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SIGNS OF PHTHISIS FROM CONGESTION. 173 of these phthinoplasms is marked by the signs of extensive dulness, absence of vesicular breath-sound and motion, and exaggeration of tubular sounds of breath and voice, persisting for months or even years; the collapse and tight dull sound of the walls of the chest of the contracting portions; the irregular and sometimes cracked or chinking dulness over the parts undergoing caseation and excavation, which also yield their signs of crepitation and gradually increasing cavernous sounds; whilst, in other portions of the lung, the breath-sound may be puerile, or mixed with crackling, from emphysematous over-distension, which is also seen in the protrusion of the intercostal or supraclavicular spaces on coughing. These and other variations in the signs of post-inflammatory phthisis have been already noticed, and will be found exemplified in the related cases, therefore it is unnecessary to enter into further details here.

There is another mode in which phthinoplasms, both contractile and caseating, may form and induce consumption, without any distinct inflammatory attack; without pain or fever; with little cough and expectoration ; but generally with shortness of breath and weakness. A peculiar crumpling crepitus invades a considerable portion of one or both lungs, superseding the breath-sound in the part—in some cases gradually inducing dulness and tubular sounds ; in others becoming mixed with wheezing rhonchi and the clear stroke-sound of emphysema. The primary condition seems to be one of congestion rather than inflammation, hence the absence of active symptoms, and the slow rate at which phthisical processes follow. In fact, they sometimes do not follow; but that portion of the lung becomes partially emphysematous, and the tendency to further deposit is thereby restrained. This is a common result of those long-continued congestions at the base of the lungs, resulting from organic diseases of the heart and liver. But, as in predisposed individuals inflammation may develope the disease, so continued or extreme congestion in the same subjects may produce a similar result. The crumpling crepitus and impaired breath-sound may be caused by congestion alone; but this does not continue without altering the nutrition further in one way or another : if chiefly around · the tubes, producing vesicular emphysema, with its wheezing breath-sounds and clear stroke-sound ; if in the alveoli—dulness, and tubular sounds, added to the crepitus, which eventually passes into cavernous sounds, audible in one or several parts of the lung texture thus invaded by the phthinoplasms.

Spontaneous miliary tubercles, scattered through the lung, without preceding inflammation, are sometimes hardly indicated by physical signs. When numerous, as in acute tuberculosis, they excite more or less general bronchitis; and the attendant sibilant, sonorous, and mucous rhonchi obscure the special signs of the tubercles, until the increasing obstruction and density of the lung become apparent from interrupted breath in parts, with patches of irregular dulness on percussion. These signs, together with the persistent high temperature-ranging from F. 100° to 105°,—and the rapidly increasing weakness, wasting, and oppression, soon declare this frightful form of the disease.

* But when the miliary tubercles are few and scattered, they may produce no signs. An increase of numbers, and, still more, their accumulating in a particular spot, will cause a roughness in the breath-sound and a prolongation of the expiratory sound over them. So, likewise, the clustering together of even a few miliary tubercles may, perchance, slightly deaden the sound on percussion in a spot, and transmit more of the voice and heart-sounds than is to be heard in other parts.



Our lamented colleague, the late Dr. Theophilus Thompson, and others, have laid much stress on the wavy or jerking respiration (respiration saccadée, entrecoupée) as an early sign of phthisis; but no one seems to have traced it to its true cause. It is nothing more than the respiratory sound modified or divided by the successive pulsations of the heart. These, on the left side especially, slightly impede the passage of air in part of the lung, and thus give its sound a jerking or interrupted character. The presence of tubercles in the lung increases this effect by transmitting the heart's pressure further, and by narrowing the area of the passing air. Hence, too, this kind of respiration is observed most in females, with a narrow chest, and a palpitating heart; and in such I have frequently heard the wavy breathing, without any evidence of the existence of disease of the lung at all. With this understanding of the true nature of the sign, we can better estimate its value as indicative of disease in the lung.

The same remark may be applied to the subclavian arterial murmur which was mentioned by Dr. Stokes as a sign of incipient phthisis. It is caused by pressure of the apex of the lung on the artery, and although such pressure is more readily produced when the lung is partially condensed, yet it does occur in some subjects without any disease of the lung.

With the advance of the tubercles to caseation and the infection of new parts of the lung, the various degrees of crepitus, click, and croak become developed, and are the more striking in lymphatic or infected tuberculosis, from not being preceded by the rhonchi or crepitus of inflammation. And the signs which follow-increased dulness, tubular sounds, cavernous croak and gurgle, pectoriloquy, hollow puff or souffle with cough, &c.--commonly have a more remarkable character of isolation in this than in

the inflammatory form, where the disease is more diffused.

But it must be kept in view that the grey tubercle represents the infective type of the disease, and that even where the first phthinoplasm has begun in inflammation, the subsequent spread of the disease will be through the lymphatic or adenoid system, in the form of grey miliary tubercles. It is this which establishes the identity of consumptive diseases, which not only have all the degenerative and wasting character, but they all tend sooner or later to infect the lymphatic system, and break out in the tubercular form. We have, therefore, to watch for the signs of these in parts hitherto untouched, especially at the summits and roots of the lungs, and in the bronchial and other lymphatic glands. And so long as we find these signs wanting, we have ground for hope that the disease has not assumed its most constitutional and destructive form, and is still limited to the part already invaded.

The consumptive disease may be known to be in an active or increasing state, when there is more obstruction to the breath-sound, crepitating or complete ; when the dulness becomes more marked and extensive; when tubular sounds are hollower or louder, or are mixed with a bubbling or moist coarse crepitus, and these signs are further enlarged into the gurgling, churning noises of softening phthinoplasms and enlarging cavities. And the increasing size of the cavities may be judged by the sound of their hollow: when small or moderate, and communicating with the bronchi, forming islands full of voice or blowing breath-sound close to the ear or stethoscope applied to the chest; when large, giving less loudness of pectoriloquy, but the more mysterious reverberations of amphoric blowing or metallic tinkling, which add a peculiar sepulchral tone to the sound.



As we do not profess to give a complete history of consumptive disease in its worst as well as in its more tractable form, it is not necessary to dwell on the symptoms which mark this last stage of decay. They indicate not only rapid degeneration and waste, but often corruption and decomposition, in which septic parasites, vibrios, bacteria, and aphthous fungi, lend their destructive aid. Thus polois passes into poopá. It is not to be forgotten, in connection with the subject of this worst form of decay, the putrefactive, that it sometimes occurs at an earlier stage in the form of gangrene and gangrenous abscess, and the fætor is a physical sign of its presence. The secretion of dilated bronchi is sometimes also very offensive, from being long retained, in consequence of the mechanical difficulty in expectorating it.

The signs of the cure of phthisis might be expected to be the complete disappearance of those of the disease, but it is rare that the disease and its effects are so completely removed as to leave no trace behind. We can record a few cases of incipient disease, chiefly of inflammatory origin, and of decidedly consumptive character, in which crepitation, dulness, and tubular sounds, have been entirely removed, and the patients have been restored to complete health.

But the cominoner degree of what may still be called a cure, is where the general health is recovered, cough, and expectoration, and other symptoms, have ceased; yet the physical signs, whilst showing a cessation of all active disease, still indicate traces of its effects on the lungs and their coverings. Thus, a collapse under a clavicle; a flattening of the upper or lateral walls of the chest; slight variations in the sound on percussion, and in the respiratory movements; a weakness or a mere roughness of the in-breath-sound in the former seat of disease ; a remnant of tubular sound, especially above a scapula, in

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