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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 cannot be placed upon any of them singly, or even collectively, unless they are confirmed by a physical examination of the chest.

In some cases there is no pain, or if any, it is so trifling that the patient will scarcely acknowledge it; whilst in others, it is most distressing. Sometimes there is no cough, or it is so slight as to be unobserved by the invalid, or if noticed, causes less anxiety to himself than to his friends. Hæmoptysis, also, which at this period is a most important sign, is sometimes altogether absent, or if present, it may be so slight that there is difficulty in ascertaining its occurrence. Other symptoms likewise, which are generally regarded as indicative of phthisis, are frequently wanting; but upon all these points I shall have occasion to dwell more fully in the next chapter.

The second stage, or that of tubercular softening, is usually accompanied by an aggravation of all the preceding symptoms. The loss of weight is still more manifest; the appearance more depressed; the pulse quicker; the skin more frequently covered with perspiration; the cough more troublesome; the expectoration more abundant; and hectic fever and diarrhoea have generally set in.

But at this stage, there is the same diversity in the several symptoms, as in the preceding one. Some persons scarcely complain of anything, however much their appearance may indicate the extent of their disease; whilst others are intense sufferers, although their looks may hardly betray their condition. But even if every phthisical symptom be present, which is seldom the case, there is nothing either in their nature or extent, to announce

with certainty that softening has begun; and, without the aid of physical signs, it is impossible to do more than conjecture that such is the case.

The third stage, in which there are cavities or vomicæ in the lungs, is shown externally only by an advance of the symptoms met with in the second. The emaciation visibly increases; the pains about the chest are frequent and acute; the breathing is short and hurried; the cough harassing, and attended with copious expectoration; the pulse very weak and rapid; hectic fever is established; the whole, or a portion of the body, is yet more frequently covered with perspiration; diarrhoea increases; the ankles and feet are apt to become œdematous; the hair frequently falls off; and the finger nails become enlarged, and incurvated :— with all this, however, the spirits often remain good; the mind continues calm; and hope is too frequently cherished even to the last. In the association of these symptoms, as in those of the preceding stages, there is great diversity; most of them occur sooner or later, but they vary so much in themselves, that it might be difficult at this period to find two cases of consumption precisely alike.

Such is an outline of the different stages of phthisis as they are ordinarily met with ;-a mere sketch, however, and intended only as the introduction to a separate and more comprehensive description of the particular symptoms.

106

CHAP. II.

A MORE PARTICULAR DESCRIPTION OF THE PROMINENT

SYMPTOMS.

The Phthisical Aspect.—A practised eye may sometimes detect consumption, even at its commencement, by means of certain physiognomical peculiarities belonging to the disease. These, although difficult to describe, are very easily recognized. The complexion differs, but is usually either sallow or of a peculiar pearly whiteness; the cheeks are subject to irregular flushing; the features are sharpened; the eye, although bright and intelligent, is expressive of a certain amount of languor; the whole appearance betrays a mixture of anxiety and animation, telling of something wrong, and of the effort, both mental and physical, made to conceal or overcome it.

The physiognomy of diseases liable to be mistaken for phthisis, is different. In malignant affections, the countenance is depressed; the features are less prominent; the skin is of a peculiar opaque and "muddy" hue; and the eyes are dull and sunken. In anæmia, the skin is of a dead white colour, and rarely sallow; the eye is heavy and inexpressive; the face puffy, and the features

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