In this investigation, we use the stethoscope with its stopper, as serving better to bring the sound of the voice to a focus. If there be an open tubercle (in synonymous terms, ulceration, or excavation), the vibrations produced by the voice passing more readily to the ear of the auscultator, than when there is no breach of surface in the lung, it seems as if the patient were speaking up the tube, and hence the exact situation of the ulceration is indicated. This phenomenon is called by the expressive term, pectoriloquism.
If the instrument be applied over the windpipe, when there is not disease, the voice produces in some measure the same effect; because at this part, the integuments are thin, and do not interpose much medium between the voice of the person speaking, and the ear of the auscultator.
It is a consoling circumstance that M. Laennec does not view tubercular consumption as an incurable disease. He mentions having several patients under his care ill with chronic catarrh, affording distinctly the sign of pectoriloquism, although in all other respects then free from symptoms of consumption.
He refers to the case of a lady, a patient of M. Bayle, in whom pectoriloquism was quite distinct. She had been decidedly affected with the symptoms of consumption eight years before: she had recovered beyond all expectation, and was then stout, not having any other symptom of pulmonary irritation than a slight cough.
M. Laennec next relates[2] the morbid appearances in the lungs, found on dissection in five cases of patients who died from other diseases. In each instance, tubercular excavations were found cicatrized, and for the most part lined by a semi-cartilaginous membrane; adding testimony therefore to the opinion already stated, that nature does sometimes exert a curative process, in cases of consumption which were apparently hopeless.
It should consequently be the study of our art to favour the salutary efforts of nature; and invariably to cherish and encourage, in a judicious manner, those hopes of the patient, which in this destructive disease are always, to a remarkable degree, so fondly entertained. It is to be observed that if a solid cicatrix be formed, and the bronchial tubes terminating in the part be obliterated, the phenomenon of pectoriloquism cannot be found; but we meet with it in two states of the diseased lung, the one in which the ulcerative process is at present going on; the other, in which there is a healed excavation or ulcer, lined by a newly-formed membrane, of a semi-cartilaginous nature, and fistulous. These respective conditions will of course be denoted by the relative state of the patient. The perfect cicatrix is more completely a curative process, than the formation of fistula.
The recovery of health from the cure of ulceration just described, may prove more or less lasting accordingly as the remaining part of the lung be free, or not, from tubercles. But even when they do exist, they may fortunately remain dormant for some years.
In every case of seeming recovery from consumption, it is incumbent on the patient to lead a life of the utmost care, and to choose a favourable climate, endeavouring to avoid the cold of winter, the extreme heat of summer, and the vicissitudes of spring and of the latter part of autumn, by the best possible management. M. Laennec is particularly partial to a sea-side residence for consumptive patients.
In some circumstances of consumption, the existence of pectoriloquism, as denoting the ulcerative process, is considered by this physician to be rather favourable than otherwise; because it is an indication that nature is making efforts towards a cure, by maturing and evacuating the tuberculous matter. The prognosis is favourable in proportion as we have reason to hope that the other parts of the lungs are healthy.
In some severe examples, numerous tubercles acquire an active state of disease; and the consequent irritation is so excessive, that death takes place without the usual process of ulceration.