PATHOLOGY. 
cafe advances another grade, and as the tubercles begin 
to foften and ulcerate, thefe fymptoms become more 
marked ; heClic fever is more tnanifeft, and fuffers even¬ 
ing exacerbations. Sweats general or partial, but always 
debilitating, break out; the blood becomes more highly 
oxygenated, either in confequence of its more rapid 
circulation through the pulmonary organs, or from its 
more extenfive and c'.ofe application to the air through 
the medium of the ulcerated cavities. Hence the phthifi- 
cal patient acquires, to a great extent, the high roman¬ 
tic and imaginative fpirit which has been fo often re¬ 
marked to attend the paffage over lofty mountains, lltua- 
tions in which the air is extraordinarily rarefied. Hence 
the never-dying hope, the abfence of all that defponding 
queruloufnefs which excites our pity, not unmingled 
with contempt, in viewing the viftim of hypochondriac 
malady. It has been faid, indeed, that the amicability, 
ferenity, and gaiety of temper, of the confumptive pa¬ 
tient, is rather the refult of the temperament that dif- 
pofes to phthifis than of the phthifis itfelf; but we be¬ 
lieve there are few practitioners who have not obferved 
that the very firft approaches of confumption are marked 
by much lefs hopefulnefs than the latter ltages ; and, 
even at times when the conftitutional dilturbance fuffers 
an exacerbation, the fpirits are higher than ufual. 
To proceed with this picture. Cafes of recovery are too 
rare to allow us much to fay as to the appearances of 
amendment. We need hardly caution the practitioner 
not to be deceived by the cheerfulnefs of the patient, 
and by the occafional abfence of all ill feeling which 
fometimes 1 alts for a day or fo. The fymptoms which 
foretel the fatal termination of the malady are well known. 
All the fymptoms are diftreffingly increafed: the quick 
pulfe, the evening exacerbations, the colliquative fweats, 
the giofly eye, the hurried and difficult refpiration, the 
diftended noftrils, and the general emaciation, are all mod: 
ftrongly manifefted. To thefe may be added, diarrhoea 
and flight delirium. Thefe arrived at the higheft pitch 
endurable by the human frame, the patient calls on the 
by-ftanders for breath, fnaps with horrid energy at the 
air, and expires. This afflicting termination only occurs, 
however, when the patient actually dies from dyfpncea, 
while the reft of the frame retains to a high degree the 
powers of life. More commonly, gradual wafting and 
decay entirely exhauftsthe fufferer, and he finks into the 
grave without a groan. 
According to I.aennec, the formation of the ulcerated 
cavities in the lungs may be known by applying the Jie- 
thnfcope (fo often mentioned) to the cheft, in which cafe 
the ro/ce of the patient ferns to come through the cylinder. 
This phenomenon Laennec calls pedoriloquifm. The ftu- 
dent may make himfelf acquainted with it by applying 
the ftethofcope to the trachea of any individual, or in¬ 
lean perfons over the infurcation of the bronchia;. The 
parts of the cheft over which the ftethofcope is to be ap¬ 
plied to afcertain an ulceration in the lungs are the an¬ 
terior and fuperior portion, the axilla, the fpace between 
the clavicle and the trapezius mufcle, and the folia above 
and below the fpinous procefs of the fcapula. It may be 
perfect, imperfeCV, or doubtful. When it is perfect, it 
is a certain fign of the exiftence of a preternatural ca¬ 
vity in the lungs. It is more clearly evident in propor¬ 
tion to the acutenefs of the voice of the patient; when 
the voice is grave or hoarfe, the peCtoriloquifm is like 
the voice coming through a fpeaking-trumpet or roll of 
paper. Accidental circumitances fometimes operate to 
prevent pe&oriloquiftn from being clearly evident : La¬ 
ennec finds it proper, therefore, to examine a patient 
feveral times; and in no cafe where peCtoriloquifm was 
manifeft did he fail to recognife, by dilTeCtion or by fymp¬ 
toms, ulceration in the lungs. 
The above circuinftances will diftinguilh the latter 
flages of phthifis from chronic bronchitis ; but the diag¬ 
nosis of its firft ftages is more difficult. In chronic 
bronchitis the abfence of pain during infpiration, the ca« 
285 
pability of refting on either fide in bed, (when there is 
no abdominal difeafe,) the wheezing noife in refpiration, 
the leaden colour of the lips, and the pallidity of the 
countenance, the appearance of the fputa, confiding al- 
raoft entirely of mucus, are fymptoms which diftinguilh 
it from tubercular phthifis. Moreover, the dyfpncea 
is greater on exertion in tubercular phthifis, and the 
patient cannot take fo large a volume of air into the 
lungs as he can in bronchitis. The dyfpncea too is lefs 
relieved by expectoration ; and there is a peculiar fenfa- 
tion of ftufling complained of in catarrh, which does not 
occur in phthifis. The expectoration is various, but 
there is always a confiderable quantity of mucus mixed 
with the pus-like matter. The quantity of matter ex¬ 
pectorated in the former difeafe is much greater than in 
tubercular confumption. The cough alio in bronchitis 
is deep and fonorous. The paroxyfms of heCtic fever 
are much lefs regular in chronic bronchitis than in tuber¬ 
cular phthifis. The perfpirations are more, and the ema¬ 
ciation lefs, in inflammation of the mucous membrane, 
than in tubercular phthifis, though we do meet with 
cafes in which the emaciation is as great in the former as 
in the latter affeCtion. When the pulmonic fymptoms 
have arifen from a difeafed liver, it is a ftrong prefump- 
tion that the feat of the difeafe is in the bronchial mem¬ 
brane ; for in almoft all cafes of this defcription the mu¬ 
cous membrane is the part affeCied. When this combi¬ 
nation occurs, the fpirits are always depreffed; and, in 
addition to the ufual pulmonic fymptoms, we have in 
this form of the difeafe a painful and diftended epigaf- 
trium, unnatural ftools, and difordered digeftion. The 
mouth is dry in a morning, and the tongue loaded. The 
fits of coughing are conftantly excited when the ftomach 
is overloaded, and are apt to come on when the patient 
is lying on either fide in bed. If chronic have fucceeded 
to acute bronchitis, the emaciation is fometimes fo great, 
the heClic fever fo complete, and the matter expectorated 
fo purulent, that a perfon feeing the difeafe after it is 
formed will often be inclined to believe that he has to 
treat an ordinary phthifis ; but an attention to the hiftory 
of fuch cafes will frequently lead him to diftinguilh the 
former affeCtion from the latter; and the event will 
ufually juftify his diftinCtion. 
The greateft advantage arifes from tracing thefe.affec¬ 
tions to their origin. We fometimes find that the fymp¬ 
toms have come on foon after the difappearance of a cu¬ 
taneous affeCtion, which ibould always lead us to fufpecl 
that the bronchial membrane is difeafed. Notwithftand- 
ing all our attention to the occafional caufe by which the 
difeafe is induced, to the habit of the patient, and to the 
modification of the fymptoms, in the latter llage of the 
difeafe it often becomes impoffible to diftinguilh catarrh 
from phthifis. 
An ignorance of the precife caufes of phthifis we have 
before lamented. We lhall put down what is ufually 
faid in medical works on this fubjeCt. The predifpofition 
is frequently hereditary, defcending from parents whom 
the difeafe had attacked, or who had, at fome period of 
their lives, been affeCted with fome form of fcrofula. It 
is diftinguifhed by external peculiarities of form and ap¬ 
pearance. Perfons poffeffing fine fkin, with large veins, 
foft hair, light eyes, a florid complexion, tall and thin 
perfon, long llender neck, narrow cheft, and projecting 
fhoulders, may be confidered as having the phthifical pre¬ 
difpofition. The fine Ikin and complexion, and llender 
form, are however much furer emblems of confumptive 
predifpofition than the colour of the hair and eyes ; for 
the difeafe often attacks dark-haired perfons. Brouffais 
refers the confumptive conftitution to an extraordi¬ 
nary development in the lymphatic fyftem. Frequent 
attacks of pneumonitis feem to become caufes of con¬ 
fumption. The fame may be faid of catarrh, of hsemop- 
tylis, or any other difeafes which caufe increafed afflux of 
blood into the lungs. But as many perfons, and even 
whole nations, fuffer pulmonary difeafe without the fub- 
fequeut 
