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some of its varieties—whiffing, blowing, long out-breath, bronchophonic—may permanently remain, evidences of trifling changes left by former diseases, but not materially interfering with function or structure, and therefore productive of no further disorder than perhaps slight shortness of breath, and disposition to cough on exertion and on changes .of temperature.
If the disease has lasted long, and especially if its phthinoplasms have passed into caseation and softening, more permanent injury is done to the lung textures; and although even these, if limited, may be checked and repaired, there remains more or less injury to the organ, producing various characteristic signs. Some of these have been already noticed in the pathological history of of the disease (pages 38, 63), and will be further exemplified in the abstracts of cases.
In the acute forms of phthisis, the first step towards arrest or cure is by the disease becoming chronic; the high temperature and other febrile symptoms subsiding, the pulse losing its frequency, and some abatement taking place in cough, oppression, pain, and other local symptoms. The physical signs, although more tardily, also show a change; the crepitus becoming less liquid, and more croaking or crumpling, and small degrees of it (subcrepitation) being heard in parts previously quite obstructed; and the dulness on percussion diminishes, in parts at least, and often is replaced by patches of unusual clearness (emphysema). If excavations exist, their cavernous sounds become more croaking and dry, and albeit often louder, yet more limited in extent; and the crepitus around them and in other parts of the lung diminishes or disappears.
A consideration of the more conservative and reparatory properties of the less decaying phthinoplasms will supply a key to a knowledge of some remarkable physical signs developed in cases of arrested phthisis. The formaCUBE AND AREEST.
tion of fibroid, or scar-tissue, checks the progress of decay and disintegration; but being itself a shrinking and dwindling material, it causes contraction and puckering of parts of the lung texture, and consequently either collapse of the corresponding chest-wall, or the emphysematous distension of neighbouring air-cells. Therefore in chronic phthisis, where the disease is arrested or retarded in its progress, we often see partial sinking or flattening of the walls of the chest, especially below and above the clavicles, whilst near or even at the same spots, a cough or forcible expiration will cause a protrusion of emphysematous lung in the intercostal and supraclavian spaces. And we have before pointed out (p. 65) that in a considerable number of cases, this substitution of emphysema for lung decay eventually converts phthisis into habitual asthma, with its signs of tympanitic strokesound, and wheezy dyspnoea and cough, and its symptoms of limited respiration and circulation, and consequent reptile scale of life.
In more partial forms of arrested phthisis, signs of emphysema are common in the vicinity of old cavities or cicatrices; namely, clear stroke-sound, dry whiffy breathsound, and sometimes more or less of a permanent dry crepitus, generally in the middle or lower regions.
Among the cases will be found examples of permanent recovery with signs of a cavity still persistent in the lung. A few also are recorded of pneumothorax, with its Tinequivocal signs, terminating in complete recovery. Instances of calcareous expectoration are more numerous, and may be referred to here, as affording a kind of physical evidence of the arrest of phthisis by its decaying matter passing into a state of mineral obsolescence. But some of these examples show that even petrified phthinoplasm may excite fresh symptoms; and it is commonly thrown off in consequence of some new attack.
ABSTRACTS OF CASES ILLUSTRATING THE NATURE, VARIETIES, AND TREATMENT OF PULMONARY CONSUMPTION.
Large number of Cases—Grounds of Selection—Division into Groups—First Group—Phthisis originating in Inflammation—Acute Inflammation— Chronic Induration—Fibroid with Contraction—With Cavities—Purulent Phthisis.
During a period of upwards of thirty years I have been in the habit of keeping notes of every case of any gravity in which I have been consulted in private practice. I find that I have 256 little volumes of these notes, containing on an average 100 cases in each, amounting to 25,600 altogether. As it is difficult to deal with such large numbers, it has been judged advisable to make selections, both for statistical purposes and for illustration. The grounds of selections for statistics will be stated in the chapter on that subject. The selections of cases now made for illustration are intended to bear on the views on the pathology and treatment of pulmonary consumption as explained in this work: in truth, these cases are samples of the facts on which those views are founded. Where the facts are so numerous, there is much difficulty in dealing with them, in choosing the most instructive and representative cases, and in confining these within reasonable limits; and I am not at all sure that I have succeeded in either of these points. In the endeavour to abridge and condense details, I have been obliged to sacrifice elegance of diction and minuteness of description; but I hope that the histories will be sufficiently intelligible for practical purposes. It has been my pracDIVISION AND VARIETIES.
tice in taking notes to confine them to the positive facts, or points of essential importance, and not to lengthen the description by negations, except in special instances. If a symptom is not described, its absence may be inferred, without the necessity of expressing ' no this' or 'no that.'
In thus professing a preference for brevity as essential in a practical work of this kind, I would not disparage the importance of accuracy and minuteness of description in clinical medicine generally; and students and young practitioners especially, should beware of slighting it. But from those sketching the results of large experience, a few bold outlines, drawn with a master's hand, may be as truthful and characteristic as a finished portrait, and are the best substitute where fulness of detail is inadmissible.
The value of numerous facts is much increased by their being accurately counted and calculated. Unfortunately, I have neither taste nor talent for figures, and it is the more satisfactory to me that my son has undertaken and worked diligently at the statistical parts of this book, and with results which appear to be of great importance. Judging from general impressions, when I delivered the Lumleian Lectures at the College of Physicians, I announced that in my experience the duration of life in pulmonary consumption had increased from two years to five. It will be seen in the chapter on that subject that, on numerically calculating the results in 1000 cases, the average duration was nearly eight years.
The cases will be distributed in groups, corresponding in some measure with the varieties indicated by the Table (p. 60), and described in the following chapters. The general head of Phthisis from Inflammation will form the first group, including these varieties :—The Fibroid, Chap. rV. and VIII.; the Suppurative, Chap. IX.; the Chronic Pneumonic, Chap. X.; the Scrofulous Pneumonic, Chap. XI.; and the Catarrhal, Albuminous, and Hemorrhagic, Chap. XII. This large group will also include other varieties originating in inflammation, but more mixed in their results, and in their course assuming more or less of the form of constitutional phthisis. See Chap. IV.
The second group comprehends phthisis of Constitutional Origin, which we have identified with the lymphatic system, Chap. V. This includes Acute Tuberculosis, Chronic Tuberculosis, and Scrofulous Consumption. Chap. XIV.
In some respects it must be admitted that this division is arbitrary, and I am by no means sure that the cases are all rightly distributed; but be it remembered, that the division is attempted to distinguish varieties only of one common disease; and although the recognition of these varieties may be useful to elucidate the forms which this disease may assume, yet it must not exclude the fact, that the disease is one and the same, and that the varieties are not always distinct, but may pass easily and variously into one another.
A group of miscellaneous cases is added; which will be found interesting in many particulars in both their nature and results.
CASES OF PHTHISIS ORIGINATING IN INFLAMMATION. Case 27.—Pleuro-pneumonia. Acute Phthisis.
E. J., aged 36, admitted into U. C. Hospital, December 19, 1840.—Carpenter; lived in London.—Quite well till four months ago; was attacked with pain in left mammary region, with cough and expectoration. Has continued to suffer ever since, with much loss of flesh and breath. Still frequent cough, with viscid, opaque expectoration. Pulse quick and weak. Sweats at night. Appetite bad.—Imperfect expansion of the lungs on both tides; complete dulness in lower portion of left chest, with little breath sound, except in the mammary region, almve which it was bronchial, but no vocal vibration. Dulness below right clavicle, with puerile breath-sound, and crepitus at end of each inspiration. Tubular sounds in right scapular region.
One small bleeding; repeated blisters, and a variety of remedies were prescribed, but with very little benefit. He became rapidly worse with