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 recom

*Rév. Med. Chir. vol. vii.

mences its march, the mark becomes plainer." Dr. 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".*

I have myself scarcely investigated the subject sufficiently to add to these remarks, further than to state that although this appearance of the gums is often present in phthisis, even at an early period, it is very far from being universally so; and, consequently, that 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, upon the multiplication of suspicious signs, more than upon the existence of any which are either very obvious or unequivocal.

*Lancet, vol. ii, 1851.

164

CHAP. III.

THE DIFFERENT 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 attack.

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.