The Sounds of Clinical Medicine

Voices, murmurs, rumblings, wheezes, clicks, cries, laughter, even obscenities,
are all part of the diagnostic landscape

linical medicine is replete with interesting noises. Many are characteristic, others are always surprising, some can make us laugh or cry and still others are very private experiences that nobody can verify.

Handheld video cameras allowed in today's delivery rooms and birthing centers will capture for posterity not only the baby's cry but all other sights and sounds as well.

Starting with the head or, more precisely, it's interior, we know of a very personal and peculiar experience—the auditory hallucinations characteristic of a schizophrenic psychosis. Tormenting voices that dictate the patient's behavior to include homicide and suicide. The use of illicit hallucinogenic drugs is today the most common cause of hallucinatory experiences, both auditory as well as visual. Another very personal but widespread auditory experience is that of buzzing and ringing in the ears, medically known as tinnitus, which in turn can be vibratory or non-vibratory. These can be due to conditions of the ear proper or the contiguous brain structures and can also be a secondary side effect of medications, typically Aspirin in high doses. At the other end of the auditory spectrum is the absence of sound—deafness—which can be congenital or acquired and due to a variety of causes, most notably viral infections such as mumps (parotitis) or be a sequel of meningitis. In most instances deafness is remediable with the use of hearing aids or cochlear implants.

Damage or functional impairment of brain tissue due multiple causes can give rise to clinical manifestations that include a number of unusual and interesting sounds and utterances. Echolalia, sometimes seen in schizophrenia, autism and Tourette's syndrome is when a person repeats the speech of somebody else in an involuntary and meaningless way (remember the movie Rain Man?). Whether a word, a phrase or an entire sentence, any utterance is repeated in its entirety along with the tone and accent of the speaker. Another disorder of speech fluency is stuttering, characterized by the involuntary repetition of sounds, syllables, parts of words, whole words, pauses and prolongations during speech. Speech language therapists and researchers say significant control, perhaps elimination of this complex problem, can be obtained if stuttering is treated early enough.

The classic seizure of grand mal epilepsy may be preceded by a sudden loud scream or a grunt or both. Mad cow disease, a type of spongiform encephalopathy caused by proteinaceous ultramicroscopic infectious particles known as prions, has been known to produce, in well documented human cases, episodes of disconcerting howling and screaming. Mad cow disease is an animal variant of another human disease known as Kuru or laughing sickness. This latter type occurs in cannibal natives of New Guinea that habitually eat human brain tissue and is characterized by unexpected attacks of laughter.^*

The crit-du-chat syndrome—a genetic deficiency characterized by multiple congenital defects—carries the name of its most characteristic feature, the production by the pediatric patient of a soft wailing sound similar to a cat's meow. The common Tourette's syndrome is a disease known for it's unstoppable nervous tics—brief and simple involuntary motions or complex spastic movements of the head. There are also vocal and respiratory tics manifested as groans and grunts, sometimes barking sounds emitted in a compulsive involuntary fashion. The involuntary production of escatological terms, obscenities and cursing is also part of the clinical picture. (The patient featured in the book and movie The Exorcist possibly suffered Tourette's syndrome).

Spasm of the powerful masseter muscles of mastication situated on both sides of the head provokes the characteristic grinding, clicking and creaking sounds of the TMJ syndrome. The TMJ (temporo-mandibular joint) is the delicate joint located right in front of each ear that can dislocate and bring articular surfaces together to produce the mentioned sounds or even become immobilized or locked if the surfaces are entirely out of alignment. Locking of the jaw refers to the characteristic finding called trismus or lockjaw which occurs in tetanus, in which case it would be due solely to a 'tetanic' muscular contraction of the masseters and not to a TMJ articular surface dislocation. And of course, we can't forget our grandmother's insistence that teeth grinding or bruxism in children is due to intestinal parasites until proven otherwise.

The classic snore or respiratory rhonchus occurs when the soft palate and other structures in the oropharynx tremble. A sneeze, an experience of most mammals, is a sign of nasal irritation particularly allergic in nature.^** Cough is the universal manifestation of infection or irritation in the upper respiratory airways. There are various types of cough worth mentioning. The typical croup or inspiratory stridor is characteristic of an infection of the larynx and trachea or the epiglottis, the entrance to the larynx.

Infection within the larynx and vocal cords can affect voice production, from typical hoarseness to aphonia, complete absence of audible sound stemming from the larynx. The other classic cough variant is the whooping cough of Pertussis—a paroxysm of from 5 to 15 short expiratory grunting coughs followed by the "whoop", a hurried and forceful inspiratory effort. Croups and whooping coughs are desperate childhood experiences that no mother will ever forget. Another typical respiratory sound is the high pitched wheezing that is associated with asthma and is due to air flowing under pressure through constricted airways. Of the classic triad of asthma—cough, respiratory distress and wheezing - it's the latter that is considered the sine qua non of asthma.

Wheezing is also typical of foreign bodies lodged in the respiratory tract. The combination of sudden onset of aphonia and wheezing in a restaurant setting is the characteristic combination for a bolus of food trapped in the upper respiratory passage.

Listening over the chest with a stethoscope we hear pulmonary sounds which are generically called rales, of various kinds and descriptions; these are due to the movement of air through pulmonary tissue wet with fluids and secretions of various kinds and quantities. The word rale was used first by the French inventor of the stethoscope, Renee Laennec. The membranous lung cover or pleura can also produce audible gritty sounding pleural friction rubs due to inflammation of the pleural surfaces.

The beating of the heart produces normal heart sounds. The majority of abnormal heart sounds are due to congenital defects or deformities of the valves through which blood flows in and out of the various chambers. These are called murmurs, which relate to the turbulence of flow. Not all murmurs are necessarily pathological, some of them, the so- called "innocent" murmurs, tend to disappear as we become adults. Other abnormal heart sounds have interesting names such as clicks and honks and rumbles. In areas of maximal circulatory turbulence one can hear and even feel thrills over the medium to large sized arteries, such as the carotids, femorals and the abdominal aorta. Also, as in the membranous cover of the lungs, the heart's membranous cover or pericardium can also produce a pericardial friction rub when inflamed.

The diphragm, the muscular bands which divide the chest and abdominal cavities can develop sudden spasmodic contractions which suck air in forcefully and involuntarily, producing a noise which we all recognize as hiccups. Within the abdominal cavity the only source of sounds is the gastrointestinal tract. Eructations (belchs, burps) are due to the rapid reflux of swallowed air that may or may not be accompanied by swallowed food—an unwelcome event in the western world, not so in other parts of the world where the host expects some healthy burps from his guests as an expression of gustatory satisfaction. Borborygmus is the normal rumbling sound of air mixed with intestinal contents which we all experience at various decibels when hunger strikes. The complete absence of intestinal sounds—known as an ileus—ocurrs when intestinal motor activity is lost as in high-grade intestinal obstructions. The expulsion of gas per rectum, called flatus, is a subject for which there is no scarcity of jokes and stories. Neither the sounds or the odor of intestinal gas passed per rectum have clinical significance. Absence of flatus, on the other hand, can be associated with a developing intestinal obstruction.

Within the musculo-skeletal system the word crepitus refers to the cracking sound of bony structures within a joint. It is a habit of some to crack the joints of their hands and fingers.

Speaking of the revolutionary use of sound in clinical medicine. The delivery of sound waves and magnetic resonance into the human body and the capture of same as they rebound from the various organs via modern ultrasonographic and other forms of imaging technology creates images that serve the clinical purposes of many specialties in modern medicine.

To end let me say a word about our classic personal listening device, the stethoscope. It has evolved from a simple primitive device to a highly sensitive and sophisticated medical instrument. The typical image of a modern physician carrying a stethoscope wrapped around his neck or shoulder in a carefree fashion, as we see on TV, would have been considered in earlier times an intolerable imprudence. It would predictably have lead to loud and unpleasant vocal sounds by a stern professor who would be offended to see the solemn instrument reduced to a hanging ornament. Times have certainly changed but the clinical sounds remain the same.^*

References:

Any of the well known comprehensive textbooks of clinical medicine can serve as references for the clinical sounds mentioned here. These include Cecil, Harrison, Oxford and the Lange library to name a few. The author has simply compiled the sounds into an accessible format for the average medical translator.

^** Today, as it did in the middle ages, sneezing elicits automatic blessings from the audience— "Bless you" or "Salud"—, intended to protect the person from the "soul loss" attendant to sneezing, at which time disease or unclean spirits may enter your body. Soul loss is, likewise, present today in rural Latin America where it is believed that "susto"—an intense frightening experience—leads to soul loss. Whatever symptoms may appear subsequent to susto will be usually be attributed to it.