The study of the vocal resonance and fremitus presents nothing novel, but corresponds with the generally-understood principles.
DURATION.—It is very difficult to determine accurately the duration of malignant diseases of the mediastinum, since for a long time the patient may be quite free from any local subjective symptom, even though a growth may have attained to a considerable size. Moreover, intra-thoracic malignant disease, especially in the non-cancerous varieties and if the digestive tract be normal, may be unattended by any of those symptoms commonly associated with malignant process, such as a peculiar tint of skin, progressive and great emaciation, or the aspect of suffering. Sarcomatous tumors usually grow rapidly, as in a case related by Jaccoud, in which death occurred within eight days after admission to the hospital. Prior to this time the patient had suffered from no objective symptoms whatever, although when admitted there was physical evidence of a large growth extending from the clavicle to the nipple.26 West records a fatal case at two and a half months; Horstman, one in which the disease originated on the right of the sternum, as evidenced by a very small area of dulness; the entire right side of the thorax was invaded within five weeks.27 Berevidge reports a case of sudden death from hæmoptysis in a man aged sixty-four years, who up to that time had appeared healthy, and only a few days before had complained of a slight cough and a feeling of oppression in the chest. At the autopsy two cancerous masses the size of a hazelnut were found, one of which overlaid a bronchus which was ulcerated to a considerable extent. The bronchi were filled with blood. Virchow mentions a case the duration of which was only two months. Walsh, speaking of malignant growths in general, assigns three and a half months as the minimum duration of these cases.
26 Leçon de Clin. méd., p. 636, Paris, 1867.
27 Trans. Path. Soc. London, 1883.
Undoubtedly, the duration will depend on the freedom from pressure upon the oesophagus, or from interference with digestion due to pneumogastric irritation, or from malignant processes in the stomach or intestines. Pain, and consequent loss of sleep, will also accelerate the termination of any case. Lebert assumes an average duration of thirteen months, and Walsh states the maximum duration in intra-thoracic malignant processes at twenty-seven months. The soft secondary malignant sarcomata or carcinomata grow more quickly, and have a relatively shorter course, than the harder forms of the same species. Lymphadenoma may persist a long time, and appear for a while to be stationary and unattended by any serious impairment of the general health, but the cases are exceptional. The persistence of fibrous, fatty, or cystic tumors depends chiefly on the mechanical inconvenience occasioned by them. All forms of malignant intra-thoracic disease, however, are steadily progressive to a fatal termination. Death commonly arises from the gradual increase in seriousness of the pressure symptoms. Inability to lie down, harassing cough, want of sleep, all tend to induce fatigue which may prove fatal. Deficient aëration of the blood may occasion stupor, or sudden simultaneous pleural and pericardial effusion or general pulmonary oedema may terminate the scene. In exceptional instances death has resulted from laryngeal spasm or from acute hypertrophy of the thyroid gland with tracheal occlusion. In a remarkable case reported by Bennett paroxysmal dyspnoea had been the only symptom of intra-thoracic disease for a few months, when suddenly a severe seizure occurred which persisted uninterruptedly for three days, till weakness and exhaustion terminated in death by asphyxia. In this case the thyroid gland was found enlarged to the size of a double fist, but the enlargement was mainly below the sternum and along the sides of the trachea, which was literally surrounded by the greatly-enlarged and firm lateral lobes of the thyroid, so as to be completely flattened laterally. The structure of the thyroid appeared healthy, but very firm, and the enlargement was due solely to hypertrophy, and not to cystic or other disease, nor was there any exophthalmos.28 Death is possible from sudden asthmatic attack, or, more rarely of all, by hæmoptysis.
28 See "Cancerous and Other Intra-thoracic Growths," Bennett, The Lumleian Lect., 1872, p. 169.
PROGNOSIS.—The prognosis is invariably unfavorable, and must continue so unless the more recent attempts for removal of primary growths in the anterior thoracic regions yield grounds for a more hopeful outlook. We may also hope that some remedy may influence or control the development of lymphoma. Considerable relief may be obtained by rest, suitable feeding, careful regulation of the digestive system, and such hygienic measures as may seem most available.
DIAGNOSIS.—From Aneurism.—When we consider that in the diagnosis of aneurism of the aorta every sign and symptom has in turn been found fallacious in the ever-varying conditions under which aneurisms appear, and that one is forced to say that aneurism has no pathognomonic signs or symptoms, the difficulties in the way of the diagnosis of intra-thoracic morbid growths may be recognized. Moreover, the diversity in the peculiarities of each case, the multifarious character of the pressure symptoms and physical signs, and the absence of a precise order of phenomena peculiar to tumors in this situation, may render a positive diagnosis in the early stages very difficult.
Aneurism in the absence of unequivocal signs of its existence may be excluded on the following grounds: the absence of conditions which predispose to disease of the coats of the arteries—i.e. syphilis, alcoholism, Bright's disease, rheumatism, laborious avocations, violent exercise. Aneurism may occur at any age, but it is rare before the age of thirty years, and most prevalent between the ages of forty and fifty years. Aneurism is also less frequent in the female sex. The distal pressure symptoms of aneurism are more variable than in other morbid growths of the mediastinum, and especially dysphagia is less constant. Great emaciation without intense pain is adverse to the diagnosis of aneurism, while severe pain with occasional exacerbations is favorable to this diagnosis. However, instances of morbid growths are recorded in which intercosto-humeral neuralgia was an initial symptom.
"An extensive area of dulness must in aneurism mean a large sac, and with such a large tumor we should almost invariably get marked expansive pulsation. Again, aneurismal sacs, before they produce extensive dulness in any portion of the parietes of the chest, point, as it were, in some particular direction, becoming distinctly prominent and producing an eccentric motion around them in consequence of the thoracic parietes being absorbed or yielding at the point of greatest pressure" (Graves). Hæmoptysis may occur not only from aneurismal leakage, but from the effects of pressure of morbid growths upon a bronchus or the invasion of the same by the malignant process. Blood-spitting cannot therefore be regarded as an important differential symptom. Unless valvular disease be associated with aneurism, the displacement of the heart is less frequent in aneurism than in morbid growths.