PART II.

THE SYMPTOMS OF CONSUMPTION.

CHAP. I.

GENERAL DESCRIPTION OF THE SEVERAL STAGES.

ALTHOUGH the course of phthisis is marked by a gradation as well defined as that of any other disease, it would be difficult to meet with its equal, in the almost endless variety of symptoms which accompany its several stages; in its career it simulates the most opposite maladies; and scarcely two cases are to be found strictly alike in their progress.

Consumption presents itself under two forms, viz., acute and chronic, both of which are subject to certain varieties; yet, in every instance, the disease is essentially the same, being only modified either by its severity, or by the varied conditions with which it is associated.

I propose giving, in the first place, a general description of the ordinary or chronic form of the disease; leaving the varieties to which it is subject for after-consideration.

The symptoms may be conveniently arranged as

belonging to two periods: viz. (1), that preceding the formation of pulmonary tubercles; and (2) that subsequent to their developement.

(1.) The period preceding the formation of tubercle. At no time is the changeable character of phthisis more apparent than at its very onset. Sometimes

this, which we may term the preliminary stage, is so well defined, that to fail in recognising it would be inexcusable; at other times, it is either too brief, or too indistinctly marked, to be detected.

Although this early period of consumption has been but little dwelt upon by medical writers,* it is, I think, very often distinguishable by the presence, in a greater or less degree, of the following train of symptoms:-From some cause, for which no good reason can be assigned, there is a slow but marked diminution of bodily vigour, compelling the individual to abandon many of his accustomed pursuits: the spirits, nevertheless, are good, and not only is the idea of consumption never entertained, but any allusion to it is at once

* This preliminary stage does not correspond with what is commonly understood as the scrofulous diathesis, or the tuberculous cachexia so fully described by Sir James Clark. It is a more advanced condition of disease. There is at this time not merely a tendency to the construction of tuberculous elements, but these actually exist, and the system is under their influence, although there is no evidence, either by local signs or general symptoms, of their separation from the blood in the form of tubercle. It would probably include many cases of what are sometimes called threatened phthisis.

ridiculed. So general, indeed, is this hopeful condition, this almost instinctive blindness to the real cause of distress, that in its absence, however suspicious certain symptoms appear, these may, with much probability of accuracy, be pronounced unconnected with phthisis. The complexion is, at the same time, pallid or sallow; the expression is that of care united with animation; the features are somewhat sharpened; the movements of the body are hurried and anxious; the mental condition is irritable and capricious; whilst every act betrays an effort, sometimes instinctive, and at others, voluntary, to conceal the presence of disease. The appetite is uncertain, and there are frequent indications of imperfect digestion, as well as of a tendency to passive diarrhoea. The pulse is slow, small, and easily excited. The sleep is restless, unrefreshing, and occasionally attended by perspirations. Loss of weight is of invariable occurrence; sometimes the decrease is so rapid that it will attract the attention of friends; at other times, it requires the periodical use of the weighing machine to detect it; the latter, perhaps, is the most usual, but I have met with examples of such rapid emaciation, that several pounds have been lost within a few days.

This preliminary stage is very uncertain in its course in some instances it will, under proper treatment, quickly subside; in others it will continue for a considerable period, and then disappear; but far too often it will resist the best efforts, both of physician and patient, and pass rapidly onwards

to the deposition of tubercle. Much depends upon the care which can be given to the health, and upon the exclusion of exciting causes. In the upper classes it is, consequently, more within our control than when we are called upon to treat it in humble life.

There is considerable variety in the association of its different symptoms; some may be altogether absent; and many are also met with in other diseases; yet, when a number of them are found together, and the patient's history-his occupation and habits of life or any other circumstances, seem to be conducive to phthisis, there can, I think, be little reason for doubting their consumptive

nature.

In childhood the symptoms are of the same character but more strongly marked. There is an evident precocity of intellect which forms a striking contrast with the bodily feebleness; the limbs are emaciated, and the abdomen tumid; the appetite is uncertain sometimes craving, but oftener defective; dentition is protracted, irregular, and difficult; and all the functions of nutrition are imperfectly performed. The child is peevish, irritable, and indisposed to exertion; and, in general appearance, is evidently labouring under some deeply-rooted malady, which, at no very distant time, will exhibit itself either as phthisis or some other form of tubercular disease.

(2). The period subsequent to the formation of tubercle. After tubercle has been deposited, the

course of phthisis is divided into three stages; the first corresponding to its miliary and crude states; the second, to its period of softening; and the third, to its expulsion from the lungs and the formation of pulmonary cavities. There is, however, no distinct line of separation between any of these stages; one passes imperceptibly into another; and there is no set of symptoms which can be said to characterize unequivocally any one particular period.

The first stage.-When the indications of diseased action, already described as belonging to the preliminary stage, become permanent, and, in spite of the strictest care, seem gradually upon the increase; when the loss of weight becomes more and more evident; the night perspirations more frequent; the pulse somewhat rapid; and the breathing oppressed;-when there is a slight cough, occasionally attended with a white mucous expectoration, perhaps a little streaked with blood; together with wandering pains about the chest, especially between the shoulders, beneath the clavicles, or at the epigastrium, there is reason to fear that the first stage has commenced.

But the transition from the preliminary period is so gradual, whilst the symptoms themselves are so variable, and bear so close a resemblance to those of many other diseases, that absolute reliance eannot be placed upon any of them singly, or even collectively, unless they are confirmed by a physical examination of the chest.