PHTHISIS (_______) or CONSUMPTION. This term, although applicable to several forms of wasting disease, is commonly used to designate a malady having for its chief manifestations progressive emaciation of the body and loss of strength, occurring in connexion with morbid changes in the lungs and in other organs.

Few diseases possess such sad interest for humanity as consumption, both on account of its widespread prevalence and its destructive effects, particularly among the young; and in every age of medicine the subject has formed a fertile field for inquiry as to its nature, its cause, and its treatment. On all these points medical opinion has under-gone numerous changes with the advance of science and the application of more accurate methods of investigation; yet, notwithstanding the many important facts which within recent years have been brought to light, it must be admitted that our knowledge of this disease is still far from complete. As regards the nature or pathology of consumption it is unnecessary in a notice like the present to refer at length to the doctrines which have from time to time been held upon the subject, further than merely to indicate in a general way the views which have been more or less widely accepted in recent times. In the early part of the present century the study of the diseases of the chest received a great impetus from the labours of Laennec, whose discovery of the stethoscope led to greater minuteness and accuracy in investigation (see AUSCULTATION). This physician held that phthisis depended on the develop-ment of tubercles in the lungs, which, undergoing various retrograde changes, led to the breaking down and excava-tion of these organs,—in short, produced the whole pheno-mena of consumption; and, further, that this tuberculous formation affected various other parts and organs, and was the result of a morbid constitutional condition or diathesis. This doctrine, which was generally taught during the first half of the century, and even longer, was to some extent superseded by that to which the greatest prominence was given by Niemeyer and others, namely, that the majority of cases of phthisis had their origin in an inflammation of the lung (catarrhal pneumonia), but that tubercle—the existence of which was freely admitted—might occasionally be evolved out of this condition. This view has had wide acceptance, but has been modified in a variety of ways, especially by its extension to inflammation in other parts besides the lungs, the unabsorbed products of which are held to be capable of producing tubercle by infection from within the system. Still more recently there has arisen another doctrine in connexion with the discovery by. Koch of the micro-organism or bacillus of tubercle, which can be cultivated and which, when inoculated, appears capable of producing tubercular disease, namely, the doctrine of the infectiveness of phthisis by means of this " microbe " received into the system from without. This view, which is supported by many striking facts and arguments, has been extensively adopted as furnishing in all probability a rational basis of the pathology of tubercular consumption. Yet it has not been universally accepted, being held by many to be insufficient to account for the origin and course of the disease in numerous instances and in certain of its forms. It is impossible to deny an important place in the course of the disease to inflammatory processes. Even in those cases where the lungs are infiltrated with tuber-cular deposit evidence of inflammation is abundantly pre-sent, while, on the other hand, it would seem that in not a few instances the process is inflammatory throughout. That phthisis, therefore, is not. the same process in all cases, but that there are distinct varieties of the disease, is made clear by the morbid anatomy of the lungs no less than by other considerations.

Whatever be the form, the common result of the presence of these disease-products is to produce consolidations in the affected portions of the lungs, which, undergoing retrograde changes (caseation), break down and form cavities, the result being the destruction in greater or less amount of lung-substance. These changes most commonly take place at the apex of one lung, but with the advance of the disease they tend to spread throughout its whole extent and to involve the other lung as well. When the disease is confined to a limited area of a lung it may undergo arrest—even although it has advanced so far as to destroy a portion of the pulmonary tissue, and a healing process may set in and the affected part cicatrize. This is, how-ever, exceptional, the far more common course being the progress of the destructive change either by the spread of the inflammatory process or by infection through the lymphatics, &c, from the existing foci of diseased lung-tissue. Various morbid changes affecting the lungs them-selves or other organs frequently arise in the course of phthisis, complicating its progress and reducing the chance of recovery. Of these the more common are affections of the pleura, stomach, liver, kidneys, and especially the in-testines, which in the later stage of the disease become ulcerated, giving rise to the diarrhoea which is so frequent and fatal a symptom at this period.





The causes influential in producing phthisis are numer-ous and varied, but they may for general consideration be embraced under two groups, namely, those which are pre-disposing and operate through the constitution as a whole, and those which are exciting and act immediately upon the organs implicated. These two sets of causes may be more or less distinctly associated in an individual case; but, on the other hand, one may appear to act in both ways—as predisposing and exciting. The following may serve to illustrate some of the conditions of a predisposing kind. A constitutional tendency to scrofula and its manifestations lends itself readily to the production of phthisis. This morbid constitution is characterized among other things by a liability to low chronic forms of inflammation affecting gland-textures, mucous membranes, &c, the products of which show little readiness to undergo absorption, but rather to degenerate. Inflammations of this character affecting the lungs, as is not uncommon, have a special tendency to lead to the breaking down of lung-texture and formation of phthisical cavities. Many high authorities hold that tubercle-formation may be evolved out of scrofulous inflammations of glands, such as those of the neck, by an infective process, like that already referred to. The mention of this constitutional state naturally suggests another powerful predisposing cause, namely, hereditary transmission. The extent to which this influence operates as a cause of consumption has been differently estimated by writers, owing probably to the various aspects in which the matter is capable of being viewed. It is impossible to deny that the children of parents one or both of whom are consumptive are liable to manifest the disease,—that is, they inherit a constitution favouring its development under suitable exciting causes. But a similar constitutional proclivity may be induced by other influences acting through the parents. Should either or both of them be enfeebled by previous disease or by any other weakening cause, they may beget children possessing a strong pre-disposition to consumption. Marriages of near relatives are held by some to induce a consumptive tendency,— probably, however, owing to the fact that any constitu-tional taint is likely to be intensified in this way. Phthisis is a disease of early life, the period between fifteen and thirty-five being that in which the great majority of the cases occur, and of these by far the larger proportion will be found to take place between the ages of twenty and thirty. The influence of sex is not marked. Occu-pations, habits, and conditions of life have a very im-portant bearing on the development of the disease apart altogether from inherited tendency. Thus occupations which necessitate the inhalation of irritating particles, as in the case of stone-masons, needle-grinders, workers in minerals, in cotton, flour, straw, cfcc, are specially hurtful, chiefly from the mechanical effects upon the delicate pul-monary tissue of the matter inhaled. No less prejudicial are occupations carried on in a heated and close atmosphere, as is often the case with compositors, gold-beaters, semp-stresses, <fec. Again, habitual exposure to wet and cold or to sudden changes of temperature will act in a similar way in inducing pulmonary irritation which may lead to phthisis. Irregular and intemperate habits are known predisposing causes; and over-work, over-anxiety, want of exercise, insufficient or unwholesome food, bad hygienic surroundings such as overcrowding and defective ventila-tion, are all powerful agents in sowing the seeds of the disease. Consumption sometimes arises after fevers and other infectious maladies, or in connexion with any long-continued drain upon the system, as in over-lactation. The subject of climate and locality in connexion with the causation of phthisis has received considerable attention, and some interesting facts have been ascertained on this point. That phthisis is to be met with in all climes, and it would seem fully as frequently in tropical as in tem-perate regions, is evidence that climate alone exercises but little influence. It is very different, however, with locality, elevation appearing to affect to a considerable extent the liability to this disease. It may be stated as generally true that phthisis is less prevalent the higher we ascend. The investigations of Dr H. J. Bowditch in New England and of Dr George Buchanan of the Local Government Board in the counties of Surrey, Kent, and Sussex agree in proving that elevated regions with dry-ness of soil are hostile to the prevalence of consumption, while low-lying and damp districts seem greatly to favour its development; and it has been found that the success-ful drainage of damp localities has occasionally had a marked effect in reducing their phthisis mortality. In all such observations, however, various modifying circum-stances connected with social, personal, and other condi-tions come into operation to affect the general result. As regards immediate or exciting causes, probably the most potent are inflammatory affections of the respiratory pass-ages produced as the result of exposure. The products of such attacks are liable under predisposing conditions, such as some of those already mentioned, to remain unabsorbed and undergo degenerative changes, issuing in the breaking down and excavation of the pulmonary texture. A neces-sary consequence of the modern doctrine of the contagious nature and inoculability of tubercle has been to bring to the front a view as to phthisis once widely prevalent and in some countries—e.g., Italy—never wholly abandoned, namely, its infectiousness. By some supporters of the recent theories of tubercle it is maintained that phthisis is communicated by infection and in no other way, the infecting agent being the bacillus. Others, while holding the view of the specific nature of the disease, deny that it can be communicated by infection like a fever, and cite the experience of consumption hospitals (such as that described by Dr C. T. Williams with respect to the Brompton Hospital) as to the absence of any evidence of its spreading among the nurses and officials. Others, again, deny both its specific nature and its direct infectious character. There appears, however, to be a growing opinion that phthisis may occasionally be acquired by a previously healthy person from close association with one already suffering from it, and, if this view be well founded, it affords a strong presumption that some infecting agent (such as the tubercle bacillus) is the medium of communi-cation. The whole subject of the infectiousness of this disease is as yet unsettled; but there appears to be suffi-cient reason for special care on the part of those who of necessity are brought into close contact with patients suffering from it.

Cases of phthisis differ widely as regards their severity and their rate of progress. Sometimes the disease exhibits itself as an acute or galloping consumption, where from the first there is high fever, rapid emaciation, with cough and other chest symptoms, or with the comparative absence of these, and a speedily fatal termination. In such instances there would probably be found extensive tuberculization of the lungs and other organs. In other instances, and these constitute the majority, the progress of the disease is chronic, lasting for months or years, and along with periods of temporary improvement there is a gradual pro-gress to a fatal issue. In other cases, again, the disease is-arrested and more or less complete restoration to health takes place.





It is unnecessary to describe the symptoms or course and progress of all the varieties of this malady. It will be sufficient to refer to those of the ordinary form of the disease as generally observed. The onset may be somewhat 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. 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. 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. 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 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 prominent 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 ward off the disease in those who show 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, <fcc, 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, etc, 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, <fcc, must be dealt with by the physician according to the indi

vidual case; but it is in this stage of the disease that the question of a change of climate in the colder seasons of the year arises among those whose circumstances render such a step practicable. There can be no doubt that as regards Great Britain the removal of patients threatened by or already suffering from consumption to some mild locality, either in the country or abroad, proves in many instances most salutary. The object aimed at is to obtain a more equable climate, where the atmosphere may have a soothing influence on the respiratory organs, and where also open-air exercise may be taken with less risk than at home. Of British health-resorts Bournemouth, Hastings, Torquay, Ventnor, Penzance, &c, in the south of England, are the best known and most frequented, and although the climate is not so certain as in places farther south in Europe they possess the advantage of home residence, and may be resorted to by persons who are unable to undertake a farther journey. The climate of the Eiviera (Maritime Alps) is of superior efficacy owing to its mild-ness and the dry bracing character of its air, and, despite the long journey, is as a rule to be recommended as one of the best for the greater proportion of the cases of phthisis. The same may be said for Algiers and Egypt. Of recent years the air of elevated dry regions, such as Davos in the Alps and the Eocky Mountains in America, has been strongly recommended, and in not a few cases appears to be productive of good in arresting the disease at its outset, and even advantageous in chronic cases where there is no great activity in its progress. Of like value, and in a similar class of cases, are long sea-voyages, such as those to Australia or New Zealand. Nevertheless, there is no doubt that consumptive patients are often sent abroad manifestly to die. It may be stated generally (although doubtless there may be exceptions) that where the disease exhibits a decidedly acute form, even in its earlier stages, any distant change is rather to be discouraged;
while in the advanced stages, where there is great prostra-tion of strength, with colliquative symptoms, the removal of a patient is worse than useless, and frequently hastens the end.
Throughout the whole course of the malady the nutrition of the patient forms a main part of the treatment, and tonics which promote the function of the digestive organs are especially helpful. Codliver oil has long been held to be of eminent value, as it appears not merely to possess all the advantages of a food but to exert a retarding effect on the disease. Where it is well borne, not only will the weight of the body be found to increase, but the cough and other symptoms will markedly diminish. The oil is as a rule best administered at first in small quantity. The frequently employed substitutes, such as malt extract, tonic syrups, &c, although not without their uses, are all inferior to codliver oil. The occasional employment of counter-irritation to the chest in the form of iodine or small blisters is of service in allaying cough and relieving local pains. Eespirators to cover the mouth and nose, and so con-structed as to contain antiseptic media through which the air is breathed, are sometimes found to lessen cough and other symptoms of chest-irritation.

Among the most serviceable drugs in the treatment of the symptoms of phthisis are the preparations of opium. Administered along with such agents as hydrocyanic acid and expectorants, they are eminently useful in soothing severe cough; along with astringents they are equally valuable in controlling diarrhoea while with quinine, digitalis, &c, they aid in allaying fever and restlessness and in procuring sleep. But besides these many other medicinal agents, too numerous to mention here, are employed with much advantage. Each case will present its own features and symptoms calling for special attention and treatment, and details upon these points must be left to the advice of the medical attendant. (J. O. A.)


Footnotes

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 he little if at all impaired, hut 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.

In 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.

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



The above article was written by: J. O. Affleck, M.D.