Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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nic hepatization ; but other parts are not excluded from the same cause.

4. Diffused over a considerable portion of the chest in hemorrhages
and destructive processes within the substance of the lungs.

5. In malignant diseases of the lungs, where the pulmonary tissue
is pushed aside and the air is excluded from the parts affected by
cancerous or fungous growth.

Diseases of i\i.Q pleura cause a dull percussion sound —
1. "In pleuritic effusion, no matter whether the fluid be blood, serum,
or pus. The dulness in either case may, and generally does prima-
rily, affect only the lower part of the serous cavity, gradually extend-
ing upwards as the fluid increases, and by its increment displacing



AUSCULTATION. 147

the lung. But it may also, on tlie contrary, in either case, extend
over only a limited spacC; to which it is confined by previously exist-
ing pleuritic adhesions.

" When the pleura is free from such adhesions, the fluid, from what-
ever part of the membrane it proceeds, may in each case gravitate to
the lowest part of the cavity, and its site may be changed according
to the varying position of the patient's body. In each case, therefore,
the part in which the dulness is observed may also vary with the
changes of position. This change in the situation of the fluid and of
the consequent dulness, according to the position of the body, is,
however, far more common in hydrothorax than in either simple
pleuritic effusion or empyema, in which diseases the fluid is much
more frequently confined to a limited space by surrounding adhe-
sions, or gravitates with less facility." Hughes.

2. "i?^ malignant disease of the pleura^ as in that of the lung, the pul-
monary tissue is pushed aside, and dulness and resistance exist on per-
cussion commensurate with the extent of the solid deposit." Hughes.

The metallic ringing ijercussion sound. This is the same sound
which we elicit by striking empty or nearly empty vessels. The pres-
ence of water is not required, but does not hinder its production. Ac-
cording to Wintrich it originates in smooth cavities, where the vibra-
tions of the sound are reflected from wall to wall in a regular manner.
It is heard in pneumothorax, over large cavities, and such cavities as
are connected with each other, whose walls must be fit for the reflec-
tion of sound; that is, they must be smooth and curved.

The crached-pot sound is similar to the metallic ringing sound, only
not so perfect — a spoiled metallic ringing. It may be produced on any
healthy chest by knocking forcibly with the fist against the sternum
during loud speaking or singing. It is said to be found where cavi-
ties exist, but Wintrich says ; " It is rather a feeling of disappoint-
ment for the physician, when he stands by the deceased body of a
patient during whose illness he many a time observed this sign and
diagnosticated a cavity in his lungs, and yet does not find noAV any
thing the like." For this reason we ought not to attach much diag-
nostic importance to this sound.

IV. Auscultation.

You may auscultate a patient either by applying your ear imme-
diately to his chest, or by interposing a stethoscope between it and your
ear. The first is called immediate and the latter mediate auscultation.

Much has been said in books about the superiority of each method



148 THORAX.

over the otlier ; but there is no need of such long disquisitions. I hear
best with the naked ear, and so will any one else who faithfallj tries
both methods. But I prefer the stethoscope decidedly, if I have to
examine an unclean person, or a person with skin disease ; or in cases
where great delicacy must be observed, or when I cannot easily apply
my ear to the parts to be examined.

There has also been a great talk in books about the form and ma-
terial of the stethoscope. It is all the same, whether it be made a little
shorter or longer, straight or bent, out of one piece or of several
pieces of wood or metal, if only its bore be smooth and adapted to
conduct and reflect the sound perfectly. That is all that is required.

In order to know any thing about abnormal sounds in the respira-
tory organs, we must first become acquainted with those sounds which
we can hear in a normal state of these organs.

The Wormal Sounds of Kespiration.

They must be distinctly considered as inspiratory and exjpiraiory
sounds.

The inspiratory sound heard at the larynx^ trachea and large hron-
cliial tubes may be imitated by forcing air against the hard palate, as is
done involuntarily in hard breathing, or in pronouncing the guttural
consonant cli. The height or depth of this sound (its pitch) depends
upon the width of the opening through which the air passes. This
sound is called bronchial respiratioyi or tubidar breathing^ and is found
in a normal state at the larynx, trachea, large bronchial tubes under
the upper part of the sternum, the inner side of the subclavian, the
inter- scapular regions, and occasionally, though less distinctly, in the
axillary regions, especially the right one. It is loudest in the larynx,
less loud at the trachea, and still less loud at the superficial bronchial
tubes, sounding as if coming from a distance. If this bronchial or
tubular breathing be heard in other localities than the above-named,
it may, with tolerable certainty, be regarded as morbid.

The expiratory sound heard at the larynx is nearly as long, and
generally somewhat stronger^ than that of inspiration.

An altogether different sound is heard during inspiration, wdien we
put the stethoscope upon any other part of the chest than those pre-
viously specified. It may be imitated by narrowing the opening of
the mouth and then drawing in the air. I'he consonant of this mur-
mur is V or b, and it is called the respiratory or vesicular murmur of
the air-cells and finer bronchial tubes.



AUSCULTATION". 149

"It varies considerably in intensity in different regions of tlie cliest.
It is most distinct in the acromial^ the central and lower 2Mrt of the supe-
rior sternal, the subclavian^ the axillary and the subscapular regions. It
is less distinct in the lateral, the right mammary, the scapular regions,
still less in the hypochondriac, and least of all in the inferior sternal
and the inner part of the left mammary region.

" Independently of the variation of the intensity of the sound in the
different regions of the chest, whether the variation arise from the
position of the organs, the amount of pulmonary tissue beneath the
ear, or the facility or difficulty with which the inspired air reaches the
pulmonary cells, the two sides of the chest frequently vary a little in
respect to the loudness of the respiratory murmur. Thus it is rather
louder in the acromial, scapular and infra-clavicular regions of the
right side, but in so slight a degree as to be scarcely worthy of con-
sideration in a practical point of view.

" The respirator}'- murmur may, both locally and generally, be more
or less loud than natural in persons who are quite free from any appre-
ciable disease. It may also be harsh or rough, scarcely audible, or
altogether absent. Thus, in childhood and in youth, the respiratory
murmur is louder than in adult life, and especially than in old age.
From this circumstance a loud inspiratory murmur is called (whether
normal, as in childhood or youth, or abnormal, from any cause, in
age,) puerile or supplementary respiration: puerile, because it is the
normal state of respiration in children, and supplementary, because
it is thought that when one lung or a part of a lung is disabled, the
increased activity of the other lung, or another part of the same lung,
8up2)lies the defective action of the diseased organ or part.

" It is always heard when the healthy respiration is more than
ordinarily active, as in persons 'out of breath,' as it is called, from
strong exertion, as running, dancing, &;c., or after the respiration has
been voluntarily suspended for a time, and the individual breathes
quickly to restore the normal balance of the circulation through the
pulmonary organs ; we hear it, therefore, also after the sudden
termination of an asthmatic paroxysm. The strength of the inspira-
tor}^ murmur, instead of being increased, may be diminished, though
no disease exist in the chest. This imperfection of the respiratory
murmur is usually observed either in parts of the lungs which have
been little used, as in the lower regions of the chest of females
accustomed to tight lacing, or in persons suffering from deformity,
whether congenital or acquired; or in the chest of persons consider-
ably advanced in life. In the first two mentioned cases the defect



150 THOEAX.

results from want of rise and consequent imperfect expansion of tlie
lung. In the last case it proceeds from atrophy and consequent
defective functional activity of tlie pulmonary tissue. It may, indeed,
be regarded as the natural character of the respirator}^ sound in old
people, and may therefore be called ' senile,^ as that existing in child-
hood is termed ' -puerile resjnration.''

" Occasionall}'' the inspiratory murmur is entirely absent from one
or a part of one lung, though no disease be present in the organ
itself This condition, however, probably never exists without some
mechanical obstruction to the ingress of air, either in the air-tubes
or upon the exterior of the organ, (spasm, foreign body, apparent
death.") Hughes.

The murmur of expiration in the normal state of the respiratory
organs causes little or no sound in the air-cells and finer bronchial
tubes ; whatever sound is heard differs from the murmur of inspira-
tion, and resembles rather a gentle aspiration or blowing. It can be
imitated only by the mouth during expiration ; the consonant which
represents it falls between / and h.

Laannec and Skoda attribute the sound of the vesicular breathing to
the friction of the air against the walls of the finer bronchial tubes
and the air-cells, the contractile power of which it has to overcome.
The reason why the inspiratory murmur of the air-cells is much
louder than the expiratory is, that the air, when it enters into them,
meets with resistance from their contractibility, but does not meet
with any in its passage out of them. It is otherwise, however, with
the large bronchial tubes, and particularly with the trachea and
larynx ; here the air, during inspiration, meets with no opposition ;
it has, indeed, rather a tendency to expansion; but during expiration
the stream of air coming from all parts of the lung out of the air-
cells, collecting in the trachea and larynx, becomes compressed and
causes friction on the walls of this tube, and especially in the narrow
glottis ; hence, the expiratory murmur of the larynx^ trachea, and
large bronchi is, as a rule, louder than the inspiratory.

Pathological Deviations from the ITormal Vesicular Respiration.

1. The inspiratory murmur. The presence of the vesicular murmur
at any part of the thorax indicates the entrance of air into the air-
cells of that part of the lung which lies beneath the spot indicated.
Its absence^ therefore, indicates those abnormal conditions which pre-
vent the passage of air into the air-cells : such are compression of the
air-cells by exudations or tumors in the pleura ; by enlargement of



AUSCULTATION. 151

the heart and other diseases ; infiltration of the lung tissue by plastic
or tuberculous matter, by blood, serum, pus, &c. ; atrophy of the air-
cells and obstruction of the bronchial tubes by mucus, blood, or by
swelling of the raucous membranes.

The vesicular murmur becomes harsher, when the lining membrane
of the air-cells and finer bronchial tubes becomes roughened, swollen,
and thickened. The presence of a harsh vesicular respiration, which
may amount sometimes even to a hissing sound, indicates, therefore, a
swelling of the mucous membrane of the finer bronchial tubes and air-
cells, as exists in catarrh ; or solitary tubercles thickly scattered through
the tissue of the lungs ; and oedema of the lungs.

2. The expiratory murmur. In a healthy condition of the lungs it
is very soft and somewhat shorter than the inspiratory murmur, some-
times scarcely audible at all. Its abnormal conditions are, therefore,
harshness and i^i'olongation. The causes hereof must be sought in a
roughened and narrowed condition of the finer bronchial tubes and
air-cells, by which greater friction of the egressing air is produced.

This prolongated, and harsh expiratory murmur is rarely heard
extending all over the lungs in a uniform manner, but is mostly con-
fined to portions of the lungs, and then is of the highest diagnostical
importance.

If it extends over a large surface of the lungs, it indicates a more
generally swollen and nneven surface of the bronchial mucous mem-
brane : as we find in acute and bronchial catarrh, with or without
emphysema. If it, however, is confined to the a])ex of the lungs, be-
tween the first and third ribs, and more in front than behind, and
more on one side than on the other, it indicates tuberculosis.

Old Dr. Jackson, of Philadelphia, was the first who, in the year
1832, drew attention to this prolonged, harsh, and partial expiratory
murmur, as a sign of tubercular infiltration, and it has been confirmed
by a number of authors since.

This prolonged, expiratory murmur is sometimes broken into two
or three jerks, and is observed in tuberculosis; also in old people and
children when frightened ; also during the chilly stage of fevers.
The inspiratory murmur also exhibits such interruptions. It is
necessary to listen in such cases to the larynx, whether the interrup-
tion is heard there too, otherwise it might easily be mistaken for a
friction-sound of the pleura.

3. Bronchial res'piration. When we auscultate the larynx or tra-
chea, the respiratory sound is louder than in any other part of the
cliest, if it be in a .healthy condition. It may be imitated, as said



152 THORAX.

before, hy forcing tlie air against the "hard palate, so as to produce
the consonant cA, gattural. This respiratory sound has been termed
hronchial respiration. If heard in any other part than that above
specified, it denotes a change in structure, which subdues the vesicu-
lar breathing, and serves as a good conductor of sound from the
larger bronchial tubes. Such conditions are : hepatization and tuber-
cular infiltration, (the most frequent;) next in frequency, thickening
of the hronchial tubes, with atrophy of the lung tissue; pulmonary oedema
and pleiiritic effusions ; and hydrothorax.

4. Rhonchi or rattling noises in the respiratory organs. When the
bronchial tubes are partly constricted, or when tough mucus exists
therein, which is set into a vibratory motion by the rush of air
during respiration, or, if sticking tightly to the walls, is suddenly torn,
then we have all sorts of noises within the thorax. Such noises may
sound high, deep, clear, husky, harsh, or hollow ; may be short, like
a snap, and return at intervals; or be continuous for a longer time,
like the purring of a cat.

"These noises," says Dr. Wintrich, ''have been called, funny enough,
dry rattle noises, and have been divided into rhonchi sicci, graves,
sonori, sibilantes, and canori. The poetical talent of some authors
has had ample opportunity to force them by comparison into the
most singular and fanciful classes, by which a cool reflection has
mighty little to think," and, I may add, by which the beginner is
thrown into utter confusion. They originate within the respiratory
tubes, exactly in the same manner as sounds originate in any other
kind of tubes. The sound is high, shrill, when the tube is narrow
or constricted in one or more places ; it is deep, when the vibrating
column of air is long, or when the vibratory undulation is slow ; it is
loud, strong, when the stream of air is of great force ; and vice versa,
it is toeak, faint, when the stream of air is weak.

These rhonchi often extend over a large portion of the chest ; if
deep, they occasion a vibration of the thoracic walls, perceptible to
the touch; if high, not. Still we cannot, as has been mentioned
already under the head of vocal fremitus, from its extension, draw
any conclusion as to the extension of its cause, because this sound
may be propagated, like the fremitus, from a single point where it
originates to all parts of the chest.

These rattling noises generally have their origin in catarrhal affec-
tions, and change constantly according to the location and the different
nature of phlegm, which is shifted from one place to another by
breathing and coughing. Exceptions to the above are the hissing



AUSCULTATIOlSr. 153

sounds, wliicTi sometimes exist continuously for weeks, and even
months. These hissing sounds, or rhonchi sihilantes, must have,
therefore, a more persistent cause, the nature of which seems to be a
constriction in some of the finer bronchi ; and we find them in such a
persistent manner only in tuberculosis of the apices of the lungs.

The so-called moist sounds are thought to originate in the presence
of a fluid, which, by the rush of air, is stirred up into large and small
bubbles, which burst. We may distinguish the following varieties :

1. Rhonchus crepitans, vesicular crepitation^ or crepitant rattle. It is
quite similar to the noise which is produced when a lock of hair is
rubbed between the fingers. /;; is heard only during inspiration.
Lsennec and all his followers, even Skoda, explain it in this way : that
the rush of air during inspiration into the finest bronchial tubes and
air-cells, if they contain a fluid, stirs this fluid into bubbles, which
burst and thus cause the crepitant rattle. Already Walshe, an Eng-
lish author, was not satisfied with this explanation, and according to
his opinion it originates through the sudden expansion of the inter-
stitial spaces around the air-cells by a full inspiratory action. He
thought these interstitial spaces glued together by the exudation of a
tough matter in pneumonia, so that a sudden expansion would tear
them asunder and cause this crepitation. This opinion of Walshe has
already been refuted by Da vies in his lectures, who says, that in pneu-
monia the exudation does not take place outside but inside of the air-
cells, as the tough sputa sufficiently show, and that the same crepita-
ting sound is also found in oedema of the lungs. Dr. Wintrich gives,
no doubt, the best explanation of this sound. He says : " This crepi-
tating sound is nothing else but the noise which is caused by the
sudden inspiratory expansion of the air-cells and finest bronchial tubes
when their walls have become glued together by means of a sticky
exudation." It is therefore not heard in a sound lung, because here
the air-cells, even during the fullest expiration, never contract to such
an extent that their walls touch each other and stick together. Wher-
ever it exists, there exists a morbid swelling and tough secretion
within these air-cells and finest bronchial tubes, which bring their walls
during expiration in such near contact that, by means of a sticky
secretion within, they are glaed together and torn asunder by the
following inspiratory action.

The intensity of this crepitation depends upon the toughness of the
secretion and upon the force with which inspiration tears the adhering
walls asunder. It does not cease after coughing and expectoration,
because it depends upon a swelling and secretion of the air-cells and



154 . THORAX.

finest broncbial tubes, wliicb no cougli can remove. It is heard at the
commencement of pyiemnonia^ just when exudation takes place, and at
its resolution; in capillary bronchitis and in oedema and sometimes in
emphysema of the lungs. In oedema the crepitant rattle is much softer
and distant, because the transudation is of a much less sticky nature
than in pneumonia or bronchitis.

It is heard, lastly, in sound lungs under the following condition, as
Walshe describes it: "If individuals whose lungs are healthy, or dis-
eased only at the apices, and whose breathing is habitually calm, are
made suddenly to respire deeply, &peciiliar,flne, dry crepitation, accom.-
yanying inspiration only, may often be detected at the basis posteriorly.
But after two or three, or, at most, five or six, acts of respiration, it
totally disappears. This pseudo-rhonchal sound seems to depend on
the sudden and forced unfolding of air-cells, which are unaffected by
the calm breathing habitual to the individual ; and its only import-
ance arises from the possibility of confounding it with crepitant
rhonchus."

It is frequently heard in patients who have lain long on their back,
especially after typhoid fevers, and may be explained in the same
manner. The pulmonary secretion collects mostly in those places
which lie deepest and are used least. By these means the air-cells
gradually collapse and stick together. A few deep inspirations tear
them asunder and at the same time remove the secretion, so that, as
there is no morbid swelling in these parts, the crepitant sound ceases
after two, three, or, at most, after five or six acts of respiration.

2. The subcrepitant rattle. This is a sound which appears to arise
from the bursting of very small bubbles in the air-passages. It is
heard most distinctly during the act of inspiration^ weaker during
expiration. It denotes a fluid secretion in the finer bronchial tubes.

3. The mucous rattle. There is sometimes a great deal of mucus
in the respiratory organs ; and yet, on auscultation, no rattling sound
is perceptible. It seems, then, that certain conditions must exist in
order to render the bursting of large and small bubbles in the air-
passages audible. These conditions are : that the walls, wherein the
sound originates, must be good reflectors of sound, like the larynx,
the trachea, cavities, and bronchi, if they are surrounded by walls
which do not contain air ; and also, that fluid (mucus, pus, blood, serum)
be contained in them, which, by respiration, is set into bubbling mo-
tion. This mucous rattle varies very much in character ; is a sound
of large or small bubbles, high or deep in pitch ; confined to a small
spot, or extended over the whole lung. By the extension of the



AUSCULTATIOISr. 155

sound we can never judge of the extent of the fluid which gives rise
to it; because this sound is propagated quite a distance from its
origin, if there exist good reflecting media. It therefore does not
indicate any particular disease, but only certain conditions, lilce con-
solidation of the lung tissue, either by infiltration or hepatization,
compression or atrophy.

■i. IVie metallic tinhling. " When, in consequence of a communi-
cation with a bronchial tube, or a portion of the lung, the pleural
sac contains a considerable portion of air, and also a small quantity
of fluid, or when a phthisical cavity of large size is similarly circum-
stanced, there is every now and then heard a very peculiar sort of
tinkling noise upon examining the chest. It resembles very nearly
the sound caused by shaking a pin in a decanter. This is the metallic
tinlcUng. It is, most commonlj', heard only at intervals ; that is, it
. may occur once in three, four, or forty respirations. It rarely, if
ever, attends the expiration. It may cease altogether, and reappear
after a considerable time. In this respect it seems to be influenced by
the position of the patient's body. It is most probably produced by
the continued and rapid reverberation of a delicate sound against the
firm and vibrating walls of a large cavity. It is in fact an echo in a
small space. The original sound from which the echo proceeds ap-
pears most commonly to arise from the bursting .of a bubble of air,
or from a drop of liquid falling upon the surface of fluid in the bottom
of the cavity. But it sometimes seems to be likewise produced by
the passage of air over a loose portion of membrane or thich secretion
situated in a tube at or near the entrance of the cavity. The physical
conditions necessary for its production appear to be a large cavity
with resonating walls, and containing a large portion of air, with a
small quantity of fluid." Hughes.

In pneumothorax much depends upon the position of the patient.
Often, when nothing can be heard while the patient is lying down,
the metallic tinhling appears at once on assuming the sitting posture.
In those cases in which tubercular infiltration extends to the diaphragm
in the left lung, it not unfrequently happens that sounds within the
lungs are conducted into the cavity of the stomach, where they cause



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 16 of 65)