I'HTHISia 



PHTHISI& 



hereditary or acquired predisposition, cognisable by the physical the suppressi 



MBditfcn of the patient, and by a disordered suite of various functions, phthisis in lU 



?S\rhich. though very gMerelly accompanied with a feeble organi- J ~ ' " 



.ation. is not inconsistent with too great development and inordinate 

 action of particular part., and even with considerable physical power of 

 the .ystem.- By far the most important and -' 



morbid 



ion. Such are the ordinary symptoms presented by 

 iu most usual form, but varieties exist in the order and 

 duration of the morbid phenomena. Thus. tuberolea my be developed 

 in the lung., and remain for a eonaiderabU period without exciting 



either cough or expectoration, or even any important general aymptomi. 

 In ether cases they give rtae to intense general symptoms, an fewr, 



change that occurs in phthisis con* isU in the development 

 wherever they may bVfound ; but as it is in the lungs that they first 

 and mort frequently manifest themselves, w* shall describe them as 

 they are s*n in those organ* Tubercle, of the >""* ** n 

 the form of small, gray, semi-transparent granulations, wh oh gradually 



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almost the whole of both lungs may be invaded by a succession of 

 tubercles their healthy structure being absorbed a* the tubercles 

 become deposited, or Involved in the destructive process consequent 

 jixm their softening. Tubercle*, unlike inflammation, almost inva- 

 riably commence at the summit of the lung., where, as well a* being 

 more numerous, they are usually found in a more advanced stage of 

 development than in any other part. The successive eruption of fresh 

 tubereies is an important feature in this disease, as it explains the 

 occasional recovery of patient* labouring under consumption. A crop 

 of tubereies may appear in the lungs, go through the various stages 

 above described, and give rise to all the symptoms of confirmed 

 phthsris; yet, provided the conditions which gave rise to them are 

 removed, no fresh eruption may take place, and the patient may 

 recover. The relative frequency of tubercles in other organs differs 

 considerably in the adult and in the infant. In the f..nn.T. M. Louis, 

 omr gissU** authority in all matters connected with phthisis, has, with 

 one exception, never observed them in any organ without their existing 

 in the lungs ; so that he regards their presence in these last viscera aa 

 a necessary condition for their development in other part*. Rut in the 

 infant this does not appear to hold good ; the bronchial glands being 

 more frequently affected than the lungs, in the proportion of 87 to 78. 

 The brain and iu membrane* ore likewise more subject to tuberculous 

 deposit, in the child than in the adult. The next most important 

 lesion which U met with in phthisis is ulceration of the intestinal canal. 

 The ulcers may vary in number, form, and size ; but they all present 

 spsoine characters peculiar to this disease, and exist in five-sixths of 

 tbeea.es which terminate fatally. The third peculiarity in reference 

 to phthisis is the change which the liver undergoes, to which 

 the French pathologist* have given the name of fou grot, or 

 fatty liver, Lastly, ulcerations of the epiglottis, larynx, and trachea 

 occur so frequently, and with such uniformity of type, as justly to 

 lead to the belief that they are a part of the disease. But besides 

 tljl - morbid change., which are peculiar to this disease, complications 

 of various kinds oocur which are common to it and other chronic 

 fflasssn By far the most frequent of these are inflammations of the 

 pleunc; so that it is extremely rare, in making the post mortem exami- 

 nations of persons who die of phthisis, not to find the lungs adherent, 

 in part or entirely, to the walls of tho chest. Inflammation of the 

 substance of the lungs is likewise a frequent complication in tho latter 

 stages of phthisis. 



Symptom* of PhAitit. These generally commence with a slight 

 .cough, which at first excite* no attention, but is regarded as a simple 

 cold. The breathing is not seriously affected, nor is the appetite 

 impaired. After a time the cough increases in frequency, and is 

 accompanied by expectoration of a clear frothy saliva ; the breathing 

 and pulse become a little hurried after meals and towards evening ; 

 and at this time of the day there is frequently experienced a slight 

 degree of chilliness, followed by heat, which continues during tho 

 greater part of the night, and is succeeded towards morning by per- 

 spiration. The patient likewise becomes somewhat paler, and U 

 languid and easily fatigued. In aotne instances, the first symptoms 

 are preceded by a more or less copious hemoptysis. In the second 

 stage of phthisis the cough becomes more frequent, especially during 

 the night ; and if violent, it sometimes occasions vomiting. Hoarse- 

 ness, or loss of voice, is not unusual. The expectoration changes it* 

 character ; it is less frothy and more opaque ; containing small 

 particles of a yellowish-curd-like substance ; or the sputa are streaked 

 with dull-yellow lines, and hnmoptysii is pretty frequent, but in 

 general not abundant. The breathing and pulse are more hurried ; 

 the fsvsr is greater; and the perspiration, more regular and copious. 

 Pains an the thorax, denoting pleuritic inflammation, often occur ; 

 and the languor and emaciation still Increase. In the last stage 

 of consumption then is nearly always profuse diarrhoea, and the 

 sweats and expectoration are more copious; the latter becomes 

 mere uniform in composition; and is separated into roundish distinct 

 masses, with floooulent edges. The emaciation and debility keep 

 naoe with the other symptom*, and the feet and ankles swell 

 toward, tvening; the appetite generally declines in the same pro- 

 portion, and the patient dies in the extreme degree of marasmus, 

 not unfrequentty nattering himself to the last with a speedy recovery. 



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anorexia, before they excite cough or expectoration, tl 



Utter appealing only a short time previous to death. To these oases 

 the term \tont pAMtn has been applied : and what is remarkable in 

 them U, the absence of appreciable organic alteration in organs whose 

 functional derangement was most violent, while the only viscu* really 

 affected seems functionally healthy. The term <!< pkAiiit is applied 

 to those esses in which the disease goes through all it. stages with 

 unusual rapidity. It occurs most frequently in the young, and in 

 those weakened by some previous disorder. In popular language it is 

 designated " galloping consumption." Cknmie pkttiiit is the rev 

 of the last, and comprehends all those canes in which the progress of 

 the disease is unusually riow and generally intermittent. 



Diamtota of PltiMt. Auscultation and percusiion are the chief 

 mean, by which we arrive at the diagnosis of phthisis [Auscot- 

 TATIOH ; PmocMiox] ; but there are several collateral circumstances 

 which must be taken into consideration in order to form a correct 

 ..pinion as to the nature of the disease. It is at the commencement of 

 1 



In females, the menstrual discharge almost always cease* when hectic 

 fever is established, and occasionally even before that is the case, which 

 lias led to a popular opinion that the disease in rich cases arises from 



-hthinm that on accurate diagnosis is of most im|rtanoe, and in 

 which the stethosoopic signs are least evident We shall be therefore 

 more particular in enumerating the indications at thin period, than Ir 

 accurately describing the acoustic phenomena which are present at a 

 more advanced stage of the disorder. As bronchitis is the disease with 

 which phthisis is mort liable to be confounded, we shall place in juxta- 

 position the principal points in which they differ. In the 

 number of cases of phthisis the cough comes on without any evident 

 cause, and many months may elapse without expectoration. This 

 apparent absence of cause and dryneas of cough are of themselvc 

 remarkable, and differ from what occurs in simple bronchitis. T 

 pains, when present in the latter affection, are generally Mt in the 

 middle of the sternum ; while iu phthisis they are situated in the sides 

 of tW chest and between the shoulders. Hemoptysis, fn>m t!<> 

 mencement or during the progress of cough, is frequent in phthisis, 

 and is almost a certain sign of the presence of tubercles ; whereas thie 

 symptom never occurs in bronchitis. Out of twelve hundred patients 

 affected with various diseases, not including cases of ainenorrhoea, or 

 those arising from external violence, M. Louis found that not one, 

 with the exception of phthisical cases, had experienced this symptom. 

 Auscultation gives us little or no aid in the earliest stages of phthisis J 

 and when the stethoscopic signs first manifest themselves, they ore 

 ^uch as result from an increased density in the structure of the lung, 

 and not from the presence of fluid in the bronchi, aa is the cntt ( bron- 

 chitis. Thus the expiration, which in health is scarcely Mdibte. 

 becomes more distinct ; the voice more resonant ; the sound elicited 

 on percussion duller. These alterations in the respiration, and in the 

 signs produced by percussion, like the development of tubercles, take 

 place from the summit to the base of the chest, and at first are almost 

 constantly confined to the upper lobe of one side. In bronchitis the 

 sounds result from fluid in the bronchi, and originate in the 

 lower p&rt of the chest, and usually on both sides. In the more 

 advanced stage of phthisis its diagnosis ia less difficult, and is made 

 from a consideration of the sputa, which we have already described, 

 and from the signs furnished by percussion and auscultation. These 

 are now decisive : the upper parts of the chest are dull on pcrcureion ; 

 the respiratory murmur is strong, coarae, or even cavernous under the 

 clavicles ; and the voice listened to in the same situation gives rise to 

 that peculiar phenomenon termed pectoriloquy. If there should be 

 much fluid in the lungs, resulting from the patient's not having lately 

 expectorated, we then have a mucous rattle in all those parts of tho 

 chest corresponding with the seat of the disease ; and whore cavities 

 containing fluid exist, the air passing through this produces that 

 gurgling noise to which the term gargmiill: mtt has been applied liy 

 the French. The space in which these different changes take place is 

 at first limited ; but it daily increases, and in some instances, 

 the entire upper lobe of the lung is converted into nurnoroua exca- 

 vations, the respiration Is coarse and more or leas trachea! throughout 

 ita whole extent. The diagnosis of latent phthisis ia not diilioult, 

 provided we make use of the proper means for ascertaining the con- 

 dition of the pulmonary organs; tho evil is, that the attention i< 

 directed exclusively to those functional derangements which < liavo 

 spoken of when describing latent phthisis, while tile real seat of the 

 disease is overlooked. 



Duration and Mortality of Phlkuii. Various circumstances 

 the duration of phthisis, OB age, sex, constitution, occupation, season of 

 the year, climate, Ac. In the upper ranks of life, where patient* have 

 all the advantages that a proper regimen, change of air, and good 

 medical treatment can afford, the average duration of the disease is 

 considerably above that in the lower classes. 



The moan duration of 314 cases tabulated by MM. Louis and Bayle 

 was 23 months, including the extreme cases ; but 162, or more than ball 

 of the cases, terminated in nine months, and the greater proportion >(' 

 them between the fourth and ninth month. By excluding those cases 

 which terminate within four months, and those) Wiat exceed four years, 



