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end in caseous consolidation, and thus produce an acute phthisis or 'galloping consumption;' and we here have occasion to refer its rapidly destructive tendency to the lifeless and aplastic nature of its products, and their consequent proneness to early decay.
But caseous consolidation may be so limited that although it destroys the part, yet it may not extend to other parts of the lung or infect the system at large. Clinical instances of this may have occurred in those cases in which after an attack of inflammation signs of excavation become evident in conjunction with the expectoration of opaque matter; after which the cavity contracts, the wound heals, and the patient recovers. More common is the necroscopic evidence met with in the bodies of those, who, after having recovered from an attack of inflammation, have died of some other disease; and there is found a cavity, lined with adventitious membrane, either empty or containing cheesy matter. If old, this exhibits more or less of the calcareous transformation, or calcification, a change to which all effete animal matter retained in the body is subject in time.1 This calcareous matter is chiefly phosphate of lime, and maybe either the mineral ash or residue of the deposit after the animal matter has been dissolved or absorbed away; or it may be the result of a chemical concretion from the pervading fluids, like urinary calculi. In all these cases of partial caseation of the lung from inflammation the aplastic matter is hedged in by a plastic process in the surrounding texture, which forms a membrane or cyst, and the softened caseous matter may either be discharged through an opening into the bronchi, or being retained, it becomes obsolete and may petrify. Small
1 Casr 5.—Miss F. M., aet. 28; brother and sister died of phthisis. In 1839 was attended by Dr. W. for cough, with opaque expectoration, which lasted several months, with considerable loss of flesh. Slight partial
cheesy or calcareous bodies, commonly but not always encysted, are so frequently found in the lungs of adult
dulness; harsh and tubular breathing were found at the summits of both lungs, most of the left, where there had been occasional pain. Under the use of iodide of potassium and sarsaparilla, with external counter-irritation, the cough abated, and flesh and strength were pretty well restored.
In 1841 a serious abdominal disease came on, attended with pain and induration of a considerable extent of the small intestines and colon, ending in ulceration and perforation of the ileum, and death. This was diagnosed to be carcinomatous disease; and so it proved on examination after death, that a scirrhous growth had spread between the coats of the intestines to a great extent, causing both stricture and ulceration in several parts. It is unnecessary to dwell on this part of the case, which is cited in reference to the arrested disease of the lungs.
Both pleurae were partially adherent, especially at the summits of the lungs. At the apex of the left lung was a thick fibro-cartilaginous patch, with puckering of the lung-tissue around its edge; and underneath was a mass of opaque yellow and partly calcified tubercle, not completely filling a'cavity, which was lined by a dense membrane forming a cyst around the caseous matter. On the right apex there was also some puckering of the pleura, with thin opaque patches, and slight condensation of tissue underneath. When cut into these were dark grey in colour, with Beveral minute cavities of size of hemp-seeds. There were no other tubercles in the lungs, but several small calcareous nodules near the roots.
These may be considered the residue of tubercle, perhaps superseded and rendered innocuous by the revulsive influence of the more malignant disease in the abdomen.
Case 6 A brewer's clerk, age 25. First seen September 13, 1847. A
year and a half ago had syphilis, and was treated by mercury for three months. Eight months ago an eruption appeared on the skin, followed by cough, slight at first, but afterwards becoming violent, with purulent expectoration, and lately accompanied by sweats, and loss of flesh, strength, and breath. Marked dulness below left clavicle, extending to mammary region; gurgling and crepitation around. Loud tubular sounds within and above right scapula. Ordered oil; and counter-irritation with iodine liniment.
May 24, 1848.—Has taken oil regularly all the winter, and has quite recovered flesh and strength. Cough slight, with scanty opaque morning expectoration. Still dulness in upper left chest, with dry cavernous sounds above and below clavicle; but no crepitation; beskular sound faintly heard in lower chest; less tubular sounds in right lung.
September, 1850.—Quite well, and taking active exercise. IhUness much diminishing; some tubular sounds in upper left chest, front and back. ATo caverntius sounds, but breathing harsh.
and old persons who die of other diseases, that they may be taken as proof that there is nothing specific or peculiar in their nature, but that they are among the common lesions of nutrition, which are injurious by their extent rather than by their kind. A reference to the table will show that caseation and calcification is a result in which most of the phthinoplasms may end and become obsolete. The frequent occurrence of caseation to a limited extent, without any evil effects, sufficiently sets aside the notion, recently propounded in Germany by Buhl and others, that acute tuberculosis is always produced by infection from caseous matter.
Dec. 26. 1856.—Heard from Dr. Carlill that this patient had just died suddenly of peritonitis from intestinal perforation. He had been apparently well, and actively engaged in business, till ten days before his death; subject only to occasional attacks of headache and costiveness. After walking a mile he was seized with suddon and severe pain in the abdomen, with collapse and other symptoms of perforation, and died in two days. A post-mortem examination was made by Dr. (now Sir W.) Jenner. The abdominal walls were found to be covered with fat an inch thick. The ileum just above the coocum was perforated by ulcers of tuberculous character, of which there were several.
Both lungs were strongly adherent at their apices, especially the left; and in both cretaceous matter was found; in the right in tubercles, varying in size from a pin's head to a pea; but in the left lung there was a large mass of the same material, which quite filled an ancient cavity at the summit of the lung.
This patient had been free from chest symptoms for eight years.
This case is less remarkable for the duration of life after recovery from the third stage of consumption, than for the completeness of the cure of the chest symptoms, and for the demonstration it afforded after death (from another cause) of the arrest of the tuberculous disease which had made rapid strides eight years before.
The phthinoplasm at the left apex must have been long in a caseous state, before it petrified, without giving rise to fresh tubercles; and those which formed at last in the intestines, and were the cause of death, are rather to be ascribed to constitutional causes than to the influence of the obsolete phthinoplasm.
VARIETIES OF CONSUMPTION FROM INFLAMMATORY
Varieties distinguished by expectoration — Catarrhal, albuminous, and hamorrhagic — Catarrh may precede or follow Phthisis—Peribronchial and fibroid variety—Albuminous, mucopurulent, and pellicular—Hamorrhagic.
Although in all inflammatory consolidations of the lung leading to consumption, the sarcophytes and fibrin constitute the basis or essential element, there are other contingent matters belonging to the hyperplasias which give a variety to the course of the disease and to the character of the consolidation. These are noticed in the second column of the table (p. 60), as a third class of morbid elements, including albumen, mucus, epithelium, and other cells and granules, red corpuscles, &c. These are thrown out in various proportions during the inflammation of the lungs and bronchial tubes, and may be studied in the expectoration, where they are often blended with the consolidating materials, and partake of their changes and results. It is chiefly, however, in the expectorated matter that these contingent products are seen; and an examination of this, in different cases, suggests three chief varieties which may be connected with phthisis, under the terms catarrhal, albuminous, and hasmorrhagic.
By the catarrhal variety I would designate those forms of inflammatory phthisis preceded or attended by mucous secretion from the bronchial membrane, with an unusual amount of cough and expectoration. There is more or
less of bronchitis in all cases of phthisis; but in some, the early history is completely that of bronchial catarrh; and the affection of the lung becomes apparent only through the persistence of the disease, and the additional physical signs and constitutional symptoms. In some cases the bronchial inflammation precedes the lung affection, and eventually induces it by penetrating deeper, in the manner already described. In others, the consolidation of the lung is evident from the beginning, but is attended with bronchial inflammation or bronchial flux to an unusual extent. This occurs especially in connection with the fibroid or cacoplastic consolidation of the lung.
The expectoration is often abundant, with various degrees of frothiness and viscidity, and contains chiefly water, with saline matter and more or less hyaline mucus, and numerous epithelial cells, ciliated and pavement, from the bronchial membrane. To these at times may be added pus-cells in various proportions, giving the expectoration the mucopurulent character, which increases with the occurrence of any suppurating or softening process in the lung. Sometimes this opaque appearance of the expectoration is attended with a diminution of the bronchial irritation. In other instances, it brings no mitigation, and only adds to the weakness and emaciation. In fact, these catarrhal varieties of phthisis are often more distressing than those of more rapid and unresisted decay. The harassing cough, exhausting expectoration, and oppressive dyspnoea, are most painful, and are sometimes very little controlled by treatment.
Under the head of albuminous expectoration of inflammatory phthisis, I would include that containing albumen, either uncoagulated or coagulated. The expectoration in the first stage of pneumonia, and in bronchitis attended with much pulmonary congestion, contains a considerable amount of liquid albumen, which may be coagulated by heat and acids. This was noticed long