the absence of those sounds and changes which are sufficiently distinct and characteristic—a condition to be expected in all earlier stages of pectoral troubles.
A life-insurance agent brings to his company's medical examiner an individual whom he considers an exceptionally "good risk." He has the facial appearance, the physique, and record of perfect health. The examiner, in making up the rigid descriptive list for his company, must assure them, as "parties of the first part," that in this case the sounds of the heart are perfectly natural; that its movements are entirely correct as regards their rhythm, strength, and frequency; that the pulse does not intermit, etc.; and that there is no disease or morbid condition, or tendency thereto. Tested by the spirometer, the applicant is found to breathe easily the amount of air known to be the average for persons of his size (more strictly, height). By the usual tests of auscultation nothing is found wrong. On a more scrutinizing review of the case, as becomes the faithful officer who is to be the impartial judge on the trial, a small area is found near the upper portion of one lung where, by percussion, the normal resonance has given place to a degree of dullness—a sound which signifies the half-way limit between the resonance of perfect health and the "flatness" of advanced change.
This quality of sound would pass unobserved, except for easy comparison with the adjacent portion of the same lung, and with the corresponding part of the opposite one. The dullness is found to be better shown by light percussion than by more forcible strokes—an indication of the superficial situation of the changed tissue.
On again applying the stethoscope over the region, the natural vesicular quality of the inspiratory murmur is found to be changed to the broncho-vesicular murmur—indicating partial solidification of lung, which, if more complete, would give the bronchial or tubular sound. The pitch of its tone is raised, and it is "rough" or "harsh." A sound of expiration is also heard distinctly, while normally it is barely audible.
There are now three facts which tend to becloud the otherwise good record of the case.
A further test may be made by auscultation of the applicant's voice. On applying the stethoscope upon the place mentioned, the subject is required to speak or count in his ordinary tone of voice. There will be heard sounds apparently near the ear, approaching in distinctness to words—not articulate, as would be heard in complete solidification, but easily distinguished from the distant jarring sound of a healthy lung, called vocal fremitus.
The applicant has now through his own honest voice given adverse testimony. Try next whether he shall whisper a confirmation of the same unfavorable story. The whispering voice heard through solidified lung-tissue is increased in intensity and raised in pitch.
