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164

Chap. in.

THE DIFFEBENT FORMS OF CONSUMPTION.

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 its subdivision into two varieties,— viz., the florid and the languid.

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 years;—chronic phthisis not unfrequently going on, even to the last stage, unsuspected or unheeded, and ultimately terminating with such suddenness as to give the disease every appearance of an acute

The really acute form of phthisis commences suddenly and proceeds rapidly, and assumes every other character of an acute disease. Shivering, succeeded by intense fever, quickness of pulse, anxiety of countenance, severe thoracic pains, dyspnoea, and cough, are its earliest symptoms. These rapidly increase, and are soon followed by those of depression, with hectic fever, profuse perspiration, or diarrhoea, under which the patient rapidly sinks from exhaustion.

It would be useless to attempt a detailed account of the onset and progress of this formidable variety of consumption, since it presents so many differences both in severity and duration, that perhaps scarcely two cases could be found strictly alike. The diagnosis is often a difficult one, and nothing but the long continuance and obstinacy of the attack will serve to distinguish it from acute pneumonia or bronchitis. In the majority of cases, —probably in nearly all—it proves fatal. In one which fell under my own observation it did so in less than five weeks from its commencement; and in another case, in about six weeks; but M. Louis relates instances of a still more rapid progress, viz., within thirty days.

In seeking for the cause of this remarkable and fatal disease, we find the whole subject involved in obscurity. It is impossible to explain why phthisis should in one case assume a rapid, and in another a chronic course. A highly developed strumous diathesis is probably essential to its production, but is not alone sufficient to give rise to it, as many persons affected with hereditary scrofula to a marked degree suffer from consumption in its most chronic form. The few cases I have witnessed presented no visible peculiarity which would lead to the anticipation of so sudden an issue; they were all young persons, of either sex, and differed from each other in what is ordinarily understood by the word temperament; but, in every instance, there was a strong hereditary predisposition to the disease, and other members of the family were unmistakeably scrofulous.

The pathology of acute phthisis is probably not always alike. In some cases it would seem that an extensive tuberculous secretion, or perhaps infiltration, is the first thing to occur, producing severe secondary bronchitis or acute pneumonia; in other cases these circumstances are, more probably, reversed ;—an attack of pulmonary or bronchial inflammation happening in a person of scrofulous predisposition, and taking the form already spoken of as the scrofulous varieties of these diseases, causes the almost immediate formation of very lowly organized tubercle, in which the softening process rapidly advances. The formation of tubercular matter to an unusual extent, and its almost simultaneous degeneration, seem to constitute the peculiar features of acute consumption.

Chronic phthisis, although, in every instance, essentially the same malady, has an evident tendency to assume, in different cases, both at its onset and throughout its career, certain peculiarities which may be conveniently explained by subdividing the disease into two varieties; viz., the florid, and the languid.

There are many persons to whose physical state, whether in health or disease, the term florid may be applied. They may be recognized by having, to a greater or less degree, some of the following characteristics :—sharp features, lively expression of countenance, vivacity of manner, acuteness of intellect, considerable nervous susceptibility, slimness of form, and a tendency to hepatic derangements and active diseases. There are other persons to whose physical condition we may equally apply the term languid. These are known by having rounded features, sedateness of manner, moderate intellectual endowment, a tendency to corpulence, and liability to anaemic, dyspeptic, and other chronic diseases. It must, however, be borne in mind, that there is no line of demarcation between these types of physical character, and that the two may even, in some particulars, be blended in the same individual. But, with such a general view before us, the course of phthisis becomes more explicable; for, just in proportion to the predominance of one or other of these characters in consumptive patients, shall we find the disease assuming the florid or the languid form.

Florid phthisis comes on more briskly than the other; the preliminary stage, although shorter, is more distinctly marked; the pulse is quicker and sharper; the features assume, if I may use the expression, a bright languor, which is very characteristic; the perspirations are earlier and more severe; the cough begins sooner and is more spasmodic; haemoptysis is more likely to be copious; and the mind is more active and hopeful. Hectic fever, however, is very likely to supervene even before tubercular softening begins; and, at length, either diarrhoea, or profuse perspirations, bring the patient, often very unexpectedly, to the close of his career. To this variety it is impossible to fix a correct average duration; it may run its course within three or four months, but from six to nine months is probably its more usual period. The difficulty—I might say impossibility—of determining exactly the beginning of the malady, makes any statistical record upon this point of little value; I am convinced, however, that it is more frequent, and of shorter duration, in the male than in the female sex, and is mostly seen at the period of life between youth and manhood.

Languid phthisis presents many points in direct opposition to the preceding. The preliminary stage is longer and more likely to be overlooked; the pulse is always slower and not so apt to become excited; the perspirations are less early and less severe; the cough may be late in appearing;

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