The acute form sets in as an attack of influenza—that is to Pay, with symptoms of bronchial irritation and adynamic fever, the preceding coryza, however, being generally absent. This condi tion becoming persistent, the pulse continues rapid and feeble ; the cheeks are flushed ; perspiration occur, especially at night; emaciation and increasing weakness follow in rapid succession, even before any physical signs in the lungs themselves indicate the presence of tubercular matter.
The full consideration of this subject can only be entered upon after the physical signs of disease of the lungs are detailed ; here we have only to do with the general features of thb diathesis. While the pulse is quick, the condition of the skin alternates between dryness and moisture, is never harsh or burning, as in fever, and the perspirations are sometimes excessive ; the state of the tongue is very various; and the bowels may be either natural in action or inclined to diarrheas; the .aspect is often instructive; a certain degree of anemia prevails, with a bright color on the cheeks; the eyes are soft and brilliant, with large pupils, and frequently fringed by long eyelashes; this is especially to be seen in childhood. The accompanying emaciation and the languid manner and sense of feebleness, afford additional grounds for a suspicion of the presence of tubercle.
• in its early stages accurate diagnosis is, perhaps, impossible, even with the aid of physical signs ; in children the supervention of cough and emaciatioa upon measles is most probably due to this cause, especially if the patient ham previously suffered from any of the symptoms of scrofula, or if scrofula or phthisis exist in the family of either of the parents, or has been evidenced in others of the children. The absence of coryza in the first onset of the disease points to sonie local cause of bronchial imtation, and not to a rmeral afro*. tion of the mucous membrane; the persistence of adynamic fever shows that the attack is not one of influenza or bronchitis properly so called; in each of which the febrile state is more transient; the condition of the tongue is seldom that of common continued fever, it is only at an advanced stage that it pre sents at all the patchy redness or chapped appearance of fever accompanied by diarrham, and it is very seldom dry ; mdeed it is rather aphthous or ulce rated than patched and chapped ; the recurrence of pempimtions is also unusual in fever. The whole characters of the case are more closely allied to those presented in a tardy convalescence, and then the previous history of an acute attack with much thirst, loss of appetite, wandenng delirious nights, ire., is quite different from the history of a gradually increasing malady ) but it must be remembered, on the other hand, that the debilitating effects of an attack of fever predispose to the incursion of tubercles, and it may be impos sible to say when the one has terminated and the other begun.
The march of chronic phthisis is always somewhat slow. Here the deposit of tubercles is much more local and more e,asily made out by a physic,a1 examination of the chest; but in the earlier stages the signs may be dubious, or null. The more important general symptoms are emaciation, night sweats, and haimoptysis; when these exist along with a dry hacking cough, wandering pains in the chest, a habitually quick pulse, a degree of huskiness of the voice, and diarrhoea, scarcely a doubt can remain that the disease has commenced, even though the stethoscopic signs be very obscure. It is remarkable how unvrilling patients generally
are to confess to " spitting of blood ;" and when the amount has been triffing, it may require much cross-questioning to elicit the truth.
As it proceeds the hectic) flush on the cheeks contrasts strangely with the clear, transparent pallor of the rest of the face; the eyes are often bright and luminous; the skin becomes soft and velvety, and, when pinched up, is found to be thin, and detached from the subjacent muscles ; the ends of the fingers become clubbed, and the nails unciform; the gait is stooping; the shoulders curved forwards; the chest flattened, and but little expanded in breath ing; while every movement of the body gives token of feebleness and languor.
Any of these symptoms may be absent, and on a just appreciation of their collective value often depends the correctness or incorrectness of diagnosis. Emaciation is never wanting, but is often' associated with other affections, of which cough may be a concomitant; night sweats, though more frequent in this disease than any other, may be merely the effect of debility; hiemoptysis does generally appear at some time or other in chronic phthisis, but not ne cessarily so, and the disease has already made some progress in most cases before the symptom is seen; when present, and there is no disease of the heart to account for it, and it cannot be explained as the result of hysteria, or as vicarious of menstruation, it is more to be relied on as an indication of phthisis than any other. A dry, hacking cough without expectoration, or with mixed mucilaginous looking sputa, where it is accompanied by pains in the chest, and there has been neither coryza nor sore throat, to indicate a simultaneous affection of the whole mucous membrane, may be very safely set down as hav ing a tubercular origin. Huskiness of the voice, caused by slight laryngeal affection, derives its sole value from its association with other symptoms ; but it may owe its existence to previous syphilis, it may be simply due to an ordi nary cold with sore throat, or it may even be caused by pressure on the tra ohea or larynx. A habitually quick pulse, when coinciding with cough and other indications of affection of the chest, is exceedingly suspicious ; but both may be caused by obscure disease of the heart, and on the other hand phthisis has often _proceeded to its most advanced stage without this symptom being present at all. Diarrhoea tends greatly to confirm our fears, because although there be no specific ground on which its tubercular origin can be determined, yet the liability to it is greater in phthisis than in any other dis ease, except common continued fever; in both a specific affection of the intes tinal glands exists. The further symptoms are those of hectic fever, and its accompanying emaciation; and as such they generally serve to stamp the phthisical character of cough, but they may be very closely simulated in cases of persistent bronchitis.