CHAP. IV. FIRST STAGE: AUSCULTATION-continued. Wavy inspiration Sound, and its Mechanism and Diagnosis. Divided inspiration Sound, and its Mechanism and Diagnosis. - Differential Stethoscope. -Jerky inspiration Sound. THE vesicular inspiration murmur of healthy lung is an even, continuous, and uniform sound, observing the same pitch and character throughout its whole duration. But at an early period of phthisis, in its first stage, though later than the period for the advent of harsh respiration, this uniformity is frequently lost, and the murmur falls and rises in pitch and intensity, it may be, one, two, or even three times during its continuance. Were the murmur denoted by a line, it would assume this form: I have generally found the murmur that is thus deprived of its uniformity to be harsh, and I think the murmur is rather more harsh just after its fall. The murmur is such, so coarse and harsh, that I am disposed to think it is generally a good deal made up of the friction sounds of the ultimate and penultimate bronchial tubules. I have very frequently observed this waviness or undulation of breath sound in company with symptoms and other physical signs, calculated to support the inference that tubercle, in a crude dry form, was present in the lung. My late respected friend, and my predecessor in the office of Physician to the Hospital for Consumption, Dr. Theophilus Thompson, paid particular attention to this sign, and, as far as I am aware, was the first observer to call attention to it. He believed it to form good evidence of the presence of tubercle in a nascent or crude unsoftened state. He has designated this modified breath sound as wavy respiration. According to my experience, it is frequently found at one apex, the diseased one in phthisis, when tubercle in a dry state has been laid down to an inconsiderable extent, and I accept it as a corroboratory sign, together with other evidence. This waviness is due to the presence of an obstructing force to the suction of air into the vesicles, consisting in the loss of the dilatability of the lung structure to a degree sufficient to produce a retarding effect without even for an instant WAVY AND DIVIDED RESPIRATION. 15 absolutely stopping the movement of the air. If this explanation be correct, the expiration should be prolonged in such cases, for the increased density of the lung and the compressed state of the tubules should suffice to prolong the outward movement of the air. Now, in such cases, we have this very effect, and the expiration sound is distinctly long and coarse. I have reason to believe that wavy inspiration is not unfrequently present when no tubercles or other morbid depositions are in operation. The respiratory movements of the muscles of delicate and agitated females sometimes act irregularly and with the loss of their normal uniformity; and the result is, that the suction power being irregularly exercised, the motion sounds of the incoming air are irregular also, and acquire an undulatory character. Such an undulatory condition of the inspiratory sound, however, is to be distinguished by the undulation caused by tubercle, by the former being heard on those sides of the chest, per totum thoracem, while in the latter case, the waviness is confined, for the most part, to one or other apex, or if found in both, the long expiration sound, and such other signs as a click, will be present to reduce the difficulty. The waving inspiration sound of nervousness is not followed by long expiration sound, except when the inspiration has been unusually long. I have heard the wavy inspiration in many nervous females free from phthisis, and I have often heard it when the heart has been rapid in its action from nervous excitement. When the heart has been much agitated, the wavy inspiration sound has sometimes been heard mostly or entirely on the left side of the chest, and this has arisen possibly from pressure exercised by the heart and great vessels on the lung. The waviness of phthisical inspiration is constant; that of nervousness is more or less inconstant or variable, and is reduced during periods of tranquillity. Instead of the sound of inspiration in phthisis being wavy as described, it not unfrequently is observed to be divided into two or three distinct and completely separate parts. This has been noticed by writers, and is described as divided respiration. I have very frequently heard it in cases of lung heavily laden with tubercle, while the opposite lung has been healthy; but I have also heard it by no means rarely in lung far advanced in the first stage of phthisis, while the other lung has been the seat of cavities, and has indeed become almost useless as an aerating organ. If we would represent divided inspiration sound by a line, it would take this form: The blank or dotted parts represent the intervals. These intervals are generally about equal in duration with the separate parts of the sound. The intervals, however, vary in duration, as do indeed the separate parts of the sound. This divided condition of the inspiratory sound is due to the same physical condition of the lung, which gives rise to the undulatory or rising and falling inspiratory sound in phthisis, viz. to the presence of an undue resistance to the in-passing columns of air; but in this case the obstacle is more complete, and, instead of simply somewhat checking or reducing the movement, puts an absolute stop to it, until the increasing and accumulating force of the inspiratory efforts overcomes the resistance, and draws in the air again, sometimes with an additional velocity, giving rise again to an augmented sound, i. e. augmented compared with the first part of the inspiratory sound. The divided sound is more frequently associated with tubercles than the undulatory or rising and falling sound, and is more seldom due to nervous action. But I have no doubt whatever that a divided inspiratory sound does not necessarily indicate either the presence of tubercles or of solidification from any cause. It is occasionally due to thickening of the mucous coats of the tubules of the lobules, and to an adhesive condition of their walls. The column of air enters so far; it is stopped by an adhering condition of the tubules; sound is suspended; with the accumulating force the adhering walls of the tubules are separated, air passes on, emitting its sound; the tubules collapse again, and, adhering, sound is suspended; the tubules are again forced open, the air is urged forward, and sound is emitted once more. An illustration of the division of a sound, uniform and continuous in health, by the operation of a cause such as I have described, occurs to me and seems worthy of notice here. During the presence of a congested and irritable state of the mucous membrane of the nostrils from an attack of catarrh, I have frequently listened to the sound of inspiration through the nostrils, and I have frequently observed that the sound has been divided into separate parts. When the sound has been suspended, I have felt the opposite sides of the nostrils to adhere; when the sound has returned, and it has done so suddenly, I have felt the sides to separate, and at the same time I have heard a clicking or separating bruit. The differential stethoscope, both in respect of undulating and divided inspiration sounds, gives very satisfactory results. The undulating or divided character of inspiration sound at one point is satisfactorily contrasted with the continuous inspiration sound in another part, by successive experiments. These abnormal inspiratory sounds in one part are readily compared with sounds approaching them in another part. When the differential stethoscope is simultaneously employed with its two cups respectively applied over the seat of these abnormal sounds and over the seat of healthy respiration sound, the two sounds, the healthy and the unhealthy, are heard separately through the ears respectively connected with them, and thus the mind of the auscultator is strongly and remarkably impressed with the difference of the two inspiratory sounds of the two parts under examination. The wavy and the divided inspiratory sounds have sometimes been designated jerky. The divided sound is more frequently the subject of the quality implied. The jerky sound is loud, and reaches the ear in successive jerks. It is not uncommonly associated with phthisis, but is frequently the associate of mere nervous disorders. CHAP. V. FIRST STAGE: AUSCULTATION-continued. Expiration: Loudness, Coarseness, Prolongation. - Prolongation of compensatory Respiration. - Associated Sounds. Mechanism. Differential Stethoscope. Hydrostatic Pneumatoscope. Protracted uno-aural Audition. -Curious Results from differential Stethoscope, with inspiratory and expiratory Sounds.-Restriction and Alternation of Sounds.-Want of acoustic Symmetry from other Causes. -Expiration of other Diseases. — Respiratory Interval. THE expiratory sound of vesicular respiration is very early affected in phthisis, and it speaks with a force nearly equal to that of inspiration, in reference to the disease, and the early stage, being regarded with more force than the visible movements of the chest, the vocal fremitus or resonance, or the percussion note. The partial occupation of a few vesicles in some few lobules of the apex of a lung by tubercular corpuscles, may not sensibly affect the expiratory sound, but I am convinced, that if the tubercular deposition be such as sensibly to increase the weight of a portion of the lung, to reduce its power of contractility, to press unduly upon the terminal tubules of a few lobules, the sound will be materially с modified, and that this modification, regarded in its combinations and deprivations, so to speak, will afford most valuable materials for deciding, at a very early period, on the presence or absence of phthisis. The first morbid alteration in the vesicular expiratory bruit, which we observe in incipient phthisis, and perhaps, in not a few examples, the very first physical sign, is an increase of loudness or elevation. In healthy lung, the expiratory murmur is more feeble than the inspiratory, and is not audible without more attention than is required for the hearing of the inspiration sound. It is difficult to express in words degrees of loudness, but it may convey some idea of the comparative intensity of the two sounds, to say that there is not merely a shade of difference, but that the mind will readily admit that between them there may be several degrees. Were we to attempt to express by figures the loudness of healthy inspiration and expiration, 4 might be set down to represent inspiration, and 1 expiration, or if we employed symbols, the following might be held to be tolerably correct. Inspiration. Expiration. In phthisis in the first stage, this order constantly tends to change. The inspiration sound is approached in loudness by the expiration sound. As the deposition of tubercle proceeds, we observe that the expiration sound becomes louder than the inspiration sound; and this latter sound, instead of being four times louder than the other, reaches in some cases only to a fourth part of the intensity of the expiration sound. The inspiration sound has lost, while the expiration sound has greatly gained, in intensity. The expiratory bruit of incipient phthisis, thus strengthened, is heard at one apex, viz. that selected for the deposition of tubercle, sometimes, rather rarely, at both, when, as in some cases, chiefly those in which a strong tendency to phthisis is made out, both lungs are found very early implicated. This loudness of expiration sound, may be confounded with a certain loudness of expiration which attends the puerile respiration of over-dilated, over-working healthy |