toration.  The  cavernous respiration is most  intense
when the cavity does not exceed the  size of an egg;  in

  * This sign was pointed out to me by M. Louis, in the winter of 1831-2. 
110
ON THE DIAGNOSIS OF
very large cavities, including the whole, or nearly the
whole, of one lobe, it becomes  amphoric, and is more
feeble and confused.  In large cavities the sound is not
reflected;  in small, and moderate sized ones, the vibra-
tion of  the air  is increased by the hardness of their
walls.  It is not very common to hear cavernous  res-
piration on both sides  of the chest at the  same time,
but on the side  least diseased the respiration is rude or
bronchial.
   The voice acquires a peculiar resonance as the cav-
ernous respiration forms;  it seems to enter the ear of
the observer from the tuberculous cavity.  If the trans-
mission be clear and distinct, it constitutes perfect pec-
toriloquy;  if it be  less distinct,  the pectoriloquy is
imperfect  or doubtful.  The imperfect and  doubtful
pectoriloquy are the  varieties of bronchophony already
described: perfect pectoriloquy should  be termed cav-
ernous  bronchophony, or  cavernous resonance.*   All
these varieties  are  more  or less  analogous,  and  are
sometimes alternately heard in the same  cavity, as its
communication  with the bronchial  tubes is  more or
less free.   If the cavity be  very large, the sound is
amphoric; which is less easily  recognized than caver-
nous resonance.
   The rhonchi are abundant in the third stage of phthi-
sis.  When tubercles begin  to  soften, the earliest  evi-
dence of it is a  sub-crepitant rhonchus; it has a drier,
more crackling sound, than it has in pneumonia.   The
name commonly given to it in the French hospitals, is

  * The confusion of names applied to the varieties of pectoriloquy, arose
from the discovery of this sign by Laennec, long before he was  aware of
the existence of bronchial respiration.  His description does not, therefore,
refer to bronchophony. 
DISEASES OF THE CHEST.
Ill
crdquement, or crackling.  As the cavities become larger,
and  contain  more liquid, mucous rhonchus is heard.
It is partly owing to the softened  tubercular matter,
but still  more to the liquid contained in the bronchi
around the tubercles.   When these  bodies  have ad-
vanced to the third stage, the tubes become inflamed,
and give rise to the mucous rhonchus.  As soon as the
cavity is of moderate size, the mucous rhonchus passes
into gurgling—a sign of the greatest importance in the
diagnosis of softened tubercles.  It is  constant,  does
not disappear for long periods, and can always, or nearly
always, be reproduced by making the patient cough.
As was remarked by Andral, gurgling is the pathogno-
monic sign  of  pulmonary cavities.    The  gurgling
increases with the size of the cavity; but  after the
tubercular matter is entirely discharged, there are great
variations in  its intensity.   If the walls of the cavity
secrete much liquid, it continues; but if there be  little
secretion, the cavernous  respiration  is  alone heard.
Besides  the  gurgling  indicative of the large cavity,
mucous rhonchus and gurgling are often heard through-
out a considerable extent of the lungs.  In such cases,
numerous  small  cavities are  partially evacuated, but
the rhonchus may occasionally arise  from the simple
accumulation of mucus in the bronchi, and much care  /
is necessary to distinguish between these causes.
   In very old cavities,  the  gurgling is much changed
in character; sometimes it  has a  creaking sound, like
that of new leather; at others, it is a very dry mucous
rhonchus.  These varieties all depend  upon the con-
sistence  and  quantity of the secretion into the cavity.
   Cicatrization of tuberculous cavities  sometimes oc-
curs, and would probably be much more  frequent, were 
112
ON THE DIAGNOSIS OF
 it not for the secondary crops of tubercles.  In one or
 two instances I have traced the progress of these cavi-
 ties, but I have  not verified it by examination after
 death.  In such cases, the cavernous or amphoric res-
 piration becomes less intense, and is gradually replaced
 by a feeble respiratory murmur.
   Of the conformation of the chest in phthisis.—Some
 of the peculiarities in the conformation of the chest of
 consumptives, have been long noted; such  as the re-
 markable protrusion of the shoulders, and the contrac-
 tion of the anterior part of the thorax, from the emacia-
 tion of the pectoral muscles.  But these extreme devi-
 ations from the natural form, occur only in  advanced
 stages of the disease.  In the earlier periods, the chest
 is more contracted than usual, either from general ema-
 ciation, or from adhesions between the two surfaces of
 the pleura, near the tuberculous deposits.  The con-
 traction  dependent  upon  emaciation,  extends to the
 whole of the chest, but is most evident at the inferior
 part, where there  are no  large muscles.  It increases
 with the progress of the disease.  The adhesions from
 pleurisy are necessarily strongest at the summit of the
 lungs,  where the tubercles  are in  greatest number;
 they are sometimes slight and  cellular, but in  a ma-
jority of cases are firm and cartilaginous.  Sometimes
 they are so thick as to form a hard, cartilaginous cap,
 completely enclosing the lung, and increasing the dul-
 ness of the percussion.   When the pleurisy has not
 been confined to the summit of a lung, the contraction
 is similar to that following the idiopathic disease, and
 is,  therefore,  of  less  importance  in  the  diagnosis
 than when it is limited  to the top  of the lung, where
 simple pleurisy is  rare.   The local adhesions necessa- 
DISEASES OF THE CHEST.
113
rily increase  the depth  of the  depressions above and
below the clavicles; if  one of them be much greater
than the other, we infer that it is owing to adhesions,
and not to mere emaciation.

 OF THE EXPECTORATION IN PULMONARY CONSUMPTION.
   In  the earliest stage, there is rarely any expectora-
tion.  When passing into the second stage, the sputa
consist  merely of the  thin whitish semi-transparent
bronchial mucus.   They retain this appearance until
cavities begin to form.  The sputa then become whit-
ish, opaque,  do not run together in masses,  but are
rounded, with irregular indented edges.  Sometimes
there are whitish or yellowish  grains  in the sputa,
which are fragments of softened tubercles.  The round
sputa generally float in  a thinner and more transparent
liquid, which is  chiefly the ordinary bronchial secre-
tion.   This variety of expectoration is called nummu-
lar, and is peculiar to phthisis.   It almost always oc-
curs during the progress of the disease, but sometimes
is not developed until it is far  advanced.  The expec-
toration rarely retains this character until the  death of
the patient, but becomes more yellow, and has a dirty
grayish tinge;  the sputa run together, and  are not
mixed with the thinner liquid.  The odour is nauseous,
and in  rare cases foetid.
   Haemoptysis, or the spitting of blood, occurs in most
of the cases of phthisis of adults.  It comes on at vari-
ous stages of the disease; sometimes, though rarely, it
is the first symptom perceived by the  patient, who is
taken with  spitting of  blood while enjoying apparent
health.  Haemoptysis is, however, most frequent  dur-
ing  the progress of the first, or the beginning of the
        p 
114
ON THE DIAGNOSIS OF
second stage, after the cough  and expectoration have
begun.   In the third stage, slight haemoptysis (from a
few  streaks of blood to a spoonful), is not infrequent.
Copious haemoptysis, that is, from a spoonful to a pint
or more of blood, is rare; but when it occurs, is much
more fatal in this period than in any other.  The spit-
ting of blood, if in greater quantity than a spoonful, is
a very sure diagnostic sign of phthisis, unless it should
follow local injuries, or be connected with some derange-
ment of the menstruation.   I allude only to those cases
in which the blood comes from the lungs,  not  the
mouth or fauces.  It is very true that  some individuals
who have had profuse haemoptysis, do not die of con-
sumption ;  but it is beyond doubt, that many of these
persons are tuberculous, although the disease may have
become stationary.   It is proven, by direct observation,
that haemoptysis  is very frequent in  patients who are
tuberculous, and  that it is  very rare  in those who are
not.   The  probability is, therefore,  very  great,  that
patients attacked with haemoptysis  (with exceptions
just stated),  are tuberculous.
  The cough of consumptive  patients is variable;  at
first it is dry, short,  and  very rare.   Patients are fre-
quently not aware of its existence; at  other times they
make an  effort to suppress it, and thus conceal its ex-
istence from themselves.  The  cough becomes  more
loose  and paroxysmal as the tubercles increase in size,
and is both frequent  and  loose when there are cavities
in the lungs.  It is much more severe  at night, or early
in the morning, than at any other hour of the day.
  Emaciation is  an almost constant  attendant  upon
phthisis,  and however acute the case may be, it is sure
to appear before the  termination.  When the emacia- 
DISEASES OF THE CHEST.
115
tion is not attended with loss of appetite, the sign is of
much greater value.  Nothing, however, is more irre-
gular than the progress of emaciation; I have seen
cases of phthisis with cavities, although the patients
were stout muscular men.
   Loss of muscular strength is very frequent, though
not universal; it  advances when the  disease  makes
rapid progress, and seems stationary when the develop-
ment of tubercles is suspended.
   It is needless  to enlarge upon those symptoms of
phthisis which are usually  found in its advanced
stages; as hectic  fever, night sweats,  diarrhoea, and
oedema of the feet.  For more copious details,  I must
refer to systematic writers.

            OF THE VARIETIES OF PHTHISIS.
   Latent consumption is far from infrequent.  In some
subjects tubercles are developed, and pass through their
different stages almost  without fever or cough.  The
diagnosis must then be  drawn from the physical signs,
which are especially useful under such circumstances.
The disease is most frequently latent in young children,
and in  persons far advanced in life.
   Acute phthisis is not often indicated by decided phy-
sical signs.   The tubercles are disseminated through a
large portion of the pulmonary tissue, and the patient
usually perishes before  any of them attain a large size.
The fever and prostration are more intense, and the
emaciation more  rapid  in  this form of disease  than in
any other.   It is more frequent in women than in men.
   The frequency of phthisis in children is remarkable.
Like all the tuberculous diseases, it is most common in
children who are badly fed, and deprived  of a suffici- 
116
ON THE DIAGNOSIS OF
ency of light and air.  It is rare before the age of two
years,  but very frequent afterwards.  The tubercles
are more equally disseminated throughout the lungs
than they are in adults,  and  are  not often much
larger in the upper lobes than in the lower.   It is very
common to find cavities and large tubercles in  the
lower lobe, while there are but few and small tuber-
cles at  the summit of the lungs.  Cavities in the lungs
are comparatively rare in children;  they generally die
before the tubercles soften.   The tuberculous matter is
more frequently infiltrated  in the pulmonary  tissue, as
it is in the monkey tribe, and  may invade a large por-
tion of the organ.  In the aged, phthisis is  compara-
tively rare, and passes into a chronic form; it is often
latent,  but does differ in other respects from the phthi-
sis of adults.
   Of the complications of phthisis.—Tuberculous con-
sumption does not seem subsequent upon other diseases,
unless  the patient has had an original predisposition to
it.  In such a case,  any malady which has kept up a
permanent febrile irritation, or deprived him of air and
exercise, may give rise to  phthisis.   There  is a class
of diseases which form only apparent exceptions to the
common  rule, that consumption is not a secondary af-
fection ; these are those which depend upon deposits of
the tuberculous matter in other organs than the lungs.
It is now generally admitted, that  all lesions whose
common anatomical  character is the  secretion of tuber-
cles, are essentially identical, and that the difference in
their symptoms depends only upon the changes in the
functions of the organ, produced by the continued pre-
sence of a foreign body.  The causes which influence
the deposit of tubercles in one organ, rather than in 
DISEASES OF THE CHEST.
117
another, are unknown; but they depend, to a certain
extent, upon the age and sex of the patient.   Tubercles
in the glands are more common  in children than in
adults;  those  of the serous membranes  are more fre-
quent in the female than in the male sex.   In adults,
they  are  almost always found  in the lungs when
they .exist in  other organs of the body;   the excep-
tions to this  law do not  exceed one  in a  hundred.*
From the very constant and early deposit of tubercles
at the summit of the lungs, an examination of the phy-
sical  signs of these  organs  will  often throw much
light upon the tuberculous diseases  of other viscera,
and especially those of the serous membranes.  On the
other hand, a knowledge  of  the  laws governing the
deposit of tubercles in different organs of the body, will
facilitate the  diagnosis  of obscure cases of  pulmonary
consumption.   The chief of these laws (for which we
are indebted to M. Louis), are as follows:—Chronic
peritonitis, which does  not follow the acute form, is
always tuberculous.  This law I have very often veri-
fied, both in  Europe and in America, without finding
an exception  to it.   Another is,  that consecutive at-
tacks of pleurisy, first on the one side, then upon the
other, are caused by tubercles in the lungs, or pleurae.
To these conclusions,  I may  add  one drawn from my
own observations.   When children or young adults are
attacked  with  the  disease  of the membranes  of the
brain, known  under  the name of meningitis, or me-

  * It has so happened that I met with one of these rare cases while writ-
ing this chapter.  It was  in a coloured woman, who had gray granulations,
or tubercles in the pleura and  the peritoneum, but not the slightest trace
of them in the pulmonary tissue. 
118
ON THE DIAGNOSIS OF
ningo-cephalitis, they have tubercular deposits in one
or more of the organs of the body.
   Tubercles are formed very frequently in the follicles
of the intestines and the spleen; less often iii the liver
and kidneys.  When they occur in the brain, they are
generally attached  to the meshes of  the pia mater.
Tubercles of the bronchial glands are more frequent in
children than those of  the  lungs, and constitute  a
variety of phthisis, which will be afterwards noticed.
   Besides the lesions  of viscera which depend upon
the development of tubercular  matter in their  sub-
stance, various organs may be inflamed or ulcerated
during the progress of phthisis.  The affections of the
intestinal canal are very frequent during its course, but
those of the trachea  and larynx are almost peculiar to
it.  When the symptoms dependent upon the affection
of the larynx are much more prominent than  those of
the lungs, the disease has  often  received a  distinct
name, and is then called laryngeal phthisis.  It is now
well ascertained, that all such cases at  the same  time
present tubercles of the lungs, so that the disease is re-
garded as one of the varieties of phthisis.
   Inflammation of the lungs frequently succeeds tu-
bercles in these organs, but is not as necessary an at-
tendant upon them as pleurisy, which is rarely absent,
although there should be no tubercles in the serous
membrane.  The pleura is inflamed at the summit of
the lungs, where they are most diseased, instead of the
base, which is the seat of ordinary pleurisy.   The ad-
hesions which follow the inflammation are a source of
safety to the patient, who would frequently perish from
perforation of the pleura, if  the cavity of this mem-
brane was still preserved near the softened tubercles. 
DISEASES OF THE CHEST.
119
  Diagnosis.—This is a much more complicated pro-
blem than that of any other pulmonary disease;  not
that there is any doubt in those instances which are
accompanied by well marked physical signs, in addi-
tion to the general symptoms;  but in a large number
of cases of consumption, both these series of signs may
fail, or be imperfectly developed.   The progress of the
disease will remove the doubt which often attends the
early stage, but it  is then  too late to remedy the evil.
Although the earliest development of tubercles cannot
be  certainly  ascertained,  we may  decide  with much
probability whether the disease exist or not.
  The early periods  of phthisis may be  confounded
with simple  pulmonary catarrh, with dyspepsia,  and
febrile diseases of  various type, or may be completely
latent.   The points in which phthisis  differs from
chronic  catarrh, are:—1st. Hereditary  predisposition,
which exerts an important influence in the production
of phthisis.  2d. The age of  the  patients, which is
rarely above  thirty, if the  disease be consumption. 3d.
Sex—if the  patient be a female, for catarrh is by far
the most frequent in males.  4th. Occupation—phthisis
is more  frequent amongst those who are obliged to re-
main within doors, and especially those who  work in
constrained  positions.  5th.  Emaciation—a very im-
portant sign, especially if it be not attended with loss
of  appetite, which  would  account for  it on  other
grounds.  6th.  Enlargement of the ends of the fingers,
and curving of the nails, which sometimes occurs at an
early period of phthisis, and almost always is very per-
ceptible toward its termination.   7th. The  fever  is
sometimes intense, and entirely disproportioned to the
extent of the local lesions; it is, therefore, a very im- 
120
ON THE DIAGNOSIS OF
portant sign in the more acute forms of the disease, in
which it  is usually most considerable.  The chronic
varieties  are  not accompanied with  fever; so that the
absence of this symptom is  not an important negative
argument against the existence  of tubercular disease.
A peculiar sensibility to cold, rather  than a distinct
rigour, often attends the fever;  and night sweats are not
infrequent, even in the early stages of consumption,
while they are rare in catarrh.   8th. The occurrence
of chronic peritonitis, shown by flatulent distention of
the bowels, constipation, and vague, inconstant darting
pains through the  abdomen, will  remove  all doubt
which might remain as to the nature of the affection.
The pleuritic pains in the sides, especially if alternat-
ing from one to the other, are also important signs of
phthisis,  and rarely occur in simple catarrh.   Laryn-
gitis, if chronic, is an almost unfailing evidence of con-
sumption ; it is indicated by hoarseness, or loss of the
voice, and pain, or slight soreness  at  the larynx, in-
creased by swallowing.   It should not be confounded
with simple  inflammation  of the uvula and  tonsils,
which may even  proceed  to ulceration, but  can be
readily detected by examination of the fauces.  9th. The
expectoration  in the early  stage of phthisis consists
merely of a little whitish mucus, and does not present
the various aspects  of catarrhal sputa.  It was already
mentioned, that the expectoration of large quantities of
blood was almost  pathognomonic of tubercles in the
lungs.
  When two or more  of the  general signs just men-
tioned are combined, they indicate  the probable exist-
ence of phthisis, especially if they do not appear to be
dependent upon other diseases.  If the physical signs 
DISEASES OF THE CHEST.
121
are absent, it shows  that the disease has not extended
far enough to involve a considerable  portion of the
parenchyma of the lungs.  The only exception to this
rule is acute phthisis, when a multitude of gray gran-
ulations, or minute tubercles, may be scattered through
the lungs, without giving rise to any material altera-
tion of  the respiration.  When,  in addition to the
symptoms above  mentioned,  there is an increased de-
pression above and  below the clavicles, dulness of
percussion in the same  part, and rude or very feeble
respiration, there can  be no rational doubt of the ex-
istence of the first stage  of phthisis.  If the rational
symptoms are very doubtful, the physical signs are less
important, unless they be decided when the disease is
clearly recognized, although  it has assumed the latent
form.
   In all  cases it must be recollected, that the diagnosis
of consumption, in  its early stages, is a complicated
problem, which  cannot be solved  without  a careful
examination of both negative and positive signs.  When
no doubt is left as to the affection, the physician must
be cautious  in informing the patient of the nature of
his disease; unless,  at the same time, he explains to
him that it is  not far  advanced, and may be checked
by a combination of  medical treatment, with the neces-
sary hygienic means.
   The second and third stages of phthisis are readily
recognized by the general and physical signs detailed
in  the  preceding pages.   It  is,  therefore,  scarcely
necessary to recapitulate  them here.  Even in these
cases, where the chances of cure are so slight, physical
exploration is  most useful, by showing the nature and
stage of the disease.  It may thus prevent an improper
      Q 
122             ON THE DIAGNOSIS OF

course of  treatment, and discourage the patient from
undertaking those long journeys, which a vain hope of
recovery often suggests.  There cannot be too  much
caution used in advising him to leave  the  comforts of
his home,  at a time when he is  least capable of severe
exertion. 
DISEASES OF THE CHEST.
123
                CHAPTER XII.


 PULMONARY APOPLEXY, AND CEDEMA OF THE LUNGS.

  These lesions are classed together, because they are
rather the sequelae of different diseases of the lungs,
than distinct affections.  They, however, occur under
very different circumstances;  pulmonary  apoplexy is
usually connected with phthisis, and rarely proves fatal;
but oedema  of the lungs often precedes death at the
close of various chronic diseases.
  When blood is secreted from the mucous surface of
the bronchi, no lesion of this membrane can be detected;
the liquid is  simply exhaled  from its surface.  But
when the blood is poured out from the lining mem-
brane of the  smaller  tubes, and  the cellular  tissue
around them,  there is often a deposit of it in the tissue
of the lung, where it forms rounded masses, from a line
to two or three inches in diameter.   These masses  are
scattered throughout the lung, are of a dark brown, or
blackish colour, and very smooth  when incised; the
consistence of the tissue is sensibly diminished, but  not
pulpy.   Both the  exhalation from the mucous mem-
brane of the  bronchi,  and the deposit of blood in  the
pulmonary tissue, are frequent attendants upon phthi-
sis ; and tubercles, in greater or less number, are found
scattered through the  lungs.  Sometimes the nodules 
124
ON THE DIAGNOSIS OF
of coagulated blood are found after death, although
none had been expectorated; but in most cases, copious
haemoptysis occurs.  The haemorrhage in itself is rare-
ly dangerous, but is alarming from its importance as a
symptom of phthisis, or  in rare cases, of a disease of
the heart.
   The physical signs of pulmonary apoplexy are chiefly
the mucous, or sub-crepitant rhonchus, which  extends
over the whole of one side of the  chest, when the
haemorrhage has been considerable; but is limited to a
small portion of a lung  when there is little effusion of
blood.   The resonance, on percussion, is  not percepti-
bly altered, unless the clot is very large, which is rarely
the case.  The rhonchus differs from that produced by
the secretion of mucus; the bubbles are evidently
formed of a thinner  liquid, and break more  quickly.
The vesicular  sound is sometimes  entirely  lost;  at
others, it is heard mingled with  the rhonchi, but  is
always much feebler than natural.  The  sonorousness
of the chest is diminished, if the  effusion of blood be
considerable; but, in most  cases, it is not evidently
altered.
  A bellows  sound of  the heart frequently coincides
with pulmonary haemorrhage, whether the blood comes
from the bronchial tubes or the vesicles.   The impulse
is at the same time greater than usual.  These altera-
tions in the sounds of the heart cease when the haemop-
tysis is arrested.

                PULMONARY GZDEMA
Is the effusion of serum into the cellular texture  of
the lungs;  when they are cut, an abundant spumous
transparent liquid issues from them.  They crepitate 
DISEASES OF THE CHEST.
125
and pit upon pressure, while their density is evidently
increased.  This lesion is very frequent in the aged,
and is often the immediate cause of death at the termi-
nation of severe fevers.  It also complicates some cases
of general dropsy, but is scarcely regarded as an idio-
pathic disease.
  The  physical  sign  indicating oedema,  is the pre-
sence of a loose and very abundant crepitant rhonchus,
which extends to a large portion of the lungs.   Its bub-
bles are larger than in the crepitus of pneumonia, but
break more quickly, and do not extend from  point to
point, in long trains;  they resemble much more nearly
the sound produced by effervescing cider or champaigne.
The crepitus is most abundant at the base of the lungs,
but, if general, is usually a fatal sign.  The sound, on
percussion, is scarcely diminished. • 
126
ON THE DIAGNOSIS OF
CHAPTER XIII.
                    PLEURISY.

  The pleurae are more frequently inflamed  than any
other of the serous membranes.  The inflammation
is  primitive, or secondary to other  diseases,  especi-
ally those of the pulmonary parenchyma.  The anato-
mical phenomena, and the physical signs of idiopathic
pleurisy, differ but slightly from those of the secondary
disease, although the general symptoms, and the prog-
nosis, may both be widely different.
  Anatomical characters.—When inflammation of the
pleura commences, the  vessels beneath  the  serous
membrane are very numerous, and form a  net-work of
a bright red colour, distinctly visible through the trans-
parent membrane.   When the membrane is detached,
it is evident that the vessels are developed in the cellu-
lar  tissue beneath, and not in  the membrane itself,
which is not perceptibly  altered.   If the disease con-
tinues, the secretion of serosity from the free surface of
the serous coat is probably at first lessened, but is soon
changed in character, and is replaced by two new pro-
ducts, which are  usually found at the same time, but
in different  proportions.  These are first, a liquid, not
unlike the ordinary serous secretion of the membrane;
and  secondly,  a  soft albuminous matter, or  plastic 
DISEASES OF THE CHEST.
127
lymph, deposited in the form  of a pellicle upon the
serous coat, or of flocculi, which sink to the bottom of the
liquid.  It is most probable that these secretions occur
in every case of pleurisy, but in various proportions.
In the slightest cases the  liquid is so little abundant
that it is not perceptible by our means of investigation;
we can then  only infer  its existence from the analogy
of severe cases.  In a still more frequent variety, the
secretion consists of coagulable lymph, without liquid.
This  form  of  pleurisy always exists  when the in-
flammation follows a previous attack of the disease,
which had passed through  its stages, and terminated in
close  and extensive adhesions.
   In  the large majority of cases, the liquid  secreted
consists both of serum and  lymph.   The  serum is
whitish, or yellowish,  never perfectly  limpid;  it fol-
lows  the ordinary  laws  of gravity, and accumulates in
the most dependent parts; its situation, therefore, varies
with  the  different positions  of the patient.   For the
same reason, it is  most frequently accumulated at the
base  of the  lungs and  along the edge of the  spinal
column—parts which are nearest the centre of gravity
when we are in a  recumbent or sitting posture.  The
lymph also  accumulates in greatest quantity  at the
lower part of the  lungs, and  the opposite parieties of
the thorax.   At the angle forming  the lowest portion
of the lung,  it  is sometimes so  abundant as  to form a
thick yellow mass, inclosing  the ^pulmonary  tissue.
When  the pleurisy is  preceded by a  disease  of the
lungs, as  tubercles or gangrene, the accumulation of
lymph is  greatest at the  parts of the pleura  which
cover the diseased mass—so  that  in phthisis, the
pleurisy, and consequent adhesions, are almost always 
128
ON THE DIAGNOSIS OF
 greatest at the summit of the lungs, where the tubercu-
 lar matter is  most abundant.   The  consistence of the
 lymph varies from that of a  soft pulp to a firm semi-
 cartilaginous membrane, detached with difficulty from
 the pleura.  It is not possible to distinguish the period
 of the disease, from  the inspection  of the anatomical
 secretions; but the false  membrane  is always less con-
 sistent, when newly formed, than in the later stages,
 although  we are ignorant of the precise  relation be-
 tween the degree of the inflammation and the consist-
 ence of the lymph.  The lymph is sometimes deposited
 as a thin uniform layer, or membrane; at other times,
 it is in irregular patches of various  thickness, or it as-
 sumes a  reticulated aspect, with cells not very unlike
 those of a honeycomb.   The masses of lymph, lying
 loosely in the liquid,  are generally less consistent than
 the layers covering the pleurae.  The membrane lines
 the whole cavity of the pleura when the inflammation
 is extensive and the  effusion considerable; when the
 disease is less advanced, it is chiefly  found at the lower
 part of the cavity, but upon both the costal and pul-
monary surfaces, though it is usually thickest on  the
pulmonary pleura.
  When the layer of lymph is  detached  from  the
 pleura, the serous coat is of a reddish colour, owing to
the numerous vascular  ramifications beneath it.  Its
transparency is retained, although it is not always as
perfect as in the normal state;  if held against the light,
there is a slight milky tint of the membrane.   The ap-
parent thickening is chiefly owing  to the coating of
 coagulable lymph; a very slight but real increase of
 thickness of the membrane may be distinguished when
the lymph has been carefully removed.  The vascular 
DISEASES OF THE CHEST.
129
ramifications are of a bright red colour, and sometimes
so numerous as to  communicate a uniform redness to
the membrane; the redness  is generally proportioned
to the quantity of lymph effused upon the  serous coat.
In patients  much weakened by .anterior diseases, the
pleura, instead of being red, is of a semi-opaque white;
in this case, the quantity of  serum is unusually great,
while the lymph is less abundant, and of less  consistence.
   The side  of the chest affected  is thrust outwards by
the effused liquid, when  it is considerable  in quantity.
The distension is  first visible at the lower and pos-
terior part of the thorax, near  the angles  of the ribs;
it is less obvious in  the axilla, and is perceived anterior-
ly in cases only of great effusion.   The local alteration,
in the conformation of the thorax, may frequently be
recognized when little or no perceptible increase of the
semi-circumference of the  chest  is  detected.   The
thorax loses  its preternatural fulness when the liquid
begins to  be absorbed; but when the effusion has been
considerable, it  never recovers its original conforma-
tion.  The  anterior surface is  depressed, slightly con-
cave, or flattened, instead of the natural convex surface;
the posterior face is less convex than usual, and the in-
tercostal spaces  are not  nearly so  wide as in healthy
subjects.  In the axilla, the depression following  the
absorption of the liquid  is less evident than elsewhere.
   While  the ribs are forced outwards the lung is com-
pressed against the spine, by the gradual increase of
the liquid.   In proportion as the effused  liquid is ab-
sorbed, the  false  membranes which cover the surface
of the lung, and retain it against the spine, acquire ad-
ditional consistence, and prevent it from regaining its
former  development.  The  lymph lining the costal
       R 
130
ON THE DIAGNOSIS OF
pleura becomes more dense and organized, approaches
in appearance to cellular substance, and is  supplied
with  vascular ramifications from the vessels of the
serous membrane.   The vessels  are minute, but  of
bright redness, and aje only visible when the  adhesion
between the serous coat and the  false  membrane has
become intimate.
  When the cure of pleurisy is  nearly complete, the
two surfaces of the membrane come in  contact, and
gradually adhere to each other.  At first  there is still
sufficient motion for the surfaces roughened by the de-
posit of lymph to rub against each  other; the friction
then causes a peculiar creaking sound.*  As the ad-
hesion gradually becomes complete, the costal and pul-
monary pleurae are closely and permanently united.
  State of the lungs in pleurisy.—The lungs in simple
pleurisy  are free  from  inflammation; but  are not,
strictly speaking, in a normal  condition.   When the
pleurisy is limited to inflammation of the serous  mem-
brane, and deposit of lymph, the lungs are less fully
expanded than is  natural,  from the pain felt by the
patient during respiration; they, therefore, contain more
solid substance, and less air, than if they were perfectly
healthy.   If there be  a secretion of liquid,  however
small in quantity, some compression of the pulmonary
parenchyma takes place,  and the quantity of air re-
ceived into the lung is less, while the proportion  of
solid matter is augmented.  If the compression be very
great, the lung is dense, has  a  leathery feel,  and con-
tains  no air.
   Physical signs of pleurisy.—In the earliest stage of
* See description of sounds. 
DISEASES OF THE CHEST.
131
the disease, the conformation of the chest is not per-
ceptibly altered; but when the effusion is considerable,
the form of the thorax is much changed.  At first, dila-
tion is perceived only in the  lower posterior  portion,
where the  intercostal spaces become  more  promi-
nent, and the angles of the ribs are higher than in the
healthy state.  At this period, no  perceptible differ-
ence exists in the semi-circumference of the two sides.
When the effusion is greater, the dilatation extends to
the axilla and anterior surface of the chest, and the in-
tercostal spaces  are decidedly protruded.   The quan-
tity of liquid is frequently so great as  to increase the
semi-circumference of the chest; so that the side affect-
ed may measure from one to three inches more than
the other; there is very commonly a difference of from
one to two  inches.   The thorax should be measured
just below the nipple.  The  shoulder is raised when
the liquid is abundant, and  the nipple is higher than
that of the healthy side.  Should there be much effu-
sion into the left side, the heart is thrust to the right of
the sternum.
   The general dilatation of the thorax is so peculiar to
pleurisy, that if it be accompanied with pain, it is suf-
 ficient for a very sure diagnosis of the disease.   The
 degree of distension of the chest indicates the progress
 of the disease, when it has reached its crisis; the pro-
 minence remains stationary for a considerable  time; it
 begins to diminish when absorption commences, and
 as the cure  advances, the ribs sink until the  affected
 side  is more depressed than the sound one.   The pro-
 gress of the  absorption may be estimated by simple in-
 spection and by measurement.  The  gradual sinking
 of the side does not  terminate by  a return to the nor- 
132
ON THE DIAGNOSIS OF
mal form;  the  intercostal spaces are diminished, and
the thorax becomes flattened instead of convex; there
is, at the same time, a depression of the shoulder, nearly
proportionate to its previous elevation.
   Percussion.—When there is no effusion of liquid,
the percussion yields as  clear a sound as in health; but
as soon as the effusion  begins, the percussion neces-
sarily becomes  dull from the compression of the lung,
and diminished volume  of air.   The dulness of sound
is at first limited to the lowest part  of  the chest, and
gradually ascends as the liquid insinuates  itself be-
tween the lung and the wall  of the chest.   The flat-
ness varies with the position of the patient, and conse-
quent change in  the level of the liquid.   If, in cases
where there is moderate effusion, the patient be placed
upon his  face, the posterior part of the chest, which
had  previously yielded an obscure  sound,  becomes
sonorous.   The variable line of the flatness is a  good
discriminating  test between pleurisy and pneumonia;
in the latter disease, the cause of the obscure sound is
in the lung itself, and change of position produces no
diminution of it.   The dulness is at first only relative;
but when the lung has been completely forced  from the
walls of the chest, or the whole of the air is expelled
from it, it becomes perfect, or absolute.   In cases where
there is so much  liquid  that the lung is  almost reduced
to a membrane, which  is closely applied to the spine,
no resonance can be obtained on percussion, in any part
of the thorax.  In the large  majority of cases, this com-
plete flatness does not occur; there is still sound at
the summit of the lung, where the liquid, from the laws
of gravity, is least likely to compress the vesicles.  In
all cases a little sound may be obtained near the spine, 
DISEASES OF THE CHEST.
133
opposite the root of the lungs; this arises chiefly from
the air contained in the bronchia, which are not easily
compressed by the liquid.
  Percussion affords the most  important signs in the
diagnosis  of pleurisy;  they are constant, easily recog-
nized, and from the changes in the level of the flatness,
the presence  of a  liquid may be distinguished from
that of a  solid body.   The sonorousness does  not en-
tirely return when  all the liquid  is absorbed;  a little
obscurity  remains for  some weeks, in cases in which
the effusion has been  moderate;  when it has been so
abundant  as to be followed by contraction of the  thorax,
the sound on percussion  is always duller than natural.
   Of the  respiration.—As soon as pain is felt in the
side, even when there is no effusion of liquid, the respira-
tion is altered.  The vesicular murmur is feebler than
natural.   The feebleness arises in part from the short
inspiration which the pain produces, but  still more
from  the  comparative immobility of the ribs  on the
affected side.  The movement of the thorax  is impeded
by the great pain produced by the act of inspiration.
As the quantity of  liquid increases, the respiration be-
comes more feeble,  and gradually  ceases as the lung is
more and more  compressed.  When the lung is per-
fectly flattened,  no  trace of respiration can be heard,
except along the spine, at the root of the lungs, where
a feeble respiratory sound, with little vesicular expan-
sion, may generally be detected.   The respiration be-
comes stronger  from below upwards, and corresponds
very nearly with the  flatness on percussion. In cases
with  moderate  effusion of liquid,  the  respiration  is
weak at the lower part of the chest, and a little within 
134
ON THE DIAGNOSIS OF
the scapulae; but if there be much liquid, the vesicular
murmur ceases at the lower posterior part of the chest,
and in  the axillae, and becomes weak on the whole
anterior surface.
  Besides the diminished  force of the respiration on
the  side affected, it  sometimes becomes  decidedly
bronchial, and is so almost  always near the root of the
lungs.   The greater distinctness of the bronchial res-
piration, in  certain cases, seems to be owing to con-
densation of the tissue of the lung, which is at times
greater than at others, and to the deposit of thick pseudo-
membranous masses  near  the large  bronchial tubes.
When the bronchial respiration is strongly marked,
there is much reason for suspecting  the complication
of pneumonia.  It is always less loud in pleurisy than
in pneumonia, and is not tubal; but it is analogous in
other respects, and is best heard in  the expiration and
near the large bronchial tubes.  The extent of the
chest over which the bronchial respiration may be
heard, is much more limited than in pneumonia, in
which this sound is always produced  when a local in-
duration occurs around a bronchial tube; but  as it is
owing to no cases of pleurisy, a force extraneous to the
lung which compresses it equally on all sides, and ren-
ders it less permeable to  the air, it  is yielded only by
the part of the  lung most  favourable for it.  The ex-
pression, bronchial respiration of pleurisy, may be used
with propriety, to  distinguish  the less forcible variety
occurring in this  disease.   The less  degree of  force
does not destroy the distinguishing characters of bron-
chial respiration, which are always diminished force of
vesicular expansion, and increase of the blowing sound,
especially in the expiration. 
DISEASES OF THE CHEST.
135
  Alterations of the voice.—In the early stages of pleu-
risy, there is no perceptible alteration in the resonance
of the voice.  When the liquid becomes  more abun-
dant, the condensation of the lung increases the reso-
nance of the voice.  It is not simple bronchophony, but
from the interposition of a layer of liquid  between the
lung and the  walls  of the chest, it has a peculiar
vibrating tone.  This vibration of the  voice is called
egophony.   It  is a sign of secondary importance;  is
not always heard during the course of the disease, and
disappears  when the effusion  is  considerable.   The
cessation of the egophony is owing to the liquid com-
pressing the lungs, so as to flatten  the bronchia, and
render them unsuitable for the transmission of sound.
The most common seat of egophony is towards the in-
ferior parts  of the chest, on a line with the nipple, and
extending from it to the spine; it varies in changing
the  position of the patient.
   There are no rhonchi in simple pleurisy; they are
heard only when  the inflammation of the pleura is com-
plicated with that of the bronchial membrane, or of the
lungs.
   Of the movement of the chest during respiration.—The
movement of inspiration is short, and  interrupted in
the  acute stage, while the  expiration is slow and pro-
longed.  But as the  pain subsides,  the respiration be-
comes more regular, but  at the same time more fre-
quent and more elevated than usual.
   The dyspnoea arises, from the diminished volume of
the  lung into which  the air can pass.   The motion of
the  chest  is chiefly performed by  the healthy side;
that in which  the  effusion has  occurred, expands less 
136
ON THE DIAGNOSIS OF
completely in the early stages, and is almost passive
when there is much liquid.

        OF THE FUNCTIONAL SIGNS OF PLEURISY.
  Decubitus generally on the back, but at the early
stage of the disease, sometimes on the sound side.   In
the chronic form, the patient lies on the back, or more
frequently on the side  affected, in consequence of the
weight  of the liquid, which would impede the motion
of the healthy lung, if the patient lay upon that side.
  The  pain  is acute in the early stage, and referred,
not to the spot where the inflammation is greatest, but
to the anterior edge of the axilla, or below the nipple.
  Cough short, dry, and very painful.
  The  expectoration is very little  abundant, transpa-
rent, or  a little whitish.
  Pulse frequent and hard  in the early stages;  when
the chronic stage has occurred, very various; in some
patients perfectly natural; in others, always febrile.
  Respiration frequent, especially when the effusion is
abundant.
  Skin  dry and harsh, during the febrile stage.
  Termination, when idiopathic, nearly always favour-
able ; the exceptions are very rare.
  Duration  very various;  recovery occurs in a  few
days, when there is little  effusion; when the liquid
is considerable,  the disease lasts from one to  three
months.

              VARIETIES OF PLEURISY.
  (a) There  is a very common form of pleurisy, which
is at first accompanied by pain, but afterwards the only 
DISEASES OF THE CHEST.
137
symptoms experienced by the patient are some diffi-
culty of breathing, a slight cough, and a little uneasy
sensation  about the chest, not amounting to actual suf-
fering.  Pleurisy may be still more completely latent,
and be free from pain throughout its whole course; in
this case,  it can only be recognized by physical explo-
ration, when the flatness on percussion, and  the feeble
respiration, will identify the disease.
   (b) Chronic pleurisy may succeed the acute form, and
is then recognized by the signs already described, as in-
dicative of the effusion of liquid.  The chances of con-
founding  this variety with phthisis  are so small, that
it is  hardly necessary to insist upon its signs, which
are perfectly characteristic.   The liquid is more puru-
lent,  and  the false membranes are greatly increased in
thickness and consistence.  The lung is firmly attached
to the spine  by the strong membranes, which some-
times acquire the consistence of cartilage, and are per-
fectly organized.   There is, also,  a variety of pleurisy
which seems essentially chronic,  and cannot be traced
from a precise origin; it generally depends  upon  the
presence  of tubercles in the lungs, and, if the  case
be examined  with care, the evidences of  tubercular
disease will be found to have preceded those of  pleu-
risy.
   (c) Double  pleurisy is nearly always dependent on
tubercular disease  of the lungs; sometimes it occurs as
an idiopathic disease, and is then usually fatal.*
   (d) The mortality of pleurisy is considerable when

   * Two cases of this kind I witnessed last winter, in which there was
double pleurisy and pericarditis.  One was, besides, complicated with pneu-
 monia.
S 
138
ON THE DIAGNOSIS OF
the subjects of the disease are very young, or far ad-
vanced in life.  In these cases the patients  are  in a
situation  similar to those exhausted by previous dis-
eases.   Many aged persons, who are supposed to die of
old age, really perish of latent pleurisy.   In children
the disease  is not rare, and sometimes proves mortal.
In one case, I found the affected side dilated to at least
twice its  former dimensions;  this patient perished of
suffocation.
  (e)  Pleurisy sometimes alternates with  rheumatism,
and is then frequently confounded  with  pleurodynia,
a mistake very easily made, unless the physical signs
prevent the error.
  (f) Pleurisy, consecutive to tubercles or pneumonia,
is not to be classed with examples of the idiopathic dis-
ease.   In this instance, it is not unfrequently mortal.
The pleurisy of tuberculous patients is generally dry,
with  secretion of lymph, but not  of liquid; but  the
effusion is not unfrequently as considerable as in idio-
pathic cases.  The disease  may then  be  easily recog-
nized, although some tact is requisite to discover its
tuberculous origin.
  Diagnosis.—It is evident that if  a patient  offer the
following  symptoms—oppression, pain in  the thorax,
fever, flat sound on percussion, extending from below
upwards,  and the  respiration is feeble or absent—that
his  disease  must be  pleurisy, and can  be  nothing
else.
  When  the chest is dilated,  the  diagnosis  becomes
still more clear.  If the pain  and dyspnoea be not at-
tended by any alteration of the percussion, or of the
respiration, other than a slight weakness of the vesicu-
lar murmur, we may still form a diagnosis, which is 
DISEASES OF THE CHEST.
139
very probable,  though not physically certain.  It is
then confirmed by the absence of the signs indicative
of pneumonia,  with  which pleurisy might easily be
confounded.  Severe pleurodynia or rheumatic disease
of the intercostal muscles, is  much less common than'
it is usually thought to be; most of these cases, when
carefully examined, prove to  be examples of pleurisy,
with little effusion of liquid. 
140
ON THE DIAGNOSIS OF
                 CHAPTER XIV.


                 PNEUMO-THORAX.

  The term pneumo-thorax is applied to a  collection
of gas in the cavity of the pleura.  It seems that, under
some circumstances,  gas is secreted  by the  serous
membrane, and, in others, there is probably a decom-
position of the fluids  contained in  its cavity.   Both
cases are accidents  of little importance, and  are  so
rare, that their existence  has been doubted.   The
common acceptation of the term pneumo-thorax, is now
limited  to the  anatomical lesion, which  consists in a
perforation of the pleura, causing the cavity of the
serous  membrane to communicate with  the  external
air through the bronchi.
  It is  not properly a  disease, but an accident, which
may be caused by any  lesion of the  lungs, produc-
ing suppuration or ulceration of these organs.   The
diseases which may give rise  to  it, are pneumonia,
and  gangrene  of the  lungs, as  well as  phthisis, but
at least nineteen of twenty  cases occur during the
course  of the  latter affection.  It is, therefore, an ac-
cidental  lesion, almost peculiar  to  phthisis, and  is
caused  by the softening of  tuberculous  matter near
the  pleura,  and  the  consequent perforation of this
membrane from ulceration.   It would  occur  much 
DISEASES OF THE CHEST.
141
oftener if adhesions between the costal and pulmonary
pleurae did not so constantly take place, when the sub-
jacent pulmonary tissue is  diseased.  The adhesions
are,  therefore, the safe-guard of tuberculous patients.
Pneumo-thorax  is about twice as frequent on the left
as on the right ride;  this difference is explained by the
greater frequency of pleurisy on the right side.  Perfo-
ration seldom occurs in lungs much  infiltrated with
tuberculous matter,  but very frequently in those con-
taining  disseminated tubercles, too few in number to
give rise to extensive pleurisy.   The opening in the
pleura is rarely large; sometimes  it is a quarter of an
inch  in  diameter, at others barely sufficient for the
head of a pin to pass.
   The  immediate consequence of perforation, is the
passage of air into the  cavity of the pleura;  the air is
introduced during the inspiration, and cannot entirely
escape in the expiration.  Pain and  dyspnoea immedi-
ately supervene; the efforts of inspiration are increased,
and the volume of air  becomes so great as to distend
the intercostal spaces, and, at the same time, compress
the pulmonary tissue.   Should the lung which is not
perforated  be much diseased, the dyspnoea increases
so rapidly as to cause the death  of the patient.   The
last case of pneumo-thorax  I  witnessed, caused  death
in less  than an hour—the dyspnoea  becoming more
and  more imminent with each convulsive inspiration.
The  diameter of the perforation in this  case was a
quarter, of an inch;  the lung was compressed against
the spine, and the intercostal spaces forcibly protruded.
When a puncture was made through the intercostal
muscles, the air was driven  out  by the  contraction of 
142
ON THE DIAGNOSIS OF
 the chest, in a little stream, like that from a small blow-
 pipe.  In the larger  majority of cases, death does not
 ensue so speedily; inflammation of the pleura follows the
 introduction of air into its cavity, and the sero-purulent
 effusion of pleurisy increases the dyspnoea and pain.   If
 the disease  terminates favourably, the  inflammation of
 the pleura, and consequently the effusion of liquid, in-
 crease, while the perforation is gradually closed by the
 lymph.   When the consecutive pleurisy is cured, con-
 traction of the chest follows, as in ordinary cases of in-
 flammation  of the pleura.  As the lungs are  generally
 much diseased before perforation occurs, the  chance of
 a favourable termination  is very small.  Death is, in
 most cases, hastened, because the lung most capable of
 supporting respiration is suddenly compressed.
  Physical signs of pneumo-thorax.—As soon as the air
 enters the cavity of the pleura,  it presses upon the in-
 tercostal spaces, and distends the chest. Its conforma-
 tion is necessarily altered: it is more rounded than  be-
 fore;  and, if the quantity of air be large, is  generally
dilated throughout the affected  side, nearly as it is in
 pleuritic effusions.
  The percussion is much more sonorous than natural;
its loudness is increased over the whole of the  side; the
 sound is hollow, like that of an empty vessel, and to-
 tally different from the resonance of a healthy lung.
 The whole side of the chest does not offer a very loud
sound, if a part of the lung is held down by  old adhe-
sions, when  the resonance is natural in the correspond-
ing part.  When secondary pleurisy and consequent
secretion of liquid occur, the percussion becomes flat at
 the lower part of the chest, but is still  sonorous in the 
DISEASES OF THE CHEST.
143
upper portion.  As the liquid increases, a dull sound
gradually replaces the loud resonance, until it extends
throughout the pleura.  The respiration may be want-
ing,  or  it may be amphoric.   If the communication
with the bronchi be free, a perfect amphoric respiration
is heard, with a sharper and more metallic sound than
is  produced  by tuberculous cavities.   The metallic
tone is most distinct in the inspiration; sometimes it is
feeble in the  expiration;  at other times  entirely want-
ing.   This diversity is owing to the various  forms of
the aperture through the pleura.   It is sometimes val-
vular, and permits the ingress, but not the egress, of
the air; at other  times it is  permanently open.  The
sharpness in  the tone is owing to the hardness of the
walls of the pleura, which are always more dense than
the pulmonary tissue surrounding a cavity.   There is
never a distinct vesicular murmur.  The metallic tink-
ling is very frequent, but is  less constant and less im-
portant than the amphoric respiration.   It may often
be heard, after ceasing for a time, by making the pa-
tient cough—when the silvery sound, compared to that
caused by the fall of a drop of liquid from the walls of
the cavity, is very distinct. The resonance of the voice
is amphoric,  and is more loud and  distinct  than that
arising from  ordinary cavities, however large  they may
be.  It is loudest near  the large bronchi, and is most
distinct in those cases in which the perforation is large
and permanently open.   When the  gas  is  absorbed,
and the opening  is gradually closed, the amphoric re-
sonance ceases entirely.  The parts of the cavity far-
thest from the opening into the pleura, yield a more
diffused and  less metallic  resonance. 
144
ON THE DIAGNOSIS OF
  The sound of the heart is heard much less loudly
than usual; this is a sign of the  more importance, be-
cause the perforation is most frequent on the left side.
As the chest is filled with air which conducts the sound
imperfectly, the heart is scarcely heard, even at the
praecordial region.
  The general signs of pneumo-thorax are sometimes
characteristic.   If a patient affected with a chronic dis-
ease of the lungs be suddenly seized  with severe pain
in one of the  sides of the chest, obliging him to lie
upon the painful part; dyspnoea, sometimes so great as
to interrupt his speech, and compel  him to assume a
sitting or  half  recumbent posture, and a short, dry,
suppressed cough, he very probably has pneumo-thorax,
from perforation of the pleura.  The pain and anxiety
rather diminish than increase after the rupture occurs,
and the patient rarely perishes of the immediate diffi-
culty of breathing, induced by the large accumulation
of gas.
  Diagnosis.—In  those  cases  of disease which  have
been observed from the beginning, or their early stages,
the occurrence of pneumo-thorax may be known with
entire  certainty.   The  well-marked physical  signs,
with the dyspnoea and sudden pain, are absolutely pe-
culiar to this lesion.  The diagnosis may be  a little
more doubtful  in cases in which all its elements are
not present.   Well-marked cases of pneumo-thorax
may always be recognized; but  mere emphysema, in
subjects who are much emaciated, and so much ex-
hausted as to render it difficult for them to distend the
lungs, may be confounded with the former lesion.  If
the vesicular murmur is  entirely absent, as it some- 
DISEASES OF THE CHEST.
145
times is in such cases, the problem is of very difficult
solution.  Examples of this kind are of rare occurrence,
and are limited to those advanced stages of disease in
which all the characteristic symptoms are more or less
obscured.  In the earlier stages of emphysema,  the
general conformation of the chest is altered, but  the
distension is not so great as in pneumo-thorax, nor is it
as exactly limited to  one side.  Besides, if the dilata-
tion be so considerable as to give rise to doubt, the pro-
gress of the symptoms of emphysema is so slow  and
gradual, as to present a  strong contrast to the violent
dyspnoea, caused by a  large volume  of  gas in  the
pleura.
   Very emaciated persons, whose lungs are little, if at
all diseased, sometimes have  a very  sonorous thorax;
but it is rather contracted than dilated.  The increased
sonorousness probably depends upon the diminution of
the  cellular substance of the lungs.
T 
146
ON THE DIAGNOSIS OF
                 CHAPTER XV.


       TUBERCLES OF THE BRONCHIAL  GLANDS.

  The bronchial glands may inflame and become infil-
trated with pus; but this rarely happens unless there
has been previous inflammation  of the pulmonary
tissue.   They are frequently softened in diseases con-
nected with a general vitiation of the fluids, as typhoid
fever, and the exanthemata;  but their most  frequent
lesion is the tuberculous degeneration.
  Tubercles in the bronchial glands are rare in adults;
but, in children,  they  are more frequently found in
these  glands than in any organ of the body.  They
are as often tuberculous in children as  the  lungs in
adults, and are not unfrequently much diseased when
the lungs are comparatively healthy, or even  perfectly
free from tubercles.  The lesion is  most frequent in
those children who have been badly fed, and are habit-
ually confined in  close, ill-ventilated apartments.
  When the deposition of tubercular matter in a bron-
chial gland begins, the tissue may either be more livid
or  more  pale than natural.  Throughout  its texture
are scattered one  or more yellow points, of a substance
evidently extraneous to the healthy tissue of the gland.
As  these points enlarge, the  tissue is  gradually com-
pressed, and thrust aside, until it is limited to one ex- 
DISEASES OF THE CHEST.
147
tremity of the ganglion, where it forms a sort of mem-
brane.  At the same time the gland increases in size,
and by the time all its original tissue has been absorbed,
it  sometimes attains the size of a pigeon's egg, or, in
very rare cases, it may even be larger.   The tubercu-
lous deposit  is rarely confined to a single gland, but
usually extends to a number of those which surround
the large bronchial  tubes.  The cyst which encloses
the ganglion thickens as the gland enlarges; it resists
long after the tubercular substance softens,  but at last
ulcerates, and allows the  softened matter  to be dis-
charged through  the opening into the nearest bronchial
tube.  These cavities  differ  from those arising  from
tubercles in the  substance of the lungs, by the thick-
ness of their cyst, and their position without the lung;
but as a certain number of these  glands are enclosed
in its tissue, they then bear a much closer resemblance
to ordinary cavities.   In such cases, I have generally
recognized them from their close contact with a bron-
chium.
   Physical signs  of tubercles in the bronchial glands.—
After a very  long and careful investigation of this sub-
ject, at the Childrens' Hospital of Paris, I  could dis-
cover no test  by  which this  lesion can be recognized.
The cause of this difficulty is very obvious:  the glands
are deeply seated, are  not in a sonorous part of the
chest, and though they surround the bronchi, it is a
very  rare circumstance to see  these  tubes really so
much compressed as to impede the passage of the air
through them.   It is not even  commonly found, that
the cylindrical form of  the bronchi has been changed.
In a few cases, I fancied  that there was an obscurity
on percussion, near the spine, with an unnatural feeble- 
148
ON THE DIAGNOSIS OF
ness of respiration on one side of the chest;  but these
signs were doubtful, and rather derived from the know-
ledge I had of the frequency of the lesion, than clearly
observed in the patient.
  The functional signs are common to all the varieties
of tubercular  diseases.   They are fever,  emaciation,
dryness and harshness of the skin, and night sweats.
There is sometimes difficult respiration.
  Dr. Selden, of Norfolk, communicated to me a singu-
lar case of tubercles in the bronchial glands.   It was
in a negro child, who was afflicted with  difficulty of
breathing, dilatation of one side of the thorax, and flat
sound on percussion.  The operation for empyema was
practised, and a thin serous liquid was evacuated.   It
was found, on the death of the child, some weeks after-
wards, that the vessels of the lung on the diseased side
passed through a  cluster of tuberculous  glands, and
were almost obliterated, so that the circulation was im-
peded,  and serous effusion consequently occurred. 
DISEASES OF THE CHEST.
149
CHAPTER XVI.
                  OF THE  HEART.

  Of the exploration of the heart of a healthy individual.
—It is well known that the heart is placed behind the
extremity of the sternum, and  a  little to the left of it.
The left ventricle  is in advance of the right, which is
behind the other, and covered by it, except a small por-
tion of its right margin.  The greater part of the peri-
cardium is not in immediate contact with the walls of
the chest;  the lungs are protruded before the heart,
and remove  it from the cartilages of the ribs.   The
space not covered  by the lungs is rarely more than an
inch square,  and  corresponds to the anterior surface of
the right ventricle;  in  a  few individuals the whole
heart  is covered by  the lungs.   The pericardium is
closely in contact with the muscular tissue of the heart,
and in the normal state does not sensibly increase the
dimensions of this organ.
  The ventricles  form the anterior and  inferior  two-
thirds of the heart.   The left is  thicker and stronger
than the right, and forms the point of the heart which
strikes forcibly against the cartilages of the ribs.   The
cavity of  the right is larger  than  that of the  left.
The auricles are placed at the  upper part of the heart, 
150
ON THE DIAGNOSIS OF
under the sternum, and near its junction with the third
costal cartilage.
  1. Examination of the heart  by percussion.—As a
portion  of the pericardium, and consequently of  the
heart, is not covered  by the lungs, percussion on the
corresponding part of the chest must yield a dull sound,
because there is no lung, and consequently no air be-
neath it.  This space  is about  an inch  square,  or
a very little larger, and begins  at the middle of the
sternum, but does not extend to the nipple.  Its length,
in a vertical line, is about two inches from the measur-
ed base of the chest along the sternum, but at its left
margin it is less than  an inch.  The form of the space
in which the sound is  dull, is, therefore, nearly triangu-
lar; the longest side of the triangle being formed by
the sternum.   The degree of dulness varies; in corpu-
lent subjects it is of course more marked than in those
who are much emaciated.  The resonance is perfectly
sonorous in patients who are affected with emphysema,
if it be far advanced; as the lungs, when expanded,
completely cover the heart.
  2. Of the  impulsion of the heart.—In the  normal
state, the impulsion of the heart is felt opposite the car-
tilage of the fifth rib,  in a space about an inch square.
The stroke of the point of the heart may be distinctly
perceived by applying the stethoscope, the hand, or the
ear.  The  impulsion  is greater in  those  individuals
whose chests  are  contracted and thin,  than it is in
robust or corpulent persons.  It is increased by violent
exercise, mental agitation, and  fever,  and diminishes
when these causes have been removed.   Various affec-
tions, foreign to the heart itself, may increase the force
of  its  pulsations;  these are, rheumatism, chlorosis, 
DISEASES OF THE CHEST.
151
sometimes hysteria, and still more frequently the men-
tal ailments classed under the general term hypochon-
driasis.
  3. Of the sounds of the  heart.—By placing the ear
near the heart of a healthy individual, we find that
each pulsation is composed  of two distinct sounds,
which are followed by an interval of repose.   The first
sound  occupies about one-half the time of each pulsa-
tion ; the second  sound a fourth, and the interval of re-
pose nearly as much.  The first sound coincides with
the contraction of the  ventricles, and is loud  and pro-
longed ;  the second accompanies their dilatation, and is
sharp and clacking.
   There is  still some obscurity as to the causes of these
sounds,  although it has been, in a great measure, re-
moved by the experiments of Messrs. D'Espine, Hope,
Williams, and other observers. Several different theories
have been proposed, which differ but little for practical
purposes, as the physical signs of the lesions of the heart
may be explained by  either.  All the  experimenters
 agree that the first sound accompanies the contraction,
 and the second the dilatation of the ventricles, and that
 no sound is  produced by the auricles, contrary to the
 opinion of Laennec, who ascribed the second sound to
 their  contraction.   The most probable theory is that
 which attributes the second, or sharp sound, to the  mo-
 tion of the valves, and the first to the  muscular con-
 traction of the  ventricles.  This theory,  which  was
 proposed by  Dr. Williams, as a modification of the  pre-
 ceding  opinions, is apparently unexceptionable  in its
 explanation of the second sound;  but it is  not yet  cer-
 tain that the first is owing to muscular contraction. 
152
ON THE DIAGNOSIS OF
  4. Of the extent of the chest in which these sounds are
heard.—This limit varies according to the dimensions
of the chest and the thickness of its walls.   In persons
of moderate embonpoint, and well developed chest, the
heart is scarcely heard, except at the praecordial region,
or at the distance of an inch or two from it.   If the ac-
tion of the heart be excited by fever or other causes, its
sound may be heard in a much greater extent, without
indicating any organic alteration.  In this case the in-
tensity of the sound gradually becomes less, as the dis-
tance from the heart is  greater.  It  is greatest at the
praecordial region, then at the upper part of the anterior
surface of the left side, then of the right, afterwards at
the posterior surface of the chest, proceeding  from the
left to  the right side.
  If the lungs are indurated, the diseased portion con-
ducts  the sound of the heart  much better than a
healthy tissue.  It is consequently heard to a greater
distance than usual, and does not always follow the rule
just mentioned, of the diminution of its loudness, as the
distance from the heart increases.   A careless observer
may easily mistake the increased loudness of the sound
the heart  produced, by disease of the lungs,  for an
alteration of the organ.
  5. Oftlie modifications of the sounds of the heart.—Be-
sides the  increase or diminution in the loudness of the
two sounds yielded by the heart, they may be changed
in character and tone.
  The sounds may be distinct, and not differ  very ma-
terially from the normal state, although their  clearness
and sharpness are  lost.   Such  a condition frequently
accompanies diseases of the heart, in which the bellows 
DISEASES OF THE CHEST.
153
or rasping  sounds are  habitually heard; but when
these are suspended, a roughness in the murmur usu-
ally remains.   A slight harshness and intermixture of
the sounds often  accompanies a state of functional de-
rangement of the heart, without the least organic lesion.
  The  bellows  sound resembles very closely the noise
made by forcing  a current  of air steadily, and rather
quickly, through the  pipe of a large bellows.   It may
be heard in the systole or the diastole of the heart, but
is vastly more  frequent during the former.  When it
is permanent, it indicates, with great certainty, an or-
ganic disease  of the  heart; but a temporary bellows
sound is very frequent in patients who have lost much
blood by haemorrhagies, or who are affected with func-
tional disorder of the heart, arising from various causes.
  The rasping sound is much harsher, and more hiss-
ing than the bellows sound; it is not unlike the noise
made by a rasp.   It is most frequent during  the sys-
tole of the heart, and certainly indicates disease of the
valves.
  The musical bellows sound has a peculiar vibration,
analogous to the  sound produced by passing a wet
finger along the edge of a glass.  It is rare, and is rather
heard in the arteries than in the heart.
u 
154
ON THE DIAGNOSIS OF
                CHAPTER XVII.


  INFLAMMATION OF THE HEART AND ITS MEMBRANES.

  Pericarditis.—The following anatomical changes are
produced by inflammation of the pericardium.
  The serous membrane is less transparent, and as-
sumes a general reddish tinge, or is dotted with innu-
merable bright red points, from the development of
vessels in the cellular tissue beneath it.  Its secretion
soon becomes more abundant than natural, and as-
sumes the usual characters of the liquid secreted by
inflamed serous tissues.   It consists of two parts: one
is coagulating lymph, which is deposited upon the sur-
face of the pericardium, in the form of irregular granu-
lations, or in uniform layers, like the false membranes
of the pleura; the other is a  serous fluid, intermixed
with flocculi  of pus or lymph, which  give it a turbid
appearance.   As the inflammation advances, the liquid
becomes more opaque and yellowish, and increases in
quantity; the false membranes are thicker, and are ir-
regular, rugous, or  divided into a  multitude of cells,
like  a honeycomb.   The honeycomb  appearance is
owing to the constant motion of the heart, which sepa-
rates the two layers of lymph from each other, before
they are organized:  they are thickest about the origin
of the great vessels. 
DISEASES OF THE CHEST.
155
  As the pericardium is distended by  the  liquid,  it
forces the lung  aside, and comes immediately in con-
tact with the walls of the chest; it expands on every
side, but retains its pyriform shape.   The proportion
-of liquid and lymph depends partly upon the intensity
of the inflammation, and partly on  peculiarities in the
constitution of the patient.  When there is little or no
serum,  the  pericarditis is dry, and is analogous to a
form of pleurisy already described.  In very feeble
patients, the effusion consists chiefly of thin liquid,
and the membrane  is  pale, semi-opaque  and  wrinkled.
  Physical  signs.—In  the natural  state, the pericar-
dium is covered by a portion of the lung, which ex-
tends  over  its whole surface, except its inferior ex-
tremity, and the margin below the sternum.   There is
sound on percussion, but it is a little less loud where
the edge of the  lung is thin, than it is in other parts of
the chest.   The pulsations of the heart, and the normal
sounds of respiration, are both heard distinctly in the
praecordial region.  When the pericardium is inflamed,
the effusion of  liquid forces the lung from  the place
which it occupies  before the heart; consequently the
sound  on percussion becomes  dull, because a liquid
yields a flat sound, instead of the gaseous resonance of
the spongy tissue of  the lungs.
   At first there is only a moderate increase of the nor-
mal degree of obscurity; afterwards the sound becomes
flat in the situation in which it is naturally dull, and
obscure in the adjoining  parts.  In extreme cases, the
flatness extends from the base of the chest to the third
rib, and from the right margin of the sternum to the
border of the axilla.   Its form is always pyramidal—
the apex of the pyramid being towards  the upper part 
156
ON THE DIAGNOSIS OF
of the thorax.  The upper part of the left side of the
thorax yields a dull sound, although the effusion does
not extend so far; but by pressure from below upwards,
it forces the lung into a smaller space, so that it con-
tains less air than usual.   As the disease advances and
the effusion increases, the extent in which the percus-
sion is dull becomes more considerable;  but  when it
terminates favourably, the resonance rarely becomes as
perfect as it is in a  healthy chest.   The thickening of
the pericardium, and frequently adhesions between the
two surfaces of the  pleura nearest the heart, give rise
to contractions of the chest, which prevent the full de-
velopment of the lung.
  The conformation of the chest, at the praecordial re-
gion, is altered when the effusion is very considerable.
At first there is so slight a prominence that it can only
be detected by a careful inspection of the space in-
cluded between the cartilages of the fifth and seventh
ribs; but when there is as much  as a pint of liquid,
the prominence is very distinct, and nearly six inches
in length; it extends from the right side of the sternum
beyond the left nipple.
  The respiration is either very feeble or totally absent
in the praecordial region, because the lung is forced
aside.  The pulsations of the heart are also very feeble,
as the layer of liquid removes it from the  ribs, and in-
terposes a soft cushion, which impedes the transmission
of sound, and  totally destroys  the impulsion.   The
sounds are usually  unchanged in character, but there
is sometimes a distinct bellows  murmur masking the
first sound.
  When the pericarditis is  dry, there is  no preterna-
tural prominence of the chest, and little dulness on 
DISEASES OF THE CHEST.
157
percussion.   The  dulness  is slight, because the lung
still retains its position before the heart, although there
is a larger quantity of solid matter than natural, arising
from the deposit of layers of lymph.   In this variety
there is often heard a creaking sound, not unlike the
grating noise observed towards the termination of pleu-
risy.   It is owing  to the sudden separation of the two
layers  of false membrane from each other, by the con-
traction of the heart.   It may be distinguished from
the sound of pleurisy by its coincidence with the con-
traction of the heart, and not with the act of respira-
tion.   The  creaking  sound is occasionally heard to-
wards  the termination of pericarditis with effusion, as
well as in the dry  variety.
  The functional  signs of pericarditis,  like those of
pleurisy, are sometimes so well defined, that they per-
fectly  characterize the disease, while in  other cases
they may be entirely absent.   In most cases there  is
more or less pain at the praecordial region; sometimes
it is lancinating, and very sharp, and increases during
the act of inspiration.  The dyspnoea may be extreme,
and oblige the patient to lie upon his back, with his
head high, or even sit erect.   CEdema of the limbs oc-
curs in the minority of cases.   The pulse sometimes
yields  no indication of the disease; at others it is quick
and small; in rarer cases it is small, feeble, and irregu-
lar.  The irregularity of the pulse is  a less important
symptom than  it was once thought to be.  Like all
functional signs, it may be absent during the  whole
course  of a fatal case, and is very often  wanting in
milder varieties.
  Diagnosis.—In cases of pericarditis with large effu-
sion, there is no difficulty in recognizing the affection, 
158
ON THE DIAGNOSIS OF
for the pyriform prominence of the praecordial region,
the perfect flatness on percussion, and the absence of
respiration, combined with the feeble impulsion of the
heart, are pathagnomonic of the affection.   The shape
of the prominence is different from that which is ob-
served in hypertrophy, and the flatness of percussion
distinguishes pericarditis from emphysema.  The func-
tional signs may confirm the physical proof of the dis-
ease,  although  these  are  in  themselves sufficient.
When an effusion of liquid  has occurred into the left
pleura, the physical signs are less easily perceived, be-
cause  they are confounded  with those  of pleurisy, if
there be a sufficient quantity of liquid to cause dulness
of sound throughout the whole left side of the chest.
In  such cases a careful history of the  symptoms is
necessary to  prevent error.   But  if the effusion  into
the pleura be moderate, it will not encroach  upon the
praecordial region;  so that the flatness and the promi-
nence peculiar to pericarditis, may still be distinguished
from the signs of pleurisy.   The difficulty of diagnosis
is scarcely felt when the disease has been treated from
the commencement; it is consequently less in private
than  in hospital  practice.   If pericarditis  succeeds
rheumatism, its occurrence is more easily discovered
than  in idiopathic cases.
   It is now well known that pericarditis is much  more
frequent and far less fatal than  was once  believed.
The  mortality  is probably not greater  than that of
pneumonia,  for it  is common to  meet with  subjects
dead of  various diseases, who have recovered  from in-
flammations of the pericardium,  as is shown by old
and well organized adhesions.   On the  other hand,
well characterized  cases of  the disease may be traced 
DISEASES OF THE CHEST.
159
through their whole course, and finally terminate in
recovery.   For a most accurate  and complete history
of the pericarditis, and the means of recognizing it, the
medical profession is indebted to Dr. Louis.
  Endocarditis.—This term has  been given to the in-
flammation  of the  internal  membrane of  the  heart.
This affection has  been recently studied.  M. Bouil-
laud described, in the first edition of his work, numer-
ous cases in which the arteries and the internal mem-
brane of the heart were reddened.  The greater part of
these cases were  ascribed by him  to an inflammation
of the internal membrane of the arterial system; but a
more extended observation has shown that redness is not
a sufficient proof of  inflammation; it may be produced
by maceration of the vessels in  blood, or by incipient
putrefaction.  Certain  conditions of the fluids  also
favour its production.   It is now generally conceded,
that the anatomical  proof  of inflammation of the inter-
nal membrane of the heart is redness, alteration of its
colour and thickness, with deposit of albuminous mat-
ter upon its surface.
  As this affection  is  rare,  and the  diagnosis  is ex-
tremely obscure, I  will  give some of the  prominent
symptoms noticed  in the case  of  a young physician,
whose body I examined at  Paris, in the  autumn of
1833.
  He was twenty-seven years of age, had enjoyed good,
but not robust health. About the beginning of October
he'perceived an oedema of his legs, which was not at-
tended by dyspnoea or any other symptom.   A slight
diarrhoea, with anorexia, afterwards came on, but the
swelling diminished; he was then taken with pain in
the right iliac fossa.  This subsided, and no prominent 
160
ON THE DIAGNOSIS OF
 symptoms appeared  until thirty hours  before death,
 when he suddenly felt an intense pain in the region of
 the heart, and  great  dyspnoea.  These symptoms in-
 creased until they  caused intolerable anguish.  The
 intelligence of  the patient was not affected during the
 whole course of the disease.
   On examination after death, we found the external
 surface of the heart dotted with semi-opaque whitish
 granulations, less than a pin's head each; a few ounces
 of serum  were contained in the pericardium, which
 was a little injected.   The lining membrane of the left
 ventricle, of the semi-lunar valves, and of the aorta, in
 its whole  course, was reddened, semi-transparent, and
 covered with opaque granulations.  They were gener-
 ally flattened, the largest  not exceeding  the size of a
 pin's  head, and adhered with some tenacity to the mem-
 brane.  The same appearance  was presented by the
 iliac and  carotid arteries.  The vessels  of the limbs
 were  not examined.  The other viscera were inspected
 with care, but presented no evidence of disease.
  I have lately met with a similar case, but much more
 chronic, in which anasarca and ascites occurred, with-
 out any appreciable lesion being found after death, ex-
 cept redness, thickening  and patches of delicate  false
 membrane on the semi-lunar valves,  and throughout
 the whole length of the aorta.   M. Bizot, of Geneva,
 informed me that he had seen  several similar cases,
 which will be described in the work he is now prepar-
 ing upon the diseases of the arteries.   The symptoms
 of these cases were  so analogous  to  those above de-
 scribed,  that he suspected  the nature of the lesion be-
fore 'death.
  Diagnosis.—It is obvious that there are no constant 
              DISEASES OF THE CHEST.           161

physical signs of this  disease.   There may be a bel-
lows sound when the thickening of the valves is suffi-
cient to impede  their functions;  but in  the  majority
of cases the diagnosis must be based upon the presence
of oedema, dyspnoea, and  palpitations, combined with
the absence of the physical signs of pericarditis, or of
an appreciable organic affection of the heart.
v 
162
ON THE DIAGNOSIS OF
               CHAPTER XVIII.


      DISEASES OF THE VALVES OF THE HEART.

  The valves may be diseased from vegetations and
deposits of lymph upon the membrane covering them,
or their form may be altered  by a  secretion of new
matter into  their fibrous tissue.  This substance is
either cartilaginous or bony.
  When the semi-lunar valves are affected, the lesion
usually begins at their central tubercle, which increases
in size until  it may attain the dimension of a large pea.
As  the lesion extends, the  flexibility of the valves is
diminished, and they either become rigid and fixed in
such a position as to offer a permanent impediment to
the passage  of the blood through them, or they are
shrivelled, and do not unfold themselves sufficiently to
close the orifice when the  blood has passed  through
it.  In either case the harmony of the circulation
is destroyed,  and important  functional disturbance
is almost sure  to ensue.  Besides the symptoms
caused  by  changes  in  the  valves,  the  muscular
texture of the heart rarely remains unaltered when
their  function is imperfectly performed, and hyper-
trophy or  dilatation of this organ complicates the ori-
ginal lesion. 
DISEASES OF THE CHEST.
163
  The left side of the heart much more frequently of-
fers alterations of the valves than the right; they are
also  vastly more  frequent  in  the aged than  in the
young or middle  aged.   Alterations of  the valves of
the left side of the heart, like those of the arteries, are
almost necessary consequences of the progress of age,
and  are physiological changes, peculiar to  advanced
life.   Patients of strong rheumatic or gouty diathesis,
are especially subject to  lesions of the valves of the
heart, as  well as to other affections of this organ.   It
was once imagined that venereal affections were a fre-
quent cause of this lesion;  but observation has shown
that this idea is groundless.
   The practical effects of diseases  of the valves de-
 pend on obstruction to the passage of the blood, caused
 by their rigidity and fixed position, which diminish
 the  orifice when it  should be widely open; or,  the
 valves are shortened and hardened, so that they are no
 longer capable of unfolding themselves,  and closing
 accurately enough to prevent regurgitation of the blood.
 The first lesion diminishes the quantity of blood which
 passes through an orifice in a given time, and  conse-
 quently the contraction of the heart becomes more forci-
 ble, in order to disburthen the cavities by a quicker
 motion of the fluid.   It is more important than the
 simple dilatation of an orifice, as the disturbance to the
 circulation is greater, and .the general symptoms be-
 come much more embarrassing.  The regurgitation of
 the blood causes dilatation  of the cavity into which it
 returns, and afterwards more powerful efforts of the
 muscular tissue.   The lesion, to a certain extent, pro-
 vides its own remedy; but after longer  duration, ex- 
164
ON THE DIAGNOSIS OF
tensive organic alterations of the heart occur, and effu-
sions of serum take place into  the  serous cavities and
the cellular tissue of the limbs.  These consequences
occur at  an earlier stage, when the valves are perma-
nently contracted.
  Physical signs of lesions of the valves of the heart.—.
The physical signs of diseases of the valves are chiefly
derived from morbid changes in the two sounds of the
heart.  Whatever theory is received as  to the mecha-
nism and origin of these sounds, the relation between
the lesions of  the valves and the  morbid sound is the
same in each hypothesis, and may be explained almost
equally well.  It must be  recollected that one fact is
totally independent  of  all theory, and  is based upon
direct observation; that is, that the first sound is pro-
duced during the systole, and the second during the
diastole of the ventricles.
  The side affected  is  most easily known by placing
the ear at a little distance from the heart, when the
natural sounds are heard  near the healthy side, and
the morbid near the diseased  part.  If the ear, or the
stethoscope, be applied immediately over the heart, then
the morbid sound, which is commonly loud, masks that
of the pulsations of the  healthy side.  When the right
sidje only is diseased, the natural sound  may be heard
at some point  of the left side of the heart, at a little dis-
tance from it.   If the right side be healthy, and the
valves of the  left are altered, then the  best place for
hearing the pulsations of the right side is at the epigas-
trium.  If the morbid sounds of the heart are heard  at
both the right and left portions of the chest, we may
infer that both sides  of the heart are diseased, although 
DISEASES OF THE CHEST.
165
it may be the semi-lunar valves on  one side, and the
auriculo-ventricular on the other.*
  The signs  of the diseases of the valves are the bel-
lows sound, the sawing or rasping sound, heard either
during the systole, or the diastole, the purring of which
may be felt by the hand, and the state of the pulse.
   Contraction of the left auriculo-ventricular orifice.—
When this orifice  is contracted, it gives rise to a bel-
lows, rasping or filing sound, during the diastole of the ■
heart.  This fact  might have been known from the
different theories of the heart; but  it is besides con-
firmed by direct observation in all those cases in which
care was taken to note the time of  the heart's motion
corresponding to the sound.   Dr. Hope was the first to
call attention  to the fact, that contraction of the auri-
culo-ventricular orifice causes a small and intermittent
pulse, more frequently than the contraction of the aortic
valves.   The reason  of this fact is,  that little blood
passes into  the ventricle from the auricle, and, there-
fore, the arterial pulsation is small.
   Contraction of the right auricuh-ventricular orifice.—
Morbid sound in place of the second  sound of the heart,
and coinciding both with theory and direct observation.
The  pulse is much less  affected  than if  the mitral
valve be altered.
   Contraction of the  aortic  orifice.—Morbid alteration
of the first sound, indicated both by theory and obser-

  * For this test I am indebted to M. Littre, who has published an excellent
article upon affections of the valves of the heart, 3nd their signs.  (See Dic-
tionnaire de Medecine, tome viii, 2d edition.)  I  have translated from the
same author, the analysis which follows, of the lesions of the valves of the
heart, and their signs. 
166
ON THE DIAGNOSIS OF
vation.  In this case the feebleness and intermittence
of the pulse are less frequent than if the mitral valve
be contracted.  It is not unusual  to find a moderate
degree  of contraction of the  aortic orifice in cases
where the  pulse had  always been  natural; but the
pulse invariably becomes small and feeble when the con-
traction is considerable.  The pulse may confirm the
other signs, although these are sufficient  to indicate
the lesion, even when  the  pulse remains perfectly na-
tural.
   Contraction of the orifice of the pulmonary artery.—
Bellows blast in the first sound; the pulse of the pul-
monary artery, of course, cannot be felt.
   With the contraction of each of these four orifices,
there may co-exist a purring sensation, easily felt by
the  hand.   This is always present when  a  rasping
sound is heard, but not always when the contraction
merely gives rise to a bellows murmur.
   Dilatation of the mitral valve.—Bellows  sound dur-
ing the systole, proved both by observation and theory.
The pulse is in general feeble and irregular, although
the  impulse of the heart is strong; at least, this was
the  case in the small number of cases observed  by M.
Littre.
   Dilatation of the tricuspid valve.—Bellows murmur
in place of the first sound of the heart.
   Dilatation of the aortic valves.—This  lesion and its
 symptoms have  been  well described  by M. Corrigan,
 and afterwards by M. A. Guyot, in an inaugural thesis.
 It is characterized by three  principal  phenomena:
 1. Absence of the second sound of the heart, which is
 replaced by a bellows blast, very audible  at the heart 
                  DISEASES OF THE CHEST.           167

   itself, in  the ascending aorta, and  in the sub-clavian
   and carotid arteries.  2. Visible pulsation in the arteries
   of the neck, of the head, and superior extremities.
   3.  By increased force, frequency, and vibration of the
   pulse. The force of the  pulse and the visible pulsa-
   tions of the arteries, are owing to the hypertrophy of
   the left ventricle, which accompanies the dilatation of
   the valves.
     Dilatation of the pulmonary valves.—Bellows sound
   in place  of the second sound of the heart.   It origi-
•   nates in  the heart, and  is thence heard in the whole
   praecordial region, especially between the second and
   third left ribs.
      It is evident from the preceding  remarks, that if the
   morbid alteration has occurred  in the first  sound of
   the heart, there is a contraction of an arterial orifice, or
   dilatation of an auriculo-ventricular one.  If the second
   sound be altered, there is a contraction of the auriculo-
   ventricular orifice, or a dilatation of the arterial valves.
   The  last case is easily known by the bellows sound
   prolonged into the  arteries during the diastole of the
   heart.
      Diagnosis.—The diagnosis of diseases of the valves
   of the heart is plain enough, if attention be paid to the
   preceding analysis  of their signs.   But in practice,  a
   difficulty  very often  occurs from a  complication  of
   several lesions of the heart,  including more than one
   of its valves.  We  must  then analyse the sound, and
   recollect that lesions of the valves of the left side are
   more frequent than those of the right.  Hypertrophy
   and dilatation have their peculiar  signs.
      The general signs of diseases of the valves will also 
168             ON THE DIAGNOSIS OF  ■

facilitate their  diagnosis.   These are, oedema of the
inferior extremities, and, to a less extent, of the cellular
tissue  of the rest of the body, puffiness of the face,
dyspnoea, and, in more advanced  stages, paleness and
sallowness  of the skin, arising  from a diminution of
the colouring matter in the blood. 
DISEASES OF THE CHEST.
169
               CHAPTER XVIII.


    HYPERTROPHY AND DILATATION OF THE HEART.

  Hypertrophy is an increase of the muscular fibre
of the heart: it is divided into three varieties, one of
which is very frequent; the other two are extremely
rare.   It is more frequent on the left than on the right
side of the heart, and is almost confined  to the ventri-
cles.  The  increase  may  be strictly  limited  to  the
fibres composing the  middle and exterior parts  of this
organ, and  its cavity may be unaltered;  this is  the
case in simple hypertrophy.  The enlargement may
take place in the fibres composing the whole thickness
of the heart, which  thus increases  upon its internal
and external surface,  and at the same time its cavity
augments in size; this variety is called  hypertrophy,
with  dilatation or  active aneurism.  It commonly at-
tends diseases  of the valves of the heart, especially
those lesions of the semi-lunar valves of the aorta, which
allow the blood to regurgitate into  the  cavity. The
third form is that in which the muscular  fibre is thick-
ened upon the inner side of the heart, so as to diminish
its cavity;  this is also a rare lesion.
  Physical signs.—There is one sign common to all
the forms of hypertrophy of the heart; that is, an in-
crease in the impulsion of the heart against the walls
       w 
170
ON THE DIAGNOSIS OF
of the thorax. .  If the increase in size be moderate, the
impulsion is augmented at the point of the heart only;
but if it be considerable, and extend to a large part of
this organ, its whole mass seems to be lifted against the
ribs, and raises the end of the stethoscope by a sort of un-
dulating motion.  The impulsion is not quick and ab-
rupt, but gradual, and  communicates to  the ear the
sensation of  a  large body slowly rising  against the
chest, rather than that of a short, quick stroke from a
smaller one.   In the most common  variety,  that  is,
hypertrophy with dilatation, the impulse is augmented
in extent much more than  in force.   The strength of
the impulsion against a  single point of the thorax, is
sometimes not greater  than it is in a healthy heart; it
may even be  more  feeble when the circulation is im-
peded in the few days that  precede death.  This tem-
porary feebleness renders the diagnosis of such affec-
tions difficult, if the patient has not been examined at
an earlier period.
  The sound of the heart is diminished if the hyper-
trophy is simple, or if the cavity is not dilated.   The
increased thickness renders the sound less  clear and
sharp.   Sometimes the sounds are nearly lost, or con-
verted  into an obscure purring; but this is rarely ob-
served, unless the valves are at the same time mate-
rially  diseased.  The diminution of loudness is still
more evident in the second  than in the first sound.
  In hypertrophy combined with dilatation, the sound
is louder,  at  the same time  that the impulse of the
heart is increased.   As valvular disease almost always
complicates this variety, and  is its  most frequent ex-
citing cause,  we generally hear either the bellows  or
the rasping sound. 
DISEASES OF THE CHEST.
171
  The percussion is always  obscure over the heart if
there be much hypertrophy; it  is, however,  less dull
than where there is a large  effusion into the pericar-
dium.   The obscurity extends in a lateral direction,
and  in  the  form of an oval, whose long diameter is
nearly parallel to the cartilages of  the ribs; it  never
assumes the pyramidal form peculiar to cases of peri-
carditis.
  The functional signs of hypertrophy  are limited to a
preternatural force in the pulsations of the heart and
arteries, in case there is no  disease of the valves.  A
moderate degree of hypertrophy does not materially in-
terfere with the  functions of the different organs, al-
though it is said to favour the development of cerebral
diseases.  But, as in a large majority of cases, the valves
are more or less altered, a variety of symptoms  occur
to complicate those of simple enlargement.  The alter-
ations of the pulse, the oedema of the limbs, and the
difficult respiration, all belong rather to the former than
to the latter affection.

              DILATATION OF THE HEART.
  Writers on the  diseases of the heart formerly con-
sidered dilatation,  with  thinning  of  the  muscular
parietes, as  a frequent lesion.  Were  this the case,  it
would  form an  exception to the  very general law,
that dilated organs increase in thickness;  but a more
extended observation has shown that this exception did
not  exist.   It is even doubtful  whether the heart  is
ever dilated and thinned at the same time;  it is certain   '
that the lesion is at least extremely  rare.
  Dilatation and thickening  of  the heart constitute
one  of  the varieties of hypertrophy already described, 
172
ON THE DIAGNOSIS OF
and is, by far, the most frequent lesion of the muscular
tissue.  When the dilatation is great, and the thicken-
ing moderate, the disease  usually arises from  an ob-
struction to the passage of the blood through the valves;
when  the  hypertrophy  predominates,  the primitive
lesion is commonly dilatation of the valves.
   Other organic lesions of the heart, as rupture of its
parietes, ulcerations, true aneurism, and the fatty de-
generation  of the muscular tissue, are rather interest-
ing as anatomical lesions,  than as  objects  of clinical
study.  They occur so rarely, and are accompanied by
symptoms  which are so imperfectly known, that it is
not necessary to describe them in  this work.   For a
detailed description of them, the reader  is  referred to
the systematic treatises on  diseases of the heart.
   Although the organic diseases of the  heart  are ex-
tremely frequent, they are  less common than its func-
tional derangement.  The  signs of functional disease
are an uneasy sensation in  the region of  the heart,
sometimes  amounting  to positive pain; palpitations,
which are  usually diminished by exercise; a  quick,
jerking impulsion, and  increased loudness  of  sound,
with frequency of the pulse.  Patients  who complain
of these symptoms, are usually young persons of irrita-
ble nervous temperament, and are often subject to dys-
pepsia, chlorosis, or hysteria.  At first sight, it might
seem  difficult  to  draw the  distinction  between  the
functional and the organic  affections of the heart; but
the former differ  from the  latter in many respects.
Their symptoms are not permanent; they diminish by
exercise, and are increased  by the passions, or by men-
tal agitation;  there is  no  alteration of  the  sound on
percussion,  and  the  impulsion, though quick  and 
DISEASES OF THE CHEST.
173
sharp, does not  communicate to  the ear the sensation
of a large body, which seems to raise it up  from the
chest.   A bellows sound may occasionally be heard
when there is no organic lesion, but it is  not perma-
nent.
  Aneurism of the  thoracic aorta may be recognized,
by physical exploration, at a comparatively early stage,
but not until the artery is about twice its natural size.
We then find a dull sound on percussion, at the upper
part of  the sternum, loud pulsation at the same situa-
tion, and a single sound, instead of the double beating
of the heart.   A bellows sound often accompanies this
pulsation; it does not always originate in the artery, but
may be conducted by it from the heart.   Diseases of the
heart may often be  confounded with  aneurism of the
aorta, unless  great attention  be  paid  to the extent of
the impulsion and  the  signs offered by percussion.
Aneurism of the pulmonary artery cannot be distin-
guished by any certain signs, but its existence may be
suspected by a careful examination of the positive and
negative signs of cardiac diseases. 
174
ON THE DIAGNOSIS OF
CHAPTER  XIX.
  OF THE METHOD OF ACQUIRING A KNOWLEDGE  OF
               THE PHYSICAL SIGNS.

  The sounds derived from auscultation and percus-
sion, may be  easily acquired by examining the  most
clearly marked  specimens of each class,  and  then
proceeding to the study of such signs as are less  obvi-
ous.   Such a method of study is especially necessary
for those physicians who are well acquainted with the
rational symptoms of disease, but have not easy access
to large  hospitals, in which the types of each sound
may be pointed out by experienced auscultators.   By
selecting well-marked cases, and comparing  the group
of functional and physical signs  presented by the
patient, no doubt can be left upon the mind of the  phy-
sician, as to the precise identity of the case before  him.
After establishing the nature of the disease,  and recog-
nizing the physical sign, it should be studied long and
attentively enough, to leave in the mind of the physician
a clear and permanent remembrance of it.   The fol-
lowing classification of the sound includes each series,
beginning  with the most evident, and then  passing to
those which are more obscure. 
DISEASES OF THE CHEST.
175
1.  Alterations of the Respiration.
  a.  Strong bronchial or tubal respiration.—Cavernous
     respiration.
  b.  Less perfect bronchial respiration.
  c.  Rude respiration.
  d.  Amphoric respiration.

2. Of the Moist Rhonchi.
   a. Mucous rhonchus.—Gurgling.
   b* Sub-crepitant rhonchus.
   c.  Crepitant rhonchus.

3. Dry Rhonchi.
   a. Sonorous.
   b. Sibilant rhonchus.

 4. Of the Voice.
   a. Bronchophony.
   b. Pectoriloquy.
   c. Increase of natural resonance.
   d. Egophony.

   The alterations of the  sonorousness on percussion
 are:
   a. Perfect flatness.
   b. Dulness of sound.
   c. Natural resonance.
   d. Increased sonorousness.
   e. Tympanitic resonance. 
176
ON THE DIAGNOSIS OF
       OF THE VARIETIES OF THE RESPIRATION.
  To acquire the  tubal  respiration, a  patient with
pneumonia of some severity should be selected.  About
the sixth or eighth day of the disease, sometimes even
at an earlier period, a pneumonic  patient will present
the  following symptoms—cough,  viscid and rust-co-
loured sputa, pain in the side, fever, great prostration.
These symptoms occurring in a patient  previously in
good health, must indicate inflammation of the lungs, for
they occur in no other disease.  If the ear be then applied
to the posterior part of the chest, between the scapulae
and the spine, strong bronchial respiration will be heard,
in at least nineteen of twenty cases; the blowing sound
will be very distinct in the expiration and the inspiration,
but especially the former.   A very moderate degree of
attention will be sufficient to recognize this sign,  and
cases of pneumonia are so frequent, that all practition-
ers may readily meet with several  in every winter  and
spring.
  Cavernous respiration is  not always  constant,  nor
quite so  strongly characterized  as the tubal  respi-
ration of pneumonia, because the opening  into a tu-
berculous cavity is not often as unobstructed as  the
large bronchia,  at  the  root  of the  lungs.   But if a
patient be examined  in an  advanced  stage of con-
sumption, who has copious  night  sweats, loose cough
of long duration,  expectoration of puriform rounded
or irregular masses, great emaciation, and other well
known rational signs of pulmonary consumption, cavern-
ous respiration is almost certainly heard at  the upper
part of one or both lungs.  The respiration should be
examined more  than once,  for the  opening into  the 
DISEASES OF THE CHEST.
177
cavity may be obstructed, or a loud gurgling may mask
the cavernous respiration; but if the sign be sought on
several patients at different times, especially after free
expectoration, it cannot fail to be  observed, and may
then be  compared with  tubal  respiration,  which  it
closely resembles.
  From these two varieties it  is comparatively easy to
pass to the examination of the less perfect bronchial
respiration of pleurisy, and the early stages of pneu-
monia.   The characters are the same, except that the
degree of intensity and distinctness of  the blowing
sound is much less than in the tubal or  in the  cav-
ernous respiration;  it is also  most easily recognized
during  the expiration.  No difficulty exists in finding
examples of  the  bronchial respiration of pleurisy, be-
cause the dilatation of the chest, and the absolute flat-
ness on percussion, are characters  so striking that the
case is instantly  known, and  the signs of the respira-
tion can then be  studied at leisure.  The chest should
be examined at the seat of the large bronchia, opposite
the root of the lungs, where there is the least compres-
sion of the pulmonary tissue.
   The rude  or imperfect bronchial respiration may be
learned  after the other varieties  are known,  by aus-
culting the upper and anterior part of the lung of pa-
tients who have  a moderate  pleuritic effusion on the
same side.   The compression of the pulmonary tissue
in the upper part is  slight, and the vesicular murmur
is still heard, combined with a decided blowing sound,
both in the inspiration and expiration.  This variety is
also heard in deep-seated inflammations of the  lung,
 and in the early stage of phthisis.  In the latter  case,
x 
178
ON THE DIAGNOSIS OF
a careful comparison of the sound heard at the summit
of one or both lungs, with the characters of bronchial
respiration on the one side, and the vesicular murmur
on the other, will explain the sound.  The rational
signs of phthisis are here of particular necessity.
  As the respiration at  the upper part of the right lung
of healthy individuals  is always a little rude, it is im-
portant, while studying this variety of the respiration,
to auscult individuals in good health, at that portion of
the chest, and  thus  obtain a type, of  comparison be-
tween  it and that more distinct variety produced by
tuberculous masses at the summit of the lungs.

                  OF THE RHONCHI.
   1. Moist rhonchi.  (a) Mucous rhonchus.—It  is  easy
to distinguish  the mucous rhonchus  by the  strong
bubbling  or  gurgling sound, caused  by the passage of
the air through a liquid.  It  is  less easily  found in
bronchitis than in other affections, because the  disease
is usually of short duration, does  not  always present
the mucous  rhonchus, and rarely retains  it  during a
long period.  It is easy to observe the  mucous  rale in
phthisis, when much advanced.  The cavernous gurg-
ling,  which  is only an  exaggeration  of  the mucous
rhonchus, may almost  always  be heard in such cases,
and is easily known from the peculiar sound of a liquid
agitated by the passage of air.   Around and  about this
gurgling, there is generally a moist  rhonchus,  similar
in sound, but  a  little less strong and less diffused,
which is the ordinary mucous rhonchus.   Another
useful means of learning the mucous rale, is to exam-
ine patients affected with pneumonia,  when  the bron-
chial respiration  has ceased, and the  viscid or rusty 
               DISEASES OF THE CHEST.           179

sputa are replaced by a puriform liquid; the mucous
rhonchus is, in such cases, heard wThere the bronchial
respiration had before been most distinct.
  The crepitating rhonchus should be learned before
a distinct idea  can be formed of the sub-crepitating,
which is intermediate between  the crepitus and the
mucous rales.  A patient ill with pneumonia, present-
ing the bronchial respiration and symptoms described,
page  176,  should  be directed to  cough.  During the
inspiration following  the effort  of coughing,  the ear
should be  passed, with attention, over the part of the
chest where the bronchial  respiration  is found, and
then around and above this place.  The crepitant rhon-
chus, with its peculiar dry sound, will be heard in little
trains, like the crackling produced by the fifing  of
moist powder.   The crepitus is generally distinct be-
fore the development of the strong bronchial respiration,
but the type is less easily learned if other signs be not
well developed.  The sub-crepitating rhonchus may
be studied in the same case  of pneumonia which fur-
nished the specimens of bronchial respiration and cre-
pitus : it is heard when convalescence approaches, after
the disappearance of the  other sounds.  In such cases,
the expectoration is less viscid; it is mucous, or muco-
puriform, but not purulent, as it is in such cases  as
terminate in suppuration.

   2. Dry rhonchi.—These rales which are easily known
from the precise and simple description of which they
are susceptible, are heard very constantly in whooping-
cough.   When the paroxysms are frequent, children
almost  always  offer  both the sibilant and  sonorous
rhonchi, frequently combined with the mucous.  All 
180
ON THE DIAGNOSIS OF
these sounds are distinct, and can be heard at the same
time, as well as the notes of a violin and flute played
in concert.

                   OF THE VOICE.
   I have placed in the same line strong bronchophony
and  pectoriloquy.  These two sounds are so analogous,
that either of them will serve for facilitating the know-
ledge of the other.  The distinction between them con-
sists in the exact limitation of perfect pectoriloquy, and
the greater diffusion of the resonance of bronchophony.
The intensity of the sound of tubal bronchophony is at
least as great as pectoriloquy, and, in a large majority
of cases, is decidedly greater.   The distinction be-
tween the two sounds was not very clearly known to
Laennec, who seems to have, in numerous cases, taken
bronchophony for pectoriloquy.*  Bronchophony is
more easily learned than pectoriloquy, on  account of
their anatomical differences. ' The large bronchial tubes
at the root of  the lungs must always yield a strong re-
sonance of the  voice, if the pulmonary tissue around
them  be  hardened.   If the  induration is perfect, the
bronchophony is tubal;  and, like perfect pectoriloquy,
it seems to enter the ear of the observer.  Pectoriloquy,
on the other  hand, requires a complete evacuation of
the  cavity, free  communication with  the bronchia, and
moderate distance from the surface.  The method of
acquiring these two sounds is similar to that for the
bronchial and cavernous respiration, as they originate
in similar circumstances, and from the same anatomical

   * This might be inferred from the work of Laennec; it is confirmed by
 the recollection of those who were familiar with the inventor of  auscul-
 tation. 
DISEASES OF THE CHEST.
181
lesions.  One variety of pectoriloquy is easily mistaken
by  a beginner; it is that produced by a very large
cavern, in which the voice is lost, instead of being dis-
tinctly formed.  In this case, an attentive examination
of all the circumstances is requisite to prevent error.
  Simple  increase  of  the natural  resonance of the
voice, or imperfect bronchophony, may be recognized
by  familiarizing the ear with the resonance of a healthy
chest, after studying tubal respiration.  Patients offer-
ing the rational signs of consumption, not very far ad-
vanced, will present examples of this variety; the sound
is especially marked at the upper  and posterior part of
the chest.
   Egophony  is less easily recognized than the other
alterations of the voice; it should be studied  after the
alterations of the voice, just alluded  to, are  perfectly
known.  Then the thorax should be ausculted in  indi-
viduals who present the following symptoms—flatness
on percussion, diminishing  from  below upwards, mo-
derate fever, cough, white, but not viscid expectoration,
 and pain in the side.   Upon making them speak, ego-
 phony may be heard below the  scapula; by strict at-
 tention, the vibrating, squeaking sound of the voice
 will be distinguished from the loud resonance of bron-
 chophony.   A  variety  of vibrating bronchophony,
 caused by the induration of the lung, complicated with
 effusion of liquid into  the pleura, partakes of the cha-
 racters of both these alterations of the voice.
    Of percussion.—There is much difficulty in acquir-
 ing the manual dexterity necessary  to percuss  accu-
 rately.  Whatever pleximeter may be  used, the  great
 secret of percussion is to tap  with the ends, not the
 bulbs  of  the fingers,  as quickly as  possible, but  not 
182
ON THE DIAGNOSIS OF
forcibly.   Forcible  percussion annoys the patient, but
does not render the sound clearer.   The best example
of entire absence of sound is chronic  pleurisy, with
large effusion;  next to this is pneumonia, if it extend
to a large portion of the lung.  As pleurisy, with much
effusion,  is  more  rare than pneumonia, it  may be
necessary to select the latter disease, and at the same
time that the strong bronchial respiration and broncho-
phony are developed, the percussion is perfectly flat.
  There is no  difficulty in finding a multitude  of
examples of  dulness of  sound:  both pleurisy, pneu-
monia, and the different stages of phthisis afford good
specimens.   The same cases which offered the per-
fectly flat sound, will yield a dull one when the disease
abates, and the  gradual  passage from  the one to the
other is then easily traced.
  The natural sonorousness of the chest is, of course,
found in all healthy subjects, but it is difficult to form
a just idea  of what it  ought to be, unless patients
with increased resonance of the thorax are occasionally
observed.
  The best  example of  preternatural sonorousness of
the chest, is to be sought in emphysema of the lungs.
The. functional signs united to the conformation of the
chest are sufficient to characterize the advanced cases
of the disease, in which the resonance is, of course,
greatest.   A  patient past the middle period of life, who
is subject to attacks of great dyspnoea, followed by the
expectoration of watery frothy saliva, and who is habit-
ually short breathed, with an  unusual development
and roundness of his  chest, is surely emphysematous.
Such a patient will offer  a great increase of the natural
resonance of the thorax,  particularly at  the prominent 
DISEASES OF THE CHEST.
183
portions.  All persons emaciated by chronic dysentery,
or diseases of other organs than the thoracic viscera,
yield a loud sound  on percussion, but never so loud as
in emphysema.
   The tympanitic resonance of pneumo-thorax is pecu-
liar, and can only be confounded with that from enor-
mous cavities.   It is too rare for purposes of study, but
when it occurs, a physician tolerably practised in aus-
cultation, will have no difficulty in its diagnosis.
   The  signs indicating the  various diseases of the
heart, are usually well marked, but their relative value
and precise  connexion with the  lesions,  are not yet
sufficiently ascertained for systematic analysis. 
 
 
n.n
 
PL I
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EXPLANATION  OF  THE  PLATES.
  Plate I—indicates the division of the thorax into regions.
These  are three in number, on each side of the chest, but are
unequal in extent.  The upper regions are the common seat of the
tuberculous deposit, and in that case they yield a duller sound
on percussion than usual.   In health, the sound is clear at the
anterior part of the chest, but less sonorous posteriorly, on ac-
count of the large muscles of the scapula.   The middle and in-
ferior regions of the anterior  surface, are the  common seat  of
emphysema, when they yield a clearer sound than usual.   The
middle posterior portions yield  an obscure sound  when the
lung is hepatized from pneumonia, or there is a very extensive
tuberculous deposit.   The inferior regions, including the lower
part of the axillae, are very sonorous naturally, but become dull
when  an effusion of serum or pus has  been  deposited in the
cavity of the pleurae.

  Plate  II—represents  a dissection of the  larger bronchial
tubes.   They are opened at their posterior portion.   It will  be
seen that the bronchi, which pass to the upper lobe of the right
lung, are much shorter and larger than those of the left, which
follow a circuitous course, beneath the arch of the aorta, as seen
in the plate.  Near the  extremity of one  of the bronchial tubes,
on  the right side, are two small  dilatations, in one of which
there were some fragments of tuberculous matter.  These dila-
tations were evidently  cicatrized  cavities.   In other respects,
both  lungs  were perfectly sound, and  the dissection  of the
bronchi, given in the plate, was afterwards repeated in a num-
ber of healthy lungs.
        Y 
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