solidification. It is desirable to recognize the existence of these. In
most instances the signs which may be distinguished as cavernous
suffice for the recognition of cavities. The cavernous signs are
furnished by percussion and by auscultation of the respiration and of
the voice.
A purely tympanitic resonance within a circumscribed space points to a
cavity, but a tympanitic resonance with either an amphoric or a
cracked-metal intonation is more especially a cavernous sign. An
amphoric or a cracked-metal resonance over a cavity may often be
obtained by observing certain rules in percussion--namely, percussing
with a single and rather forcible blow, the mouth of the patient being
open and brought close to the ear. These signs may be rendered still
more distinct by means of the binaural stethoscope, the pectoral
extremity being close to the patient's opened mouth, an assistant
making the percussion. These cavernous signs are not present when
cavities contain much liquid or when communication with the bronchial
tubes is temporarily obstructed; hence the signs are sometimes present
and sometimes absent.
There is a distinctive cavernous respiratory sign. This assertion is
called for by the fact that the existence of the sign is not as yet
recognized by all medical writers. According to Laennec, the
respiratory sounds derived from cavities resemble the bronchial
respiration. From his description it would be impossible to distinguish
the former from the latter. Skoda considered the cavernous and the
bronchial respiration as absolutely identical; and this view is held by
German writers at the present time. Walshe indicated an essential
differential point pertaining to the inspiratory sound in cavernous
respiration--namely, its low pitch. The fact that in purely cavernous
respiration the pitch of the expiratory is lower than that of the
inspiratory sound was stated by me in 1852.[19] The distinctive
characters of the cavernous respiratory sign as then indicated were as
follows: An inspiratory sound low in pitch and non-tubular in quality,
followed by an expiratory sound still lower in pitch and non-tubular.
The quality of the sound in inspiration and in expiration may be said
to be blowing, after the term soufflante used by Laennec, but applied
by him to a sound either bronchial or from a cavity, when the air seems
to be drawn from the ear of the auscultator.
[Footnote 19: Vide "Prize Essay."]
Appreciating clearly the characters which are distinctive of cavernous
respiration, it is impossible to confound this sign with bronchial
respiration, both the inspiratory and the expiratory sound in the
latter sign being high in pitch and tubular in quality. This cavernous
sign approaches much nearer to the normal vesicular respiration. The
only distinction between these two signs is the presence of the
vesicular quality in the latter and its absence in the former. Hence,
the only liability to error is in confounding the two. This error can
only be committed when the respiratory murmur is so feeble that the
vesicular quality is not readily appreciable. In order to avoid the
error, the respiration should not be pronounced cavernous when the
sounds are quite weak, except there be present other correlative
cavernous signs.
Cavities are often situated in close proximity to lung solidified by
tuberculous deposit or interstitial pneumonia: cavernous respiration
and bronchial respiration are then in juxtaposition, and their
differential characters are {417} rendered very distinct by contrast.
Under these circumstances, however, the cavernous respiration is
sometimes modified by combination with the characters of the bronchial
respiration. Not infrequently a cavernous inspiration is joined to a
bronchial expiration, the more intense expiratory sound representing
adjacent solidification extending over the site of the cavity and
drowning the weaker cavernous expiration. In another mode of
combination the inspiratory sound is bronchial at the beginning and
cavernous at the end. Here the cavernous sound occurs a little later
than the bronchial, and the latter is supplanted by the former. This
variety of broncho-cavernous respiration has been recently described by
Seitz under the name metamorphosing respiratory murmur
(metamorphosirendes athmungs geräusch). In like manner, the characters
of the cavernous and of the normal vesicular respiration may be
combined. This combination may be expressed by the term
vesiculo-cavernous respiration.
The effect of a cavity upon vocal resonance is to increase its
intensity without giving rise to the characters distinctive of
bronchophony--namely, nearness to the ear, concentration, and elevation
of pitch. Increased vocal resonance, and not bronchophony, is therefore
a cavernous sign. If bronchophony be present over a cavity, it denotes
adjacent solidification of lung. With the vocal resonance more or less
increased the vocal fremitus appreciable on auscultation is often
intensified.
A cavernous whisper has the characters of the expiratory sound in the
cavernous respiration; that is, it is low in pitch and blowing or
non-tubular in quality, being in contrast, as regards these characters,
with a high-pitched tubular sound in whispering bronchophony. The
latter sign is often found near a cavity, showing the proximity of
solidified lung.
Amphoric respiration, amphoric voice, and amphoric whisper are
pathognomonic signs of a cavity, provided pneumothorax be excluded. The
same is to be said of metallic tinkling, a very rare cavernous sign.
Gurgling within a circumscribed space is a cavernous sign of some
value. Pectoriloquy--that is, the transmission of articulated words--is
not, per se, a cavernous sign; that is to say, the speech may be
transmitted by solidified lung as well as through a cavity. This is
true alike of words spoken with the loud and with the whispered voice.
It is, however, easy to determine whether pectoriloquy be or be not due
to a cavity. If with the loud voice the transmitted speech be
unaccompanied by the characters of bronchophony, it denotes a cavity.
So, if transmitted whispered words be unaccompanied by the characters
of the bronchophonic whisper, they denote a cavity. On the other hand,
the transmission is by solidified lung if bronchophony and pectoriloquy
be conjoined in either the loud or the whispered voice.
The shrinkage of lung incident to the formation of tuberculous cavities
increases the depression apparent on inspection in the infra-clavicular
region. The site of a cavity is sometimes indicated by a circumscribed
bulging of intercostal spaces, within a localized area, on forced
expiration or an act of coughing. A sharply-defined circumscribed
depression corresponding to the area of a cavity is visible in some
cases. Another effect of shrinkage of lung is to uncover the aorta in
the second intercostal space on the right side, or the pulmonary artery
in a corresponding situation on the left side. The pulsation of these
arteries may then be perceived by the touch, and perhaps, also, by the
eye. This effect should not lead to the error of inferring the
existence of aneurism. Shrinkage of the upper lobe of the left lung may
cause considerable elevation of the heart, also enlarging considerably
the space within which is felt the cardiac impulse.
With a practical knowledge of the physical signs of which a concise
account has been given, it is practicable to determine, first, the
existence of phthisis in its incipiency when the tuberculous affection
is small; second, during the {418} progress of the disease to ascertain
the degree and the extent of the tuberculous solidification; and,
third, to recognize the existence of, and to localize, cavities.
Recapitulating the signs belonging to the foregoing phases of the
disease, in incipient phthisis they are slight dulness on percussion,
broncho-vesicular respiration approximating to the normal vesicular or
a respiratory murmur too weak for its characters to be studied, some
increase of vocal resonance, increased bronchial whisper, and, as
occasional accompanying signs, subcrepitant râles, pleuritic friction
murmur, and abnormal transmission of the heart-sounds, more or less of
these signs being limited to the summit of the chest on one side. After
further progress of the phthisical affection the signs are, dulness on
percussion more or less marked, either a broncho-vesicular respiration
approximating to the bronchial or a purely bronchial respiration,
either notable increase of vocal resonance or bronchophony, either
increase of the bronchial whisper or whispering bronchophony, and moist
bronchial or bubbling râles which may be either coarse or fine, or both
may be combined. After the affection has advanced to the formation of
cavities the cavernous signs are added to those of
solidification--namely, circumscribed tympanitic resonance on
percussion, cracked-metal and amphoric resonance, cavernous
respiration, cavernous whisper, increased vocal resonance and gurgling.
Pectoriloquy may be present before and after the formation of cavities;
in the former instance the transmission of speech being by solidified
lung, and in the latter through a cavity, the two modes of transmission
being easily differentiated by means of the characters associated with
the pectoriloquy.
An intercurrent pneumonia, not tuberculous, may lead to the error of
supposing the tuberculous affection to be much greater than it is.
Especially is there liability to this error if the patient have not
been under observation prior to the intercurrent pneumonia. The latter
may give rise to bronchial respiration and bronchophony, with notable
dulness on percussion over a considerable space. If the patient have
been under observation, the rapidity with which the solidification
denoted by these signs has been developed is a diagnostic point. A
notable diminution of the solidification within a few weeks or days is
evidence that it was due to an intercurrent pneumonia. The tuberculous
deposit is never absorbed with such rapidity. The following case may
serve as an illustration of this complication: A man aged thirty had
had for some time slight cough and want of breath on active exercise,
but he had kept about, actively engaged in business, until within a few
days of the date of my visit. He was then up and dressed, his chief
complaint being want of breath on any exertion. The physical signs gave
evidence of considerable solidification of the upper lobe of the right
lung. The question was, whether the solidification was due exclusively
to phthisis, or whether with this disease was associated an
intercurrent pneumonia. The question was settled definitively by an
examination of the chest six weeks afterward. At the time of this
examination the solidification had in a great measure disappeared;
there was only slight dulness on percussion, with increase of vocal
resonance and feeble respiratory murmur. Meanwhile, the symptoms had
denoted progressive improvement; the cough was now slight; he no longer
suffered from want of breath on exertion, and he had improved as
regards appetite, strength, etc. This patient consulted me seven years
and four months afterward. In the mean time he had considered himself
in fair health, but he had been subject to cough, and for the preceding
six months the cough had been persistent. There was now dulness at the
summit of the chest on the right side, with feeble broncho-vesicular
respiration, increase of vocal resonance, abnormal transmission of the
heart-sounds, and subcrepitant râles. He had held his weight and
strength, and his appetite and digestion were good.
{419} An occasional event in cases of phthisis is obstruction of a
primary bronchus from the pressure of an enlarged bronchial gland. This
event may explain a degree of embarrassment of respiration out of
proportion to the changes which have taken place in the lungs. The
bronchial obstruction is shown by notable feebleness or by suppression
of the respiratory murmur on the side of the obstruction, and an
increase of the murmur on the other side of the chest. Obstruction of a
primary bronchus may prevent the appreciation of morbid respiratory
signs on the obstructed side.
During the progress of phthisis the symptoms concur with the physical
signs in showing the progressive inroads of the disease upon the
pulmonary organs. They show, more than the physical signs, the inroad
upon the powers of life. They also afford evidence, in conjunction with
the physical signs, of arrest of the disease. More reliance is to be
placed on the symptoms than on the signs in judging of the rapidity on
the one hand, or on the other hand of the slowness, of the progress of
the disease. In these several points of view the consideration of
symptoms comes more properly under the head of the prognosis.
The symptoms pertaining to complications of phthisis may be the first
to lead patients to consult a physician. Not infrequently advice is
sought for harshness or hoarseness of the voice, arising from chronic
laryngitis, the cough and other symptoms which preceded this affection
not having been regarded as of sufficient consequence to require
medical aid. It is to be borne in mind that chronic laryngitis, when
not of syphilitic origin, is generally secondary to phthisis. The chest
is therefore to be examined carefully with reference to the signs of
the latter.
Pleurisy with effusion may be a complication which the physician is
called upon to treat. A lung compressed by liquid which fills the
affected side of the chest cannot be interrogated by means of physical
signs. Under these circumstances subcrepitant râles may denote a
phthisical affection on the summit of the chest on the opposite side.
The existence of cough and expectoration prior to the pleurisy is
strong evidence of an antecedent phthisical affection. The occurrence
of hæmoptysis adds greatly to the evidence.
A tuberculous patient who has not been under any treatment may apply to
a surgeon to be relieved of the inconvenience of a perineal fistula.
Operative interference for this affection should never be resorted to
without a careful examination of the chest.
PROGNOSIS.--Whether pulmonary phthisis is ever a curable disease has
hitherto been a mooted question. Prior to the time of Laennec instances
of apparent cure were open to doubt on the score of diagnosis. Laennec
did not admit the probability of a cure before the formation of
cavities, but he gave the histories in a number of cases in which the
cicatrization of cavities had taken place.[20] If by the term
curability be meant a complete restoration of the portions of lung
affected by tuberculous disease to the normal condition which existed
prior to the disease, the doctrine of Laennec is probably true. A
moderate or even a small phthisical affection leads to changes which
are permanent. There remains more or less impairment of the integrity
of the pulmonary organs. But if by the term be meant that all pulmonary
symptoms cease, that the patient has good general health, and that the
{420} damage to the lungs is not sufficient to prevent an adequate
exercise of their functions, a cure may take place before as well as
after the formation of cavities. Accepting the latter sense of the term
curability, no one at the present time will deny the statement just
made--a fact which is due, at least in a measure, to the different
views in regard to the treatment of phthisis now as compared with the
time of Laennec.
[Footnote 20: "Les observations contenues dans l'ouvrage de M. Bayle,
ainsi que ce que nous avons dit nous-mêmes ci-dessus du dévelloppement
des tubercles, prouvent suffisamment que l'idée de la possibilité de
guérir la phthisie au prémier degré est une illusion. Les tubercles
crus tendent essentiellement à grossir et à se ramollir. Il est peut
être au pouvoir de l'art de ralentir leur dévelloppement, d'en
suspendre la marche rapide, mais non pas de lui faire un pas
rétrograde. Mais s'il est impossible de guérir la phthisie au premier
degré, un assez grand nombre de faits mont prouvé que dans quelques cas
un malade peut guérir après avoir eu dans les poumons des tubercles qui
se sont ramollis et ont formé une cavité ulcéreuse" (_Traité de
l'Auscultation médiate_).]
The appearances found after death in cases which may be considered as
exemplifying, practically, recovery from phthisis vary according to the
extent of the tuberculous affection and the stage to which it had
advanced. In a case referred to in connection with the diagnosis (vide
p. 407) an examination after death, nearly thirty years having elapsed
from the date of recovery, showed within small circumscribed spaces at
the apex of both lungs a condensed pulmonary tissue. In the following
case there was a similar condition within larger spaces: The patient, a
man aged about forty, was attacked with hæmoptysis in April, 1846. Soon
afterward the symptoms and signs of tuberculous disease became
manifest, and death took place in the following June. On examination
after death the lungs were found to contain infiltrated tuberculous
deposits, some of which had undergone softening, and miliary tubercles
in abundance. In addition to these appearances, at the apex of each
lung was a solid mass nearly as large as a hen's egg, that on the right
side being somewhat larger than that on the left. The surface over
these masses presented a marked depression and a puckered appearance.
On dividing the masses they appeared to consist of condensed
parenchyma: they were of a reddish color, friable, and contained an
abundance of minute calcareous particles. They were surrounded by a
thick, firm wall isolating them from the adjacent pulmonary structure.
Eighteen years before his death this patient had cough and other
symptoms which were regarded at the time as denoting pulmonary
phthisis. He recovered, and had good health up to the fatal illness.
The only exception to this statement of his previous good health was
the occurrence of a perineal fistula, which was nearly cured by
division of the gut nine months before the hæmoptysis.
No one can doubt that tuberculous cavities may completely cicatrize.
Instances in abundance have been observed since the publication of
Laennec's treatise. The gradual contraction and final closure of a
cavity may be observed during life, the cavernous signs becoming less
marked, and at length disappearing. At the present time I see
frequently two persons who have recovered from phthisis, recovery in
one taking place nearly twenty, and in the other nearly ten, years ago.
In these cases the cavernous respiration was well marked in situations
in which now there is a feeble vesicular murmur. In both cases there is
a circumscribed depression of the chest in these situations.
Recovery may be said to take place when cavities do not cicatrize, but
remain, being lined by a membraniform structure and free from morbid
products. Under these circumstances cavities are innocuous. There is an
approximation to recovery when cavities furnish more or less matter of
expectoration, the lungs elsewhere being free from tubercles or
tuberculous products.
Recovery with calcification of tubercles is illustrated by the
following case: A farmer from Illinois, aged forty, consulted me in
June, 1843. Within the preceding four months he had from time to time
expectorated calculi, some of which were of the size of a small pea, in
great numbers. A hacking cough had existed for several months before he
began to expectorate the calculi. At the time of the expectoration of
these the cough was severe and he raised some bloody mucus. In the
intervals the cough was slight and without expectoration. The
examination of the chest was negative as regards any signs of disease.
Thirteen years afterward this patient came to report his condition of
health. The expectoration of calculi had continued for some {421} time
after his former visit; then his cough ceased, and meanwhile he had
been perfectly well.
It is a question whether the tuberculous product is ever absorbed. The
fact that in some instances the physical signs in life and the
appearances after death give no evidence of either tuberculous deposit
or cavities, and the fact that tuberculous solidification is observed
to diminish or disappear when apparently the deposit has not been
expectorated, render it probable that under some circumstances
absorption does take place to a greater or less extent. It is doubtless
true that, as a rule, the deposit is not absorbed; the tuberculous
affection in this respect affords a striking contrast to
non-tuberculous pneumonia.
Cases of recovery from phthisis are cited by medical writers as proving
the curability of the disease. The term curability implies that
recovery is due to remedial agencies. It does not therefore embrace a
truth of great importance in its bearing on the prognosis and the
treatment--namely, the disease in certain cases ends in recovery purely
from an intrinsic tendency. My clinical studies have furnished facts
which conclusively establish this important truth. Out of a large
number of cases (640) recorded during a period of thirty-four years,
recovery took place in 44. In 23 of these 44 cases there were no
measures of treatment to which the recovery could be attributed. The
disease ended favorably in these 23 cases from self-limitation. This
assertion does not express a conjecture or a theory, but a logical
conclusion. Self-limitation, therefore, is a highly important element
in prognosis; it is a highly important factor in the treatment. The
claim in behalf of phthisis of self-limitation, based on the analysis
of cases of recovery, was made by me nearly a quarter of a century
ago.[21] It has not as yet received that recognition in medical
literature which it is desirable that it should receive in view of the
importance of its practical bearings. It will enter here into
considerations connected with treatment and prognosis.
[Footnote 21: Vide _American Journal of the Medical Sciences_, January,
1858.]
Recovery from phthisis involves, of course, cessation of the progress
of the disease. This cessation of progress may be due either to an
intrinsic tendency or to arrest by measures of management, or to both
combined. Recovery may or may not follow the cessation of progress.
Owing to the disposition and the extent of the tuberculous affection,
reparation of the lesions does not take place. It is a useful grouping
of cases into--first, those which become non-progressive and end in
recovery; and, second, those in which the cessation of progress is not
followed by complete recovery. It is also useful to consider as forming
a third group cases in which the progress of the disease is extremely
slow. The cases in the latter group are the opposite to those in which
the progress of the disease is continuous and rapid, giving rise to the
name galloping consumption.