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observe in L'Union Médicale for June 16th, 1860, that Dr. Woillez has reported to the Société Médicale des Hôpitaux the particulars of a case in which the same sound was detected. Dr. Woillez's case occurred in the person of a young man, aged 22, a medical student at Vienna, who had a peculiar thoracic deformity. This patient, though delicate, had experienced no inconvenience in breathing, nor pulmonary disease. There was also in him no hereditary predisposition to thoracic disorder. In the anterior part of his chest there was an irregularly oval depression, funnel-shaped, nearly ten inches long, in the vertical direction, i. e. from the commencement of the cleft of the sternum and internal portion of the clavicles as far down as the level of the epigastrium ; seven inches in the transverse direction; and two inches and three quarters deep. Apart from this deformity, the general conformation was satisfactory; there was no lateral deviation of the vertebral column. In a word, there was simply extreme depression of the sternum.
The physical signs presented by Dr. Woillez's patient were peculiar. On percussion, there was a slightly dull sound at the level of the centre of the heart. On auscultation, the maximum of the impulse and of the sounds of the heart was distinctly perceptible at the level of the cartilage of the third left rib, and these sounds were normal. At the apex the sounds were obscured by a portion of lung, the vesicular murmur being here discernible. The respiratory movements were mainly by the upper ribs. The
respiratory sounds were weak in the two sides of the thorax, but tolerably strong in the axillary region on the right side. On the left side of the thorax posteriorly, the beatings of the aorta were distinct. These beatings were heard in the upper part of the back, immediately to the left of the spine; but diverged from it in proceeding downwards to a distance of about two inches and a half, opposite to the deepest point of the sternal depression. At this point a sound was distinguishable, very different from the simple arterial sounds perceptible above. The arterial sound heard at the level stated, was not uniform nor well defined : if the patient were told to hold his breath, an intermitting vascular sound was heard, regular and synchronous with the pulse, and which was neither a blowing sound, nor a rasping sound, nor a simple arterial bruissement, but a sound manifestly granulous in character, beginning and ceasing with the beating of the artery, but without an analogue in the anomalous vascular sounds which have been described. Moreover, when the patient was made to resume his breathing, immediately the normal vesicular murmur and the aortic sound were heard again. Each new examination, often repeated, produced identical results. · A propos of the aorta, Dr. Woillez explains the cause of the “granulous murmur” as follows: “The aorta, being several centimètres distant on the outside of the vertebral column, was necessarily surrounded on all parts except behind by pulmonary tissue ; for the respiratory murmur was heard to the inner as well as to the outer side of the aorta. At the level of the maximum of the anterior sternal depression there
fore, the contiguity of the lung and of the aorta must have been very close, whence the rubbing of the pulmonary tissue at each aortic dilatation gave a granular sound, as if the air were driven successively from several pulmonary cells.” This explanation of the sound heard by Dr. Woillez is the same as that which I had already given in the cases reported above. I name this fact specially, because, from a note which he has made on those cases, he seems to have misinterpreted my reading of the phenomenon, and to convey a difference of opinion between us which in reality does not exist.
DIAGNOSIS OF PULSATILE PULMONIC CREPITATION,
DIFFERENTIAL AND ABSOLUTE. Differential Diagnosis. There are four physical signs of disease, diagnosable by the stethoscope and by percussion, with which pulsatile crepitation may be confused. These are:
MINUTE Mucous Rale. Pneumonic Crepitation, at first sight, and on careless analysis of facts, may easily be confounded with pulsatile crepitation; for it usually happens, that this lastnamed specific sound is heralded by an acute inflammatory paroxysm, in which there is much thoracic and febrile disturbance. The distinction in diagnosis rests on two broad differences. 1st, the pulsatile crepitation is louder and coarser than ever occurs in pneu
monia. 2nd, The crepitation is not absolutely governed by respiration : it is not absent when the breath is held, but is then most fully developed ; it is presented in alternation with inspiration and expiration, during ordinary breathing, but is always synchronous with the beat of the heart or the pulse. 3rd, It is localised to particular points; i. e., to points where a portion of lung, a pulsating organ, and an opposing thoracic wall, are all brought into one focus.
Tubercular Crepitation may be co-existent with pulsatile pulmonic crepitation, in the same case. But tubercular crepitation may be known by the ear directly as a different phenomenon. If the tubercular sound be that which indicates an early stage of tuberculosis, its fine pneumonic character is sufficiently differential. If the tubercular crepitation indicate a late stage of tuberculosis, the moist character of the crepitation is equally differential : for the pulsatile crepitation, though loud and coarse, is essentially dry. Add to this, that the tubercular crepitation is independent of any pulsation, and is governed purely by the respiratory acts, and the distinction between the two phenomena is sufficiently clear.
Moist Frictional Crepitation, occurring in cases where, with tubercular deposit situated on the outer surface of the lung, there is slight pleuritic effusion, might be mistaken for pulsatile crepitation by the unwary; for in these cases the abnormal sound is superficial. But the crepitation in these tubercular pleurisies is moist and small, and is brought out only by a respiratory act. I have seen two cases where,
with tubercle in the lower anterior margin of the left lung, there was moist pleuritic friction; and, the impulse of the heart being plainly perceptible over the same region, a certain analogy was detectible, as between the sound thus induced and the pulsatile sound. But, on careful inquiry in both patients, the fineness and moistness of the crepitation, and its occurrence independently of the cardiac rhythm, were so obvious that no doubt could remain as to the diagnosis.
Minute Mucous Rule, occurring from effusion into the finer bronchial ramifications, is the last sound with which I am conversant, as possibly mistakeable with pulsatile crepitation. But every one who can distinguish a râle from a crepitation, can distinguish the difference required for this diagnosis; not to say, further, that the râle is synchronous with respiration and independent of the circulation,—not pulsatile.
Add, lastly, to all these facts, this one: that whereas, in cases of pneumonic crepitation, acute tubercular crepitation, moist frictional crepitation, or minute mucous râle, there is dulness on percussion over the seat of the auscultatory sound, while there is resonance on percussion over the seat of pulsatile crepitation; and the differential diagnosis is as perfect as can be desired.
Absolute Diagnosis. Pulsatile pulmonic crepitation is a loud harsh crackling sound, resembling that which may be produced by inflating a piece of lung-tissue, and, during the inflation, making forcible quick compression of the lung, so as to dislodge rapidly the air from the vesicles. The