An inaugural dissertation on pulmonary consumption

by Edward Delafield

The disease having been excited into action, produces a succession of symptoms which are now to be detailed. Its attack is frequently extremely insidious and slow; at other times, well marked and rapid in its progress. It is to this insidious and gradual mode of attack, that Consumption owes much of its fatal character. Before the unfortunate patient suspects himself to be seriously indisposed, it but too frequently happens, that his fate is sealed, and death is inevitable. This arrives in part from the resemblance that Incipient Phthisis bears to a long continued catarrh. It frequently is only marked in its earliest periods by a slight, dry, hacking cough, trivial during the day, increased at evening, and most troublesome at night; a sense of weight about the breast, and some little difficulty of breathing, increased on taking any unusual exercise, or ascending a height; the pulse is slightly accelerated, and sometimes only so after taking food: occasionally, burning hands and feet, and a slight flush in the cheek are the only symptoms of fever. These symptoms may be so slight as hardly to attract the patient’s notice; at other times they are more severe and distressing. Frequently, on any little unusual exercise, the cough is increased, the patient feels a pain in the side, and expectorates a frothy mucus, and blood is discharged from the lungs. This, perhaps, is the first symptom which excites the alarm of the patient. Expectoration of blood is generally preceded by a saltish taste in the mouth, and a sense of irritation at the upper part of the trachea. It is known to come from the lungs and not the stomach, by its frothy appearance and admixture with mucus, while that from the stomach is generally dark coloured and mixed with the food; and by being brought up by coughing and not vomiting. The blood coming from the stomach too, is generally in larger quantity than that from the lungs.

In addition to these symptoms, the patient is often affected by an increased sensibility of the lungs, observable on any exposure to cold, change of dress, or going from a warm to a cool apartment. There is a sense of soreness in the lungs attended with a sensation of stricture about the chest. Pain is felt in the side or breast, and the patient lies with difficulty on the side affected. The pain is frequently lancinating, and shooting through the breast, sometimes in the direction of the mediastinum, at others, confined to one side.

As the disease advances, the symptoms of fever become more marked. The tongue is dry, attended with thirst, loss of appetite, nausea, and occasional vomiting, and a desire for acids. The secretions generally are checked. Perspiration is diminished, and the skin is hot and dry. The urine is at first diminished in quantity, and high coloured. The menses, in females, are either suppressed or very irregular. The bowels are frequently costive. The patient passes restless nights, and is prevented sleeping by a tormenting cough, or if he sleeps, is troubled with dreams. In consequence of indigestion, pain is felt in the situation of the stomach, attended with flatulence. The patient begins to have a pallid countenance, and emaciation gradually takes place.

These symptoms may continue a length of time, gradually debilitating the patient. But the expectoration which at first was frothy, in small quantity, and coughed up with difficulty and pain, increases, and gradually passing through all the stages between mucus and pus, at length becomes decidedly purulent. A new train of symptoms follow. Hectic fever makes its appearance, commencing with irregular cold and shivering fits, returning frequently during the day. It soon, however, assumes a decided character, and has two marked exacerbations, the one at noon, the other at night. These exacerbations begin with a sense of coldness, succeeded by heat, and at night terminating in profuse perspiration. During the chill and hot fit, the cough, pain, and dyspnœa are aggravated, but relieved by the sweating. The pulse before the paroxysm is accelerated and weak, during its continuance quick and strong, but abates as the perspiration flows. The countenance is generally pale, but during the exacerbation is marked by a circumscribed crimson flush, which occurs mostly at noon, but may be produced by taking food or any other cause of excitement. The profuse sweats do not occur after the exacerbation at noon, but in the morning, while the patient is warm in bed, with the system relaxed by sleep. The perspiration is principally confined to the superior parts of the body, as the neck, breast, and about the shoulders. The tongue is often very clean during hectic fever, but sometimes furred. The bowels are generally torpid, alternating with diarrhœa.

The disease continuing to advance, the cough and dyspnæa increase, and the hectic symptoms become more marked and violent. Emaciation rapidly goes on, the face looks sharp and haggard, and the absorption of fat makes the eyes appear remarkably large and prominent. At the same time, the teeth appear unusually white and beautiful. The appetite becomes extremely irregular, the pulse more accelerated and diminished in strength. The mind is extremely vacillating, at one time depressed, at another, elated with hopes of recovery. Profuse diarrhœas, alternated with obstinate torpor of the bowels, exhaust the patient; the eyes assume a ghastly and pearly whiteness; the mouth becomes filled with apthous eruptions; sometimes hiccup ensues; the patient’s mind becoming more and more disturbed, delirium comes on, which soon terminates in death.

An assemblage of some or all these symptoms, constitutes Phthisis Pulmonalis, differing however very materially in number, degree and violence in different patients. They are variously modified by a number of attending circumstances, which require some attention.

Many authors declare, that an expectoration of pus does not always attend this disease. The matter may be confined in a vomica, and the patient die with the symptoms of Phthisis before it bursts. Nor does a purulent expectoration necessarily indicate the existence of an ulcer in the lungs. The matter may be poured out from the secreting surfaces of the lungs without ulceration, precisely as it comes from the adnata of the eye after opthalmia, or the urethra in gonorrhœa, where no ulcer is suspected. In the New-York hospital, dissections of numerous patients who have died of Phthisis, sufficiently prove the fact in question.

Nor does pain in the side or breast, always accompany this disease. Dr. Reid remarks that many cases have occurred in his practice, where no pain in any part of the chest has been observed during the whole course of the disorder. “I have witnessed,” says Dr. Heberden, “many deaths from genuine pulmonary consumption, where dissection has demonstrated an entire destruction of the substance of the lungs, and where through the whole course of the disease, neither expectoration of blood, difficulty of breathing, nor pain in the side had been present.” On the other hand, pain in the side may occur merely as a consequence of the debilitated or irregular action of the muscles, as in walking, and should not be mistaken for a symptom of Consumption.

In the course of the disease, dropsical effusions, constituting Ascites, Hydrothorax and Anasarca, are not unusual, as in other diseases where great debility is produced.

In the advanced periods of Consumption, diarrhœa constitutes a prominent and troublesome symptom. This is sometimes produced by any cause which checks the profuse sweats; while on the other hand, if the diarrhœa be checked, the cough and dyspnœa, which perhaps had been relieved by it, frequently return with redoubled violence. Under these circumstances, the condition of the patient is hopeless indeed.