of the tuberculous affection. Bronchitis, peribronchitis,
periarteritis, endoarteritis, interstitial pneumonia, and pleurisy are
terms which denote inflammation. To these are to be added ulceration
and suppuration within cavities. The infiltrated tuberculous deposit is
to be regarded as an inflammatory exudation. There is an intrinsic
propriety, therefore, in calling it a pneumonia. But the behavior of
this deposit differs widely from that of the exudation in lobar
pneumonia. In the latter affection it is readily absorbed and
disappears, leaving the pulmonary structure intact, whereas in phthisis
it is absorbed with difficulty, and in most cases leads to more or less
destruction of the pulmonary structure. For these reasons, irrespective
of histological points of difference, the term tuberculous should be
used to distinguish the exudative pneumonia which is characteristic of
phthisis. The term desquamative pneumonia was proposed by Buhl. The
so-called cheesy degeneration of the tuberculous products--a necrotic,
not an inflammatory, process--was considered by Laennec as a
distinctive mark of the products. This doctrine has been disproved.
Other morbid exudations and growths may undergo similar degenerative
changes.
DIAGNOSIS.--It is evidently very desirable to recognize the existence
of phthisis at as early a period as possible with reference to the
adoption of {411} measures with a view to prevent the further
development and progress of the disease. It is also very desirable, if
practicable, to determine that phthisis does not exist; that is, by the
absence of diagnostic points to exclude it. Difficulty of diagnosis
relates almost exclusively to an early period when the phthisical
affection is small. The diagnostic points pertaining to the symptoms
and the physical signs in the incipiency of the disease therefore
especially claim attention.
A cough of more or less duration, which was at first slight and dry,
gradually increasing and accompanied by the expectoration of mucus,
should always excite a suspicion of phthisis, especially if the
patient's age be between twenty and thirty years. This is not the
history of a chronic primary bronchitis. A cough as just described
should never be considered as nervous or sympathetic without due
investigation. It should not be attributed to pharyngitis, although the
latter affection is found to exist. Want of breath on exercise is a
symptom pointing to something more than a bronchial or pharyngeal
affection. The import of these symptoms is still greater if, after the
commencement of the cough or from an earlier date, there has been
decrease in weight and strength. Their significance is much increased
by the occurrence of hæmoptysis. Hæmoptysis followed by a persistent
cough, and still more if cough preceded its occurrence, is always
presumptive evidence of a phthisical affection. Occurring without
having been preceded by cough, and when cough does not immediately
follow, it should suggest the probability of phthisis. In the larger
proportion of cases under these circumstances it is a forerunner of the
diagnostic symptoms and signs of the disease. In connection with the
cough a persistent increase of the temperature of the body is an
important diagnostic symptom. Chilly sensations and flashes of heat are
symptoms of some importance. Especially significant are pleuritic
stitch-pains referable to the upper part of the chest or beneath the
scapula, these being symptomatic of the circumscribed dry pleurisies
which may occur at an early period of the disease. Impaired appetite,
pallor of the face, and a tendency to perspire during sleep have much
significance taken in connection with the pulmonary and other symptoms.
A positive diagnosis must rest on physical signs, together with more or
less of the foregoing symptoms. The physical conditions which furnish
the diagnostic signs are solidification of a small portion or of small
portions of lung, usually at or near the apex, the presence of mucus in
the small-sized bronchial tubes, and perhaps fibrinous exudation on the
pleural surface within a circumscribed area corresponding to the
solidified portion or portions of lung. The signs furnished by these
conditions are slight dulness on percussion, a broncho-vesicular
(formerly called rude or harsh) respiration, some increase of vocal
resonance and of the whispered voice, subcrepitant râles, and perhaps a
grazing friction murmur. It may be important to consider the physical
signs of phthisis with some detail. Aside from their importance, a
reason for this is that terms by which some signs are designated are
not used in precisely the same sense by all medical writers.
A small phthisical affection gives rise to slight or moderate dulness
on percussion. In order to appreciate this sign if the dulness be
slight, attention should be paid to the pitch of the resonance as well
as to the lessened intensity of resonance. The pitch is always raised.
By attention to the latter character, in conjunction with the
diminution of intensity, a degree of dulness may be sometimes
appreciated which, without attention to the pitch, might not be
determinable.[13] In determining abnormal dulness in the
infra-clavicular region on one side, the normal disparity between the
two sides of the chest {412} in this region must be taken into account.
The resonance at the right summit, as compared with that of the left
summit, is, normally, somewhat dull. Hence it is not as easy to make
out an abnormal dulness at the right as at the left summit. If the
relative abnormal dulness at the right summit be but slight, the
question is whether there be more than a normal disparity. This
question is rendered difficult by the fact that the degree of normal
disparity varies somewhat in different healthy persons. In cases of
doubt little reliance is to be placed on this sign alone, but it is to
be taken in connection with auscultatory signs.
[Footnote 13: The author was the first to indicate the fact that
dulness is always associated with elevation of pitch. Vide "Prize Essay
on Variations of Pitch in the Sounds obtained by Percussion and
Auscultation," _Transactions of the American Medical Association_,
1852.]
With reference to the auscultatory signs in cases of phthisis, it is to
be premised that often, owing to the importance of studying the sounds
derived from a limited area and of localizing morbid conditions, the
use of the stethoscope is indispensable. It is impossible to meet all
the requirements of physical diagnosis by immediate auscultation. After
an experience of more than a quarter of a century the writer would
advise the binaural stethoscope in preference to any other. For the
benefit of those who are not practically familiar with this instrument,
it should be added that in order to appreciate its advantages, the
instrument, in the first place, must be properly constructed, and, in
the second place, some practice is necessary. A sound produced within
the instrument is at first an obstacle, but it is speedily overcome by
use.[14]
[Footnote 14: The dissatisfaction with the binaural stethoscope so
often comes from defects in its construction that it seems proper to
refer to Tiemann & Co., and to Ford & Co., of New York as reliable
makers of this instrument.]
A small tuberculous solidification is represented by a
broncho-vesicular respiration. This sign was named and described by me
in 1856. The name takes the place of the terms rudeness, harshness, and
hardness--terms which are not only inadequate, but convey an erroneous
idea. Quoting from another work, the characters of the
broncho-vesicular respiration and its comprehensive signification are
as follows: "The sign represents the different degrees of
solidification of lung between an amount so slight as to occasion only
the smallest appreciable modification of the respiratory sounds, and an
amount so great as to approximate closely to the degree giving rise to
bronchial or tubular respiration. In other words, all the gradations of
respiratory modifications caused by incomplete or an inconsiderable
solidification are embraced under the name broncho-vesicular. The
gradations correspond to the amount of solidification; that is, they
show the solidification to be either very slight, moderate, or nearly
sufficient to be regarded as considerable or complete. The sign is
therefore important as evidence, first, of the existence of
solidification, and, second, of the degree of solidification. Analyzing
this sign, the most distinctive feature is the combination of the
vesicular and the tubular quality in the inspiratory sound. These two
qualities may be combined in variable proportions. The pitch of the
sound is raised in proportion as the tubular predominates over the
vesicular quality. The expiratory sound is more or less prolonged,
tubular in quality, and the pitch raised. The prolongation of this
sound, its tubular quality, and the raised pitch are proportionate to
the predominance of the tubular over the vesicular quality in the
inspiratory sound. If the solidification be slight, the characters of
the normal vesicular respiration predominate; that is, the inspiratory
sound has but a small proportion of the tubular quality, and is but
little raised in pitch, the expiratory sound being not much prolonged,
its tubularity not marked, the pitch not high. If, on the other hand,
the solidification be almost enough to give a bronchial respiration,
the inspiratory sound has only a little vesicular quality, the tubular
quality predominating, the pitch proportionately raised, and the
expiratory sound is prolonged, high, and tubular, nearly to the same
extent as in bronchial respiration. The less the solidification the
more the characters {413} of the normal vesicular respiration
predominate over those of the bronchial respiration; and, per contra,
the greater the solidification the more the characters of the bronchial
predominate over those of the normal vesicular respiration."[15] By
means of the broncho-vesicular respiration a slight morbid
solidification may be recognized in one of the infra-clavicular regions
or over the scapula. Here, however, as with regard to percussion, an
allowance is to made on the right side for a normal disparity. The
respiratory sounds on the right side at the summit, as compared with
those at the left, have normally the characters more or less marked of
a broncho-vesicular respiration. These characters are more marked as
the stethoscope is brought toward the sternum. Hence a small
solidification of lung is more easily ascertained by auscultation at
the left than at the right summit.
[Footnote 15: Vide _Manual of Auscultation and Percussion_, by the
author; also, paper contained in the _Transactions of the International
Medical Congress_, London, 1882. The broncho-vesicular respiration was
called by Skoda indeterminate (unbestimmt), and this term is still used
by German writers. These sounds are not indeterminate if the characters
derived from pitch and quality be analytically studied; they are sounds
intermediate between the normal respiratory murmur and bronchial
respiration.]
Not infrequently in cases of incipient phthisis the respiratory sounds
at the summit on the affected side are so weakened that their
characters cannot be studied. Weakness of the respiratory murmur in
these cases becomes a diagnostic sign taken in connection with other
signs.
A small tuberculous deposit may increase the vocal resonance. But,
again, a normal disparity between the two sides must be allowed for.
The normal vocal resonance is always greater on the right side. If,
therefore, it be a question as to the existence of a small tuberculous
affection at the right summit, it is to be decided whether the
disparity be greater than normal. A small tuberculous deposit at the
apex of the left lung, on the other hand, may not increase the
resonance to an equality with that at the right summit.
Attention should be paid to the whispered voice, and, still again, the
two sides show a normal disparity. The sound heard with the whispered
voice, which may be distinguished as the normal bronchial whisper, is
louder on the right than on the left side, and somewhat higher in pitch
on the left side, at the summit of the chest. If at the right summit it
exceed the normal disparity, and the pitch be higher than at the left
summit, the sign may be distinguished as increased bronchial whisper,
and it denotes solidification. If, on the other hand, the sound at the
left summit be louder than that of the right summit, there is increased
bronchial whisper, representing the solidification at the apex of the
left lung.[16]
[Footnote 16: The different abnormal modifications of sounds produced
by the whispered voice were first named and described by the author.
Vide _Manual of Auscultation and Percussion_.]
The normal points of disparity at the summit of the chest render the
diagnosis of incipient phthisis by means of alterations in the
resonance on percussion, the respiratory sounds, the vocal resonance,
and the whispered voice a problem in some cases of not a little
difficulty. In these cases an examination of the sputa for the presence
of the tuberculous parasite may furnish proof of the existence of the
disease. This proof may in some instances be obtained when the physical
signs, together with the symptoms, do not render the diagnosis
positive, and it may be sought for in order to corroborate the evidence
derived from other sources. The author can testify from considerable
experience to the value of an examination of sputa for bacilli in cases
in which the diagnosis is not rendered positive by other signs and by
symptoms. It must, however, be borne in mind that the absence of
bacilli in the sputa is not sufficient to exclude phthisis, especially
if but a single examination be made. In doubtful cases, if an
examination of the sputa be negative, the examination should be
repeated. The weight of evidence against the {414} existence of
phthisis is, of course, greater in proportion to the number of
examinations with negative results.[17]
[Footnote 17: The following method of staining the bacilli tuberculosis
in the sputum is essentially that recommended by Ehrlich in the
_Deutsche medicinische Wochenschrift_, Mai 6, 1882:
It is important that the sputum to be examined should be derived from
the lungs, and should not be solely that from the upper air-passages. A
small opaque particle from the sputum is to be pressed between two
cover-glasses, so that when these are drawn apart a thin film will
remain upon each. Each cover-glass, as soon as the film is dry, is to
be passed, with the preparation upward, rather rapidly three times
through the flame of a Bunsen's burner or of an alcohol lamp. The
preparation is now ready for staining.
A small quantity of water in a test-tube or flask is now shaken with an
excess of aniline oil (which need be only in small amount), and after a
few moments is filtered through moistened filter-paper. To the clear
filtrate thus obtained is to be added, drop by drop, a saturated
alcoholic solution of fuchsin (gentian-violet, methyl-violet, and
several other aniline colors may be substituted) until the fluid begins
to be opalescent, showing that it is saturated with the coloring agent.
In this manner an alkaline-aniline staining solution is prepared.
Into this staining solution the cover-glasses, having the dried films
of sputum prepared as above described, are dropped, preferably so that
they will float with the preparation downward. Here they remain from a
half hour to twenty-four hours. If taken out in a short time, the
fluid, at least for a time during the staining process, should be
heated moderately over a water-bath, and in any case the process of
staining is accelerated and rendered more certain by heating.
After removal from the staining fluid the cover-glass is washed for a
few moments in water, and is then dipped into a mixture of one part of
pure nitric acid (it should contain no nitrous acid) to about three or
four parts of water. Here it remains only a few moments, when it will
be found that the preparation has lost its color, although a part will
be restored by the subsequent washing in water, which should be done at
once. If the preparation has not been sufficiently decolorized, it may
be placed again in nitric acid, but it is not necessary or desirable
that it should remain there many minutes. The object of the nitric acid
is to extract the color from all but the tubercle bacilli.
The preparation may now be at once examined either in glycerin or
(after drying or after treatment with alcohol and oil of cloves) in
balsam. Ehrlich recommends, previous to this, a staining of the
background with some color other than that of the bacilli; thus, with
methyline blue if the organisms are stained red with fuchsin. This
staining of the background, however, is not necessary. While the ideal
method of studying the stained bacilli is by means of Leis's
oil-immersion lenses and Abbé's illuminating apparatus, they can
usually be seen readily enough with the high powers in ordinary use,
such as the one-fifth or one-sixth inch objectives of our American
microscope. After staining with fuchsin the bacilli appear as short
rods of a red color, frequently curved or bent.]
The adventitious sounds which have been mentioned--namely, the
subcrepitant râle and the pleural friction murmur--sometimes afford
valuable aid in the diagnosis. Taken in connection with the direct
signs obtained by auscultation and percussion, these accessory signs
when present make the diagnosis positive: they are by no means
uniformly present, and therefore their absence is not proof against the
existence of a phthisical affection. To these accessory signs another
sign may be added--namely, an abnormal transmission of the heart-sounds
within one of the infra-clavicular regions. In the middle of this
region there is nearly an equal transmission of these sounds normally.
Comparing the two sides as regards the two sounds respectively, the
first sound is a little louder on the left, and the second sound a
little louder on the right side. Now, with a little solidification the
sounds may be better transmitted, so that they are abnormally loud on
the affected side.
A decision that there is no physical proof of phthisis must rest on the
absence of all the foregoing signs after repeated examinations of the
chest.
It is not to be concluded that for a positive diagnosis of incipient
phthisis all or most of the foregoing diagnostic signs must be
recognized. They are not all present in all cases. Two or three of
these signs, and even a single one if well marked and associated with
diagnostic points pertaining to the symptoms and history, may suffice
for a positive diagnosis.
It is an interesting question how small a portion of solidification may
furnish signs sufficient for a diagnosis. I have the records of two
cases bearing {415} on this question. A patient came under my
observation at Bellevue Hospital in 1867. In the right infra-clavicular
region the respiration was abnormally broncho-vesicular, the vocal
resonance was increased, and there was increase of the bronchial
whisper within a small circumscribed space. On these signs was based
the diagnosis of a small tuberculous deposit. The case served to
illustrate the signs just named to classes for practical instruction in
auscultation and percussion. The patient, who was employed as a helper
in the apothecary's shop, died suddenly from taking by mistake an
overdose of the fluid extract of aconite. The autopsy showed at the
apex of the right lung a nodule of the size of a filbert, no
tuberculous deposit being elsewhere found.
A recent medical graduate, twenty-two years of age, had cough and two
attacks of hæmoptysis. His father and a sister had died with phthisis.
There was slight dulness on percussion on the summit of the chest on
the left side, with crepitation at both summits. These were the only
signs noted. This case was included among the cases of recovery
reported in my work on phthisis published in 1875. He enjoyed excellent
health and was notably vigorous for twenty-eight years. Death took
place in 1880 from disease of the heart and kidneys. The autopsy showed
at the apex of each lung a small indurated portion somewhat larger on
the left than on the right side. Elsewhere there was no appearance
denoting present or past pulmonary disease.
It is in only a small proportion of cases that, when patients first
come under medical observation, the phthisical affection is so small as
to render the diagnosis difficult. The tuberculous solidification is
generally sufficient to give rise to well-marked signs. The shrinkage
of the lung at the apex from interstitial growth and diminished
capability of expansion may have caused a small infra-clavicular
depression and restricted respiratory movements in this region. The
dulness on percussion is readily recognized. The characters of the
broncho-vesicular respiration are easily determined. The increase of
vocal resonance and increased bronchial whisper admit of no doubt. With
these signs, oftener than at an earlier period, are associated
accessory signs--namely, subcrepitant râles and bubbling in larger
tubes, pleuritic friction murmur, and undue transmission of the
heart-sounds.
At a somewhat later period, and sometimes even when cases are first
observed, the physical signs denote a still greater degree of
solidification. Infra-clavicular depression and restricted movements on
one side are marked. The respiration is bronchial and the voice
bronchophonic. There may be pectoriloquy with the bronchophonic
characters, showing that the speech is transmitted through solidified
lung.[18]
[Footnote 18: Bronchophony is to be understood as a sign distinct from
increased vocal resonance. In bronchophony the resonance may or may not
be increased. Intensity is not a character of this sign. Its
distinctive characters are concentration of the voice sound, nearness
to the ear, and elevation of pitch. The terms concentration and
nearness to the ear properly express what was intended by Laennec in
the words "la transmission évidente de la voix à travers le
stethoscope." Pectoriloquy is to be distinguished from bronchophony.
These two terms are sometimes confounded. Bronchophony is transmission
of the voice, pectoriloquy the transmission of speech--that is,
articulate words.]
Exceptional cases are to be referred to in which over lung containing
solidified portions from tuberculous deposit dulness on percussion is
wanting. Not only is dulness wanting, but the resonance is greater than
normal. The resonance is altered in character. With an increase of
intensity the quality is in part tympanitic and the pitch is raised.
This is the sign described by me many years ago under the name
vesiculo-tympanitic resonance. The distinctive characters are those
just mentioned--namely, increase of intensity, the quality a
combination of the vesicular and the tympanitic, and more or less
elevation of pitch. The name vesiculo-tympanitic expresses these
characters. It is the sign of pulmonary emphysema. It denotes that
portions of {416} lung situated between islands of solidification have
become emphysematous. The emphysema is vicarious; that is,
supplementary to the shrinkage of the portions solidified, and, added
thereto, probably collapsed lobules. Were one to be governed by
percussion alone in the physical diagnosis, this sign would in some
cases mislead. The liability to error is avoided by taking due
cognizance of the associated signs furnished by auscultation.