Page:Encyclopædia Britannica, Ninth Edition, v. 18.djvu/893

PHTHISIS 857 sudden, as where it is ushered in by haemoptysis (spitting of blood), but more commonly it is slow and insidious and may escape notice for a considerable time. The patient is observed to be falling away in flesh and strength. His appetite fails, and dyspeptic symptoms trouble him. But the most marked feature of the condition is the presence of a cough, which is either persistent or recurs at certain times, as in lying down in bed or rising in the morning. The cough is dry or is accompanied with slight clear ex pectoration, and the breathing is somewhat short. Feverish symptoms are present from an early period, the tempera ture of the body being elevated, especially in the evening. The patient often complains of flying pains in the chest, shoulders, and back. Such symptoms occurring, especially in one who may possess by inheritance or otherwise an evident tendency to chest disease, should excite suspicion, and should be brought under the notice of the physician. They constitute what is commonly known as the first stage of phthisis and indicate the deposit of tubercle or else inflammatory consolidation in the lung. 1 Not unfre- quently the disease is arrested in this stage by judicious treatment, but should it go on the symptoms characteriz ing the second stage (that of softening and disintegration of lung) soon show themselves. The cough increases and is accompanied with expectoration of purulent matter in which lung -tissue and the bacillus of tubercle can be detected on microscopic examination. 2 The symptoms present in the first stage become intensified : the fever continues and assumes a hectic character, being accom panied with copious night -sweats, while the appetite and digestion become more and more impaired and the loss of strength and emaciation more marked. Even in this stage the disease may undergo abatement, and improve ment or recovery take place, though this is rare ; and by careful treatment the advance of the symptoms may be in a measure held in check. The final stage (or stage of excavation), in which the lung has become wasted to such an extent that cavities are produced in its substance, is characterized by an aggravation of all the symptoms of the previous stage. In addition, however, there appear others indicating the general break-up of the system. Diarrhoea, exhausting night-perspirations, and total failure of appetite combine with the cough and other pulmonary symptoms to wear out the patient s remaining strength and to reduce his body to a skeleton. Swelling of the feet and ankles and soreness of the mouth (aphthae) proclaim the approach of the end. 3 Death usually takes place from exhaustion, but sometimes the termination is sudden from haemorrhage, or from rupture of the pleura during a cough and the consequent occurrence of pneumothorax. A re markable and often painful feature of the disease is the absence in many patients of all sense of the nature and 1 The examination of the chest by the usual methods of physical diagnosis reveals in this stage the following as among the chief points. On inspection the thorax is observed to be narrow and poorly developed, or it may be quite natural. At its upper region there may be noticed slight flattening under the clavicle of one side, along with imperfect expansion of that part on full inspiration. On percussion the note may be little if at all impaired, but frequently there is dulness more or less marked at the apex of the lung. On auscultation the breath- sounds are variously altered. Thus they may be scarcely audible, or again harsher than natural, and the expiration may be unduly pro longed. Sometimes the breathing is of an interrupted or jerky char acter, and is occasionally accompanied with fine crepitations or rales. Pleuritic friction-sounds may be audible over the affected area. - la this stage the physical signs are more distinctive of the disease. Thus the flattening of the chest-wall is still more marked, as is also the dulness to percussion, while on auscultation the breathing is accompanied with coarse moist sounds or rales, which become more audible on coughing. The voice-sound is broncho -phonic. 3 The physical signs now present are those of a cavity in the lung viz., in general absolute dulness on percussion cavernous breathing, gurgling rales, and pectoriloquy. gravity of the malady from which they suffer, and their singular buoyancy of spirits (the spes phthisica), rendering them hopeful of recovery up till even the very end. This description is but a brief and imperfect outline of the course and progress of an ordinary case of phthisis. It is scarcely necessary to remark that the disease is greatly modified in its course and progress and in the presence or absence of particular symptoms in individuals. Thus in some the chest-symptoms (cough, &c.) are pro minent throughout, while in others these are compara tively in abeyance, and diarrhoea or fever and exhausting perspirations or throat -troubles specially conspicuous. Nevertheless, essentially the same pathological conditions are present in each case. Further, as has been already mentioned, there are types of the disease which obviously influence alike its main features and its duration ; these have been embraced under two classes, the acute and the chronic. In the former, which includes the acute tuber culous and acute inflammatory or pneumonic phthisis, the progress of the disease is marked by its rapidity and the presence of fever even more than by local chest-symptoms. Such cases run to a fatal termination in from one to three or four months, and are to be regarded as the most severe and least hopeful form. The chronic cases, of which the description above given is an example (and which embrace various chronic changes, e.g., chronic interstitial pneumonia or cirrhosis of the lung), progress with variable rapidity. Their duration has been estimated by different authorities at from two to eight or more years. Much, however, necessarily depends on the effect the disease exercises upon the patient s strength and nutrition, on his circum stances and surroundings, and on the presence or absence of weakening complications. Many cases of this class remain for long unchanged for the worse, perhaps under going temporary improvement, while in a few rare in stances, where the disease has become well marked or has even attained to an advanced stage, what is virtually a cure takes place. The treatment of phthisis has received much attention from physicians as well as from empirics, by the latter of whom chiefly many so-called cures for consumption have from time to time been given forth. It need scarcely be stated that no " cure " for this disease exists ; but, while this is true, it is no less true that by the adoption of certain principles of treatment under enlightened medical guidance a very great deal may now be done to Avard off the disease in those who shoAv a liability to it, and to mitigate and retard, or even arrest, its progress in those who have already become affected by it. The preventive measures include careful attention to hygienic conditions, both personal and surrounding. In the case of children who may inherit a consumptive tendency or show any liability to the disease much care should be taken in bringing them up to promote their general health and strengthen their frames. Plain wholesome food with fatty ingredients, if these can possibly be taken, milk, cream, &c., are to be recommended. Ex ercise in the open air and moderate exercise of the chest by gymnastics and by reading aloud or singing are all advantageous. An ample supply of fresh air in sleeping apartments, schools, <fec., is of great importance, while warm clothing and the use of flannel are essential, especially in a climate subject to vicissitudes. The value of the bath and of attention to the function of the skin is very great. The like general hygienic principles are equally applicable in the case of adults. When the disease has begun to show any evidence of its presence its treatment becomes a matter of first importance, as it is in the early stages that most can be done to arrest or remove it. Special symptoms, such as cough, gastric disturbances, pain, etc., must be dealt with by the physician according to the indi- XVIII. 1 08