The above are the physical signs in a typical case of the disease ; but it must be confessed that in many cases, especially in the younger children, cavities may form in the lung without any sign, of their existence being noticed on examination of the chest. In such cases the signs are chiefly those of catarrhal pneuMonia ; but the dulness begins at the upper part of the chest instead of the lower, and the rhonchus is usually larger and more ringing and metallic than in an ordinary case of bronchopneumonia. The child in all cases looks excessively haggard and ill. The wasting is very rapid ; in a surprisingly short time the temples and cheeks get hollow, and the flesh seems to fall away from the body. Often more or less general 'oedema is noticed, although an examination of the urine may discover no trace of albumen.
A little girl, aged thirteen years, was said to have been healthy until the age of six years, when she had an attack of measles followed very shortly by scarlatina. Enlarged glands formed in her neck soon afterwards, and some of these suppurated. Since that time the girl had been delicate, but had never coughed until ten months before coining under observation. For four months her cough had been very distressing, and she had suffered much from pain in the side. She had been very feverish, had sweated profusely at night, and had wasted rapidly.
The girl was much emaciated and very weak. She had a distressed, haggard expression. The cervical glands were enlarged, and her neck bore many scars resulting from former suppurations. On examination of the chest the clavicles were seen to be very prominent from retraction of the apices of the lungs. There was much diminution of resonance over the whole of the right side and at the upper third on the left ; and much coarse, metallic, bubbling rhouchus was heard over the whole of both sides. The respiration was cavernous towards each apex, and bronchial below. The liver was enlarged, reaching nearly to the navel.
The girl complained greatly of dyspnoea and sweated freely at night. Her cough was troublesome, and she expectorated nummular sputa. She said the sputa had never contained blood. Her face and feet were oedem atous, and her urine contained albumen. There was no diarrhoea.
During the first few clays the girl's temperature was 101° at night, sink ing to the normal level in the morning. It then became subnormal both morning and evening, and the patient died on the twelfth day after admis sion into the hospital. On inspection of the body cavities were found at the upper part of each lung, and other small collections of purulent matter were scattered over both organs. The pulmonary tissue generally was red, and easily broke down under the finger. At the base of the right lung a marked increase in the fibrous tissue was noticed, and the bronchial tubes in that situation were somewhat dilated. No grey or yellow tubercles were to be seen. The pleural surfaces were firmly adherent. The kidneys
appeared to be healthy.
Death is preceded in these cases by great prostration, restlessness, and inability to sleep, complete anorexia, a glossy eroded tongue, and sorties upon the teeth and lips. The duration of the illness is comparatively short, and death usually takes place at the end of five or six months.
Diagnosis.—The disease with which acute phthisis is most liable to be confounded is acute pulmonary tuberculosis. In the beginning, however, the affection may be mistaken for croupous pneumonia. The sudden onset, accompanied by pain in the side, cough, and high fever, presents sometimes a close resemblance to an ordinary case of inflammation of the lung. Still, the temperature does not maintain the same little varying elevation in acute phthisis as in croupous pneumonia, and the course of the illness in the two cases is very different. Instead of the sudden crisis which occurs in pneumonia about the end of the first week, the symptoms persist and grow more and more severe, the signs of consolidation con tinue to extend themselves, the opposite lung is quickly affected, and very soon elastic tissue, and perhaps bacilli, can be discovered in the sputum.
From acute pulmonary tuberculosis the disease is distinguished by its more abrupt onset, the early signs of pulmonary consolidation, and the absence of indications pointing to the implication of other cavities of the body. Comparatively few cases of pulmonary tuberculosis in the child terminate without some signs of intracranial mischief ; but when acute phthisis is uncomplicated by tuberculosis these are absent. The two diseases are, however, sometimes present together. The existence of the tubercular malady is then made evident sooner or later by the onset of convulsions, squinting, rigidity of joints, and other symptoms pointing to meningitis.
Prognosis.—Acute phthisis is a vei.'y fatal disease, and the prognosis is consequently very unfavourable. The patients do not invariably die, but instances of recovery are exceptionally rare. In any case the best we can hope for is a remission in the acuteness of the symptoms. Sometimes the disease, its first force expended, loses a part of its energy and becomes more measured and tranquil in its course. It may even settle down into an ordinary case of chronic phthisis. It is impossible in any individual instance to anticipate such a result ; but a diminution in the pyrexia, if combined with an improvement in the appetite and a brighter expression in the face of the child, is a sign of good omen. A decrease in the fever, if unaccompanied by other signs of improvement, so far from being a favourable symptom, is one to be regarded with great anxiety ; and if, under such circumstances, the temperature fall to a subnormal level, it may be an indication that the end is not far off.
The treatment of these cases will be considered afterwards.