many exceptions as are those relating to this subject; but I am convinced that, should additional observations be made upon a sufficiently large scale, they will only serve to confirm the statements I have advanced.

Lactation is by no means uniform in its effects; sometimes helping to retard the appearance or progress of the disease; at others, promoting or greatly aggravating it. The latter, perhaps, is the most usual, it being far from uncommon to see pulmonary consumption both commencing and running rapidly onwards during the period of suckling. If, however, it should, like pregnancy, keep the disease, for a time, in check, the ultimate result is the same; the tubercular affection progressing afterwards only with increased rapidity. But of all things, perhaps the most energetic in arousing a phthisical predisposition is, the evil practice of long-continued nursing,-one especially common amongst the poorer classes, in whom it is no very rare thing to find it carried on for a period of two years and upwards. To this cause I have frequently traced consumption; and this, not only in persons who had a previous tendency to it, but also in others who had hitherto enjoyed excellent health, and were, to all appearance, quite free from hereditary taint. I believe, therefore, that it may, in certain cases, act both as the predisposing and exciting cause.

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98

PART II.

THE SYMPTOMS OF CONSUMPTION.

CHAPTER I.

CHRONIC PHTHISIS.-GENERAL DESCRIPTION OF ITS

SEVERAL STAGES.

ALTHOUGH the course of phthisis is marked by a gradation as well defined as that of any other disease, it would be difficult to meet with its equal in the almost endless variety of symptoms which accompany its several stages: in its career, it simulates the most opposite maladies; and scarcely two cases are to be found strictly alike in their progress.

Consumption presents itself under two forms, viz. acute and chronic, both of which are subject to certain varieties; yet, in every instance, the disease is essentially the same, being only modified either by its degree of severity, or by the varied conditions with which it is associated.

I propose giving, in the first place, a general description of the ordinary or chronic form of the

disease; leaving the varieties to which it is subject for after consideration.

The symptoms may be conveniently arranged as belonging to two periods: viz. (1) that preceding the formation of pulmonary tubercles; and (2) that subsequent to their developement.

(1.) The period preceding the formation of tubercle. At no time is the changeable character of phthisis more apparent than at its very onset. Sometimes this, which we may term the preliminary stage, is so well defined, that to fail in recognizing it would be almost inexcusable; at other times, it is either too brief, or too indistinctly marked, to be detected.

Although this early period of consumption has been but little dwelt upon by medical writers, it is, I think, very often distinguishable by the presence, in a greater or less degree, of the following train of symptoms. From some cause, for which no good reason can be assigned, there is a slow but marked diminution of bodily vigour, compelling the individual to abandon many of his accustomed pursuits: the spirits, nevertheless, are good; and not only is the idea of consumption never entertained, but any allusion to it is at once ridiculed. So general, indeed, is this hopeful condition, this almost instinctive blindness to the real cause of distress, that in its absence, however suspicious certain symptoms appear, these may, with much probability of accuracy, be pronounced unconnected with phthisis. The complexion is usually

either pallid or sallow; the expression is that of care, united with animation; the features are somewhat sharpened; the movements of the body are hurried and anxious; the mental condition is irritable and capricious; whilst every act betrays an effort, sometimes instinctive, and at others voluntary, to conceal the presence of disease. The appetite is uncertain, and there are frequent indications of imperfect digestion, as well as a tendency to passive diarrhoea. The pulse varies in different cases, but is generally small, and easily excited. The sleep is restless, unrefreshing, and occasionally attended by perspirations. Loss of weight is of invariable occurrence; sometimes the decrease is so rapid that it will attract the attention of friends; at other times, it requires the periodical use of the weighing machine to detect it; the latter, perhaps, is the most usual, but I have met with examples of such rapid emaciation, that several pounds have been lost within a few days.

This preliminary stage is very uncertain in its course in some instances it will, under proper treatment, quickly subside; in others, it will continue for a considerable period, and then disappear; but, far too often, it will resist the best efforts both of physician and patient, and pass rapidly onwards to the formation of pulmonary tubercle. Much depends upon the care which can be given to the health, and upon the exclusion of exciting causes. In the upper classes it is, consequently, more within

our control than when we are called upon to treat it in humble life.

There is considerable variety in the association of its different symptoms; some may be altogether absent, and many are also met with in other diseases; yet, when a number of them are found together, and the patient's antecedents-his occupation and habits of life-or any other circumstances, seem to be conducive to phthisis, there can, I think, be little reason for doubting their consumptive nature.

In childhood the symptoms are of the same character, but more strongly marked. There is an evident precocity of intellect, which forms a striking contrast with the bodily feebleness; the limbs are emaciated, and the abdomen tumid; the appetite is uncertain, sometimes craving, but oftener defective; dentition is protracted, irregular, and difficult; and all the functions of nutrition are imperfectly performed. The child is peevish, irritable, and indisposed to exertion; and, in general appearance, is evidently labouring under some deeplyrooted malady, which, at no very distant time, will exhibit itself either as phthisis or some other form of tubercular disease.

(2.) The period subsequent to the formation of tubercle. After tubercle has been deposited, the course of phthisis may be divided into three stages; the first corresponding to its miliary and crude states; the second, to its period of softening; and the