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but for the want of the concomitant rational signs,' a diagnosis is deferred.

SYMPTOMS AND PROGRESS OF CONSUMPTION.— Having enumerated the cases which are to afford us illustrations of phthisis, in reference more particularly to its local phenomena, I will first briefly consider the symptoms and progress of this disease.

As the symptoms and signs of consumption will depend upon the stage of its

progress, it will be more convenient and instructive to consider the signs and symptoms along with the march or progress of the disease.

The first symptoms which manifest themselves in tubercular phthisis are by no means the same in all cases. Indeed, those initiatory symptoms are varied in their development, and in many cases different in character. In the cases just detailed, you will remember that the first symptom of ill-health, or rather such as pointed to permanent disorder, that manifested itself in the case of the young man Henry Allen, was debility and night-sweats, after recovery from a quartan intermittent fever; whilst in the case of Mike Guilday, pain in the side, and cough, after an acute attack of pleuritis, were the first symptoms that were noticed. Sometimes, and quite often, too, according to many observers, the first symptoms of declining health are referred to the stomach and digestive apparatus, as is witnessed in one of the women's wards, in the case of Hannah Rodley. With regard to this latter symptom, I will remark that whilst most modern observers, and particularly those who have paid especial attention to the rational or general symptoms of consumption, have dwelt with some emphasis upon the coincidence of early gastric disturbances, I have not witnessed this symptom, except in a few cases, until quite late in the disease. In the large majority of the cases that have come under my treatment, and particularly in those about the age of puberty, or a little beyond that age, digestion has been quite vigorous, and the appetite good. It will be well for you to remember, however, that this is by high authority regarded as an early symptom worthy of special attention. The most frequent symptom of consumption in its commencement is, perhaps, a slight cough, with loss of strength and shortness of breath, the latter symptom more particularly observed when exercising the body in walking or manual labor. Under such circumstances the patient believes he only has a slight cold, until its obstinacy forces him to seek the advice of the physician, but often, however, not until he has exhausted his patience by the use of quack postrums.

There are other cases, in which the earliest symptoms are, increased frequency of pulse, with emaciation, most usually, however, with a concomitant cough. Spitting of blood, or hæmoptysis, and sometimes hæmorrhage from the lungs, first gives warning of this disease. I saw a young gentleman, but a short time ago, who believed himself in good health until he was taken with quite an active hæmorrhage from the lungs; and I have witnessed many such cases.

But it is proper

for you to know that in many of these cases, although the patient will deny the presence of cough, if strictly interrogated and watched, you will find that at some time in the day, particularly in the morning, there will be some cough admitted or observed. In the case of Henry Allen cough was emphatically denied until I observed a pellet of sputa upon his floor, with streaks of blood, and on pressing him, he admitted that he frequently in the morning brought up with slight cough such sputa, but thought it came from the “ back of the throat."

There is another early symptom of this disease to which I will direct your attention; it is a peculiar pallor, observed more particularly in the morning, and accompanied with a clear, lively expression of the countenance. This early evidence of the accession of the cachexia, however, is by no means always present. It shows itself more particularly in the highly predisposed, or those of what is termed the tuberculous diathesis.

But whatever may be the first symptoms observed, cough of a peculiar hacking, laryngeal character will in almost all cases soon make its appearance: not always, however; for some cases progress even to death without this symptom ever making its appearance. Louis has recorded one such case, if no more.

These, gentlemen, are the rational symptoms; but they cannot form data for a positive diagnosis. To make a positive diagnosis, to assure yourselves of the presence of tubercle in the lungs, you must bring to your aid the resources of physical exploration of the chest.

In this, the first stage of pulmonary consumption, you have witnessed the examination of the young man Allen. You have seen the chest inspected, and marked the depression below the right clavicle; you have heard the sounds elicited by percussion, and noted the dulness, corresponding with the depression, when compared with the clear resonant sound emitted from a corresponding point on the left side. The ear, on being closely applied to the two infra-clavicular regions, has also distinguished marked differences in the two corresponding regions. On the right side the respiratory murmur is almost inaudible, whilst a bronchial respiration is perceived to usurp its place; it appears that the sound

emitted by expiration is lengthened to almost equality with the inspiratory sound; that the vocal resonance is increased, at least much greater than on the left side, and that the sound of the heart-pulsations is more audible than in health ; whilst, on the other hand, the respiratory murmur over the left infra-clavicular region is noisy and distinct, constituting puerile respiration. With these positive signs of tubercular consolidation, or first stage of the disease, we have the negative sign of absence of râles or ronchi. But, gentlemen, you do not always have so simple and marked a case to deal with, where the rational and physical signs both point to the same pathological state. You do not always in this early stage see the depression below the clavicle, and witness hæmoptysis; and when it is the right side that is suspected, you will remember that, according to Flint, the sound on percussion is usually more clear and distinct on the left side, and that the vocal resonance and expiratory murmur are more marked upon the right side than on the left. I say, when

you bear in mind these facts, and have not the rational signs to assist you to an opinion, you must suspend a positive diagnosis, as we have done in the case of Hannah Rodley.

In the second stage, or that of softening of the tubercular deposit, as witnessed in the case of Mike Guilday, we have all of the rational symptoms increased in severity. Instead of the muscular roundness of the first case, here is marked emaciation; and in place of a clear, steady voice, there is perceived hoarseness and a slightly tremulous speech; slight evening febrile dryness of skin is succeeded by a more pronounced febrile paroxysm; there is diarrhæa, fastidious appetite, cough, and expectoration, with clubbing of the ends of the fingers. Inspection shows depression under both clavicles, more marked, however, under the right; percussion elicits flatness of sound, with increased resistance and diminished elasticity. On applying the hand and causing the subject to speak, the vocal fremitus is felt to be increased; by auscultation of the respiration a large subcrepitant ronchus is heard on the right side, with humid crackling on the left, and the voice is slightly bronchophonic on the right side.

The third or last stage of this disease, or that of pulmonary excavation, is well illustrated in the woman in the syphilitic ward. In her you have all of the most grave rational and physical signs of this stage. You perceive an extremely emaciated subject; great muscular debility, with regular paroxysms of hectic fever; a permanent increased frequency and diminished volume of the pulse; deep and stifled cough, with abundant sanguineo - purulent expectoration. On exposing the chest you perceived the sharp outlines of the bony anatomy under a smooth

waxy-looking skin; you observed no partial motion of the ribs, and but slight general motion of the thoracic walls; both clavicles were seen to stand out prominently, and twisted downward upon their long axes; the pectoral muscles are wasted, and the intercostal spaces are sunk deep between the ribs. On percussing the infra-clavicular regions you remember that on the left side the sound was flat, but on the right it was more clear, and between the fourth and fifth ribs a sharp stroke brought out a chinking sound, called cracked-pot sound, (bruit de pot félé.) Auscultation detected gurgling on both sides, with amphoric respiration and pectoriloquy on the right side.

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PATHOLOGY.—In considering the pathology of pulmonary phthisis, we have to look at it as a general as well as a local disease; indeed, it is its general or constitutional characteristics that more particularly interest us as practitioners; for we can little hope to arrest or cure this disease by any means that

may

be directed to the local mischief. Our only hope for arresting or curing consumption must rest upon constitutional treatment; and such treatment will be more or less successful according as

have more or less correct views of its general pathology, or the nature of that departure from the physiological state of the functions of assimilation and nutrition called the tubercular cachexia. Now two very different views may be taken of the pathology of this affection, at least as regards its point of departure—viz. : first, It might be assumed that there is a depravity of nutrition in the tissue in which the tubercular matter is deposited; that from some original or acquired defect in the vital properties of the tissues the normal passes into an abnormal nutrition, and therefore, instead of the healthy and proper appropriation of the plastic elements of the blood, an abortive nutrition is set up, which results in the formation of that low degree of organization called tubercle; and that as this process of deposition goes on, besides wasting or exhausting the elements of nutrition, the local irritation reacts upon the organism, and both together produce, as a secondary consequence, that state of recognizable general depravity termed tubercular cachexia. To illustrate - that the healthy nutrition of the bronchial mucous surface results in the constant production of epithelial cells; that in pulmonary phthisis the first, or original vice, is in the reproductive force of the basement membrane of the bronchial mucous membrane, and that, instead of normal epithelia being produced, incomplete cells and nuclei, or the nitrogenous elements of tubercular matter, is the result.

The second view, and perhaps the most plausible one, is, that the tubercular diathesis is nothing more nor less than the inflammatory diathesis, or that diathesis which tends to the elaboration in the organism of an excess of plastic matter; but that, in the case of tuberculosis, instead of a highly vitalized plasma, capable of organization as in the true inflammatory diathesis, the plasma elaborated is of a low vitality, and only capable of organization under the most favorable vital influences, and that the deposition of tubercular matter is but the excretion, in a semi-organized state, of this excess of plastic matter existing in the blood, just as the fibrinous exudations in acute inflammation relieve the blood of its excess of fibrin or plastic matter.

I do not mean that consumption is a chronic inflammation—that the local phenomena attending the deposition of tubercular matter are the same as the local phenomena attending the exudations of inflammation proper. I simply mean that the diathesis is the inflammatory, and the constitution of the blood is identical with that of the inflammatory constitution—with this difference, however, that in the latter case the vitality of the plastic elements of the blood is depressed in degree, and perhaps perverted in its formative tendency; that the deposition of the tubercular matter, or plastic elimination, if I may so speak, is governed by laws and attended by phenomena of its own.

Allowing, at the same time, that under the usual exciting causes of true inflammation, this, the inflammatory process, can and does take place concomitantly with tuberculosis, I will make an illustration :

The female organism, in gestation, elaborates more plastic matter than is requisite for the due nourishment of its own body, and therefore the blood is rich in these elements of tissue nutrition, and the diathesis for the time being is inflammatory; but the excess of plastic matter is expended, in other words, eliminated, upon the placental surface of the uterus, where it is absorbed by the placenta, and appropriated to the growth of the fætus. But this elimination is not inflammation. Again, the gouty or rheumatic diathesis is inflammatory, yet the elimination of plastic excess in the gouty and rheumatic constitution is governed by a peculiar law; the kidneys carry off the excess in the form of uric acid and the urates. Now, the kidneys in this elimination are not inflamed any more than the placental surface of the uterus, or the air-cells and bronchial tubes in tubercular deposit.

But in the pregnant woman, as well as in the gouty constitution, true inflammation is quite liable to set in, attended by true inflammatory exudations, in the same manner as pleurisy, pneumonia, etc., may accompany tuberculosis. I do not insist, of course, upon the correctness of these views; they are only presented as the most plausible theory known

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