CONSUMPTION OF THE LUNGS. 231 



may ultimately attack the air-vesicles. In such cases the physician is 

 often entirely at his ease about his patient, as, in spite of the cough 

 and expectoration, the latter has no fever, maintains his strength, and 

 is in a fair nutritive condition, when the scene suddenly changes and 

 the symptoms of consumption appear. 



There is also some variety as to the original seat of this treacherous 

 catarrh. Sometimes it is situated in the smaller bronchi from the very 

 outset ; but it by no means rarely commences in the larynx or trachea, 

 whence the process gradually extends into the air-vesicles. The fre- 

 quence with which such cases occur is shown in the following descrip- 

 tion by Andral an unqualified adherent of Laennetfs from the 

 fourth volume of his " Clinique Medicale : " " The phlegmasia of the 

 air-passages, the symptoms of which precede those of tubercle, does 

 not always commence in the minuter bronchial ramifications, nor even 

 in the greater bronchi. So far from it, indeed, that we have more than 

 once found its point of departure to be in the upper portion of the air- 

 passage, and to consist at first of a simple laryngitis. Persons of this 

 class (who are to be distinguished from those in whom laryngitis only 

 supervenes at a more advanced period of tubercular consumption) do 

 not at this time present any symptoms whatever indicating disease of 

 the lungs, until they are attacked by an angina, which at first seems of 

 but little gravity. The voice, however, remains hoarse ; the larynx is 

 the seat of a feeling of uneasiness rather than of pain. Sooner or 

 later, the cough returns in more fatiguing paroxysms. The unpleasant 

 sensation formerly confined to the larynx, now extends successively to 

 the trachea and to the bronchi. Each fit of coughing occasions an un- 

 pleasant pricking sensation and a disagreeable feeling of heat, and 

 sometimes a genuine pain beneath the sternum. Thus we may, in a 

 measure, follow the phlegmasia, step by step, in its progress from the 

 organs of deglutition through that of the voice and through the trachea 

 to the bronchi and their ramifications. It is only at this period that 

 the malady assumes a graver aspect. Circulation becomes disturbed, 

 nutrition is impaired, and it becomes evident that tubercles have de- 

 veloped in the pulmonary parenchyma." 



In badly-nourished, delicate persons, the extension of the catarrh 

 into the air-vesicles and caseous metamorphosis of the infiltration are 

 more to be dreaded than they are in well-developed and robust ones. 

 Individuals are especially threatened whom we know have often suf- 

 fered from a catarrh, and whose previous catarrhs have been of very 

 protracted character. 



Finally the sputa expelled duing the precursory catarrh sometimes 

 furnish a means of estimating the danger. It is a bad sign if the 

 sputa contain sharply-defined, deep-yellow streaks ; for it shows that 



