80 PRACTICE OF MEDICINE. 



patient's mouth, strikes the other ear ; but the utterance is never so 

 distinct. When heard to this degree in parts where there is naturally 

 little or no resonance of the voice, it proves beyond doubt the exist- 

 ence of a cavity communicating with the bronchi. 



By imperfect 'pectoriloquy is meant that form in which the voice 

 does not seem to enter the stethoscope, but only to resound at the 

 end. This sign cannot be relied upon when heard in the sternal 

 half of the infraclavian and mammary regions, the axillge, and in- 

 terscapular spaces. 



There is yet another class of sounds to be spoken of. It was said 

 before, that the pleura sometimes ulcerates, so that a communication 

 is formed between a vomica and the pleural cavity. In consequence 

 of this aperture, air passes at each inspiration into the pleural cavity, 

 whilst the lung collapses ; and more or less liquid will also escape 

 from the vomicae. The spot where this perforation occurs, is gene- 

 rally, says Dr. Watson, opposite to the angle of the third or fourth 

 rib. The indications of this state of things will be, 1st, great clear- 

 ness on percussion ; 2d, complete absence of respiratory murmur ; 

 3d, a peculiar resonance of the voice, breathing, and cough, called 

 by the French amphoric resonance. This is a sound of metallic 

 character, and greatly resembles that produced by speaking or 

 coughing over an empty barrel or copper boiler, or by blowing into 

 an empty bottle ; 4thly, there is occasionally a tinkling sound of a 

 metallic character, produced by the fall of a drop of liquid from the 

 upper to the lower part of the cavity. 



Now, these four sounds, all indicating, as they do, the existence 

 of a large cavity containing air and liquid, and communicating with 

 the trachea, are generally caused by pneumo-thorax, as before said. 

 But they may also, though very rarely, be caused by the presence 

 of a very large vomica. In this case they will only be heard in the 

 upper part of the chest, and instead of great clearness, there will be 

 extreme dulness on percussion. 



Of the sjmtujn. — In pulmonary consumption, there is no constant 

 relation between the appearances of the expectorated matter and the 

 state of the lung. In many cases, it is not at all characteristic ; 

 indeed, it may be mucous while large cavities exist in the lung, or 

 purulent from bronchial irritation. Dr. Forbes observes — " In the 

 earliest stage of the disease, the cough is either quite dry, or attended 

 by a mere watery or slightly viscid, frothy, and colourless fluid : 

 this, on the approach of the second stage, gradually changes into an 

 opaque, greenish, thicker fluid, intermixed with small lines or fine 

 streaks, of a yellow colour. At this period, also, the sputa are in- 

 termixed with small specks of a dead white or slightly yellow colour, 

 varying from the size of a pin's head to that of a grain of rice, and 

 which have been compared by Bayle to this grain when boiled. 

 These have been noticed by many writers, from Hippocrates down- 



