SOUNDS AND ORGANIC ALTERATIONS.

29

CHAP. VI.

FIRST STAGE: AUSCULTATION-continued.

The vesicular Sounds of the First Stage vary much according to the various physical Conditions of the diseased Lung.

THE various forms of departure from the normal conditions of the vesicular sounds just described, and from their periods and intervals, although present during some part of the first stage of phthisis, if we except that generally very short time during the deposition of tubercle in extremely fine points. not larger than pin-heads, and only thinly scattered over one apex, or even throughout a considerable portion of the lung. But the extent to which these various acoustic departures form the healthy state varies to a very great degree at different periods of the first stage, according to the extent of organic change, and to the various morbid physical conditions of the diseased lung itself. Though we speak of phthisis in its first stage, and though we must have in this stage one condition always present, viz. crude tubercle corpuscles, either in defined masses, or infiltrated throughout the tissue, forming ever a great character in common; and though this character is so important, in the great proportion of examples of phthisis which we see, as to form a most useful and broad obvious line of demarcation from phthisis in its second and third stages, still the practical physician has no alternative but to confess that, in taking a full survey of the first stage, the presence of tubercle in the condition of consistent deposit or infiltrated tubercle without softening and disintegration of the surrounding lung structure, is but a highly imperfect exponent of the actual physical condition of the lung. For we find differences in the actual physical characters, in respect of weight, consistence, elasticity, inflatability, liquid infiltration, conduct in respect of sound both in its origination and transmission, of lung at different periods of the first stage of phthisis, in different examples of the disease, so great as to separate the specimens widely asunder; and even in some cases to force upon us the conviction that more difference exists between these examples of the first stage, than is to be found between other cases, some of which belong to the first, some to the second, and some to the third stage. For instance, we may have in the

first stage great consolidation, in the second, very partial softening, and in the third, a very small quiet cavity.

It is unnecessary in this place, to describe fully the very different physical conditions of lung, which we find in different examples of phthisis in the first stage, for these will be treated of in their proper place; but it may be useful at this moment to enforce the principle that we cannot have the same acoustic results from lung having only a few scattered minute pin-head like spots or points of tubercle throughout, giving a scarcely sensible addition to its weight and resistance, and from lung which we often find still only in the first stage of the disease, rendered obviously to the eye fuller and rounder, non-collapsing under the weight of the atmosphere; greatly increased in weight, gorged with blood, scantily inflated with air, pressing effectually upon even the larger bronchi and blood-vessels, and densely studded with large masses of yellow tubercle, the size of garden peas, filling the finer tubules of the lungs in cylindrical forms and imparting to the incised surface as much of a tubercular and solid as a vesicular aspect.

Such differences in the coarser physical conditions of the lung lead to differences in the acoustic properties of the lungs, and we therefore look in vain for precisely the same characters of vesicular respiration in all examples of the first stage of phthisis. The roughness and coarseness of respiration sounds will be faint at first, and will increase for some time with the progressive deposition of tubercle. This sign will then be succeeded by deficiency of sounds, or be replaced by an entirely new sound, viz. bronchial or pipe breathing sound, as in the progress of the disease the vesicular structure of the lungs is obliterated or rendered uninflatable, and the inspired and expired air passes along, merely through constricted and narrowed bronchial pipes, and fails to penetrate cellular structure and to produce that healthy vesicular sound which attends this act. Obliterated bronchial tubes, compressed by masses of tubercle and the presence of liquid secretion in still pervious tubes, cannot fail to impress new characters, such as sibilant and sonorous rhonchi, upon the respiration sounds; and such conditions, rare in the first period of the first stage, are common before the commencement of the second. Constricted and congested pipes will succeed in drowning or eclipsing the minor sounds of harsh, rather harsh, feeble, and deficient inspiratory and coarse expiratory bruits.

FIRST STAGE: AUSCULTATION-continued.

Bronchna Sounds. Localities. In various Diseases. Rarity in acute Phthisis. Features in different Stages. Heard through differential Stethoscope. - Curious acoustic Results. — Mechanism of Sounds. during first Stage.

Conduct

WHEN in the first stage of phthisis the amount of tubercle has become so great as to fill up most of the vesicles of some considerable part of a lobe, or by means of pressure to render them or many of them uninflatable, and when the bronchial tubes of larger or quill-like size are yet left patent and free enough to be filled with air during the act of inspiration, then we have a bruit different from that of vesicular respiration, and resembling the bruit produced by air passing quickly along pipes of the size indicated. This kind of respiration sound is called bronchial breathing sound. It is usually found at an advanced period of the first stage, follows the period of rough and deficient respiration sound, and precedes the moist crepitation of the second stage of the disease. The sound seems to proceed from tubes offering no fine or numerous points for friction such as are presented by the vesicles and terminal bronchi. It seems to be of larger volume than rough vesicular breathing. It is wanting or deficient in multiplied or rustling character. The inspiratory act presents it, but it generally attends likewise the expiratory function. The sound is generally that of air passing with tolerable ease and at a moderate rate, but it occasionally becomes quick, noisy, and whiffing, as if the current were quickened and friction were increased by means of the pipe calibre being reduced. This character of whiffing is noticed when, beyond a dense mass of lung, a portion of lung is still inflatable, which is supplied by bronchi passing through or near the morbid mass. This tubular breathing sound, as it is sometimes called when appertaining to phthisis in the first stage, is generally located in one apex, but it is frequently found at both, and obviously for this reason, that it corresponds to a comparatively advanced period of the disease, when it is usual to find both lungs implicated. It is readily found above the clavicles and immediately under them. It is most decisive when found near the humeral extremities of these bones. I have frequently found this form of breathing

sound more pronounced during expiration than during inspiration. Its phthisical origin is strengthened, i. e. rendered more probable, when it is associated with dullness on percussion, increased vocal fremitus, particularly if on the left side; by great distinctness and strength of the thoracic voice, by a degree of flattening of the chest, occasional hoarseness of the oral voice, and by its (pipe sound) absence at the base and lateral regions, except in very advanced cases. When heard at the base and lateral region in a marked manner, it may be dependent upon hepatisation, the result of intercurrent inflammation, but this will be revealed by the history of the case and the dull percussion note. This sign may be dependent upon partial pressure on the bronchi from aneurismal tumours of the aorta, mediastinal tumours chiefly cancerous, and from cancer of the lung itself, generally connected with cancer of the mediastinum; but the limited area of dullness, the presence of dyspnoea to excess, the absence of the characteristic sputa of phthisis, and the signs of obstructed circulation, such as dropsy, varicose veins of chest and neck, will suffice to justify the exclusion of phthisis, and lead to a correct diagnosis.

Bronchial respiration sound, though usually present during the latter portion of the first stage of phthisis, and particularly in the chronic form of the disease, may not be recognised at all in some cases. The examples of the disease, in which we most frequently fail to find bronchial respiration or bronchnœa, as I propose to call it, are those in which the rapid deposition of miliary or small tubercles is early followed by ramollisement of the structure of the lung, and with copious secretion denoted by much moist large crepitation, the sounds of which obscure the sound of bronchnoea. The signs of the second stage, and even the third stage, so soon succeed to those of deposit in some acute cases, that time is not afforded for the establishment of a separate marked period of bronchnoea, of any but the shortest duration.

Though bronchnoea bruits are common attendants upon the later periods of the first stage of the disease, they are heard occasionally in the second and third, and care must be taken to ascertain to what stage they appertain, and this may be done with certainty in nearly every example.

Bronchnoa bruits may be heard in the second stage when the moist crepitation and fine moist cavernulous sounds are faint, and when the bronchial tubes remain patent and free from accumulating secretions or exudations, when the respiration is forcibly carried on, and when the lung structure is

more than usually dense and heavy, and has thus become a cause of increased resonance, and is free from vesicular respiration. When the moist sounds abate from temporary causes checking secretion, bronchnoea sounds are heard for a time, but in a few hours, or in a few days, the moist sounds return and these sensorially silence the bronchnca bruits. Sometimes the second stage is arrested, the progress of softening no longer proceeds, the secretions are permanently checked, the loud moist large crepitation departs or becomes rare and feeble, and the lung previously softening becomes firmer in structure. Feeble pipe respiration may be then established and become permanent. These facts should serve to guard against our mistaking the bronchnoa sound of the first for that of the second stage of the disease.

The third stage of phthisis may restore bronchnoea sounds or produce them for the first time. The moist crepitation and fine cavernulous sounds of the second stage having ceased, by the expulsion of the broken down lung, and the formation of a silent cavity free from secretion or friction or creaking sounds, the proper pipe or bronchnoea bruits may be reestablished. This is by no means an uncommon occurrence; and though bronchnoea sounds are more especially the sounds of the first stage of phthisis, they are to be regarded as the not unfrequent attendants of that disease in its third stage when the conditions of the cavity or cavities are such as have been referred to. The finest example, perhaps, of bronchnoea respiration sound which I have lately had, was one in a young lady (C. H.) I lately examined, having a large cavity on the left side, dry and silent. In this case the respiration, including inspiration and expiration, was loud, but of short duration. The sound was that of air passing through a tube half an inch in diameter. The inspiration was continuous and uniform, while the expiration was distinctly divided into two parts. The cavity was denoted unequivocally alike by the history of the case, the presence of superficial articulating, non-vibratory pectoriloquy, the retraction of the costal cartilages and the intercostal spaces, and the short dull sound of percussion. By such accompaniments we are enabled to distinguish the bronchnoea sounds of the third stage from those of the first stage of phthisis, with which we are now more particularly concerned.

The bronchnoea bruits of phthisis are satisfactorily made out by means of the ordinary stethoscope. But the employment of the differential stethoscope will be found highly useful in enforcing, as it were, at once upon the mind of the

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