In early phthisis, when the signs are still obscure, considerable difficulty in making a correct diagnosis may arise from the coexistence of bronchitis : on the one hand, we may recognize the bronchitis, and reason correctly regarding that, and yet be quite wrong in prognosis, because of overlooking the presence of tubercles; on the other, we may recognize the phthisis, and come to very false conclusions regarding its progress. because of attributing to it signs which are in reality due to bronchitis. When along with an attack of bron chitis we observe general symptoms leading to a suspicion of phthisis, it is wise to wait before giving an opinion as to the tubercular or non-tubercular character of the disease until the former have disappeared ; it is a very sus picious circumstance when the morbid sounds linger at the *pima after they have ceased in other parts of the chest : and this is still more true of bron chitis limited to one lung ; the very fact of the limitation offers a presumption that there is something abnornal in the lung so affected.
Another common complication of phthisis is partial pleurisy near the apex of the lung : but the attack is not always so limited, and sometimes general pleurisy occurs when the lungs are already tubercular. It has been mentioned that the sounds heard in the clavicular region, when the lung is condensed by pleuritic effusion, exactly resemble those of consolidation with a cavity sub jacent : the percussion sound, while dull, has often a sort of tympanitic reso nance ; the breathaound is remarkably blowing, with prolonged expiration; the voice loud and ringing ; and if bronchitis be present, moist sounds are also heard : but with moderate care such a condition ought not to be mistaken for phthisis. During the existence of pleurisy it is very unwise to give an opinion regarding the presence of tubercle. It is alleged by authots that double pleurisy is a suspicions circumstance ; probably mdicating a complication of phthisis, and the hint should not be lost sight of ; but it amounts to no more than a mere suggestion. Chronic pneumonia, if the term be used at all, may be applied to the condition of the lungs met with at one stage of tubercular deposit, particularly when the disease is widely disseminated : a more active form may be excited by its rapid development in the upper lobe, which during its existence obscures any evidence of phthisis : but m a decided attack of sthenic pneumonia, we may feel great confidence that there is no tubercle : such at least has been the rule in cases coming under my own observation, and the nature of the two diseases is so distinct, that it is exactly what dpriori we have reason to expect Severe and commonly fatal meningitis, in the form of acute hydrocephalus, frequently found in the tubercular diathesis ; and when inflammation of the bmin occurs about the period of adolescence, it will often be possible to deter mine its nature by an examination of the lungs. Chronic peritonitis st the
same age is another disease which very commonly has a tubercular origin, and calla for a similar examination. Diarrhcea may be rather regarded as a direct symptom than as a complication of phthisis.
§ 10. Tumors.—These have been referred to in speaking of the causes of dulness on percussion ; and while certain phenomena have been pointed out as possibly explicable on the -hypothesis of their existence, no signs have been mentioned as direct proofs of it : more true wisdom is often shown in a confession of igno rance than in an assumption of knowledge ; and though a man of large experience and pathological knowledge may sometimes give a shrewd guess at the true solution of the difficulty, there are points which render it almost impossible to reason correctly, bee,ause the facts are not only wanting, but to a certain extant unattainable. In such circumstances we must be content with the sort of empirical knowledge which amounts to no more tha,n this—" I have seen such and such a case, and it turned out so and so, and I thrnk it highly probable that this case will have a similar termination." Such knowledge is the reward of careful observa tion, and is one of the most valuable acquisitions of the accom plished physician.
Tumors in the chest are either aneurism or morbid growth. The ktter is found sometimes disseminated through the lung, sometimes developed from the glandular structure at its root, or attached to the parietes; and the indi cations will necessarily vary according to its site : the former, from the situa lion of the great vessels, presents symptoms somewhat analogous to that of growths from the root of the lung.
The history of these cases is so far alike, that there is never anything to fix a correct date for their commencement, because in most instances the patient has only become conscious of inconvenience when some other disease has supervened. Neither do particular classes or forms of growth produce any constant series of effects, the phenomena being commonly casual or accidental, and not essential. The patient generally complains of cough and dyspncea, and sometimes of pain: difficulty of breathing iv most perceptible when the tumor presses on some of the large tubes.