markably modified in its phenomena, not exhibiting its more common symptoms of globus hystericus, fits of laughter, crying, or convulsions, but manifesting itself by great aggravation of cough or dyspnoea, and even, it would appear, as in the case of E. B., by capricious and inordinate hæmoptysis.

Even when you are quite convinced that consumption has commenced, you must not conclude that the disease will necessarily make rapid progress; on the contrary, it not unfrequently remains apparently stationary for a considerable time. The causes of variation in this respect are often obscure, but are usually connected with constitutional conditions, the nature of the exciting causes, the habits of the patient, and the resources at command for the adoption of appropriate treatment.

Among the causes tending to retard the progress of pulmonary consumption, I am disposed to mention fistula in ano. A few years since there happened at one time to be under my care nine consumptive patients affected with this disease. I had the curiosity to inquire into the duration of the malady in each case, and found, on adding the periods together, and dividing by the number of patients, that I obtained an average of two years and nine months, although the disease had not in any instance advanced beyond the first stage. When you reflect that the duration of phthisis, in a majority of cases, does not exceed eighteen months, you will concur with me in the impression that fistula may, possibly in the way of derivation or counter-irritation, retard the progress of the malady. Practically this subject claims particular attention. When the surgeon operates on fistula in the phthisical, the wound is inapt

to heal; but, were it otherwise, the operation would be a measure of questionable propriety, if the disease tends directly or indirectly to abate consumption.

This subject leads me to remark, that although obstinate diarrhoea is a complication belonging for the most part to the later period of phthisis, yet that it sometimes sets in rather early. If excessive, it may exhaust the strength of the patient before the tubercular deposit has softened; if moderate, or kept in check by remedies, a certain amount of disordered action, at this part of the system, may occasionally tend, in the way of derivation, to prevent the progress of the pulmonary disease. The colliquative diarrhoea which so often rapidly exhausts the remnant of strength in advanced phthisis, is usually associated with ulceration or softening of the mucous membrane of the large intestines. Such an example I show you in these ulcers of the colon, from a patient in whom this symptom had been very urgent and intractable. The appropriate treatment of this distressing complication requires discrimination. The adoption of a bland, unstimulating diet is of great importance. The function of the liver sometimes requires to be assisted by means of a dose of blue pill, guarded with Dover's powder, and whenever there is enough of local tenderness to indicate the application of a few leeches, much relief may be expected from their use. Familiar remedies, such as chalk-mixture with opium, or the compound kino powder, are frequently successful, but in many instances more direct astringents are required; of these, acetate of lead is usually most prompt in its effect. Two pills, each containing one grain of acetate of lead, an eighth part of a grain of opium, and two

grains of extract of henbane, may be given at appropriate intervals, washed down with a little distilled vinegar and water, in order to obviate colic; in some instances, the addition of half-grain doses of nitrate of silver has appeared to increase the efficacy of this remedy. Occasionally, even after the failure of acetate of lead, sulphate of copper proves useful; it may be given in doses of a quarter of a grain, with the same quantity of opium, and two grains of extract of Spanish liquorice.

You will recollect my having mentioned, in a former lecture, that on giving charcoal for another purpose, I was struck with its effect in checking diarrhoea (it also corrected fetor of the breath); and I have since been interested in learning that charcoal has long been employed in the West Indies as a remedy for diarrhoea.

In connexion with this subject, it may not be uninteresting to mention, that Dr. Pearce, in a letter to Dr. Lettsom, dated March 4th, 1768,* speaks strongly of the efficacy of gunpowder and lemon-juice in dysentery. Dr. John Davy also informs me that he has been accustomed to administer gunpowder, in the treatment of the last-mentioned disease, with very good effect. It is reasonable to believe that the charcoal had a considerable share in the efficiency of the remedy. In any trial you may be disposed to make of this agent, I would advise you to use animal charcoal, and to give the preference to that obtained from bullock's blood by means of heat. Charcoal, however useful it may be in obviating the effects of acrid intestinal secretions, does not appear to have any special adaptation to the treatment of the

*See Pettigrew's "Memoirs of Lettsom," vol. iii.

diarrhoea of phthisis. There are objections to the administration of powerful astringents, in the treatment of this form of diarrhoea. Amongst these objections I would particularly mention the occasional production of the opposite condition, by the employment of such medicines; and, on the whole, there is no remedy for this affection, which has acted so satisfactorily under my observation, as the trisnitrate of bismuth, which I commonly administer at intervals of four or six hours, in doses of five grains, combined with three grains of gumarabic and two of magnesia. A larger dose may be given with safety, but that specified has appeared to me the most appropriate for the purpose. It is probable that in many cases phthisical diarrhoea depends more on the condition of the vessels in the neighbourhood than on the ulcers themselves, and the bismuth probably exerts a tonic influence on these vessels, as well as on any ulcerations. This opinion is not altogether speculative, since I have had opportunities of observing the power of this remedy, when scattered over the languid granulations of cutaneous ulcers, in restoring them to a firm and healthy character. The bismuth is not so prompt in its effect as acetate of lead, and therefore requires to be used with perseverance; but when care has been used to correct collateral derangements, I rarely fail in two or three days to observe amelioration of the symptoms, with this advantage, that the good effect is permanent and without incidental disadvantages. Indeed, it usually gives a better tone to the digestive organs generally, and corrects the sinking feelings about the epigastrium, with which the consumptive patient is occasionally distressed.

LECTURE IX.

Interrupted, jerking, or wavy inspiration—Varieties, and their causes-Examples-Probable relation of the sign to a deposit in the lungs, not necessarily tubercular-Microscopical appearances of the blood-Indications afforded by the spirometer -Variations of weight in reference to the progress of consumption.

AT the last lecture, gentlemen, we were occupied chiefly with the consideration of circumstances which may be considered distinctly indicative of the commencement of consumption. To-day I propose to bring under your observation a symptom of some interest and significance, and not without relation to phthisis, but still, as it appears to me, not a conclusive sign of the existence of the disease. The symptom to which I refer is a modification of the inspiratory sound, designated "inspiration entrecoupée," by Laennec; "inspiration saccadée," by Fournet; by some English writers, "jerking inspiration"-a term liable to objection, since it conveys to the mind the idea of the spasmodic jerk in the breathing (produced by asthma, hysterical conditions, or other nervous disturbance,) rather than the delicate and uniform peculiarity under our consideration. It is difficult verbally to describe this peculiar inspiration. To some observers, it might

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