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CHAPTER XVII.

OUTLINE OF PHYSICAL SIGNS OF VARIETIES AND STAGES OF PULMONARY CONSUMPTION.

Signs of Phthisis originating in BronchitisOf Pneumonia passing into PhthisisSuppurationSigns of Congestion leading to Phthisis or EmphysemaSigns of miliary TuberclesSigns of increasing DiseaseSofteningExcavationCorruptionSigns of Cure, and arrest of ConsumptionCompletePartialResiduary Lesions and SignsCalcareous Expectoration.

There has been so much said on the pathology and clinical history of consumptive diseases, that we cannot afford space for a complete separate description of their signs and symptoms. It must suffice to sketch the most common and remarkable physical signs which attend the development and progress of phthisis in its chief varieties.

When a common cough or bronchial cold turns to consumption, there will generally be an increase of the signs of bronchitis in particular spots, especially in the upper portions of the lungs. Below a clavicle, or at or above a scapula, a persistent sonorous or sibilant rhonchus, or still more any degree of crepitus, is suspicious; and the more so, if these signs are confined to these parts. In general capillary bronchitis there is also crepitus; but, then, it is more in the lower than in the upper regions. All fine crepitus may be taken as a sign of the parenchyma being either congested or inflamed; and the finer, the sharper, and closer to the ear—the more purely vesicular, like the crepitation of pneumonia. But the crepitus of early phthisis is not like this; it is more subcrepitant, crumpBRONCHITIS PASSING INTO PHTHISIS. 169

ling, or mere roughening, of inspiratory sound, and often accompanies the expiratory, which the crepitation of pneumonia never does. The natural vesicular breath-sound is impaired, or superseded, by the crepitation, except when it is so slight as only to roughen it. Fine crepitus, with or instead of the breath-sound, signifies some intermitting or vibrating obstruction to the entry of air into the lung tissue, such as may be produced by swelling and increased secretion of the bronchioles and air-cells. Now, wherever these sounds of crepitating obstruction are heard, it may be inferred that some plastic or histotrophic change is going on-—sarcophytes are at work, proliferating and migrating, whether for euplastic or for phthino-plastic results: therefore does the sign at its first appearance demand attention.

Soon other signs follow, indicating the partial consolidation of the lung. The sound on percussion becomes duller, very slightly it may be at first, but still perceptible on careful manipulation, and on comparison of the . two sides of the chest. Then may come also the tubular sounds, usually inaudible through the ill-conducting lung texture, but now transmitted through its becoming more solid. These are hardly distinct where and whilst the crepitation prevails; but as this diminishes with increased obstruction, in situations overlying considerable bronchi, below the clavicle, above, within, and at tke scapulae, and in the axillary and middle dorsal regions, the sound of air passing into and out of the tubes is heard, having more or less of a whining or sharper blowing quality, which contrasts well with the soft diffused character of vesicular breath-sound. Often too, but not always, the morbid sound differs in an increase in loudness and duration of the expiratory sound, which is hardly audible in natural breath. This is not one and the same thing as tubular breath-sound, for although this commonly includes it, yet expiration is sometimes long and loud, without being tubular. It would take too much space to discuss and explain the whole of this subject; and it may be stated that, besides the ordinary loud expiration of tubular breathsound, transmitted from the large tubes, expiration may be made audible and prolonged by any resistance to the escape of air through the small tubes, short of producing a rhonchus or wheeze (which is a totally different sound), and such a resistance may be caused by tubercles or other solids outside these tubes. So likewise the expiratory part of tubular breath-sound is increased in intensity, by partial obstructions in the large bronchi, as at the root of the lungs, from pressure of enlarged bronchial glands; in the trachea, from goitre or aneurism; in the larynx, from constricted glottis; and even in the throat by enlarged tonsils. Exaggerated tubular sounds of this kind may sometimes be heard through every part of the lungs, where there is no disease, but then may readily be traced back to their source. Excluding such extreme cases, tubular sounds near the root of the lung, especially the right, heard above and within the scapulae, are among the earliest and most common signs of disease in the lungs; and it is rare to find a case with mischief in other parts of the lung of any duration, without this becoming manifest. But I have before explained that it may arise from an enlargement of the bronchial glands, without involving the lung tissue; and whilst we recognise its significance, as proving an infection of part of the lymphatic system, we must not accept it as an indication of the consolidation reaching into the lung, without the additional evidence of dulness on percussion, bronchophony, or impaired, or crepitating vesicular sound in the part.

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Bronchophony, or tubular voice, does not always accompany tubular breath-sound. It generally requires more consolidation to transmit it, and a greater freedom PNEUMONIA PASSING INTO PHTHISIS.

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of the tubes from constriction and secretion. It is most heard in vicinity of large tubes, like tubular breath; and its combination with this forms the snuffling or whispering bronchophony so ominous under a clavicle, or above a scapula. Over smaller tubes it has often a reedy quality, as in the mammary and subscapular regions.

If phthisical tendency prevails, soon signs of softening and excavation follow, in increase of crepitation in one or more spots, looser and coarser, or of more croaking character, generally with diminished breath-sound, and small crepitation around. These spots, soon becoming cavities, form little islands of cavernous voice and breath-sound, first mixed with coarse crepitus or gurgling; afterwards, more croaky and dry, with the characteristic pectoriloquy, and the occasional concomitant, cracked-pot, or chinking percussion. When the cavities become large, the souffle voilee, or cavernous puff with the cough; the amphoric resonance or metallic tinkling, which I long ago explained as an echo from the walls of the cavity, give decisive information of the ravages of the consuming disease in the lung.

Thus, in bronchitis passing into phthisis, there is a gradual transition of the signs of the former into those of the latter. In the variety when the phthino-plasms are peribronchial, there is a longer persistence of bronchial rhonchi, sonorous, sibilant and mucous, giving the disease a wheezy or asthmatic character, until softening ensues and cavities form, which relieve the constrictions.

Acute pneumonia passing into phthisis, from the hepatisation being a plastic or of cheesy nature, is marked by the persistent dulness and by the same loud1 tubular

'The remarkable loudness of the tabular sounds of a completely hepatised lung has not to my knowledge been satisfactorily explained. The 'consonance' of Skoda is not applicable, inasmuch as it would require a certain relation between the sound of the voice and the size of the tube, aq sounds, and other signs of consolidation giving place to coarse liquid crackling or gurgling, commonly in the central or superior portions of the lung, and the signs of one large or of several small cavities soon follow, to announce the rapid destruction in this form of galloping consumption.

The signs of suppuration of the lung, or abscess ending in phthisis, are those of one or more cavities forming and extending; and of tubercles or other phthinoplasms forming in other parts—such as crepitus, dulness, and tubular sounds at or near the apex of the opposite lung, which may have been previously sound.

The more common mode in which pneumonia or pleuropneumonia terminates in phthisis, is through the chronic consolidation, which they leave behind them, instead of dispersing, becoming phthinoplasms — that is, degenerating into fibroid and caseous matter, the one dwindling and contracting—the other softening and disintegrating—the affected tissues of the lung. The course

in the case of the reciprocating notes of tubes or chords. But I believe the true explanation to lie in the fact that, whereas the lungs are naturally constructed to destroy the vocal sound by the tubes ending in a spongy texture, which thoroughly damps or chokes all sonorous vibration—no sooner is this spongy tissue made solid than the tubes become reflecting cavities, capable of reverberating the voice with all the loudness which it has in the trauueu, and the vocal vibrations are not only heard, but may be felt by the hand applied over the part. Thus the voice is not only better conducted, as supposed by Laennec, but it is also greatly intensified, by the solidification of the lung. There is yet another acoustic effect developed in the tubes of a consolidated lung, which explains the loudness and almost musical tone of its tubular breath-sound. Naturally the air passes to and fro in the tubes and air-cells, and although its passage causes the breath-sound, and any accidental rhonchus in the tubes, yet this prevents any longitudinal vibrations in the whole tube. But when the tubes are stopped at their vesicular end by consolidation, the air breathed no longer passes through them, but passing across their open ends, in its way to and from the still pervious lung, it may cause a hollow whistling sound like that produced by blowing across the open mout h of a panpipe. The same principles are applicable to some sounds heard in cavities in the lungs.

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