CHAP. Diffused tubercle double. 8 years. Diffused tubercle double. 4 years diffused crepitus left. Oil, iodine externally, pil. conii c. morph. January 1862.-Has taken oil 31⁄2 years, doing well. Phy. signs as before. Under observation 3 years, duration 5 years. R. W. æt. 27, waiter. Maternal predisp., constant cough 8 years, hæmopty. frequent, streaky, formerly severe sweats; is only slightly wasted, expect. considerable, digestion good, never had diarrhoea; dulness, diffused dry crep. from apex to base left, diffused smaller crep. of a dry character anteriorly right. Improved much on oil and sedatives, with counterirritation. Duration over 8 years. Nov. 1857.-A. H. æt. 23, porter. No predisp., hæmopty. one quart eight ms. ago, slight five wks. ago, cough eight ms., abundant increasing expect., marasmus 2, strength fails, stationary. sweats formerly, digestion good; dulness very marked, extensive coarse crep. of a dry character left, crepitus base post. right. Ol. mist. ferri, c. calumb., linctus, opii. Improved steadily. Went to Bournemouth and Torquay, and in Feb. 1861 was doing well. Same physical signs. Under observation and taking oil 3 years, duration over 4 years. September 1858.-W. F. æt. 42, painter. No predisposition, hæmoptysis six years ago; two inflammatory attacks on chest with hemoptysis since. Under Dr. Cotton three years ago. Partial aphonia for years, marasmus 2, not losing, expect. considerable, no fever, digestion fair; diffused double crepitation of a moist clicking character, largest at both apices, bases scarcely clear. Oil and chloric æther mixture. In Dec. 1861 was doing well; had taken oil; 3 years under observation; same physical signs. Duration over 9 years. Diffused tubercle double. 9 years. C. B. æt. 12, schoolboy. No predisp. to pht. or rheumatism, has had three attacks of rheumatic fever in last four ms., had cough for an indefinite long time previously, very anemic, much wasted, with orthopnæa at night, no oedema. Cardiac dulness very extensive, impulse much increased, whizzing, mitral systolic murmur. Dulness whole right chest, and diffused moist crepitation. Ordered tr. digitalis with salines, blister to region of heart; was much relieved a month later. E. T. æt. 40, upholsterer. No predisp. ; out-patient for some years (Dr. Quain, Dr. Pollock); no hæmoptysis, cough habitual, severe, with scanty difficult expect., considerable wasting, distressing dyspnoea, remarkable arcus senilis. Dulness, extensive diffused humid crepitation anteriorly left, strong impulse cordis, double rough mitral murmur. Ordered mixture of squill, æther, tr. lobeliæ, also emp. lytte, which relieved; afterwards chloric æther, and stramonium. He was much in the same state one year later. CHAP. XIII. diffused fever. Nov. 1857.-J. B. 44, tailor.-No predisp., cough for two Double years, with mod. expect., no hæmopytsis, spare habit, no loss tubercle. of flesh, no fever, app. good, b. reg., t. very white. Humid Rheumatic crep. both sides diffused, with more dulness on right, but crep. to base on left. To take oil and pil. conii c. morphia, stationary linimentum ol. crot. pectori. Feb. 1858.-Doing well, less 3 years. dyspnoea. March.-Acute rheumatism of joints. Treated with salines and colchicum. Improved much on quinine afterwards, and chest disease remained chronic and quiescent while under observation for some months. CHAPTER XIV. XIV. Third stage. Definition. CHRONIC THIRD STAGE. CHAP. THE third stage of phthisis may be said to be reached when masses of tubercle in the lung have become involved in such a process of softening as to cause destruction of the lung tissue to an extent sufficient to originate the physical signs indicating cavity. Of course, every softened tubercle makes a cavity; but aggregation of the deposit, clearing out of the morbid matter, and destruction of the lung tissue, must coexist to some considerable extent to form this stage. Localisation of cavity. Time in which cavity is formed. Its locality, as is well known, is generally at the apex of one lung; but in rarer instances an excavation is found towards the middle, or at the base. Excepting in a very rapid form of the disease, it is very rare to find cavities in both lungs produced simultaneously. Such an occurrence evidences an extent of local disease and of constitutional disorder very perilous, as it is fortunately very unusual. It is difficult to state the time which it takes for a cavity to form in the lung. In most acute phthisis I have witnessed the occurrence in six weeks from the outset of the disease, and in two months thirteen cases of rapid consumption had reached the third stage. In all of these both lungs were engaged; but the cavity was formed in one side only. According to my experience* the left lung is gene *This experience seems borne out by that of Cotton, Alison, Walshe, and others. XIV. rally found to form a tuberculous cavity more rapidly CHAP. than the right; and the posterior part of the apex begins to soften before the anterior. The signs of cavity Forms may therefore be frequently detected in the supra- pidly in spinous fossa before they are evident in the subclavian left side. region. more ra For diagnostic purposes the physical condition is Prognosis. sufficiently marked; for purposes of prognosis the state of the surrounding portions of lung is alone important; and having ascertained the existence of cavity by the usual signs of blowing inspiration and expiration, gurgling on cough, and in certain instances by vocal phenomena of varying intensity (from 'mere resonance' up to perfect pectoriloquy), we should direct our closest attention to the state of the lung immediately below these signs, as well as to the other parts of both lungs; for, as far as physical indications can guide us, the future of our patient is to be estimated not by the cavity but by the integrity of the remaining portions of lung tissue on both sides. which in the cavity The ordinary process of coalescence of masses of Causes tubercle, while in a state of softening, implies neces- fluence the sarily that the intervening portions of lung have under- nature of gone ulcerative absorption or destruction. It is this formed. fact which renders the formation of cavity so perilous. Were each tubercle to soften separately, and the deposit to be much diffused throughout the lung, we should have the disease in a different form, and less urgent in its accompanying systemic disorder. Their aggregation is a necessary condition to the formation of cavity. With great massing, and isolation of the morbid Massing of product, although we should expect a large cavity, we may have a residual portion of lung comparatively free. When the former (diffused) condition prevails, and at the same time large masses of tubercle are infiltrated near the apex, we have, on their breaking up, an irregular portion of lung destroyed, without attempt at insulation. tubercle. XIV. CHAP. Instead of condensed tissue, the product of more or less inflammatory action underneath such a cavity, we have Irregular other tubercles less advanced, but still ever ready to cavity. undergo destructive changes, which involve a further Integrity of the interven ing portions of lung. Diffused tubercle. portion of lung in their disintegration. An irregular anfractuous cavity is the result, often burrowing deep into the pulmonary tissues. This is the ordinary termination of consumption. Not only is there a certain continuity of diseased action from first to last of the case, but there is continuity of the diseased products in the lung, and by mere mechanical extension a spreading ulcer is formed, resembling more those phagedenic affections of the skin, and subjacent cellular tissues, which we so often witness in unhealthy constitutions, than any purely visceral inflammation. The integrity of the intervening portions of lung tissue is the measure of the progress of the case. A lung, even extensively infiltrated, but with large portions of healthy, permeable pulmonary tissue intervening, is slow to undergo the softening changes which destroy surrounding parts; and this is the condition, often very chronic, which we have described as 'diffused tubercle.' A lung studded with massed tubercles so near as almost to run into one another, and with a repetition of deposits, is the condition most favourable to the formation of anfractuous irregular cavities; while a single, massed, but isolated deposit in the apex, with the rest of the lung clear, affords the highest probability of forming a circumscribed and tolerated cavity. Irregular The irregular and burrowing cavity is then the most burrowing cavity. perilous, as it is the most frequent result of phthisis. Few indeed die of the disease without reaching this stage; and after a close scrutiny of post-mortem records of our hospital, amounting to 556 cases of phthisis, more than 500 were found to have excavations of the irregular cavity, and generally in both lungs. The only exceptions are those comparatively few cases |