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 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
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 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.
In cases of advanced phthisis cavities are added to tuberculous 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.