CHRONIC ULCERATIVE PHTII I SIS. The onset of this disease is varied; it may have commenced in an acute tuber culosis of the lungs which has merged into the chronic type. It is not uncom mon to see a galloping consumption di agnosed as pneumonia or typhoid fever, and after several weeks the case pass on to one of chronic phthisis.
By far the commonest mode of onset is with a bronchitis; the patient may have been severely exposed, and speaks of having contracted a cold which finally settled on the chest and which he can not get rid of; there is more or less cough, dry at first; but finally profuse expectoration occurs, with fever and emaciation.
The disease may first manifest itself by gradual loss of strength and appetite; vomiting may occur, and there may be marked anaemia. Frequently it is ush ered in by hemorrhage, which may be either profuse or slight; usually the amount of blood lost is slight. The pa tient may experience a sensation of tick ling over a given lung-area, but is sel dom able to tell from which lung the haemorrhage takes place. These haemor rhages may occur at varying intervals of years, with little or no progress of the disease, or, as occasionally happens, the other symptoms rapidly appear and the patient succumbs to the disease in a short time.
The rupture of some ramification of a pulmonary artery passing through a cav ity is usually the cause of the blood spitting. In S79 cases observed blood was expectorated in 30 per cent., and over half a litre in 15 per cent. This is a most unfavorable symptom if the tem perature afterward rises, but in the early stages blood-spitting is usually a very favorable alarm-signal. Gerhardt (Berl. klin. Woch., No. 21, '99).
It is quite common to see well-ad vanced laryngeal tuberculosis with only slight pulmonary involvement, but in volvement to a greater or lesser extent almost always exists. The majority of cases of pleurisy with effusion coining on insidiously are of tubercular origin, and the suspicion is not to be abandoned if the microscopical examination of that effusion prove negative. Localized areas
of dry pleurisy are frequently the first indication of a tubercular process. In the beginning the disease often simulates intermittent malaria, with chill, fever, and sweat; but its resistance to quinine should excite suspicion, particularly if there are other factors in the case, such as cough or gradual loss of weight. In children tuberculosis of the lungs not uncommonly results from the downward extension through the lymph-channels communicating with diseased cervical glands.
Pulmonary tuberculosis in children frequently manifests itself without a cough. There may be moist riffles at times, a little harsh breathing, and slight elevation of the temperature. Frequently there are small areas of dullness in the lung, caused by either consolidation or from enlarged and swollen bronchial glands. again, there are eases of tuberculosis in which there may be no pulmonary symptoms or either percus sion or auscultation, and where the clin ical history is absolutely negative.
The symptoms to be relied upon chiefly in making a diagnosis are loss of weight, disturbances of digestion, a slight attack of febrile malaria, besides constant irri tability. Such children will frequently show very slight, if any, pulmonary symptoms, so that the diagnosis must be made by a process of exclusion. Such distinct diagnostic features as the pres ence of cough, expectoration and tuber cle bacilli, dullness on percussion, with moist rifles and night-sweats, as found in the adult, are out of the question. It is not an easy matter to diagnose a case of tuberculosis, and it is a safe ad vice to follow, "to observe a suspected case of tuberculosis for several weeks, and sometimes months before giving a positive opinion relative to either the diagnosis or more particularly to the prognosis in a given case." Louis Fischer (Jour. of Amer. Med. Assoc., Oct. 29, '93).