half an hour; or, the patient may die in a few hours; or, he may rally and live many days or weeks, or even months: I have myself seen the disease continue upwards of four months, and instances are recorded of a considerably longer duration. But it more generally happens that the system, already greatly exhausted by long-continued disease, speedily gives way under its first effect.

A low inflammatory condition of the pharynx is not an unfrequent attendant upon phthisis, and sometimes appears amongst its earliest symptoms. It usually commences at its posterior wall, and has a tendency to spread, not only over the whole pharynx, but also into the larynx, laying, in many cases, the foundation of what is termed laryngeal phthisis.

The mucous membrane presents, at first, a number of dark or vivid red patches or streaks, which gradually coalesce; a yellowish tenacious mucus soon appears upon its surface; the tonsils become enlarged, and the uvula is elongated. If the mucous follicles upon and behind the tonsils be now carefully examined, they are often seen to contain a yellowish-white substance, apparently of a scrofulous nature, which, becoming expelled, frequently leaves behind it small ulcerations. These ulcerations sometimes spread and involve a considerable portion of the pharynx, especially at its posterior part. The epiglottis, meanwhile, frequently becomes red and congested; the laryngeal mucous

membrane participates in the attack; and the general symptoms of laryngeal inflammation-of which more will be said elsewhere-make their appearance. In many instances, the diseased action remains limited to the pharynx; but in those cases where it extends to the larynx, it sometimes altogether leaves the pharyngeal membrane.

This tubercular inflammation of the pharynx has not, I believe, hitherto received much attention. The simple follicular inflammation often occurs unconnected with phthisis; but the yellow tuberculous matter and subsequent ulceration, are, I have reason to think, essentially phthisical symptoms. I have seen numbers of cases, in which they have occurred, gradually pass into ordinary phthisis; and have frequently noticed them in connexion with the early symptoms of consumption.

Dyspepsia is, perhaps, of all complications, the most distressing. Usually beginning at an early period, and being always liable to occur, few consumptive persons are entirely free from it; and in a great number, it forms the chief source of complaint. It constitutes, moreover, the greatest obstacle we have to encounter in the treatment of phthisical cases; for, so long as the stomach is unfitted for the digestion of the particular diet suited to the consumptive invalid, there can be but little hope either of restoring the health, or of arresting the formation of tubercle.

The dyspepsia of phthisis is sometimes only func

tional; but, more frequently, it depends upon some organic change in the stomach itself. The investigations of M. Louis have shown that the stomach of phthisical persons is sometimes enormously distended; that its mucous membrane is often either reddened, soft, attenuated, or destroyed; and that, in some instances, it is thickened and mammillated. These different conditions are neither so constant in, nor so exclusively related to, tubercular affections, as to point to a necessary connexion between them; but the subject is an interesting one, and seems the most likely of any to lead, at some future period, to a more correct idea than we have at present of the primary cause of tuberculous diseases.

Although phthisical dyspepsia is not always alike, there are certain peculiarities about it which may serve in some measure to distinguish it from that which is either idiopathic, or dependent upon some other condition; or, at least, to give it extra importance, when associated with other symptoms having at all a consumptive aspect. Nausea and sickness are particularly common, the latter being easily induced by coughing; and so frequently is this the case, that some practitioners have considered one peculiarity of the consumptive cough to consist in a tendency to end in vomiting; whatever value, however, is to be attached to the circumstance, it is clearly referable rather to the dyspepsia than to the cough. Pain and tenderness at the epigastrium, pyrosis, a remarkable craving

for food, flatulency, and a subsequent tendency to diarrhoea, ordinarily coexist.

The actual condition of the stomach is undiscoverable, either by the kind or degree of dyspepsia, and must always remain unknown previous to post-mortem examination. When the mucous membrane is softened or ulcerated, there is usually a feeling of pain or soreness upon pressure; yet, this is as likely to be experienced when the stomach is simply irritable: the nausea or sickness also, may be equally distressing, whether there be structural change or not; and we can only judge of the probable state of the organ, from the length of time the dyspepsia has continued, - its long duration arguing strongly in favour of structural disease.

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 have undergone hypertrophy; it is broader and altogether larger than before, and so rounded from side to side as to approach almost to a semicircle, showing also, in some cases, a disposition to curve over the extremity of the finger.

The fingers themselves have likewise a congested appearance, and are unusually cold; and becoming, in many cases, enlarged at their extremities, assume the peculiar form which has been appropriately termed “ clubbed”.

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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 before cavities have formed. The nails also may be much incurvated, and the fingers little clubbed; and vice versa. They are obviously 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, the nails sometimes become curved; but I have never seen them changed to the same degree,

M