None of these symptoms are always present, and some are very liable to be found in other diseases, but one or two have more value than the rest. Among these we reckon family history; hiemoptysis, when there is no disease of the heart, no relaxed throat or spongy gums; quick pulse and night-sweats, thin skin, clubbed nails and emaciation : especially when these are found about the period of puberty, and from that onward to the age of thirty. Hasmoptysis is studiously concealed by some patients in whom it has really existed, is much talked of by others in whom it has been only simulated, especially the hysterical and hypo chondriac. The quickness of the pulse is generally an index of the severity of the disease; and a natural pulse, when the evidence of phthisis is distinct, is always a favorable indication as to the progress of the case. Clubbed nails seem to have some direct relation to the condition of the lungs and heart, and thougii most commonly seen in phthisis, yet attain even higher degrees of de velopment in rare oases of disease of the chest, when not a tubercle exists.
The auscultatory phenomena vary according to the site of the deposit„ and the progress it has already made. An important fact in their elucidation is, that tubercle has a remarkable tendency to be located in the apex of the lung; and that however disseminated through other parts of the organ, it is very generally found there too ; this law is all but universal : the converse is also true to a less extent; that in other diseases of the lungs the signs are more fully developed in other parts : we shall therefore consider the symptoms of tubercles at the apex first. The facts of which auscultation and percussion in this region give evidence, are the original deposit of tubercle in solitary small masses, their gradual increase in size, the excavation of the lung which follows on their softening and expulsion ; and incidentally inflammation and irri tation of the bronchial tubes, of the pleura, or even of the pan3n ohyma of the lung, which may be excited by their prellence.
If the previous chapters have been carefully studied, the phe nomena necessarily resulting from, such causes will be known a priori. A very small amount of deposit can only affect the breathing in the way of making the expiration a little longer, and the inspiration a little shorter, and harsher or louder, or perhaps weaker, than on the opposite side, or by giving it a wavy or jerk ing character : the voice-sound will be a little louder : the per cusaion-sound can only be very slightly if at all altered; but it must not be forgotten that both voice and breath-sounds have a tendency to be leader on the right than the left side in health. Sometimes a confirmation of the existence of tubercle in this early stage may be obtained from the heart's sounds being heard more loudly at the right apex than the left, which is impossible in health; a bruit in the subclavian artery, when it cannot be heard in the carotid or at the heart, is also of value, although the rationale of its development is not understood. These are, after
all, very uncertain grounds on which to determine that so serious a disease as phthisis has begun, and yet they are sometimes all that auscultation and percussion afford. An opinion ought not to be pronounced on such insufficient data, if standing alone ; but we may feel very safe in the deduction, if the history and general symptoms point to the probability of phthisis, and if the physical signs be only taken in conjunction with the whole evidence which the case supplies. Above all, let me warn the student against supposing that he is reasoning accurately in taking them in con junction with only one of the more general symptoms; such, for example, as a weak and quick pulse, or Inemoptysis : this is the most common cause of error.
As the disease proceeds, the evidence of consolidation becomes more distinct, and along vrith it we have signs of irritation of the bronchial tubes (sonorous and moist sounds), of inflammation of the pleura (friction and creaking sounds), sometimes of inflamma tion of the parenohyma (true crepitation), or of the progress of the tubercular disease itself (clicking or crumpling sounds); and we admit the great probability that these signs are caused by the presence of tubercle : yet we cannot dispense with the evidence derived from the history of the cue, because they only prove local consolidation, and no more, and this may be inflammatory.
Still further in the progress of the case, the evidence of local consolidation is accompanied by louder blowing breath-sound from commencing excavation when the cavities are empty ; and at a more advanced stage, the dull percussion stroke may be con verted into something approaching to tympanic hollowness ; the breath-sound is still more blowing, and the voice-sound is some times painfully loud, as if aome one were speaking into the other end of the stethoscope ; this cavernous sound, as it is called, is even more clearly brought out occasionally when the patient whispers. • The necessary result of air entering these cavities when fluid is present is, that the superadded sounds become bub bling, gurgling, or even metallic. An important fact in relation to this stage of the disease especially, is flattening or sinking of the ribs, and deficient movement m inspiration ; without this our signs of excavation are probably altog.ether wrong, and we must look for some other explanation. The general symptonas, too, are necessarily more pronounced, and the history of the disease extends over a longer period.