It will be found, as a general rule, that those cases in which dyspepsia has been the most prominently marked, suffer earlier and more severely than others from subsequent diarrhoea; showing the tendency to an extension of diseased action lower down the alimentary canal. Incurvation of the finger nails has long been reckoned amongst the symptoms of consumption. There is no definite period for its commencement, but it is seldom particularly marked before the second stage. The first indication of it consists of a slight tumefaction, of a dark and congested appearance, around the root of the nail; soon, the nail itself is observed to become of a more or less livid colour, and to grow unusually fast. After a progress often so gradual that it escapes the patient's notice, but at other times of marked rapidity, the whole nail seems to undergo hypertrophy; it is broader and altogether larger than before, and so rounded, as to form, in many instances, almost a semicircle; whilst it shows also, in some cases, a disposition to curve over the extremity of the finger. Concurrently with this change, the fingers gradually assume a congested appearance, and are unusually cold; their extremities frequently enlarge, and ultimately assume the peculiar form which has been appropriately termed "clubbed". These appearances are subject to infinite variety. In some patients, even in the third stage, they are scarcely, if at all, discernible; whilst in others they are highly marked long before cavities have formed. The nails also may be much incurvated, and the fingers little clubbed; and vice versa. They are more common in the male sex, and amongst the lower classes, than in females, and the higher orders; and are almost always accompanied by an increased growth of the hair. Sometimes, but not always, the nails of the feet participate in the alteration; but I am unable to state the proportion of cases in which they do so. In other chronic diseases attended with emaciation, as well as in certain organic affections of the heart, the nails sometimes become curved; but I have never seen them changed to the same degree, or in precisely the same manner as in phthisis; the extreme lividity, coldness, rounding, and rapid growth, which have been described, are, I think, characteristics of consumption: the fingers also, so far as I have observed, although sometimes congested and enlarged, do not absolutely become clubbed except in consumptive cases. The whole phenomenon is difficult to explain, appearing to consist of one of those strange sympathetic actions which are exhibited in so many different ways in almost every disease; and of which another instance may be seen in the symptom next to be described. A brick-red or blue streak upon the gums, opposite the lower, and sometimes also the upper incisor teeth, was first noticed as a phthisical symptom by M. Frédericq,* whose statements have been, in a great measure, confirmed by the recent observations of my friend and colleague, Dr. Theophilus Thompson. M. Frédericq believes that, although a similar appearance is common to the latter periods of all chronic maladies, the coloured line is invariably present as one of the earliest signs of phthisis; the red denoting an inflammatory, and the blue a less active kind of tubercular disease; the deepness of the colour, moreover, bearing a direct proportion to the rapidity with which the particular case is destined to proceed. He also observes, that "arrested cases continue to have the blue mark, but paler than before; and when the disease recommences its march, the mark becomes plainer.' Thompson states that "it exists in a very large proportion of cases, but the most so in the male sex"; that" whenever any patient has exhibited it clearly defined, whatever may have been the prominent complaint, a careful examination of the chest has led to the detection of phthisical disease"; and that "the absence of such a streak may incline to a favourable interpretation of suspicious indications"; the condition itself denoting "a tubercular taint in the constitution".† Dr. Although this appearance of the gums is often present in phthisis, even at an early period, it is, I am convinced, very far from being universally so; *Rév. Med. Chir., vol. vii. † Lancet, vol. ii, 1851. and, consequently, its absence is no negation of a tuberculous diathesis. And when we consider the delicacy of the appearance itself, and the possibility of its being caused by other agents-such as iodine and mercury, or even by the local irritation of accumulated tartar,-I think it must be looked upon rather as one of the curiosities of phthisis than as a symptom of much importance: yet it is just one of those things which may sometimes be available when the detection of the disease depends, as it often must do, more upon the multiplication of suspicious signs than upon the existence of any which are either very obvious or unequivocal. CHAPTER III. THE DIFFERENT FORMS OF CONSUMPTION.-ACUTE PHTHISIS. FLORID AND LANGUID. LARYNGEAL CHRONIC PHTHISIS: THE Protean character of phthisis has gained for it a number of different appellations, which might fairly be supposed to represent a real difference in its nature; but whatever variety the disease may assume, it is essentially the same, having the like regular succession of stages, and presenting, although under modified conditions, the same characteristic symptoms. For practical purposes, however, it is divisible into the acute and chronic forms; the first of which is of pretty uniform character, but the second presents certain differences which admit of a subdivision into two varieties,—viz., the florid and the languid. 66 Acute phthisis is happily a rare disease. We often hear of what is termed "rapid”, or galloping" consumption, but these cases hardly come under the true meaning of the term acute, most of them being the sudden and unexpected termination of a disease which may have existed for months or even M |