CHRONIC PULMONARY PHTHISIS.
The two principal forms in which chronic pulmonary phthisis usually presents itself in the child have well-marked and very distinctive char acters. Chronic catarrhal or pneumonic phthisis, which begins as a slowly forming consolidation of one lung, or succeeds to an attack of acute catar rhal pneumonia from imperfect absorption of the solidifying material, has at first the characters of a local disease. It is accompanied by certain signs and symptoms which indicate the existence of irritation within the lung ; but as a rule the general health is comparatively little interfered with, nutrition is fairly performed, and the appearance of the child gives little evidence of serious pulmonary mischief. It is only when softening is set up at the seat of consolidation, and infection of the system follows with secondary deposits in the opposite lung and other parts of the body, that signs occur indicating that the patient is suffering from a general disease. Even when these general symptoms arise, they remain for a long time insignificant as compared with the signs of extensive disease discovered on examination of the chest. On the other hand, chronic tubercular phthisis has completely different characters. From the first—indeed, before any signs of pulmonary irritation have been noticed—there is some fever and wasting, showing general distress of the system ; and throughout the whole course of the illness the general symptoms continue severe out of all proportion to the actual extent of lung mischief discoverable by the stethoscope. Therefore, whatever opinions may be held with regard to the pathology of these two varieties, they still remain two distinct clinical types marked out from one another by very separate and distinctive features.
Symptoms.—The peculiarities in the size and shape of the chest often met with in children of consumptive tendencies are elsewhere referred to (see page 399). It may, however, be remarked that although small lungs and a narrow elongated chest are often found associated with an inherited pulmonary weakness, phthisis is not confined to such subjects. We shall never be justified in excluding pulmonary phthisis because the child's shoulders are broad and his chest well proportioned. In the pneumonic form of phthisis the eye often detects nothing to raise a suspicion of pul monary mischief. It is the tubercular variety which is most constantly combined with narrow sloping shoulders and flattened ribs.
In both varieties of phthisis we find local symptoms significant of pul monary distress, and general symptoms arising from irritation of the system and impaired nutrition. The severity of the case is usually very fairly indicated by the degree in which the latter predominate over the former.
If chronic pneumonic phthisis the first sign of the disease is usually cough. The patient may have lately passed through an attack . of acute catarrhal pneumonia, or may have suffered from neglected pulmonary catarrh with gradual implication of the alveoli at one apex. In the first case the child recovers his strength but slowly. He continues to cough, often violently ; and is more or less feverish at night. After a time, how ever, the fever subsides, and the child regains flesh and a certain propor tion of his strength ; but he still looks pale and has a frequent hacking cough. In the second case the disease creeps on insensibly, and at last it is noticed that the child coughs, and is pale and easily tired. However the disease may have originated, the symptoms are insignificant as long as the unabsorbed deposit in the lung is undergoing no active change. A child with an unabsorbed mass of caseous matter in his lung may be plump, active, and cheerful ; but he is usually rather pale, may complain of pains in the limbs, and is apt to cough a little in the morning or in the day after exertion. On examination of the chest at this period we find slight dulness with some little increase of resistance at the apex or any other part of the chest on one side. If at the apex, the dulness is best detected at the supra-spinous fossa. The breathing is bronchial and some coarse clicks are heard with inspiration. The resonance of the voice is also in creased. Children with the lung in this condition are very susceptible to chills ; and if first seen when the lungs are the seat of a fresh catarrh, general bubbling may be heard all over the diseased side ; and also, but to a less extent, over the opposite lung. When this happens it is difficult to form a correct opinion as to the actual amount of disease present in the chest ; and it is well to correct our first impressions by the results of a subsequent examination. • At this stage of the illness, before softening has begun, absorption is still possible, and sometimes occurs in young subjects many months after the first symptoms have been noticed.