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to the last in all parts of the lungs besides; and upon dissection, that all parts are often found healthy which a tubercle or vomica does not actually occupy.
• The difference between the present form of pulmonary consumption and the former is this—that the former lingered long in the tubercular stage, tubercular matter continuing to be deposited year after year, but no vomica occurring, until, at a very advanced period, many were formed simultaneously, or in quick succession, and hurried on the patient to dissolution with great rapidity; whereas, in the present, the vomica, and vomica only, is the object recognised by auscultation. Tubercle must precede it. But the tubercle is hardly deposited before the process of softening and evacuating it arises, and a vomica is the result. Thus tubercle is formed after tubercle (as it should seem) with some interval of time between, and vomica after vomica ; but the vomica is the more abiding morbid condition. These are genuine and unmixed forms of pulmonary consumption; and I have dwelt upon them because they are so, and because I am indebted for my knowledge of them, as distinguished from others, to auscultation.
* Of those two genuine and unmixed forms of phthisis, the first is unquestionably the most hopeless. Where tubercles are largely deposited, and continue still to increase, and do not pass on to vomicæ, there is never the smallest attempt towards a restoration to health-not even of a temporary or apparent restoration. But where tubercles arise one by one, or a few together, and this one or these few pass rapidly into the state of vomicæ—and where a pause ensues between each successive formation of tubercles and vomicæ—then, during that pause, there is an opportunity for the powers of reparation to come into action ; and, in truth, there often does arise a manifest endeavour after health --an endeavour which succeeds so far as to recover some of its conditions, and to suspend the disease: and then, during that pause, there is always the hope (for where disease is suspended and health is partly recovered, we cannot help hoping) that reparation may be complete, and the disease abolished altogether.'—pp. 247-254.
Dr. Latham here takes occasion to discuss the question, ' Does consumption ever admit of cure?' And he considers, that, if ever, it must be in this form of unmixed phthisis which he has last described. To this important question, taken in a mere pathological sense, he answers in the affirmative, and allows that a vomica is capable of reparation. To the same question, taken in the sense which those intend who have more than a scientific interest in proposing it, his experience has not allowed him to return the same satisfactory affirmation ; but it has allowed him to speak many words of encouragement and comfort to those who may ask it in too desponding a spirit.
* Does consumption ever admit of cure? A vomica certainly admits of reparation so far as not to be a vomica any longer, but not so far as to leave no trace within the lungs. It leaves behind it a scar—that is, the disease ceases in the part, but the part is not restored to the exact condition in which it was before the disease began.
In examining by dissection the bodies of those who die of pulmonary consumption, among many existing vomicæ we occasionally find the traces of a vomica healed. At the apex of the lung we find an indentation, and descending from it, for half an inch or an inch, a thick perpendicular line of tough ligamentous substance. Sometimes this substance, by being pulled asunder, is discovered to contain the remains of a cavity, and sometimes not. But what imports this reparation of a single vomica, if so many besides still exist? A reparation of a twentieth part of the existing disease cannot be called a cure.
But in those who have not died of any pulmonary symptoms, and who were never known during their lives to have had any symptoms apparently phthisical, the same evidences have been found after death of what once was a vomica, but no existing vomicæ together with it. This is a cure, or tantamount to a cure. It is as much a cure as when a single scrofulous cervical gland goes on to suppuration and heals with a scar. A single vomica, you may say, is as much of the essence of consumption, as a hundred ; and if the morbid structure (no matter how small) in which the disease essentially consists be repaired, the disease is cured—that is, the consumption is cured. But it was a consumption which nobody knew to exist. Now all this may be very fine reasoning; but it does not meet the plain meaning of the inquiry whether consumption be curable. It is not proof enough to common sense of its being so, that a few isolated vomicæ, which gave no sign of their existence, should have undergone reparation. All the world is asking us whether consumption be curable? Indeed, all the world is interested in the question : for there is hardly a family into which consumption, sooner or later, does not enter; and when a man makes the inquiry (as it were) speculatively, or indifferently, he has most likely a real practical interest in it at home. He says, “ Is consumption a curable disease?” But he would say, “ I have a wife or a child, a brother or a sister, who is decidedly consumptive ; is there the least possible hope left me that they can recover?”
"To the question proposed with such intent, it is a mockery to answer “ Consumption is a curable disease ;” because, forsooth, its entire process from beginning to end its formation, progress, curemay be secretly transacted within the body without our knowing or suspecting anything about it.
If you ask me, as a physician, whether I have ever had experience of a perfect and satisfactory recovery taking place, where there have been all the best known popular symptoms of phthisis decidedly marked, symptoms which (as far as they go) no physician could possibly say were not those of phthisis? I answer, “ Often."
But if you ask me whether I have ever had experience of the like perfect and satisfactory recovery where there were all these popular symptoms, and, withal, the conditions proper to phthisis, ascertained by auscultatory signs to exist beyond a doubt within the lungs? I answer, “ Hitherto never.”
'What shall we say then? How shall we answer the popular question in the popular sense, and still answer it truly? We cannot say
that that consumption is curable; but we can say (and truly) that there are cases of imputed consumption which put on such an aspect of the real disease that they are with difficulty distinguished from it, yet have not its essence. These are all within the possibility of cure.
We can say that there are cases essentially phthisical, in which the disease is so lingering in a particular stage, that many years are often required to bring it to its fatal termination. The decline is gradual, almost imperceptible, but sure. These fall within my first description.
And we can say that there are cases essentially phthisical (and these fall under my second description) in which the disease accomplishes its course, as it were, by parts and parcels ; many times apparently beginning, and many times apparently ending, but always (as far as I see) beginning again : a year or two of disease, a year or two of health, then a year or two of disease again. Yet, upon these terms, I have known those who have passed neither a short, nor a useless, nor an unhappy life. I have known those who have so gathered up the fragments of their broken health as to make them serve for high and useful purposes, and put to shame the fewer and smaller performances of stronger men.'-pp. 254-258.
The mixed phthisis next comes to be considered, and the mixed nature of its auscultatory signs. The mixed character of the disease is derived from hæmorrhage or inflammation being united with it in individual cases. We have not room for more than the passage in which Dr. Latham describes generally the condition under which the combination takes place.
I think I have observed that, as long as the pulmonary consumption remains in its tubercular stage, if an inflammation or an hæmorrhage be added to it, they are apt to occur in distinct attacks, occasionally and casually.
I formerly mentioned the frequent cases of hæmoptysis admitted into this hospital, which were connected with tubercles of the lungs. The attack is usually sudden; the quantity of blood lost in a short time considerable; the treatment required usually active; and the result, as far as the mere hæmorrhage is concerned, usually successful. Moreover, the auscultatory signs denote the mixed nature of the disease. While the spitting of blood continues, and perhaps for a short time after it has ceased, there is a large or small crepitation commonly arising from a considerable space at the lower part of one or both lungs. This denotes the bronchial or vesicular effusion, as distinguished from the deposition of tubercles. Then there is a diffused dulness both to peroussion and auscultation somewhere; perhaps between the clavicle and mamma on one side; and an exaggerated respiratory murmur somewhere else; perhaps between the clavicle and mamma on the other side. These denote the deposition of tubercles, as distinguished from the bronchial or vesicular effusion.
• To my experience bronchial or vesicular hæmorrhage is more familiar as an accompaniment of phthisis, than bronchial or vesicular inflammation; the effusion of blood than the effusion of serum or mucus,
while the disease is yet abiding in its tubercular stage. But when inflammation does occur, I have generally remarked in it the same circumstances and attendant conditions which belong to the hæmorrhage; the same sudden and distinct mode of attack; and that degree of excitement of the blood-vessels which requires the same treatment, and the same successful result. Moreover, there have been the same auscultatory signs; namely, crepitation at the lower part of the lungs, produced by the effusion of serum or mucus; and dulness at the upper part, produced by the deposition of tubercles. The only difference is, that in one case serum or mucus is expectorated, and in the other blood.
But it is when pulmonary consumption has advanced beyond the tubercular stage that we find the most frequent examples of its mixed character. Bronchial or vesicular effusion is almost the constant accompaniment of vomicæ; and the expectoration is now often as much supplied by the mucous lining of the air-passages as by the cavities themselves. You have only to go into the wards of the hospital, and you may at once acquaint yourselves in a dozen instances with the mixed character of the auscultatory sounds. Gurgling cough, gurgling and cavernous respiration, pectoriloquy, one, or several, or all together, will show that this, that, and the other patient, have vomicæ in their lungs; and large and small crepitation, one or both concurrently, will show also that this, that, and the other patient, have fluid effused here, there, or everywhere, within the respiratory passages.
Now, when vomicæ have been long formed, and the expectoration long established, hæmorrhage and inflammation are less liable to occur in sudden and distinct attacks. The blood, or mucus, or serum, which are now separated from the surface of the air-passages, result from a vascular action of less force, but of more permanency, and are themselves more abiding. It should be remarked, however, that blood, which is more common in another stage of pulmonary consumption, is more rare in this; not that blood does not now sometimes appear, but it appears rather as a part of the expectorated matter, streaking or staining it, than as pure and sincere blood. Assuredly, after the expectoration is established, sudden and profuse gushes of blood seldom occur. Probably the expectoration itself is the security against them, the circulation thus obtaining all the relief it stands in need of. Probably, too, the security becomes greater in proportion as the expectoration is more copious and more free, and proceeds from a larger extent of mucous surface.
'All this is, in the nature of things, very probable, and it is confirmed to me by the striking fact which, in a few instances, I have known, of a copious muco-purulent expectoration suddenly ceasing, and a frightful hæmoptysis at once bursting forth; as if the circulation, being suddenly baffled, had sought and found the nearest way to free itself. In these instances, when the hæmorrhage ceased, the expectoration was re-established. It should be mentioned, that in the destructive processes connected with the formation of many and large vomicæ, the blood-vessels of the lungs do not always escape ulceration, or rupture, while they are yet pervious; and then a mortal hæmorrhage is the con
sequence. But such hæmorrhage is purely accidental, and independent of any proper hæmorrhagic action (if I may so call it) in the vessels themselves. Let me guard you against a vulgar error. Hæmoptysis and rupture of a blood-vessel are, in the popular sense, convertible terms; so much is one conceived to be the natural and necessary consequence of the other. But rupture of a blood-vessel, which has been esteemed the only cause of hæmoptysis, is unquestionably the rarest cause of all; and this accident, which one might expect to find frequent in pulmonary consumption, nature has taken great pains to guard against; for no sooner does the destructive process of forming vomicæ within the lungs begin, than she sedulously betakes herself to closing up the arteries which lead to them by clots of blood : and as to the veins, partly (I believe) by the same process, and by otherwise arresting the circulation through them, she reduces them to impervious shreds.
“Now, in all cases of pulmonary consumption arrived at the stage of vomicæ, I would recommend a constant regard to the extent of the disease beyond its specific limits. I would recommend that, besides attending to the sounds indicative of cavities, you should take especial note of crepitations, and how they vary in the distance to which they spread themselves from time to time. The gargouillement, and the pectoriloquy, and the vomicæ, from which they arise, are beyond our reach remedially; not so the crepitations, and the vascular action which produces them. In my treatment of pulmonary consumption, I am accustomed to make these crepitations serve me for practical indications, endeavouring by all means to lessen and circumscribe them, and thus seeking, under the guidance of auscultation, to bring back the disease as much as possible within its specific limits.
* The bronchial and vesicular effusion, which is the concomitant of vomicæ, submits itself to the influence of medicine in various degrees. Very often, when there are gurgling cough, and gurgling and cavernous respiration and pectoriloquy, at certain points, and, withal, large and small crepitations diffused widely through the lungs, a seasonable remedy will entirely sweep away the latter sounds, and leave the former alone. A small cupping, a few leeches, a blister, a liniment, a mustard cataplasm-one or other of these, according to the degree of vascular action, applied at the right time and in the right place, will produce immense relief, by bringing the disease back for a while within its specific limits.
* It is thus, as perhaps you may have remarked, that almost every phthisical patient brought into the hospital experiences great relief for a short time after his admission. The poor, alas! are not only the chief victims of phthisis, but they suffer the disease with all its occasional superadded evils, which their exposure, their hardships, and their needful toils, will not allow them to escape. With them, the superadded evils are often beyond all proportion to the disease itself. The tubercles and vomicæ may be few, and the bronchial and vesicular effusion immense; and is superadded effusion may be for the first time submitted to a remedy when they reach the hospital, and then it is often in a great part or altogether swept away. No wonder that, from the relief which