A manual of auscultation and percussion

Preface

Hardly had auscultation been created by the genius of Laennec, than it was welcomed as one of the most precious discoveries by all those who are interested in the progress of medicine. The signal services that it renders to the science of diagnosis, cannot be called in doubt by whomsoever will take the pains to make himself acquainted with the working of the new method. The invention was too great not to strike impartial minds at once. The emulation to which it gave birth, the efforts that were afterwards made, either to give greater precision to its results, or to enlarge its domain, are a proof of its importance; and the extension which observers have given to it, the happy applications which have been made of it to the more exact and complete study of the diseases of the circulatory apparatus, to obstetrics and to surgery, testify 1* vi

PREFACE.

to the impulse which it has given to the whole science of medicine.

Nurtured by the study of the magnificent work of Laenncc, we have for a number of years abandoned ourselves with ardor to the practice of auscultation • and after having displayed in oral lessons the principles of stethoscopy; after having taught its application at the bedside of the sick ; we thought that a book would facilitate its study, and spread the knowledge of it. It has appeared to us useful to collect into a treatise the precepts of Laennec, the facts that he proved, and the new discoveries wbich have resulted from the labor of observers in all countries.

Besides, we have not limited ourselves to gathering up tbese scattered elements of science : being both of us hospital physicians, and devoted to clinic observation, we have added our own knowledge to the treatise, both by criticizing the facts of which auscultation is composed, and by some new discoveries.

In the study of the symptoms which come to the knowledge of the physician by the medium of hearing, we have taken care to establish the rules whose practice is of consequence to the exact perception of sensations; then we have

PREFACE.

VU described the sonorous phenomena perceptible in the physiological and pathological conditions. Then having pointed out a single morbid sound, we have examined its characteristics, its differential diagnosis, its signification, and its semeiological value.

"We desire those who are entirely novices in auscultation, to hold fast to this treatise at first, but afterwards, when their senses are more exercised, and their medical knowledge more extensive, to recur to its data, either to enlighten doubtful points, or to complete their first opinions.

In adding to the Compendium of Auscultation an appendix, in which we succinctly expose the principal ideas relative to percussion, we have not pretended, in so small a number of pages, to compose a treatise on pleximetry. But, as in practice the two methods are constant!}7" assisting each other, we thought that to bring together their data, and to display their results, as it were, simultaneously, would facilitate the study of the physical diagnosis of diseases.

In closing, let us repeat what we have said before.

We have studied facts without preconceived opinions, without preoccupation of theories, and viii

PREFACE.

without respect to persons; we have spoken them with sincerity; and when we have combated opinions which were in opposition to our own, we hope that we have done it with that decorum of language which belongs to scientific discussions. In everything we have had but one aim, utility; but one motive, the love of truth. We wish also to preserve our liberty of thought, convinced of the correctness of our opinions, and in the mean time ready to modify them if our own researches, or those of others, should prove to us that truth is to be found elsewhere. To change thus is to follow progress, and it is towards progress that all our efforts shall tend.*

* Extracted from the larger work of Messrs. Barth and Koger, " Traite" Pratique d'Auscultation, &c. Paris. 1865."— Trans.

CHAPTER I. Auscultation of the Respiratory Apparatus

PAGE

Art. I. — The Respiratory Murmur, . . 13 \ 1. Normal Respiration, .... 13 \ 2. Changes in the Respiratory Murmur, 14 1st. Changes in Intensity, .... 14

A. Strong or Puerile Respiration, . 15

B. Feeble Respiration, ... 15

C. Respiration that is Null, . . 16 2d. Changes in Rhythm, . . 17 3d. Changes in Character, .... 18

A. Harsh Respiration, ... 18

B. Bronchial or Tubal Respiration, . 19

C. Cavernous Respiration, ... 20

D. Amphoric Respiration, ... 21 § 3. Changes by Anomalous Sounds, . . 21

First Kind— Rattling (Rales), ... 23 1st. Vibrating Rattles, . . . .23 2d. Blebby Rattling, 24

A. Crepitating Rattle, ' . . .24

B. Subcrepitating Rattle, ... 25

C. Cavernous Rattle, .... 27 Appendix, . . . • - .28

X

TABLE OF CONTENTS.

Art. II. — Auscultation of the Voice, . . 28

A. The Exaggerated Resounding of the

Voice, or Slight Bronchophony, . 29

B. The Bronchial Voice, ... 29

C. The Tremulous Voice, ... 30

D. The Cavernous Voice, ... 31

E. Amphoric Voice, .... 32

Art. III. — Auscultation of the Cough, . . 32

Metallic Tinkling, .... 34

Sound of Thoracic Fluctuations, . 35

Art. IV. — Auscultation of the Larynx, . 35

CHAPTER II. Auscultation of the Circulatory Apparatus

Art. I. — Auscultation of the Heart, . . 38

1st. Changes of Seat, 41

2d. Changes in Intensity and Extent, . 42 3d. Changes in Rhythm, . . . .43

4th. Changes in Character, ... 45

5th. Anomalous Sounds of the Heart, . 46

First Kind— Sounds of Souffle, ... 47

A. Soft Sound of Souffle, ... 47

B. Sounds of Rasp, File, and Saw, . 55

C. Musical Sounds, Whistling, "Whin-

ing (piaulement), . . .56

Second Kind — Sounds of Friction, . . 57

TABLE OF CONTENTS.

xi

PAGE

Art. II. — Auscultation of the Great Vessels, 58

1. Aortic Sounds, 59

2. Vascular Sounds, 62

A. Arterial Sounds, .... 63

B. Vascular Sounds, Venous and

Mixed, 64

Chapter II. — Circulatory Apparatus, . Ill Percussion of the Heart and the Great Vessels,. 11

\ 2. Physiological Phenomena, . . . 112 I 3. Pathological Phenomena, . . . .114

Sec. II. Percussion or the Abdomen, . . 11

\ 2. Physiological Phenomena, . . .11 \ 3. Pathological Phenomena, . . .12

Sec. III. Percussion of the Head, the Neck,

the Spine, and the Members, . 150

Percussion and Auscultation Combined,

MANUAL OF

AUSCULTATION AND PERCUSSION.

Chapter I.

Auscultation of % ILesgiratorg Apparatus.

The auscultation of the respiratory apparatus is exercised upon the thorax, and upon the laryngotracheal tube; it has for its object, the study of three orders of phenomena, furnished by the respiratory murmur, the voice, and the cough.

AET. X.

THE RESPIRATORY MURMUR. \ 1. Normal Respiration.

If, in the physiological state; the ear is applied to the breast of a person breathing, there is heard a light murmur, analogous to that which is produced by a person sleeping peacefully, or heaving a deep sigh; this is the

AUSCULTATION.

natural respiratory sound, or the vesicular murmur. Soft and mellow to the ear, it is composed cf two distinct sounds, that of inspiration, which is more intense and more prolonged, and that of expiration.

The vesicular murmur is strongest in those points which correspond to a greater thickness of the lungs; it is a little more harsh towards the roots of the bronchi (normal bronchial respiration). Equal on both sides, in those points which correspond to each other, it is in some persons a little more intense at the top of the right lung. More loud when the respiration is full and rapid ; its force is also increased in children (puerile respiration); on the contrary it is weaker in the old. Generally its intensity increases in proportion as the chest is large, and its walls are thin.

\ 2. Changes in the Respiratory Murmur.

These may be divided into four classes, — 1st. Changes in intensity ; 2d, in rhythm ; 3d. in character; 4th, alteration by anomalous sounds.

1st. Changes in Intensity.

Considered under this point of view, respiration may be either strong, feeble, or null.

CHANGES IN INTENSITY.

A. Strong or Puerile Respiration. — This consists of a vesicular murmur, whose intensity is greater than in the normal state, preserving however the soft and mellow character of the respiration. It announces not so much a lesion in the pulmonary organs, in that point at which it is heard, as disease in a portion more or less distant, the healthy parts in this case supplying the inaction of the affected parts.

B. Feeble Respiration. — This is characterized by a diminution in the normal force of the vesicular murmur, the latter preserving at times its natural softness, at times becoming a little more harsh. This proceeds either from the sound being transmitted less completely to the ear, or being produced with less intensity.

In the first case, this feeble expiration may be caused by pleuritic effusions, by thick pse udo-membranes deposited upon the pleural, or by tumors, which remove the lung from the walls of the thorax.

In the second case, its causes will be recognized as pleurodynia, contractions of the larynx, partial obstruction of one or more of the bronchial branches by a mass of mucus, or by a foreign body; the narrowing of their

AUSCULTATION.

cavity or the compression of their walls by tumors. It is also met with in pulmonary emphysema, and in the first degree of phthisis.

Of all the diseases that we have just enumerated, and which are often made known by a feeble respiration, tubercles, pulmonary emphysema, and liquid effusions within the pleura being much the most frequent (bronchitis, which is also common, has its own especial rattling'), the physician ought to devote his attention almost exclusively to these. If the feebleness of the vesicular murmur coincides with an exaggerated sonorousness of the thorax, there is emphysema; with dulness, there are tubercles or there is pleural effusion. If feeble respiration, accompanied by dulness, is limited to the top of the lung, there are probably tubercles; if it is circumscribed below, there is probably pleuritic effusion ; if it exists at the two apexes, there are almost certainly tubercles of the two sides; if it exists at the base of the two lungs, there is double pleurisy, or rather double dropsy of the chest.

C. Respiration that is Null. — We say that the respiration is null when the ear, applied to the chest, hears absolutely nothing; the vesicular murmur is also wanting, and no

CHANGES IN RHYTHM.

sound takes its place; the silence is complete.

Respiration that is null is governed by the same physical conditions as feeble respiration, consequently it announces the same diseases, with this difference, that it indicates more decided anatomic lesions. But the complete silence of the respiratory murmur being nearly exceptional in emphysema and in tubercles; the diseases of the larynx revealing themselves by especial phenomena; the obliteration of the bronchi, their obstruction by foreign bodies, as well as pneumothorax without perforation, etc., being rare affections in comparison with liquid effusions within the pleura, it results from these facts, that respiration which is null is a symptom of very great value, a frequent indication of these effusions, and, as most frequently, pleurisy is single, and dropsy of the chest is double, it follows that the silence of the respiratory murmur, declared by a single side of the chest, almost certainly announces pleurisy with effusion.

2d. Changes in Rhythm.

Respiration which is changed in rhythm, may be slow (from twelve to seven inspira-

2*

AI SCULI ATION.

tions in a minute) as in many diseases of the cerebrospinal apparatus, or frequent (from 30 to 80) as in a great number of thoracic or abdominal affections. Sometimes it is jerky, in asthma, in pleurodynia, at the commencement of phthisis, in chronic pleurisy with adhesions, etc.

Sometimes it is long, sometimes short; finally at times there is prolonged expiration, and then almost always the respiratory sound is at the same time more harsh.

Of these different changes, the last alone is of importance in diagnosis. We may say that prolonged expiration is the indication of two diseases alone : pulmonary emphysema, or tubercles at the stage of formation. In some cases, it is the first or only stethoscopic symptom of phthisis,

3d. Changes in Character.

A. Harsh Respiration. — This displays various degrees of force, of harshness, of dryness, and these changes affect both expiration and inspiration, or either alone.

It is met with in emphysema of the lung, at the commencement of phthisis, finally in all cases where there is pulmonary induration (melanosis, chronic pneumonia, etc.) Of all

CHANGES IN CHARACTER.

these diseases emphysema and phthisis most frequently produce harshness in the respiratory sound. If this harshness is joined to dryness, coincident with hollowness and exaggerated sonorousness of the thorax, it indicates pulmonary emphysema; if harsh respiration is accompanied by a sound of prolonged expiration, if it is limited to the top of the chest, with resonance of the voice, and dulness on percussion, we must diagnosticate newly formed tubercles.

B. Bronchial or Tubal Respiration. — Remarkable at once for an augmentation of intensity, and a more elevated tone, bronchial respiration is well imitated by inhaling and exhaling through the hand, when rounded to a tube, or through the stethoscope ; the more swiftly and forcibly we breathe, the more nearly we approach the tubal breathing.

When it is slightly marked, bronchial respiration differs but little from harsh respiration, of which it is but an exaggeration. When well defined, it has a peculiar tone — tubal — which serves to distinguish it from cavernous respiration, which generally has a hollow character peculiar to itself.

Bronchial respiration may be heard in a great number of affections of the pleurse, of

AUSCULTATION.

the bronchi, and especially of the lungs, such as inflammatory hepatization, considerable agglomeration of tuberculous matter, extended pulmonary apoplexies, etc.; liquid effusions of the pleurae, various tumors compressing the lung; finally, uniform dilatation of the bronchi, with hardening of the surrounding tissue.

Of all these diseases, the most frequent are pulmonary phthisis, pleurisy, and pneumonia.

If this bronchial respiration is but little marked, circumscribed at the top of the thorax, and supervening on a chronic disease, it should be attributed to the presence of newly formed tubercles in the parenchyma of the luns;. If the bronchial murmur is more intense, if it shows itself in an acute affection of the chest, we can only think of pleurisy or pneumonia; if it is proportioned neither to the intensity nor to the extent of the dulness of the thorax, it is rather the indication of pleuritic effusion ; if, on the contrary, it is intense, truly tubal, and if it is perceived in the whole extent of the dulness, there is reason to believe in the existence of pulmonary hepatization.

C. Cavernous Respiration. — This resembles the sound which is made by breathing into

CHANGES BY ANOMALOUS SOUNDS.

a hollow space. It is imitated by inspiring and expiring- with force into the two hands, placed in the form of a cavity. Its habitual seat is in the top of the chest.

It announces the dilatation of a bronchus into a somewhat voluminous cavity, or the existence of a cavern, properly speaking. But on account of the rareness of bronchial dilatations and of pulmonary excavations following abscess, gangrene, etc., compared to the frequenc}7 of phthisis, we may conclude that, nine times in ten, cavernous respiration will indicate a cavern resulting from the softening of tubercles.

J). Amphoric Respiration. — This is a resounding noise, a metallic tone, which is well imitated by blowing into a hollow pitcher, or into a decanter with resounding sides. It coincides almost always with the metallic tinkling. Well-marked amphoric respiration indicates almost infallibly pneumothorax with pulmonary fistula. Ill-defined, it may announce the same disease, but be the symptom also of a vast cavern, almost always tuberculous.

\ 3. Changes by Anomalous Sounds. Anomalous sounds are of two kinds, — rattling and the sound of friction.

AUSCULTATION.

First Kind. — Sound of Friction.

Pleuritic Friction. — The two leaves of the pleura, in their normal condition, glide upon each other in silence during the motion of the lungs; but when certain pathological conditions are met with, there is a friction accompanied by noise. Pleuritic friction, somewhat analogous to the rubbing of parchment more or less dry, is generally jerky, and as if composed of several successive crackings. It presents varieties of harshness and of intensity, which has been the cause of admitting two varieties — a gentle friction, or grazing, and a harsh friction or scraping. When it is very strong, it may be felt by the hand applied to the thorax; at times the patient himself can feel it. In order to produce the sound of friction, the leaves of the pleura, or at least one of them, must present asperities, and they must glide upon each other in the motion of raising and depressing the ribs. These asperities depend almost always on the presence of false membranes, deposited on the surface of the pleune.

We meet with pleuritic friction in pleurisy, in certain cases of tubercles of the pleura, without adhesions, in some other organic

RATTLING.

changes of this membrane, and very rarely in some varieties of pulmonary emphysema; but most frequently this phenomenon indicates pleurisy in process of cure. If it were heard exclusively at the top of the chest, we might suspect tuberculous pleurisy.

Second Kind. — Rattling. (Rales.)

Rattlings are anomalous noises formed during the act of breathing by the air, as it traverses the air-passages. They mix with the respiratory murmur, and obscure it, or completely replace it. We divide them into two groups: the first called dry, or vibrating, because they consist only of variable sounds; the others humid, or blebby, because they are caused by blebs.

1st. Vibrating Rattles. — "We comprehend under this name the two principal varieties of the sonorous rattle, the acute or sibilant sonorous, and the grave or snoring sonorous. The first consists of a whistling, more or less acute; the second is characterized by a graver musical sound, which resembles the snoring of a man asleep, or, rather, the sound which a base chord gives under the finger. Often united, at times they alternate and displace each other.

AUSCULTATION.

The sonorous rattle may be heard in a great number of diseases, such as pulmonary emphysema, phlegmasy, or catarrh of the bronchi, and the compression of these conduits by tumors situated within the passage. These morbid states are various, but they all have a common element, — namely, the momentary or permanent contraction of one point or another in the air-passages.

By reason of the frequency of bronchial catarrhs, and the comparative rareness of other morbid conditions, in which snoring or whistling can manifest themselves, the sonorous rattle announces almost certainly a state of inflammation, or of fluxion in the bronchi.

2d. Blebby Rattling. — This comprehends the crepitating, the subcrepitating, and the cavernous.

A. Crepitating Battle. — The crepitating or vesicular rhonchus presents to the ear the sensation of a fine and dry crackling, analogous to the sound which is produced by salt when made to crackle by a gentle heat in a basin, or to the sound which is heard on pressing between the fingers a lamina of aerated lung. Its blebs, perceived exclusively in inspiration, are very small, very numerous,

RATTLING.

equal in volume, and a little dry. Its seat of predilection is the posterior and inferior part of the chest, on a single side.

The crepitating rattle is found in pneumonia, in certain forms of pulmonary congestion, in oedema, and in apoplexy of the lung.

By reason of the extreme frequency of inflammation of the lung, opposed to the comparative rarity of oedema and of apoplexy, the crepitating rhonchus — ahove all, when its characteristics are very decided — is the almost pathognomonic symptom of pneumonia, at the period of choking (engouement).

B. Subcrepitating Battle {mucous, bronchial, humid). — The subcrepitating has been justly compared to the sound which is perceived by blowing with a straw into soapsuds. The varying volume of its blebs must distinguish it into fine, middling, and coarse subcrepitating; the number of the blebs and their character are equally variable. The rattle accompanies both inspiration and expiration, and its place of election is the inferior and posterior part of the chest, on both sides.

The subcrepitating rattle maybe perceived in a number of diseases, such as bronchitis in the second stage, different kinds of catarrh of the pulmonary mucous membrane, the 3

AUSCULTATION.

dilatation of the bronchi with supersecretion, certain forms of pulmonary congestion and apoplexy, and phthisis at the beginning of the softening of the tubercles.

Of all these affections, the two most frequent are bronchitis, and .tubercles at the beginning of the softening stage. The manifestation of the subcrepitating rattle will cause us then to think first of those two diseases, and it is the knowledge of the seat of predilection of the rhonchus which will guide the diagnosis. If the blebs, being very numerous at the base of the two lungs, diminish as the ear of the observer approaches the top of the chest, the existence of bronchitis is almost certain; if, on the contrary, being absent or scarce at the base of the thorax, they are heard above, especially on a single side, and become more and more evident and numerous as we rise in auscultating, we must diagnosticate tubercles at the softening stage.

In certain cases of bronchitis complicated with pleurisy, accompanied by compression of the more flexible parts of the lung, the humid rattling, perceived at the middle and posterior regions of the chest, assumes sometimes the character of a true gurgling, capable of making us infer serious lesions, but

RATTLING.

which disappears by degrees without leaving any traces. In other analogous cases, with more considerable pressing back of the lung, there is heard at times under the clavicle a humid rattle with great blebs, which would cause us to believe in the presence of pulmonary cavities, but which depends in reality only on bronchial mucus collected in the branches of the superior lobe.

C. Cavernous Rattle (gurgling). — This rattle is formed by blebs, very numerous, large, and unequal, and mixed with cavernous respiration; it is this mixture which forms its distinctive character. Perceived in inspiration and expiration, it is generally circumscribed at the top of one of the two lungs. Sometimes the rhonchus, while seated in the superior portion of the chest, has very small blebs, with a clearer tone, unmixed with cavernous respiration. This is the cavern ulous rattle.

The cavernous rhonchus announces the existence of a pulmonary excavation, or of a neighboring abscess, communicating with the bronchi, or, perhaps, bronchial dilatation. If it coincides with the cavernous voice and has its seat at the apex of the lung, it is the almost certain indication of tuberculous excavation.

AUSCULTATION.

Appendix

There are still several anomalous sounds different from the preceding, and giving to the ear the sensation of rubbing, of a plaintive cry, or of the clapping of a valve. These phenomena, which are rare, are generally connected with pulmonary excavations.

A tinal sound, much more important, consists of a series of small crepitatk>ns, at first dry, afterwards humid, and which, being generally perceived at the top of the chest, are one of the most characteristic symptoms of tubercles about to soften.

-A-ZELT. IX.

AUSCULTATION OF THE VOICE.

If we auscultate upon the larynx of a person speaking, the vocal sounds resound with noise under the stethoscope, and strike the ear with force. Along the trachea this reso-

AUSCULTATION OF THE VOICE.

■29 nance is a little less grave and less intense, and upon the chest we hear only a confused hum (bourdonnement). The natural resonance of the voice which represents exactly all the varieties of the voice itself, is as much more intense as the latter is stronger, and more sonorous, as we auscultate nearer the great bronchial tubes, and as the chest is larger and its walls more thin ; equal on both sides in corresponding points, it is a little more marked towards the apex of the right lung, because of the greater diameter of the principal bronchial tube upon this side.

In the pathological state at times the vocal resonance is only exaggerated, again it suffers at the same time modifications in nature, and the voice becomes bronchial, tremulous, cavernous, amphoric.

A. The exaggerated resounding of the voice, or slight broncho-phony, is characterized by a resonance of the voice a little stronger than is natural, and it is only one degree less than the bronchial voice, true bronchophony. It is connected with changes generally similar but less extensive or less marked.

B. The bronchial voice is a resonance much stronger than is normal; it is remarkable for its intensity, its extent, its fixedness, its per-

3*

:)0

AUSCULTATION.

manence. It almost always coincides with the bronchial respiration. It maybe verified in dilatation of the bronchi, in pleurisy, and above all in induration of the lung. But on account of the rarity of dilatation of the bronchi, it is almost always pulmonary induration which is announced by bronchophony. Now of all the changes in which the density of the lung is augmented, pneumonia and tubercles are incomparably the most frequent. The conditions of the bronchial voice being better fulfilled in pneumonia than in tubercles, this voice is more decided in the former disease than in the latter; it scarcely exists except in certain cases of pleurisy, and if at that time it is strong and extensive, we may infer that the pleuritic effusion is complicated by pneumonic or tuberculous induration.

C. The tremulous voice (ajgophony) is a peculiar resonance when the voice takes a harsher tone, and becomes more tremulous and jerky. At times it sounds as if the patient spoke with a counter placed between the teeth and the lips (Polichinello voice). It is usually heard on a single side in the inferior half of the infra-spinata fossa, and when it occupies a more considerable extent, it is in this point still that it is the most decided; it may change

AUSCULTATION OF THE VOICE.

its seat in different positions of the patient. It coincides almost always with the weakness or absence of the vesicular murmur at the base of the chest.

True eegophony announces a pleural effusion, which is almost always serious. If it is perceived on one side alone, with coincidence of fever, there is pleurisy ; if on both sides, without fever, and with general dropsy, there is hydrothorax. If it appears in the course of a phlegmasy of the pulmonary parenchyma, and if besides, it changes its place as the patient changes his position, it indicates pleuro-pneumonia.

D. The cavernous voice (pectoriloquy). — The voice is cavernous, if it seems to us, in auscultating a speaking patient, that the vocal vibrations are concentrated into a hollow space, whose walls return the sounds to the ear, more or less distinctly articulated.

It is generally circumscribed at the superior part of the chest, and coincides either with the cavernous rattle, or, especially, with cavernous respiration.

Cavernous voice, like cavernous breathing, indicates the existence of bronchial dilatation of tuberculous, purulent, apoplectic, or gangrenous excavation.

AUSCULTATION.

From the rarity of bronchial dilatations, and of pulmonary excavations, independent of phthisis, compared to the frequency of caverns in consumptive patients, we conclude that nine times in ten, cavernous voice announces tuberculous excavation.

E. Amphoric voice is characterized by a resonance entirely similar to the metallic and cavernous hum which is produced in speaking through the neck of a great pitcher threequarters empty. It usually coincides with amphoric respiration, and announces, like it, pneumothorax, and more rarely, a vast pulmonary excavation.

-A-IK-T. III.

AUSCULTATION OF THE COUGH.

If the ear be applied to the chest of a healthy man, we perceive when he coughs, a dull and confused sound, accompanied by a concussion which shakes the pectoral cav-

AUSCULTATION OF THE COUGH. 33 ity. This phenomenon, compounded of impulsion and of noise, is more perceptible as it passes nearer the ear, and in the more voluminous bronchial tubes, and when the patient coughs with more force. The cough heard upon the larynx and trachea, and, in subjects with a narrow chest, at the root of the bronchi, is somewhat cavernous, and gives the sensation of the rapid passage of air into a tube. In the pathological state, the cough offers especial characteristics ; it is bronchial or tubal, cavernous, amphoric.

When the cough is tubal, the ear feels the sensation that would be given by a column of air, traversing with much noise, force, and rapidity, tubes with solid sides. It shows itself under the same conditions as bronchial respiration, and above all, is connected with pulmonary hepatization.

The cavernous cough consists of a resonance, stronger and especially more hollow than that of the normal cough. It is accompanied by an impulsion against the ear which is entirely characteristic. It is one of the most positive symptoms of a pulmonary cavity.

The amphoric cough is characterized by a very distinct metallic resonance ; it announces, when joined to the amphoric respi-

AUSCULTATION.

ration and voice, the existence of pneumo-hydrothorax, or of a vast pulmonary excavation.

METALLIC TINKLING.

This name is given to a little silvery sound, single or multiplied, similar to the sound which is produced by letting one or more grains of sand fall into a metallic cup. It accompanies the respiration and voice, but it is generally more distinct during the cough. It announces the existence either of a very great pulmonary cavern, or of pneumothorax, or of hydropneumothorax, with or without fistulous perforation of the bronchi.

Because of the rarity of caverns sufficiently spacious to cause this phenomenon, the metallic tinkling, when it is well marked, is almost always the indication of pneumothorax. As the gaseous effusions of the pleura rarely .exist without liquid collection, or without pulmonary perforation, if the tinkling is produced constantly and distinctly, by respiration and by the voice, it is a pathognomonical symptom of hydropneumothorax, with fistulous communication of the pleura and bronchi.