Not unfrequently the date which is assigned as the commencement of the attack is altogether erroneous ; the first symptoms have not been observed, or have been forgotten ; some persons speak of having had cough as long ne they can remember; others are unable to recall to mind the colds and coughs of last winter; and a false date is worse than none at all; but it is not without value. in a diagnostic point of view, that the patient is unable to assign a date, because it indicates the insidious approach of the malady ; more com monly some period is named at which it is alleged that cold was caught. Beyond this, perhaps, all inquiry fails in getting any information ; the points of greatest importance are the existence of pain and fever in an illness of recent date, and the occurrence of luemoptysis in one of old standing.
In the history of antecedent illnesses we are sure to find, when the symp toms of chest affection are primary, and the attacks repeated, that the lungs are the organs chiefly implicated ; while by the previous occurrence of rheu matism or dropsy we are led to expect disease of the heart, and the affection of the lungs is more likely to be subordinate and of minor importance. When • confined to the respiratory organs, we either meet with severe symptoms of occasional occurrence, or with habitual winter cough ; the patient may be an old asthmatic, or may have been always delicate ; or he may never have thor oughly recovered from the effects of a more acute attack ; latterly he may have lost flesh and strength ; and we endeavor to contrast his present stAte with what we can gather from description to have been his usual condition of health prior to the illness under which he is now laboring.
Prom this we are led to inquire what is that actual state; the presence or absence of fever will be indicated by the skin. pulse, tonFue, &c. ; but here we often meet with the adyeamic form called hectic, in which the rapidity of the pulse is not always accompanied by a furred tongue or a hot skin—at one time it is dry and burning, at another it is bedewed with moisture or dripping. with perspiration ; in such cases the tongue is often chapped, peeled, or glazed, and the bowels tend to diarrhcea. Real inflammation of the lungs (pleurisy or pneumonia). as well as pericarditis, can scarcely have place without the coexistence of inflammatory fever. Irregularity of pulse invariably indicates disease of the heart ; its frequency in cases clearly tubercular marks the dis tinction between the acute and chronic type of phthisis ; an habitually quick pulse in bronchitis would lead to the snapicion of tubercles. when there is no other proof of their presence ; a quiet one may tend to disprove such a con clusion, when some probabilities are in its favor.
The absence of emaciation is often at once taken as decisive against the supposition of tubercular disease ; but neither is this without exception, nor Is the converse absolutely true that chronic chest ailment with emaciation indicates phthisis ; an experienced eye may diacriminate between the one and the other, especially if the discoloration of the face in chronic bronchitis, or the hectic flush in phthisis, be taken into account. The dusky flush of pneu monia is a very remarkable sign to one who watches the physiognomy of dis ease, as is also the peculiar dragging of the she of the nose, with hurried breathiug, noticed in pleurisy or peritonitis. Not less distinct are the blue nose and lips of disease of the heart.
The patient, by his attitude, often unwittingly reveals to the observant practitioner sensations which he fails to express in words. A phthisical person rarely cares to have his shoulders raised in bed, while one with bronchitis often does; in disease of the heart the semi-erect posture, which has sug gested the name of orthopncea, is most commonly selected ; and even when the long symptoms are the most prominent, its presence pretty constantly proves that there must be something more ; in some peculiar forms of disease a prone position is the only one in which ease is obtained. A patient with cme pleura full of fluid very generally, even when raised in bed, inclines to the affected side, except when pain prevents his doing so ; the rule and the ex ception are still more invariable when the position is horizontal.
Among the sensations of the patient. the consciousness of dyspncea—short ness of breath, felt especially in ascending a height or going up stairs. has more distinct reference to disease of the heart than complaint of cough, which. when associated with expectoration, more probably indicates affection of the lungs. The principal facts to be elicited in regard to pain are its locality, and the circumstances which attended its commencement. It may be across the upper part of the thorax or at either apex; and this is common in phthisis ; sometimes its position at the lower part of the chest, and the freedom of the respiration, prove it to be connected with the Momach or some of the abdominal viscera. On the other hand. pain, distinctly referred only to one side, sharp and cutting, and situated just below the nipple, always much increased, perhaps only felt, in the act of coughing or breathing deeply, is very probably caused by inflammation. This point is to be considered with reference to the coexistence of fever, because rheumatic and neuralgic pains are similarly aggravated. We have already referred to the pain of angina pectoris in discussing forms of neuralgia.