When more minutely examined, various symptoms indicative of disordered digestion may be remarked. The lips are often dry and cracked, the tongue is furred, red at the tip and edges, or with bright red spots projecting through the fur. The hands are hot, especially towards evening, and thirst is complained of. The appetite is very variable, at times ravenous; at other times the child cannot be tempted to eat anything. The abdomen is usually tumid, sometimes tender, and the bowels are confined, with occasional attacks of diarrhoea. The alvine evacuations are invariably disordered; often of a grey colour and pasty, and almost always mixed with mucus.

As the disease progresses, the languor and loss of flesh become more manifest; a short cough comes on, pains of the chest and head are complained of, and before long either the stethoscope indicates consolidation in the lung, or inflammation takes place in the peritoneum or pia mater, from deposit of tuberculous

matter.

In the case of adults the symptoms are somewhat different. In the greater number the patient has been either subject to bilious attacks for a length of time, or is affected with them shortly before the more serious indications of disease make their appearance. Vomiting of bile may take place only at intervals of a few weeks, or may occur for a short period two or three times a day. Acidity and flatulence after food are very usual symptoms, and with these there is a decided distaste for fat. A sense of languor is generally present, and in many cases it is the only

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cause of complaint. The emaciation is at this stage very slow, and is generally rather observed by the friends of the patient than by himself. The skin becomes sallow and unhealthy; in some cases it is dry and harsh, in others perspirations occur after the slightest exertion. The bowels are usually confined, often obstinately so, and the alvine evacuations are unhealthy. The urine is generally scanty and loaded. Gradually a short cough makes its appearance, the languor increases, and hæmoptysis, or some other serious symptom, attracts the attention of the patient or his friends to the dangerous nature of the disease.

Whenever languor persists for any length of time in a young person without obvious cause, it indicates something serious, and it is therefore necessary that the medical practitioner should most carefully search for the cause of the feebleness. Such a case requires very careful attention, for we know not how soon all chance of successful treatment may be destroyed by permanent injury to some vital organ.

As regards the treatment of the precursory stage of phthisis, most writers have agreed as to the great value of mercury, and my own experience confirms the truth of their observations. It should, however, be only used as an alterative, and it acts best when given in small and repeated doses. The hydrarg. cum cretâ is the preparation best fitted for children, and the pil. hydrarg. for adults. In the treatment of both it is useful to combine the mercury with a small dose of rhubarb or of aloes. Whilst giving mercury, it is a good plan, at the same time, to exhibit an alkali along with some light

bitter, and if the state of the bowels requires it, an occasional aperient.

After a short continuance of the above treatment I have seen excellent effects produced by sarsaparilla and taraxicum. The former is chiefly useful in the cases of children, and is often borne where a more decided tonic creates irritation in the digestive organs. The taraxicum is valuable when the complexion remains sallow, the tongue foul, and the alvine evacuations disordered after mercury in alterative doses has been fairly tried. Dr. Todd strongly recommends a combination of taraxicum, nitrate of potass, and infusion of rhubarb, as a substitute for mercury in strumous subjects.

As soon as the condition of the digestive organs will permit, we must have recourse to the stronger tonics, and in the choice of them we must be guided by the circumstances of the case.

When the tongue is large and flabby, and the alvine evacuations remain of a dark colour, the mineral acids are generally useful. If the skin be soft, and the patient liable to perspirations, they should be combined with cinchona or quinine.

Steel in its various forms is invaluable in the treatment of these cases, and acts well in restoring the strength. The most useful forms are the syrups of the iodide and phosphate of iron. If there be much depression of the nervous energy, it will be found useful to combine some preparation of steel with the hypophosphite of lime or soda.

There can be no doubt that the remedy which is most generally useful in the precursory stage of phthisis is cod-liver oil. Its good effects are more

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particularly seen in those cases in which emaciation is an early and prominent symptom. We cannot give it advantageously under all conditions, for it aggravates the symptoms when prescribed before the derangement of the digestion has been corrected by other means.

When the circumstances of the patient permit it, change of air will be found of the greatest service. It is in fact chiefly at this stage of phthisis that real and permanent benefit may be expected from such a measure. In the case of children, a residence at the sea-side is usually to be preferred, but adults derive more advantage from frequently changing their abode, so as to combine amusement with variety of air and

scene.

It has been before mentioned that in a small number of cases of phthisis, the mucous membrane of the stomach was found to be affected either with adhesion of its secreting tubes to each other, showing the effects of chronic gastritis, or with superficial ulceration in the pyloric region. We meet with cases, probably of this kind, in which the dyspeptic symptoms are of such severity, that they mask the indications of the disease of the lungs.

There are two well-marked classes of cases, in which the predominance of the symptoms of gastric derangement is apparent.

The subjects of the first class are found in young females from thirteen to seventeen years of age. In some the earliest symptoms are those of subacute gastritis. There is a constant pain at the stomach after food, vomiting, thirst, and loss of appetite. In others the complaint commences more insidiously, and

pain is experienced in some part of the abdomen, with nausea and loss of appetite. Its ordinary situation is to the left and a little above the umbilicus; but I have known it affect the hypogastrium so severely, that the young lady in whom it occurred was treated for some obscure disease of the uterus. When the abdominal symptoms have disappeared, as they usually do under treatment, the patient still remains pale, thin, and languid. She is unable to make much exertion, and seems listless and desponding. The appetite is fickle, she is subject to flatulence and occasional vomiting after food, and the bowels are disordered. In this state she may remain for two or three years; never feeling strong, and yet unable to complain of much, beyond the dyspeptic symptoms. The catamenia are very irregular, or they never make their appearance, and to this circumstance the friends often attribute her ill-health.

But gradually the real nature of the disease begins to show itself. Cough sets in, at first only in the morning; this is frequently followed by vomiting, the appetite becomes more fickle, the pain in the epigastrium increases, and emaciation progresses more rapidly. The pulse is quickened, and the case gradually slides into well-marked phthisis.

The other class comprises men from thirty to forty-five years of age. They are usually tall, spare, of nervous temperament, and often endowed with more than the average amount of energy and mental ability. They have always been victims to indigestion, and have for years suffered from acidity, flatulence, and occasional pain after food. When they come under medical treatment it is often more