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THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
PRESENTED BY
PROF. CHARLES A. KOFOID AND
MRS. PRUDENCE W. KOFOID
CONSUMPTION
ITS EAELY
AND EEMEDIABLE STAGES
BY
EDWARD SMITH, M.D., LL.B., P.R.S.
Assistant Physician to the Hospital of Consumption and Diseases of the Chest, Brompton ;
Physician to the Royal Dramatic College ; Corresponding Member of the Academic des
Sciences, Montpellier, and of the Natural History Society of Montreal.
LONDON :
WALTON AND MABEELY,
UPPER GOWER STREET AND IVY LANE, PATERNOSTER ROW.
1862.
[2%e Right of Translation is Eeserved.']
V
LONDON' :
BRADBURY AND EVANS, PRINTERS, ■\VHITEFR1ARS.
k-^C
3tf
Sm JAMES CLAEK, BAET., M.D., ERS.,
PHYSICIAN IN ORDINARY TO THE QUEEN,
&C. &C. &C.
t)EAR Sir James,
On considering the Medical History of Consumption in our
own time, it is impossible not to perceive in how great a degree
the profession has been indebted to you for the enlightened
views in reference to the early or predisposing conditions of
Phthisis, which were propounded in your work published in 1835.
But the obscurity which has long rested upon the disease has
deterred from, rather than invited to, scientific investigation ;
and hence, whilst the disease is still as fatal as it was many
years ago, and the necessity for a new line of practice universally
admitted, there has not been that general attention to the
remediable period which the importance of the subject has
merited.
It is with the view of again challenging professional inquiry
in a direction somewhat similar to that which you pointed out,
that the following work has been written ; and, although the
views to be advanced may not altogether accord with your own,
I trust that they may meet with your general approval.
To no one could a work on the early or remediable stages of
Phthisis be so fitly inscribed, and I am gratified that you have
done me the honour to accept this small tribute of my deep
respect and esteem.
I have the honour to be.
Dear Sir James,
Your most sincere and grateful servant,
EDWARD SMITH.
M351806
Digitized by the Internet Archive
in 2007 with funding from
IVIicrosoft Corporation
http://www.archive.org/details/consumptionitseaOOsmitrich
PREFACE.
The author, in writing the following work, has had
four principal ohjects in view, viz., to take advantage of
the growing belief of the day, that there is a stage of
Phthisis in which the disease is as remediable as it is
irremediable at a later period; to write a practical
work in which may be faithfully represented the actual
condition of these cases when regarded in the great
numbers in which they have been brought before his
observation; to treat the subject, as far as possible, on
the inductive method, and on the improved physiology
and pathology of the day; and to give practical, effect to
numerous series of special inquiries v/hich have been
made by him during the preceding seven years.
It is not important, in reference to the first, that
the views differ as to the limits, characteristics, and
designation of the early stage, since, when the existence
of the stage shall have been well established, an agree-
ment as to its nature wiU certainly follow. Numerous
authorities from distant ages, both as to Phthisis in
vi PREFACE.
general and the early stage in particular, are cited ; and
whilst the author has not omitted to state his own
views he has generally founded his observations rather
upon the agreements than the disagreements of indi-
vidual observers.
In seeking to make the work practical the author
has entered largely into all the questions which relate
to food, exertion, climate, and others constituting
hygienics, because such is in accordance with general
feeling at the present time ; because this part of medi-
cal knowledge is now being placed upon the sure foot-
ing of scientific research; and because it must be
through the conditions of the every-day life of the
patient that medicinal and other remedial agents may
influence the constitution in so chronic a disease. For
the same reason minute details have been considered
of great importance, since it is upon them that the
efficient working of a general plan will essentially
depend.
The arrangement of the work upon physiological and
pathological indications and the use of propositions
will, it is hoped, conduce to clearness of exposition
and facility of reference, whilst it may also dissociate
the consideration of the treatment from that of the
evidences, and cause the same conditions or remedies to
be viewed under various aspects. It cannot be doubted
that assigning views as to the reasons for any par-
PREFACE. vii
ticular course will be welcomed by an intelligent and
inquiring Profession, whether such views be univer-
sally or only partially allowed to be just ; and also that
it may tend to promote inquiry in thoughtful minds ;
but in order to summarize the whole plan of treatment
the various recommendations have been collected
together in one chapter and given in an empirical
manner. In reference to the author's special investi-
gations, which have been embodied in the work, it is
only necessary to ask attention to the explanation
offered at the end of the work, in reference to a statis-
tical inquiry of great extent, which was completed
whilst the sheets were passing through the press.
London : 16, Qtjeen Anne Street, W.,
April, 1862.
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TABLE OF CONTENTS.
PAGES
Dedication • . . . iii
Peeface • . • . V
PART I.
II^TEODUCTOEY AND HISTORICAL.
CHAPTER I.
Preliminary Observations : —
Phthisis commonly fatal, yet curable if regarded in the
early stage — Influence of Laennec's views — Tubercle a
consequence and not the cause 1-7
CHAPTER II.
historical sketch as to the nature and treatment
OF phthisis.
The Ancients : —
Yiews of Hippocrates, Aretieus, Galen, Aristotle, Diosco-
rides, and Celsus . . 9-13
The Middle Ages :
Views of Trallian, Paulus -^gineta, Avicenna, Forestus,
Paracelsus, Oribasius, Aetius, Capivaccius, and Avenzoar 13-14
The Moderns to the Time of Dr. Baillie : —
"Views of Bennet, Morton, Desault, Mudge, Gilchrist,
TraUes, Stark, Portal, and Peai-son . . . .14-16
X CONTENTS.
PAGES
Views eespecting Tubercle : —
Sylvius, Tralles, Clayton, Willis, Boerhaave, Eeid, Sydeu-
ham, Eush, Brillouet, Eadcliffe, and Simmons . . .16-18
Age 18
Causes : —
Yiews of Sennertus, Hofmann, Huxliam, Borelli, Spigelius,
Van Swieten, Stahl, Sims, Avicenna, Eush, Walker,
Musgra-ve, Withering, and De Haen 18-19
Connection with Hectic and Hemoptysis : —
Views of Bontius, Macbride, CuUen, Hofmann, Desault,
Mudge, Gilchrist, Calen, and Van Swieten . . 19-20
Contagion : —
Views of Sylvius, Hofmann, Desault, Van Swieten, Darwin,
Morgagni, Valsalva, and Portal . . . . .20
Nature of Phthisis : —
Views of Stark, Desault, and Eush 20-21
Treatment : —
Milk, milk and lime water, eggs, meat, fish, olive oil,
mutton suet, sea voyaging, exertion in open air, horse
exercise, swinging, living in cow houses, steel, bark,
early abstinence, counter irritation, loud speaking, bleed-
ing, opiates, astringents, inhalation of oxygen . . 21-23
Opinions of our Day : —
Baillie, Bayle, Laennec, Carswell, Louis, Piorry — Change
of climate and cod-liver oil 23-28
Summary 28-30
CHAPTER III.
HISTORICAL SKETCH AS TO THE VIEWS IN THE EARLY STAGE OF
PHTHISIS.
Views of Bayle, Laennec, Andral, Louis, Clark, Barlow,
Bennet, Eoe, Quain, Cotton, Lawson, Ancell, Markham,
the Author 30-41
CONTENTS. xi
PART II.
NATUKE AND EVIDENCES OF THE EARLY STAGE OF
PHTHISIS.
CHAPTER lY. .
GENERAL OBSERVATIONS.
PAGES
Stages of the Disease — Co-existence of general and local
disease — General expression of diseased action — Vari-
ations of the type of health and disease — Inquiries on
1,000 cases into temperament — The hair, eyes, com-
plexion, habit of body and excitability .... 42-52
CHAPTER Y.
Mental and Nervous Organisation 53-54
CHAPTER YI.
alimentation.
Appetite : —
Inquiries on 400 cases into dislikes for acids, sugar, tea,
coffee, vegetables, fruits, bread, meat, and fat — relation
of dislike of acids to much perspiration and to sour per-
spiration — Comparison with asthma and bronchitis —
Relation of dislike of sugar, tea, and coffee to much per-
spiration and to sour perspiration — Further inquiries on
500 cases on the distaste for fat in phthisis, bronchitis,
debility, liver complaint, &c.— Inquiries on distaste for
meat and milk 54-64
Digestion 64
Amount of Food : —
Inquiries 65
Assimilation :—
Weight and bulk of the body— What it includes— Circum-
stances affecting it — Food, excretion, urine, fat « . 65-72
:jdi CONTENTS.
CHAPTER YII.
ELIMINATION.
PAGES
The Skin :—
Its action as lieat regulator— Amount of perspiration— Table
of incLuiries into ingesta and egesta .... 74-79
Ueine : —
Inquiries into quantity— Specific gravity . . . .80
Perspiration :—
Constitutional tendency— Frequency— Acidity . . .83-86
CHAPTER YIII.
Temperature of the Body . . .... 87-89
CHAPTER IX.
Muscular Power 90-91
CHAPTER X.
The Circulation : —
Considerations of ms ot, tergo and vis dbfronU — Inquiries into
rate daily, during one month — Importance . . . 93-98
CHAPTER XI.
Respiration : —
Chest movement — Quantity of air inspired under exertion
— Causes of feeble respiration — Dyspnoea . . . 99-105
Rate of Respiration . . . . . . . 105-106
Vital capacity — Spirometers 108-114
CHAPTER XII.
Innervation 115-116
CHAPTER XIII.
The Menses and Leucorrhcea : —
Inquiries as to the epoch of menstruation — Irregularities
of menstruation — Frequency of leucorrhcea . . . 117-120
CONTENTS. xiii
CHAPTER XIV.
PAGES
Muscular Pains :-
Causes, seat, and relations 121-12S
CHAPTER XT.
The Theoat :—
Aspect— Hypersesthesia, pallor, follicular disease . . 124-128
CHAPTER XYI.
CoiJGH : —
Conditions of the act — The pharjoix the true seat — State
of contraction of pharynx — Causes of cough . . 129-134
CHAPTER XYII.
Expectoration : —
Its nature and cliief source — Cretaceous expectoration . 135-141
CHAPTER XVIII.
HEMOPTYSIS : —
Statistics of frequency — First occurrence — Quantity —
Source — Importance — Its significance as a sign — Fre-
quency in bronchitis— Cause of frequency in phthisis . 142-150
CHAPTER XIX.
Vomiting : —
Relation to cough and meals 151-152
CHAPTER XX.
The Lungs : —
Relation of the lungs to the general system in phthisis —
Phthisis a general or a local disease — Tubercular
deposition not the first stage — State of the blood —
Cause of selection of the limgs 153-159
CHAPTER XXI.
the lungs.— external pulmonary evidences op phthisis.
Lessened Movement of the Chest : —
Method of observations — Difference in the sexes — Chest
measurers , • . 160-164
xiv CONTENTS.
PAGES
Expansibility of the Lungs : —
Structure of the lungs facilitates expiration — Bronchial
tubes — Air cells with their spiral arrangement— Modes
of retraction of the air cells 160-172
CHAPTER XXII.
the lungs— internal pulmonaey evidences of early phthisis.
Feeble Beeathing : —
Characters — Diagnosis from debility .... 173-176
Prolonged Breath Current :—
Structure of lungs opposes inspiration — Effect of tuber-
cular deposits 176-178
Wavy or Jerking Respiration :—
Site and conditions 178-179
Dulness on Percussion :—
Unequally" appreciated — Natural variations — Relation to
tubercular deposits ....... 179-182
Summary of Evidences of Phthisis 182-184
CHAPTER XXIII.
pathology of the first stage of phthisis and tubercle.
Bronchial Tubes— Air Vesicles 185-186
First Stage : —
Lessened vitality of air vesicles — Cause of deposition —
Dr. Flint on the hesoin de respircr . . . . 186-189
Second Stage :— Tubercle.
Forms of tubercle described by Laennec — Seat — Cars-
well, Rainey, Rokitansky, and Lebert . . .190-192
Microscopic characters — Formation of mass of tubercles —
Rainey, Ancell — Nature of tubercle — Cellular cha-
racter — Granular matter — Blood origin — Amorphous
and plastic characters— Prof. Alison, Williams— Con-
ditions not explained by the blood theory — Epithelial
origin — Van der Kolk, Addison, Bennett, Rokitansky,
Lebert, Gulliver, Vogel, Virchow, Walshe— Explains
many facts — Selection of the apices— Carswell . . 192-203
CONTENTS. ' XV
CHAPTER XXIY.
PEOGRESS OF TUBERCLE.
PAGES
As to the tissues — As to the tubercle — Removal of tu-
bercle from the lungs— Two conditions — Hall on epi-
thelium in the sputa — Softening — Elastic tissue — Van
der Kolk and Clark — Expectoration of tubercle — The
arrest of tuberculisation in the lung — Obsolescence or
arrest of tubercle — Cretaceous expectoration — Absorp-
tion of tubercle— Piorry 204-214
PART III.
TREATMENT.
CHAPTER XXV.
restore the bulk of the body by lessening elimination.
The Skin :—
Inunction of oils and fats — The ancients — After the hot
bath — In hot and cold countries — Analogous to the Wet
sheet — ^Mode of action is physical — Olive oil, cod-oil,
neat's-foot oil, lard — Method of inunction , . . 215-222
Application of Cold Water : —
Mode of action — Method of application — Salt Water . 222-225
Clothing : —
Frequency of use of flannel shirts — Excessive and defec-
- tive clothing — waterproof clothing .... 225-229
Exposure to the Atmosphere . . . . . . 229-230
Food :—
Alcohols, fats, coffee . 230-232
Medicines : —
Metals: zinc, iodine, iron, lead — M. Beau's practice —
Acid perspiration — Remedies — Case .... 233-239
xvi CONTENTS.
CHAPTER XXYI.
RESTOEE THE BULK OF THE BODY BY LESSENING ELIMINATION.
PAGES
The Kidneys and Bowels : —
Drinking fluids — Thirst— Frequency of dejection . . 240-243
CHAPTER XXVII.
eestore the bulk of the body by increasing THE supply.
Deficiency of Nitrogen in Adolescence : —
Action of nitrogenous foods— Proportion of nitrogen in
bread and milk — Nitrogen in scheme of daily dietary —
Effects of gluten bread, semola, and chocolate . . 244-249
Scheme of Daily Diet :—
Special articles of food — Essential characters of the dietary
— Action of gelatin, tea, coffee, chocolate, fish . . 249-254
CHAPTER XXVIII.
increase the vital actions.
General observations — Increase heat and deposits in tissues 255-25-T
Increase of Appetite : —
Effect of caprice and habit — Rules to regulate the admin-
istration of food 257-261
Improvement of the Digestion : —
Hypersesthesia of the stomach, acidity, remedies — Food
attached to the pharynx causing cough — Foul tongue —
atonic dyspepsia 261-265
CHAPTER XXIX.
increase the assimilation of food.
Exertion : —
Effect over air inspired and urea — Regulation of exer-
tion — Kinds of exercise, athletic, running, jumping,
skipping, walking 266-271
Food :—
Passive and active foods . . . . . . 271-274
CONTENTS. xvii
PAGES
Respiration : —
Relation to vital changes — Impurity of the air in
towns and crowded places — Roscoe, Angus Smith,
Frankland, Welsh 274-277
Pulsation : —
Relation of fulness and rapidity to vital transformation —
Increase the vis d frmite and vis d, tergo — Food,
compressed air bath, Grindrod, McLeod . . . 277-279
Tempeeature : —
Cold, heat ; proper degree of temperature . . . 279-282
Certain Intimate Chemical Changes : —
Alkali and chloride of sodium in the blood— Liebig,
Fernet 282-283
CHAPTER XXX.
REOriATE MENTAL AND BODILY LABOUR.
Mental labour, and bodily labour .... 285-288
CHAPTER XXXI.
INCREASE INNERVATION.
Dr. Churchill's theory of the hypo-phosphites . . 289-294
CHAPTER XXXII.
the lungs before the deposition of tubercle.
Promote Expansion of the Lungs : —
Sir H. Holland — By general innervation and food, by
exertion, by deep voluntary inspiration . . . 294-306
CHAPTER XXXIII.
the lungs after the deposition of tubercle.
Ordinary Limits of Remediable Conditions :—
Removal of tubercle, isolation of tubercle, isolation
and possibly closure of a cavity — CoUapse of the air
ceUs 305-316
b
COls^TENTS.
CHAPTEE XXXIY.
THE THKOAT.
PAGES
Mode of examination, ansemic and congested forms —
Remedies 316-320
CHAPTER XXXV.
HEMOPTYSIS.
Always examine the fauces and chest — Local appli-
cations — Styptics — Rules of treatment . . . 322-324
CHAPTER XXXYI.
MUSCULAR PAINS.
Mechanical supports, plasters — Counter-irritants — Con-
nected with Rheumatism and Spermatorrhcea . 325-328
CHAPTER XXXYII.
Categorical statement of the whole plan of treatment —
Food — Exercise and Employment — Bathing— Clothing
— Residence— Medicines 329-337
CHAPTER XXXVIII.
COD LIVER OIL.
Very ancient remedy — Modern use in phthisis — Dr. De
Jongh and Professor Bennett — Special inquiries upon
in-patients, assigned modes of injury and improve-
ment—Medical report — Relation to dislike for fat —
Summary — Mode of action, mode of administration
— De Jongh's oil 338-350
CHAPTER XXXIX.
THE INFLUENCE OF CYCLICAL CONDITIONS.
The cycle of the day — The cycle of the seasons — Pro-
portion of cases naturally bearing heat badly— Per-
spiration — Change of the seasons .... 351-358
CONTENTS. xix
CHAPTER XL.
TEEATMENT WITHIN HOSPITALS.
PAGES
Special requirements and existing defects — More fitted
for later stages — Cottage liosx^itals .... 359-363
CHAPTER XLI.
Voyaging and Residence : — .
* Voyaging — General conditions required — Localities —
Residence on land — Conditions required . . . 364-367
CHAPTER XLII.
Summer Climates : —
Scarborough and Isle of Man — Their general characters
and meteorological conditions in June to December,
from 1855 to 1860 — The English lakes — Scotland,
Norway, Switzerland and the Tyrol . . .368-394
CHAPTER XLIII.
Winter Climates in Great Britain :—
Period of change from summer climate — Ventnor,
Torquay, Hastings, the Channel Islands and Clifton,
their general characters and meteorological conditions
in January, February and March, from 1855 to 1860 . 395-413
Winter Climates in Foreign Countries : —
The Nile, Pau, Madeira, Algeria, Nice, Naples,
Mentone, and Rome, their general characters . . 413-424
CONTENTS.
PART IV.
PEOGKOSIS.
CHAPTER XLIY.
Specific Conditions : — pages
ravourable and unfavourable in tlie lungs and the
general system 425-432
CHAPTER XLY.
prognosis.
General and Numerical Conditions : —
Special inquiries upon 1000 cases when in health . . 433-434
Parents : —
Mortality — Age at Death — Feeble health — Unsteady —
Died of consumption — Suffered from rheumatism,
asthma, liver disease, gout, fevers, ague, insanity,
diabetes and scrofulous affections— Consanguinity —
Age at birth of the patient— Number of children in a
family — Order of patient amongst the children —
Hereditary predisposition 434-435
Patients : —
Age — Feeble health and appetite — Dry-nursed —
— Perspiration — Worn flannel shirts — Had measles,
scarlet fever, small-pox and hooping cough, and their
effects — Scrofulous diseases — Inflammation of lungs —
Rheumatism, typhus, diarrhoea, and liver disease —
Married — Sterility — Children — Age at birth of the first
child— Number of children in a family — Health of the
children — Abortions — Sexual abuse — Masturbation —
Emissions — Syphilis — Gonorrhoea — Led a bad life —
Drank — Smoked tobacco — Late hours — Anxiety —
Injurious conditions of occupation — Taken mercury —
Bled at the arm — Excessive liability of females —
Relation of these facts to prognosis .... 436-440
PART I.
INTRODUCTORY AND HISTORICAL.
CHAPTER I.
— ♦ —
PEELIMINARY OBSERVATIONS.
The word consumption almost universally suggests
an incurable condition, and one which proceeds slowly
yet steadily to its termination, so that there is without
doubt in the public mind a greater dread of it than
of any other chronic disease. This is well based upon
the facts of the widely spread cases of the disease, the
opportunity which nearly all persons have of tracing
its progress from a certain point, and the multitudes
who die from it ; but on reflection it will be seen that
all this may be true, and yet the inference which has
been drawn may be unsound, for it only proves that
consumption is not commonly cured, and not that it is
incurable. Indeed, admitting as we do the general
truthfulness of the received opinions, we feel assured
that there are good grounds for believing both the
apparently contradictory statements, viz., that con-
sumption is commonly fatal, and yet is commonly
curable ; and we do this without assuming that there
has been any want of due investigation as to the
2 PRELIMINARY OBSERVATIONS.
nature, or of care and talent in the treatment of tlie
disease.
In reference to the nature of the disease in past
ages, we think that there are some reasons for believ-
ing that it was not precisely the same then as now, as,
for example, in the inflammatory tendency which was
common in the seventeenth, eighteenth, and the early
part of the nineteenth century, and which is rare now ;
and hence we shall not be justified in adducing
former experience either in aid of, or in opposition to,
the present opinion. But the most widely spread
source of fallacy is the fact that neither the profes-
sion nor the public has taken cognisance of the
disease in its early manifestation, but has admitted
its existence onl}?- after much advance has been
made, and then watching the case from that starting-
point, it has been seen that the disease is almost
universally fatal. If that starting-point were the
earliest period at which we could become acquainted
with the disease, then we think that the popular belief
could not be gainsayed. Hence, the whole question
turns upon that point, viz., the general recognition
both by the profession and the public of the disease in
its earliest manifestations.
In this view it is easy to admit that the present age
might be right in believing consumption to be curable,
whilst former ages were equally right in their con-
firmed belief of the contrary : for, until our improved
means of diagnosis were discovered and widely known,
and cases of the disease were brought together in large
numbers for careful investigation and study, it was
PEELBimARY OBSERYATIONS. 3
quite impossible either for the public or the mass of
medical practitioners, to do otherwise than commence
their recognition of the disease at an advanced period
in its progress. Then the disease seemed involved in
mystery as to its nature, and so hopeless was it in its
progress that practically little attempt was made to
control it ; but at present we have means of tracing
conditions pre -existent to those which constituted the
starting-point of former times, and, notwithstanding
the disputation which still exists as to the nature
of the material deposited in the lungs, which is said to
be the essence of the disease, we venture to affirm that
but few diseases are more clear in their nature, or more
readily capable of detection in their early manifesta-
tions. It is common to speak of the mysterious
character of phthisis, as though we assumed that there
were other conditions of disease which were more clear,
forgetting that we are unacquainted with the essential
processes by which either healthy or unhealthy nutri-
tion is carried on, and with the nature of the various
conditions of disease to which we have given names.
In all these instances we are acquainted with certain
leading facts, whilst the minute changes which they
grossly represent are hid from view ; and in like
manner, and in various degrees, we possess certain
powers by which we may violently arrest the processes
upon which the diseased action appears to depend, but
in all our duty is chiefly confined to aiding the efforts
of nature. In truth we doubt, with so high an autho-
rity as Sir James Clark, if the want of success which
has attended our efforts to arrest the progress of
B 2
4 PRELIMINARY OBSERVATIONS.
phthisis is greater than has attended all efforts to
arrest the progress of any other disease, accompanied
by an equal destruction of the organ with which it is
associated ; and it is only the great prevalence of the
disease, and the vast importance of the organ affected
in relation to the animal economy, which has led to
the present belief of the special incurability of phthisis.
It need not be affirmed that we are equally powerless
to restore the structure or the function of the liver, or
of any other organ on which an equal amount of injury
has been inflicted.
Hence we infer that whilst the present belief may be
true under existing conditions, the opprobrium which
has specially been cast upon the healing art in re-
ference to phthisis, is at least in great part undeserved ;
and that now, admitting the practical incurability of the
disease after it has made a certain degree of progress,
it is our duty to look at the disease in its earlier aspect,
and in doing so, to lay aside opinions founded upon
facts belonging to a later stage, so that with unpre-
judiced minds we may ascertain if in that new condi-
tion we have not the materials by which the remedial
art may act more effectually, and a disease which is in
its nature curable.
There is one leading particular in reference to this
question in which the present is less unprejudiced than
former ages. From the days of Hippocrates to those
of Laennec the disease was distinguished by its general
symptoms almost exclusively ; but Laennec introduced
a new era, in which the state of the lungs took prece-
dence of that of the general symptoms, and tubercle
PRELIMINAKY OBSEEYATIONS. 5
came to be regarded as the essence, tlie mark, and the
starting-point of the disease. This view was a tangible
one, because the tubercle was to be seen by every ob-
server ; and by the proposition, only tuberculous cases
were regarded as phthisical, so that it was generally
adopted, and has necessarily influenced the opinions of
men educated in it, and who, from its recent occurrence,
have lately lived, or are still living. Those who have
been more recently educated, or who will hereafter
enter upon the study of the subject, will probably regard
this question with greater breadth and fairness.
In considering this question, it must be remarked
that the tubercle is not the cause, but only one conse-
quence of the disease. This, at the present moment,
is in part practically admitted, and in other part as
practically denied. It is admitted, inasmuch as there
has been an attempt to assign it an origin either in the
place where it is found or in the general depraved cir-
culation; and even to this hour the latter source is
constantly referred to. But, on the other hand, the
changes which occur in the deposited tubercle have
been carefully watched, and the progress of destruction
of the lung, with all its consequences, have been attri-
buted to the changes which take place in the tubercle,
and the tubercle has become the foundation of the
disease. It must be admitted that the tubercle is
almost universally regarded as the essential feature of
the disease, the cause of its progress in the lungs, and
the source of injury to the general system ; and the
great desideratum has been its removal. The general
system has been regarded in two aspects: as asso-
6 PEELIMINARY OBSERVATIONS.
ciated with the deposition of tuhercle, and as influ-
enced by the deposition ; and the evil has not been in
regarding it in this double light, but in giving an undue
prominence to the latter, when considering the relation
of tubercle to phthisis. In truth, modern views have so
engrossed the mind, that one condition in the progress
of phthisis has (because it is always found at some
period) been raised from the minor to the dignity of
the major premiss; and instead of the statement that
all cases of tubercle (in the lungs) are phthisis, it is
averred that in all cases of phthisis there is tubercle.
We venture to affirm that this consideration is worthy
of careful attention in any attempt to obtain a true view
of the nature of this disease.
If tubercle be due to pre-existent causes, whatever
may be their nature, the disease is not in the tubercle,
but in the cause of the tubercle ; and the tubercle itself
is but a result — an evidence, and all the changes in the
tubercle are secondary influences. It cannot be affirmed
that the tubercular element of the disease possesses an
innate power of destruction such as is found in the
elements of cancer, for whatever may be the origin of
tubercle in the lung, it is found upon free surfaces, and
does not spread by extension ; whilst cancer infiltrates
the tissues and has the power of extension, and conse-
quently of displacement or destruction. Tubercle itself
is a foreign but a passive agent; and all actions, of
whatever kind, which proceed about it, originate and
are carried on, not by the tubercle, but by the contain-
ing tissues. It is placed in the lungs, and accumulates
by new deposits ; and the subsequent changes are not
PKELIMINAKY OBSERVATIONS. 7
due to any disintegrating action in the tubercular ele-
ment, but in the tissues which contain it.
Hence surely the tubercle is not the essence of the
disease, but only one of the results — a result doubt-
less met with at some, but not at every period in the
progress of each case. So long as inquirers fix their
attention upon this or any other single product of the
disease, they will fail to recognise its true nature ; and
so long as the aim of the practical man is to find a plan
whereby the tubercle may be absorbed or ejected, he
also will fail. We therefore think that whilst our age
has made the great advance of distinguishing more
carefully those cases of wasting which are associated
with a particular disease of the lungs from those due
to other causes, and has therefore given to us a large
group of cases of a similar character, it has greatly
erred in fixing its attention upon one of the conditions
of the lungs, and regarding it, not as one of many
results of diseased action, but as the essence of the
disease, and the prime cause of mischief. It has cast
aside that minute attention to the general system which
was the especial subject of observation of the fathers of
medicine, and has been content to concentrate all its
powers of observation upon one internal condition
which has this in common with the external symptoms,
viz., that both are effects of the disease, and not the
disease itself. We have limited our cases to one class
only, and have spent our time in determining the cha-
racteristics of that class, but have made little progress
in that higher department of knowledge — the determi-
nation of the true nature of the disease.
CHAPTER 11.
HISTORICAL SKETCH AS TO THE NATURE AND TREATMENT
OF PHTHISIS.
We do not purpose in the following sketch of tlie
opinions which have been hitherto held respecting
phthisis, to enter into large detail, but we desire rather
to trace the changes of opinion or the additions to the
knowledge of the disease which have occurred in large
seras of medical history, with a view to show the real
amount of progress which has been made since the
days of the earliest records of our art. This may be
in part effected by the aid of the labours of Dr. Young,
to whom the profession is indebted for abstracts of the
works of nearly all preceding writers on consumption —
accurate, no doubt, and arranged in chronological order,
but having the great defect of an absence of scientific
arrangement in the direction of the present inquiry,
and being consequently of comparatively little value
except to the most painstaking medical reader. We
think that it will suffice for our purpose if we state in
a few words the opinions which were held by the
ancient physicians to the time of Galen, those found
in the works of the Arabian physicians and the phy-
sicians of the middle ages, and lastly, give a short
THE ANCIENTS. .9
analysis of the views held hy the moderns since the
sixteenth century ; and since the advance of knowledge
during those periods has not been very great, we shall
avoid wearying the reader by multiplying quotations.
The leading characteristics of these seras in the
knowledge of the disease may be thus epitomised. The
ancients confounded phthisis with other diseases, both
of the lungs and other organs, attended by wasting,
but were yet well acquainted with the disease as we see
it at this day. The Arabian physicians and those of
the middle ages adhered to the opinion of Hippocrates
and Galen, and advanced no new views of the nature of
the disease ; whilst among the moderns there has been,
with advance of time, a gradual limitation of the
disease to a tubercular state of the lungs, attempts to
describe tubercle, speculations as to its immediate
origin, an examination of its relation to scrofula, a
consideration as to whether phthisis be essentially a
disease of the general system or of the lungs, and a
desire to generalise the conditions which mark the
consumptive patient. Besides these there have been
in all ages disputations as to the relation of haemoptysis
to phthisis, the contagious character of phthisis, and
the efficiency of various remedial agents.
THE ANCIENTS.
Hippocrates (fourth and fifth centuries B.C.) describes
several forms of consumption under the heads of
phthisis, phthoe, and empyema, and mentions tubercle
of the lungs, but he does not regard the tuberculous
state of those organs as the essential condition of the
10 HISTORICAL SKETCH.
diseased" His description of a true phthisical case, as the
disease is now regarded, is, however, very clear and
decided. He includes also such diseases of the lungs
as pleijrisy and empyema. In a second form he also
includes bronchitis, remitting during the summer ; and
in a third, scrofulous diseases of the spine. In refer-
ence to the cause of the disease he considers that the
first form, which includes true phthisis, arises from
haemoptysis, and begins with a kind of catarrh, in
which acrid matters descend from the head and cause
ulceration of the lungs. He affirms that the expec-
toration in phthisis arises from ulcerations of the lungs,
and he describes a test for pus which has held its
ground until modern days ; but expectorated matters in
general were considered to descend from the head.
The treatment of the disease may, in its broad out-
lines, be regarded as that adopted at the present day,
viz., the free use of milk, whether asses', mares',
goats', or cows' milk, when there was not much fever
or headache, a moderate quantity of meat, fat fish, and
other fats, with walking exercise for many miles daily,
and the avoidance of changes of temperature.
• The small portion of the works of Aretcsus (second
century) which has been preserved is quite inadequate
to inform us as to the views of that great master of the
art, but the following description of the general evi-
dences of phthisis are as truthful and life-like as any
which have been placed upon record : —
" There is present, weight in the chest (for the lungs
are insensible to pain), anxiety, discomfort, loss of
appetite ; in the evening coldness, and heat towards
THE ANCIENTS. 11
morning ; sweat more intolerable than the heat as far
as the chest : expectoration varied as I have described."
.... " Voice hoarse ; neck slightly bent, tender,
not flexible, somewhat extended; fingers slender, but
joints thick; of the bones alone the figure remains, for
the fleshy parts are wasted; the nails of the fingers
crooked, their pulps are shrivelled and flat, for, owing
to the flesh, they neither retain their tension nor
rotundity ; and owing to the same cause, the nails are
bent, namely, because it is the compact flesh at their
points which is intended as a support to them ; and the
tension thereof is like that of the solids. Nose sharp,
slender; cheeks prominent and red; eyes hollow,
brilliant and glittering ; swollen, pale, or livid in the
countenance ; the slender parts of the jaws rest in the
teeth as if smiling ; otherwise of a cadaverous aspect.
So also in all other respects ; slender, without flesh ;
the muscles of the arms imperceptible ; not a vestige
of the mammae, the nipples only to be seen ; one may
not only count the ribs themselves, but also easily
trace them to their termination ; for even the articula-
tions at the vertebrae are quite visible, and their con-
nections with the sternum are also manifest ; the
intercostal spaces are hollow and rhomboidal, agreeably
to the configuration of the bone ; hypochondriac region
lank and retracted ; the abdomen and flanks contigu-
ous to the spine; joints clearly developed; prominent,
devoid of flesh, so also with the tibia, ischium and
humerus ; the spine of the vertebrae, formerly hollow,
now protrudes, the muscles on either side being
wasted ; the whole shoulder blades apparent, like the
12 HISTORICAL SKETCH.
wings of a bird. If in these cases disorder of the
bowels supervene, they are in a hopeless state."
As he had taken Hippocrates for his model, was a
man of acute observation, and lived several centuries
later than his master, it may appear strange that he
does not refer to tuberculous disease of the lungs in
connection with phthisis, but we are not thence enti-
tled to affirm that he was unacquainted with that condi-
tion. He also confounds phthisis with other diseases.
In the treatment of the disease he particularly recom-
mends sea voyages and the free use of milk and eggs.
Galen, a cotemporary of Aretseus, adopted the view
of the Greek physicians, that hectic fever and phthisis
were not the same diseases, but he considered them to
be so connected that consumption or marasmus occurs
in the second stage of hectic. He evidently knew that
hectic fever occurred with other diseases than con-
sumption, and also that it was associated with the latter
disease. In his view the disease might be due to an
affection of the lungs or of other parts of the body,
but when it was a true marasmus he regarded it as
incurable. In reference to its cause he affirms that it
is due to want of moisture, and that it is a drying up
of the body, but it is probable that under this descrip-
tion he simply indicated the slow emaciation which is
the constant characteristic of the disease. He, and
others, had noticed the expectoration of calculous
concretions in the sputa, and made the important obser-
vation — which needs to be repeated now-^that bleeding
from the fauces may be mistaken for bleeding from the
lungs, as an indication of the existence or the progress
THE MIDDLE AGES. 13
of phthisis. In treatment he recommends asses', goats',
cows', and human milk.
We do not stay to refer to the statements of Aristotle,
Dioscorides, or Celsus, since whilst the first held
strong views as to the contagiousness of the disease,
the second gave much attention to treatment, and
the third described with great care the symptoms and
treatment of the disease, including the use of mutton
suet boiled with flour, and the relation of haemoptysis
and catarrhal secretion, their views are represented by
the authors already quoted.
Hence the general expression of the ancient views
upon this subject is that the physicians well knew of
the existence of true phthisis ; they recognised the
existence of tubercle, but did not associate the two
conditions as belonging to the same disease; they
doubtless included other deposits with those of tubercle,
and included many diseases both of the lungs and
general system with phthisis ; they also believed that
hsemoptysis was commonly a cause of phthisis, that
catarrh preceded the attack, and that the proper
treatment of the disease was by the improvement of
the nutrition of the system by milk, flesh, meat, fat,
exercise, and sea air.
THE MIDDLE AGES.
The views of the physicians from the time of Galen
to the sixteenth or seventeenth century were essentially
those of the earlier period, and we cannot find any decided
advance in the knowledge of the disease if we except
perhaps the views of Alexander Trallian, who called
14 HISTORICAL SKETCH.
especial attention to the existence of tubercle of the
lungs, and showed that its presence is followed by
dyspnoea, and this by cough and the expectoration of a
secretion generally viscid, but sometimes containing a
calculus so hard as to cause a sound when it is spat
upon a resisting surface. Paulus Mgineta treats of both
hectic fever and consumption in cases of suppuration of
the chest, and also mentions the expectoration of
calculi; and in this respect the writings oi Avicenna ^ndi
Forestus agree. The Arabian physicians in general,
with Paracelsus, Orihasius, Aetias, and other distin-
guished men of those days, followed the Hippocratian doc-
trines. The two latter, Avicenna and Forestus, attached
great importance to the use of the milk of various ani-
mals. Avicenna recommended a dry air, Forestus,
discountenanced the arrest of haemoptysis, Capivac-
cius gave sulphuric acid to cleanse the ulcers of the
lungs, and Avefizoar advised the free use of olive oil
in the treatment of the disease.
Hence the merit of the middle ages in reference to
this department of medicine was the same as was due
to them in general knowledge — that they kept and
handed down to succeeding ages the knowledge of the
early fathers, but being bound down by the authority
of previous ages, they did not pursue investigations
calculated to the increase of knowledge.
THE MODERNS TO THE TIME OF DR. BAILLIE.
In considering the views entertained by the physicians
of the seventeenth and later centuries, we may divide
them into those of two geras, with the line of separation
THE MODERITS TO THE TIME OF DR. BAILLIE. 15
drawn at the period of the puhlication of Dr. Baillie's
researches on tuhercle. This, however, must be re-
garded merely as a matter of convenience, and not as
indicating that the line separates two well-defined
classes of opinions : for whilst it is true that careful
investigation of tubercle may date from the time of
Baillie, it is also true that increasing importance was
attached to the subject as the seventeenth passed into
the eighteenth century. Indeed, in this, as in all other
kinds of knowledge, improvement was gradual, until a
period arrived when an observer having increased
knowledge rapidly, utilised the speculations and labours
of his predecessors, and became the representative
of a class of opinions.
Of the numerous writers who preceded Baillie we
must select Bennet, Desault, and Tralles, as represen-
tatives of the class who began to be aware of the
essential connection which exists between a tubercular
condition of the lungs and phthisis, although not with-
out the admission that consumption might exist without
disease of the lungs.
Bennet dissociated catarrh from phthisis, and showed
that the secretion proceeds from the lungs primarily,
and does not descend from the head. He accurately
described the symptoms of true phthisis, and yet
believed that consumption might occur when the lungs
were sound. He also regarded haemoptysis as a cause
of the disease.
Morton adopted similar views as to the distinction
between catarrh and consumption, and described the
symptoms of the latter very accurately. He considered
16 HISTORICAL SKETCH.
that there was a form of consumption of an asthmatic
kind.
Desault had very clear views of the true connection
between tubercle and phthisis, and believed that
generally haemoptysis occurs subsequently to the
tubercle, and in this latter opinion he was supported
by Mudge and Gilchrist. The ulceration of the lungs
was known to be an effect and not a cause of the
disease. He drew attention to the frequency with
which disorders of the liver attend consumption, and
held to the doctrine that the latter is a contagious
disease. In his opinion the beneficial effect of exercise
was by breaking down the tubercle.
Tralles expressly believed that tubercle was the
immediate cause of consumption.
Stwrk described tubercle and vomicae with much
minuteness, and stated that he had found them in the
cellular membrane. His views were an advance upon
those previously held.
Portal divided phthisis into several varieties, and
believed that there were three kinds of tubercles.
Pearson published in the " Philosophical Transac-
tions " a series of minute inquiries into the character
and composition of different kinds of expectoration.
VIEWS RESPECTINa TUBERCLE.
The views of tubercle as found in the lungs are
very various, and deserving of attention.
Sylvius regarded them as glands in the lungs which
suppurate and form vomicae. Tralles considered them to
be bronchial glands and vesicles distended by humours.
VIEWS KESPECTIlSrG TUBERCLE. 17
Clayton injected the veins of a dog with mercur}^,
and found minute suppurations in the lungs, having
each a glohule of mercury at its centre. This was
believed to indicate the mode of formation of tubercle,
Willis was of opinion that the expectoration in phthisis
proceeded from the minute vessels of the trachea, and
was derived from the serous parts of the blood. "When
retained it putrified and formed ulcers. Boerhaave
considered consumption to be a conversion of all the
blood and chyle into pus. Thomas Reid believed that
tubercle consists of obstruction of the exhalent vessels,
caused by the viscidity of their contents. Sydenham
divided consumption into four kinds, and in reference
to the first — which includes cases of true phthisis — he
states that the lungs, being incapable of assimilating
the proper aliment, are overwhelmed with a crude
phlegm, and that a part of the humours which ought
to be thrown off by perspiration is retained by the
lungs. Bush believed tubercle to be a collection of
inorganic mucous substance. On considering these
various opinions of the nature of tubercle, we cannot
avoid seeing the similarity between some of them and
those recently promulgated, and then withdrawn by
Eokitansky, based upon the chemical learning of our
day, which affirmed that the albuminous matters of the
blood were expended in the formation of tubercle.
The connection between scrofula and phthisis which was
held to exist by those above-mentioned, who regarded
tubercle as a gland, was generally maintained, and par^
ticularly by Brillouet in 1789, emdBadcliffe, (the latter
at least believing it to be so in cold climates,) and also
18 HISTORICAL SKETCH.
by the Edinburgh school in general. On the other
hand Simmons, in 1780, denied the connection both
of phthisis and scrofula, and of tubercles and scrofulous
glands.
AGE.
The age at which this disease prevails was the same
two thousand years ago as now, for Hippocrates in-
forms us that in his day it was from eighteen to thirty-
five years.
CAUSES.
Inreference to the assigned causes of the disease which
were held up to this period, we may first cite catarrh,
to which reference has been already made, and acrid
humours, either generated in the lungs, or descending
from the head, and produced no doubt by the catarrh,
as held by Sennertus, and Hofmann, and by Huxliam,
in 1758, when tubercles had been previously formed.
Borelli believed that the smoke from the wicks of
candles, and fat and oil when poured into a confined
space and inhaled, was a cause of phthisis. Singelms
affirmed that in England it was commonly caused by
tight dresses ; whilst Van Swieten was of opinion that
it was produced by the excess of animal food in which
Englishmen indulged. Stahl agreed with the latter in
believing that it was often due to inactivity and full
living. Sims thought it to be frequently caused by the
retention in the body of morbid matters produced by
sj^philis and gonorrhoea. Avicenna remarked upon
the greater prevalence of phthisis in cold countries,
and Blane affirmed it to be less frequent in hot
CONNECTIOIT WITH HECTIC AND HEMOPTYSIS. 19
climates. Rush associated the disease with civilisa-
tion, for he remarked that it was unknown to the North
American Indians before they associated with white
men, and was not found among colonists in the earliest
stage of civilisation. Walker , speaking of the atrophy
of nurses, attributed that disease to the use of tea in
the place of food. Musgrave saw a connection between
gout and consumption. Withering remarked that
ostlers and grooms living in the alkaline air of the
stable were rarely consumptive ; and De Haen noticed
the arrest of phthisis during pregnancy.
CONNECTION WITH HECTIC AND HEMOPTYSIS.
The connection of consumption with hectic fever
has been already referred to. Amongst the Greeks
the two conditions were held to be distinct, except so
far that consumption appeared in the course of hectic
fever ; but in later times the hectic came to be regarded
as a cause of consumption. Bontius recognised a true
consumption with hectic. Macbride regarded phthisis
and tabes as the principal species of hectic fever, but
yet he admitted that the symptoms of phthisis precede
the hectic, Cullen defined consumption as an expec-
toration of purulent matter with a hectic fever, more
or less exquisitely formed, and commonly with ulcera-
tion.
In reference to the connection of phthisis and
haemoptysis, it has been shown that the early fathers
regarded the latter as a cause of the former, and this
view has been shared by many moderns. Cullen states
that " the consequence of haemoptysis is phthisis," and
c 2
20 HISTORICAL SKETCH.
Hofmann asserts that half the cases arise from hsemo-
ptysis ; but Desault, Mudge (who believed it to be the
consequence of obstruction in the lung), and Gilchrist
affirmed it to result from, or at least to follow, the
deposition of tubercle. We have noticed the observa-
tion of Galen as to the occurrence of faucial haemorrhage,
and Van Stvieten believed that haemorrhage from the
palate might be mistaken for tubercular haemorrhage.
CONTAGION.
The contagious nature of the disease was perhaps
universally believed by the ancients, and the belief has
been conveyed through later ages to our own times.
Sylvius, Hofmann, Desault, Van Swieten, and Darwin
adopted it, and so much impressed were Morgagni
and Valsalva with this quality of propagation that they
declined to open the bodies of consumptive patients,
and thus excused themselves for their inability to
determine the immediate seat of tubercular deposition.
Portal denied the contagious nature of the disease.
NATUEE.
, In reference to the nature of the disease in the sense
of phthisis, as now understood, we have seen that it
was regarded by the ancients as an ulceration of the
lung ; then there was a connection perceived between
tubercle and phthisis ; and then, as at the sera of
Stark or Desault, tubercle was regarded as having an
essential connection with phthisis, but Rush main-
tained that phthisis was not essentially a disease of
the lung, but an affection of the general system, and
TREATMENT. 21
primarily a disease of debility. It may be ques-
tioned as to how far those who regarded it as a hectic
fever believed it to be essentially a disease of the lung,
and indeed many such writers affirmed that consump-
tion might exist and yet the lungs be sound.
TREATMENT.
We do not purpose to give an analysis of the methods
of treatment which have been proposed, but shall be
content to make a few observations only. Milk has
been recommended in all ages with singular concur-
rence, and with enthusiasm by Aretceus, if we may
judge by the list of good effects which he ascribes to it ;
but Gideon Harvey sneered at it, since he considered
that it was to aifect the disease by being directly
applied to the cavity of the lungs. He, however,
admitted that its fatty particles might possibly puff up
those who swallow it into some degree of corpulency.
Mead also attached less value to it than was the practice
with other physicians of his day. Numerous phy-
sicians, as Fr. Hofmann, added lime water to the
milk. Eggs, meat, and fish were commonly recom-
mended. Olive oil was commended hj Ave7izoar, fat by
Hippocrates, mutton suet by Celsus. Sea voyaging was
advised by Aretceus and the early physicians, but not by
them universally. Carmichael Smyth, in modern times
regarded it as prejudicial, and Gilchrist greatly approved
it. Exertion in the open air was insisted upon by
Hippocrates, who commended walking ten to fifteen
miles a day; and in the middle ages and modern
times physicians have recommended their patients to
22 HISTORICAL SKETCH.
become coaclimen, in order to spend their time in tlie
open air. Horse exercise lias been commended in all
ages, and in modern times by Sydenham, Fuller, Mead,
Gilchrist, Pringle, Van Sivieien, &c. Carmichael
Smyth recommended swinging, which, he said, lowered
the pulsation ten beats per minute. Beid recommended
persons in phthisis to live in cow-houses. Steel w^as
employed in the middle ages, and bark in cases of
haemoptysis in modern times, by Morton and Mead,
before the lungs had become ulcerated. Fothergill,
recommended early abstinence, milk, vegetables, quiet
■of mind, good hours, moderate exercise and change
of scene. Counter-irritation by caustics was prac-
tised by Hippocrates and Aretceus, and by the actual
cautery by Galen, and the practice, in some form, has
been common in all ages. Sulphuric acid was employed
in the middle ages with a view to its supposed local
action upon the ulcers. Speaking with a loud voice
was commended by Sanctorius. Bleeding was practised
in all the period^ under examination by a certain
number of physicians. In modern times it has been
enjoined by Gideon Harvey, Pringle, &c., but Bartholin
found the heart thin and dry, or, in other words, fatty
and shrunken, and but little blood in the body, and
Cheyne remarked that the quantity of blood was much
diminished in hectic fever. Gideon Harvey, besides
bleeding, recommended the use of steel, opiates, and
astringents.
At the end of the eighteenth century many physicians
practised inhalation of various gases and vapours in
the treatment of tubercular phthisis, amongst whom
opi:$i[ioNS OF OUR ow:n' day. 23
we may mention Mudge, Fourcroy, and Beddoes. Four-
croy observed the effects of the inhalation of oxygen,
and found that it accelerated the pulse and respiration,
and increased inflammatory action, and hence he
regarded it as inimical to phthisis. Beddoes, whose work
is a monument of industry, based his practice upon
chemical theories, and ariived at the conclusion that
in phthisis there is an excess of oxygen in the system,
and consequently that free air was injurious to the
patient. All these ideas tended to the belief that the
inhalation of air containing carbonic acid was the
proper plan of treatment. In our day we see this
theory of hyper-oxidation revived by Liebig, and also
upon chemical grounds, and the recommendation that
in phthisis the respiratory action should be lessened.
OPINIONS OF OUR OWN DAY.
We will now offer a few remarks upon the opinions
which have been held since the time of Baillie, and
endeavour to state those of distinguished men up to
our own day upon some of the more important ques-
tions which have already been discussed.
Baillie, Bayle, Laennec, and Carswell gave a great
impulse to researches into the nature of tubercle, and
have brought down the knowledge almost to the present
time. Baillie describes with great minuteness the
physical characters of tubercles, and affirms that they
are found in the cellular tissue, are not glandular, and
are not derived from the mucous follicles of the bronchia,
but that they are minute at first, and increase in size ;
are firm, then curdy, and are converted into capsules
U HISTORICAL SKETCH.
containing a fluid, and occasional^ they unite and form
abscesses. In some cases they are diffused through the
lungs. Bayle affirmed most distinctly that there is an
essential relation between phthisis and the state of the
lung, whatever may be the general symptoms. He
divided phthisis into six species, and named them
tubercular, granular, melanotic, ulcerous, calculous,
and cancerous, and thereby included many deposits
which have not lately been regarded as tubercle. He
affirmed that there is a blood-vessel in every tubercle,
and that the ulcerations are always lined by a mem-
brane; but the expectoration is chiefly derived from
the bronchial mucous membrane. He added a fourth
stage to phthisis, which he called occult, because there
was disease in the lung without any obvious symptom.
Laennec regarded tubercle as an accidental produc-
tion, or a substance foreign to the natural organisation
of the lungs. He restricted phthisis absolutely to the
tubercular disease, but with a slight recognition of a
phthisis nervosa, and a form of chronic catarrh simu-
lating tubercular phthisis. He divided or accepted
the division of tubercles into two principal forms, the
insulated bodies, subdivided into miliary, crude, gra-
nular, and encysted, and the interstitial injection or
infiltration with the three varieties, irregular, grey, and
yellow. The miliary form is the most common, whilst
the granular and encysted forms of Bayle are rare.
He doubted if a blood-vessel were generally, much less
always, present in the centre of a tubercle. He distin-
guished six stages of tubercle, viz., semi-transparent
granulations, yellow and opaque at the centre, yellow
OPINIONS OF OUR OWN DAY. 25
and opaque throughout hut yet firm, grey infiltration
chiefly around cavities, softened at the centre, and
excavations ; and he states that in the same lung two
or three successive eruptions may be found. Louis
substantially adopted the views of Laennec, and even
more than the latter agreed with those of Bayle, and
all affirmed that the apices of the lungs were especially
liable to this deposit.
Dr. Carswell, in 1838, called attention to the im-
portant fact that tubercle is not usually found in the
cellular tissue of organs, but, in the vast proportion of
cases, upon mucous surfaces, and, as a general ex-
pression, upon the secreting surface of hollow organs.
He affirmed that the grey semi-transparent substance
did not necessarily precede the formation of the pale-
yellow or opaque tubercular matter. The latter is
found in but few organs, whilst the former is found in
the air-cells and the serous membrane. It is without
organization ; but in the cow and other animals it
assumes a concentric or laminated form, from the pre-
sence of albumen and fibrin. It is composed in men
of albumen, fibrine, and gelatine, and softens from the
circumference, and not from the centre.
Subsequent to this period the microscope has been
more particularly employed in determining the precise
nature of tubercle, and certain cellular and granular
elements have been found in the deposit.
In 1816, Laennec commenced the series of researches
which led to his system of Mediate Auscultation, and
which must be regarded as the most important disco-
very in medical science of this century. Not that he.
26 . HISTORICAL SKETCH.
in truth, was the first to make some use of the ear to
ascertain the state of the chest, for Hippocrates did
the same, to a limited extent, and Avenhrugger to a
much greater degree ; hut for all that has rendered
knowledge upon this subject exact, and built up into a
science, we are indebted to Laennec. The signs,
and consequently the diagnosis of phthisis, and the
knowledge of its progress, and therefore the pro-
gnosis, became more exact from his labours.
Louis followed in the same path, and gave a more
accurate detail of the symptoms, etiology, and patho-
logy of the disease than any who had preceded him.
, M. Piorry has, at various times, expressed novel and
independent views both as to the nature and the treat-
ment of phthisis ; and in a paper, recently read before
the Academie de Medecine, he developed the following
propositions : —
" 1. Pulmonary Phthisis is a combination of multi-
farious variable phenomena, and not a morbid unity;
S. Hence there does not and cannot exist a specific
medicine against it; 3. Therefore, neither iodine nor
its tincture, neither chlorine nor sea salt, nor tar, can
be considered in the light of anti-phthisical remedies ;
4. There are no specifics against phthisis, but there are
systems of treatment to be followed in order to conquer
the pathological states which constitute the disorders ;
5. In order to cure consumptive patients, the peculiar
affections under which they labour must be studied and
appreciated, and counteracted by appropriate means;
6. The tubercle cannot be cured by the use of any
remedy, but good hygienic precautions may prevent its
OPi:^IONS OF OUR OWN DAY. 57
development ; 7. The real way to relieve, cure, or pro-
long the life of consumptive patients, is to treat their
various pathological states, which ought to receive dif-
ferent names according to their nature ; 8. ConsLimption
thus treated has often been cured, and oftener still life
has been considerably prolonged ; 9. Phthisis should
never be left to itself, but always treated as stated
above; 10. The old methods, founded on the general
idea of a single illness called phthisis, are neither
scientific nor rational, &c.; 11. The exact and method-
ical diagnosis of the various pathological states which
constitute the malady, will dictate the most useful
treatment for it."
The most remarkable features in the treatment of
the disease during the present century have been, the
removal of the patient to a milder climate, and the
administration of cod-liver oil. The former was ad-
vised in all stages of the disease, and seemed to be
called for by the urgency of the cough, and perhaps by
the frequent presence of inflammatory complications.
Hence multitudes were sent away to die distant from
their home and friends. This evil has been abated of
late years, and care is now taken to avoid such a
recommendation when the disease is far advanced and
the life is in peril. The latter is of very recent intro-
duction into general use — only since the commence-
ment of the career of the distinguished Professor of
the Institutes of Medicine in Edinburgh; but, as a
remedy in other diseases, it had been recommended
and adopted to a small degree at the end of the last
century. During the last fifteen years its use has been
tab HISTORICAL SKETCH.
universal, in all stages of phthisis, and in many
other diseases.
SUMMARY.
Having thus sketched the progress of opinion and
knowledge upon this subject, let us, by way of sum-
mary, endeavour to show in what degree the knowledge
of the present day differs from that of preceding
ages :
1. The diseases formerly included in the term
Phthisis or Consumption were found to be various, and
one class has been selected out from the number, and
the term rigorously restricted to it.
2. Tubercle in the lungs is regarded as the dis-
tinctive mark of this class.
3. The term tubercle formerly included numerous
deposits, varying in nature and character ; but now it
is, as far as possible, restricted to one kind of deposit.
4. The increase of the means of investigation has
opened new difficulties in determining the nature of
deposits, because the new kind of knowledge is yet
imperfect ; and hence the nature of tubercle has not
been settled on its histological characters.
5. The question of the essential identity of scrofula
and phthisis is yet undecided.
6. The intimate nature of phthisis, as to whether its
first origin lies in the lungs or in the general system,
is still undecided.
7. The immediate source of the deposit found in the
lungs is still undetermined.
8. The occurrence of the deposit is generally still
SUMMAKY. 29
held to be the first evidence of the existence of the
disease.
9. The existence of the deposit and its nature,
the progress of the deposition in the lungs, and the
site, degree, and progress of the destruction of those
organs, is a knowledge perhaps peculiar to this century,
and is now in a highly advanced state.
10. The state of the general system was as well
known to the ancients as to ourselves, if w^e select those
cases known to the former which are now alone admitted
by the latter.
11. The fatal tendency of the disease has been in all
ages alike admitted, and at this day nearly one-eighth
of the whole mortality in England is due to this now
carefully selected class of cases.
12. There is an impression that, within a few years,
the effect of modern treatment has been to prolong life
during the attack of the disease ; and our distinguished
colleague. Dr. Williams, has felt himself justified in
saying how long it is increased. There are also grounds
for believing that a cure is sometimes effected ; but the
mortality referred to, and the general feeling of profes-
sional and non-professional people alike, is that the
disease is a fatal one.
15. The general principles of treatment and the
methods employed are still the same as in former
ages (due allowance being made for the separation
of the particular class of cases which we are now able
to effect), except that now^ bleeding is not resorted to,
and the connection with catarrh is not necessarily
admitted, although we fully admit the influence of a
80 HISTORICAL SKETCH.
cold in developing the disease. That there has been
a change in the aspect of the disease at various aeras is
highly probable, according to the habits and prevailing
constitution of the age, and hence the former practice
and views might then have been as little incorrect as
ours are now.
16. There has been but little variation in the reme-
dies employed in all ages, as we have seen that milk,
cream, eggs, meat, vegetables, exercise, open air, sea
voyaging, change of climate, and adaptation of tempera-
ture and dryness of the air, steel, bark, olive oil,
mutton suet, &c., have been heretofore employed.
There have been the selection and rejection of minor
remedies as emetics, digitalis, hydrocyanic acid, &c.,
with every age, and the leading treatment of this day
has been anticipated, although not in the precise form
of cod liver oil.
17. Hence as a final expression we may state
that, whilst we have a selected class of cases, with
an improved diagnosis and pathology, and these im-
proved views are so largely shared by all practitioners,
that the treatment is now similar in all parts of the
kingdom, we are not agreed as to the essential nature
of the disease, have no unfailing mode of treatment,
and the disease is still essentially and almost as uni-
versally a fatal one as it has been in all ages.
CHAPTER III.
HISTORICAL SKETCH AS TO THE VIEWS ON THE EARLY
STAGE OF PHTHISIS.
In the foregoing historical sketch we have always
referred to phthisis as a disease commencing with the
deposition of tubercles in the lungs, and its fatal
character and progressive changes in the lungs apply
to the disease when so considered. But there has
been, at least in recent years, a belief that there are
conditions existing anterior to this deposit which have
such a connection with phthisis, that, if continued, the
deposition in the lungs commonly appears. These have
not been regarded necessarily as cause and effect, but
as pre-existent circumstances, having a general ten-
dency to the sequence just pointed out, and have
commonly been designated " predisposing causes," and
whether that or the term " first stage of phthisis,"
would the most correctly indicate them, will depend
upon the view which is taken of their causative in-
fluence. If it be shown that they have such a connec-
tion with the deposition of tubercle, that they are
necessarily, or nearly so, pre-existent to the deposit,
then we truly have a stage of the disease in which the
conditions are quite different from those found after
32 HISTOKICAL SKETCH.
the deposition of tubercle, and to which the fatality of
the later stage would not necessarily belong. This we
consider one of the most important questions of the
day, and worthy of the most serious and unbiassed
consideration of medical men ; for if there be such a
stage, if it can be recognised, and if it be curable, then
it follows that instead of our energies being wasted
upon a comparatively hopeless task, we may find the
highest of all rewards to which the physician can
aspire — the saving of a countless multitude of lives.
Hence we propose before expressing our own views,
upon the subject, to adduce such testimony as the
medical literature or experience of the present age will
afford, and endeavour to determine its precise value
upon this subject.
In pursuing this plan it is manifest that we cannot
go back beyond the period of Laennec's discoveries,
because until then there were not the means of deter-
mining the existence of tubercle with the exactitude
which is now requisite, neither can we expect that
Laennec or his cotemporaries should give any response
to our question, because they had established the
separation of this class of cases by the very fact of
tubercle being present in the lungs, and consequently,
could not admit that the disease existed previously to
the deposition of tubercles. Hence, from the works of
Bayle, Laennec, Andral, and Louis, we learn only that
there were sometimes conditions as diarrhoea, which
preceded and led to the deposition of tubercle, and such
designations as "irregular manifest phthisis," and
"latent phthisis," concerning which it was stated
VIEWS ON" THE EARLY STAGE OF PHTHISIS. 33
either that the disease did not begin in the lungs, or
that the evidence of disease of the lungs was entirely
wanting, whilst the general symptoms were urgent.
Sir James Clark in the preface to his admirable
monograph* especially calls attention to the state of
the general system in which tuberculous disease of the
lungs originates, and shows clearly that tubercle is a
secondary condition resulting from a pre-existent state
of the general system. He remarks that " the total
inefficacy of all means hitherto adopted for diminish-
ing the frequency or reducing the mortality of this
class of diseases is of itself sufficient incitement to us
to seek for some other method of remedying the evil ;
and it is evident to me that this can only be done, with
any reasonable prospect of success, by directing the
attention to such measures as are calculated to prevent
the hereditary transmission of the particular morbid
state in which the primal disease originates, and to
correct the predisposition to it in infancy and youth."
In the introduction he further remarks that the views
of Laennec " have tended to keep up the idea that
consumption is a local disease referable to a local
cause, and thus the investigation of the constitutional
origin of tubercles, by far the most important part of
the subject, has been neglected." " We must carry
our researches beyond the pulmonary disease which is ,
only a secondary affection, the consequence of a pre-
existing constitutional disorder ; the necessary condition
which determines the production of tubercles." " That
* " Treatise on Pulmonary Consumption," &c.
34 HISTORICAL SKETCH.
which is considered the early is in reality the advanced
stage of the disease, and that tubercle is a secondary
affection . originating in a peculiar morbid condition of
the system." " If the labour and ingenuity which
have been misapplied in fruitless attempts to cure an
irremediable condition of the lungs had been rightly
directed to the investigation of the causes and nature
of tubercular disease, the subject of our inquiry would
have been regarded in a very different light from that
in which it is at the present period." Sir James
strongly held the view that there is a diathesis allied to
the scrofulous in which the disease originates, and his
aim was so to improve the general system that tuber-
cular disease in the lungs should not appear.
Dr. Barlow writes ;* " The stage of deposition, which
is often regarded as the first, is that in which tubercles
are first present in the lungs, and as they are generally
considered as essential to Phthisis, it may, perhaps
appear illogical to speak of any previous state of dis^
ease ; but setting aside this difficulty, as rather formal
than real, it must be obvious that since tubercle is
itself a pathological epigenesis or morbid product,
there must have been some antecedent diseased action
preceding or even causing this product. This previous
marked condition is of a twofold character,-^the one
generally affecting the whole system, constituting what
has been already described as the tubercular diathesis,
and the other local, depending upon a determination of
blood to the lungs."
* " Mantial of Practice of Medicine."
VIEWS ON THE EARLY STAGE OF PHTHISIS. 35
Dr. Hughes Bennett remarks ; * '* Phthisis in its
incipient stage may he considered a very curahle dis-
ease, indeed so much so, that cure is, as we have seen,
spontaneously accomplished by nature in a vast number
of cases."
Dr. Hamilton Roe, our senior colleague, has kindly
expressed to us his opinion upon this subject in the
following words: — ''Consumption never attacks any
one until his health is broken down, and therefore it
must be preceded by the ordinary signs of cachectic
condition, and though few or any of them are so cha-
racteristic of any particular complaint that they* may
not be the forerunners of some other, they are so very
frequently followed by Phthisis, that wherever they
appear we have cause to apprehend that it is approach^
ing. The signs which first attract observation, and
which gradually became more marked are, an altered
expression of the countenance, an unusually faded
colour of the face and skin generally, that differs from
ansemia, a look of languor, debility and depression of
spirits, and dulness of the eyes. On inquiry we learn
that a degree of exertion which at one time was not felt
at all inconveniently now produces fatigue ; that going
up stairs causes breathlessness and disturbance of the
heart's action ; that the appetite is capricious, and
plain food unpalatable ; that symptoms of indigestion
are manifested ; that sleep is not sound as usual, and
that the patient wakes in ^ the morning unrefreshed i
that tlie temper is irritable and the pulse feeble."
* " Pulmonary Consumption," 1859.
36 HISTOEICAL SKETCH.
Dr. Richard QiiainhsiS also courteously communicated
to us the following observations. Every clay's clinical
experience decides that tubercles in the lungs are but
the local manifestation of a morbid process which has
its origin elsewhere. What this process is, what the
exact seat of its origin, and why the lungs become the
seat of tubercles are some of the most important
subjects to w^hich investigation can be directed. Scien-
tific research and cHnical observation have, v/ithin a
few years, supplied many facts calculated to aid in
answering these inquiries ; and practical physicians
have* sought by gaining " early information " of the
features which characterize the constitutional con-
ditions, and of the physical signs which mark local
changes in the lungs, to anticipate the malady in its
earliest stage, and thus to check a progress which, if
allowed to continue, might be impossible to impede.
Enough has been gained to justify the confident belief
that much more is within reach of earnest inquir3\
Dr. Cotton* under the general heading of " The pe-
riod preceding the formation of tubercle " states that,
" sometimes this, which we may term the preliminary
stage " (or dawn as he elsewhere terms it), " is so well-
defined that to fail in recognising it would be almost
inexcusable ; at other times it is either too brief or too
indistinctly marked to be detected." These symptoms
are commonly, slow diminution of bodily vigour, good
spirits, pallid or sallow complexion, animated yet care-
worn expression of features, hurried and anxious move-
* On Consumption.
VIEWS ON THE EARLY STAGE OF PHTHISIS. 37
ments, uncertain appetite, imperfect digestive power, and
diarrhoea. Variable, but generally small and excitable
pulse. Sleep restless and occasional perspiration, and
invariably loss of weight. The duration of this stage
is very variable. He also devotes a chapter to the
" treatment of Phthisis before tubercle is deposited."
Dr. Lawson* explicitly treats upon the symptoms
and signs of the precursory stage, and explains that
" the phrase precursory stage is designed to indicate a
morbid state existing intermediately between the mere
diathesis on the one hand, and the deposit of solid
tubercles in the lungs on the other. The diathesis is a
constitutional predisposition to disease, which, under
favourable circumstances, may never become developed;
the precursory stage, on the contrary, is the beginning
of a positive morbid action which, if not arrested, surely
and steadily progresses to the deposit of tubercles."
He then divides the symptoms into those which refer
to the state of the general system, and "those which
spring directly from the pulmonary organs and respira-
tory passages." Those w^hich refer to the state of the
general system are, defective vital powers, impaired
strength, slight loss of weight, and lowness and irregular
action of the functions, chills and febricula from vari-
able conditions of calorification and innervation, a state
of debility of the heart and arterial and capillary circu-
lation, disease of the pharyngo-laryngeal structures in
a large majority of cases, trivial cough and spitting,
and perhaps a little haemorrhage.
* On " Phthisis Pulmonalis," 1861.
38 HISTORICAL SKETCH.
The evidences furnished by the lungs are, debility of
the moving parietes of the chest, with incomplete dila-
tation, but capability of perfect expansion on deep inspi-
ration. The percussion note is less clear, and over a
large area, from deficient mobility of the thorax ; and
the respiratory murmur is generally (not partially) weak
and jerking. He strongly asserts that these evidences,
described b}^ him in detail, are associated with the pre-
tubercular period.
Mr. Ancell, in his laborious work on "Tuberculosis,"
states : — " The inspiratory and expiratory motions
being accelerated, but small, or small without being
accelerated, indicate that the function of respiration,
m,easured by the extent of these motions, is below the
standard of health; the frequency of motion by no
means compensating for the loss of extent. It shows
a diminution of the vital capacity or breathing power of
the lungs, which occurs in tuberculosis before any de-
posit or appreciable organic disease in these organs."
Since 1855 we have called professional attention to
this subject on numerous occasions, as in papers *' On
the Curable Stage of Phthisis," read before the Western
Medical Society; on "The Pre- Tubercular Stage of
Phthisis," read before the Medical Society of London,
and published in the " Edinburgh Medical and Surgical
Journal," 1856 ; on " The Principles and Treatment
of Chronic Phthisis," in the " Midland Quarterly Me-
dical Journal," and since separately published ; and in
a course of lectures on " Certain Views on the Nature
and Treatment of Phthisis," delivered at the Hospital
for Consumption, &c., Brompton, and published in the
VIEWS ON THE EAELY STAGE OF PHTHISIS. 39
*' British Medical Journal," 1856-7, as well as in other
papers since published in the same journal. In the
paper on *' The Principles and Treatment of Chronic
Phthisis" we introduced the following observations on
the evidences of the first or pre-tubercular stage : —
" Its own evidences are shorter breathing, less breath-
motion, feeble and shorter inspiratory sounds, and par-
ticularly the vesicular sounds ; and this may be more
or less general over the whole of both lungs. Expira-
tion quick, forcible, and perfect. Deep inspiration may
be effected, but it is not effected, by the patient, unless,
at least, his attention be directed to the defect, and
more commonly not until he has given attention by
repeated efforts. This may be readily proved by the
inspiration. The quantity of tidal air is often dimi-
nished in ordinary breathing ; the general indications
of the body are those of atonicity, and possibly the
rate of pulsation and respiration may be increased, and
the complexion and condition of system evince a state
of mal -nutrition. There will probably be flattening
of the chest, depending upon original conformation, or
upon the progress of the disease. The same remark
will also apply to dulness on percussion. Cough may
or may not exist, as also some haemoptysis. The
essence of the whole is less respiratory action, and as
this varies in degree, extent, and duration, so will the
other signs vary."
In the discussion which followed the promulgation
of these views, and which appeared in the '* Medical
Times and Gazette," 1857, Dr,Markham stated: — "Of
course we all know well enough that there is a morbid
40 HISTORICAL SKETCH.
condition of the body existing anterior to tlie deposit
of tubercle in the lungs ; that tubercle is not the dis-
ease, but merely the external and tangible manifesta-
tion of that anterior condition — perhaps the last of a
long series of antecedent changes which have been
working in the system ; that the disease may be thus in
the body from the moment of the first evolution of the
ovarian vesicle ; and we know also that treatment is
not directed to the tubercle, but to the averting, it may
be, of that morbid condition which presides over the
deposition."
Such are the opinions which have been placed upon
record as to the existence of a precursory or pre-tuber-
cular stage of phthisis. For the reasons which we
have already assigned, the numbers of persons who
could give testimony of the nature sought by us are
few ; but in proportion as they have been educated at a
period distant from that of the teaching of the Laennec
school, and in proportion also as a spirit of inquiry has
become more general, we find those who entertain
the view that there must be a condition of the general
system, or of the lung, or of both, which precedes and
leads to the deposit of tubercle. There are also many,
and even distinguished men, who have not sufficient
belief in the efficiency of auscultation to reveal the
earliest deposition of tubercle, and who will not admit
that, although there are no evidences of the deposition,
they are not entitled to affirm that the deposition does
not exist. This confidence, we are aware, presupposes
the possession of a degree of knowledge only to be
attained by constant and large experience in the careful
yiEWS ON THE EARLY STAGE OF PHTHISIS. 41
examination of these cases ; but for those who possess
it to hesitate in the mass of cases, to believe that
tubercle is absent when there are no evidences of its
presence, implies, we think, a desire for a degree of
evidence which is not required in management of the
ordinary concerns of life, and to attach undue import-
ance to the cases (very few in comparison with the
whole) in which small nodules of so-called tubdrcle
have been found after death, but neither discovered nor
sought for during life.
We think that we may, with confidence, refer to the
authorities now adduced as proof of the advance which
has been made on this subject within the last few years;
and whilst they differ in opinion as to the nature of this
early stage, they all tend to prove that there is a stage
of the disease which exists before the deposition of
tubercle, and that its evidences are to be found both in
the lungs and the general system. We cannot but con-
gratulate ourselves that the views which we propounded
seven years ago are almost identical with those which so
able a writer as Dr. Lawson has recently issued.
PART 11.
NATUEE AND EVIDENCES OF THE EARLY
STAGE OF PHTHISIS.
CHAPTER IV.
GENEEAL OBSERVATIONS.
Having thus concluded our sketch of the history of
the disease, and shown how far an early stage has
been heretofore recognised, we proceed to consider the
nature and evidences of the latter, as a preliminary
proceeding to a consideration of the treatment.
STAGES OF THE DISEASE.
It is customary at the present day to mark the
progress of Phthisis by reference to the lungs only, and
to divide it into three stages, of which the 1st is
limited to the period of deposition of tubercle ; the
2nd includes softening of tubercle, and destruction of
tissue, and the 3rd is that period when a cavity exists.
There would no doubt be defects in every arrange-
ment which might be proposed, but we think that
there is a radical defect in this one in the omission of
all reference to the general system, and in separating
the period of destruction of tissue from that of the
STAGES OF THE DISEASE. - 43
formation of a cavity, which are evidently parts of the
same process. The first has existed ever since the
modern views were first established, but the latter was
unknown to Laennec and Louis, for they recognised
but two stages, those of consolidation and destruction.'
The existing arrangement has also the further defect
of imptying that the importance of the case increases
in proportion as the stages advance, omitting all re-
ference to the important facts of the greater or less
extent of the lung disease, its limitation to one lung or
otherwise, and the amount of injury inflicted upon the
general system, whereas we know that so far is this
from being necessarily true, that no adequate opinion
can be formed of the condition of a case by indicating
the stage in which the disease exists. Moreover, it
has the defect of impljdng that the general tubercular
condition is as exactly limited in its progress as the
stage indicates, so that the deposition having proceeded
to a certain point, is arrested, and the work of destruc-
tion commences, and this at length ends in the 3rd
condition, in which the softened matter is removed, and
a vacant place or cavity is left, but in truth all the
actions proceed simultaneously in different parts of
the lungs in nearly every case, and whilst the agent of
destruction is busy in one part, new tubercle is being
deposited in others. Hence the basis of the classification
is only valid when we fix the attention upon one and
the same restricted portion of the lungs. If relation
to the danger of life and the progress of the disease
could be included in the grounds of classification, it is
clear that the state of the general system would take
44 GENERAL OBSERVATIONS.
precedence of that of the lung, for at all times it is the
condition of the general system to which we refer when
Ave attempt to estimate the chances of impending
danger. The condition of the lungs is good ground
for diagnosis, hut that of the system is the true ground
for an immediate prognosis.
As our purpose in the following work is to limit
the attention to that state of the disease in which
treatment is of the greatest avail, we shall not enter
further into the question of classification, hut shall
content ourselves with indicating the division which
we would adopt. We divide the progress of the disease
into three stages, the 1st including all the conditions
existing before any evidence of the deposition of
tubercle is afforded ; the 2nd the period of tubercular
deposition ; and the 3rd that of destruction ; thus
adopting the earlier classification, with the addition of
the pretubercular period of the disease.
CO-EXISTENCE OF GENERAL AND LOCAL DISEASE.
We now purpose to consider the nature and the evi-
dences of the early stages of phthisis, and to show how
far they may be distinguished both from the more
advanced state of the disease, and from other conditions
with which the general evidences are allied, and we
hope to prove that the first stage has a substantive
existence, and presents features by which it may be
readily recognised.
The evidences of the first stage are associated both
with the general system and the lungs, and in both they
are co-existent in time.
CO-EXISTENCE OF GENERAL AND LOCAL DISEASE. 45
In this part of the discussion it must be borne in
mind that whilst the lungs may be regarded as separate
organs, with special duties and responsibilities which
cannot be delegated to other structures, they are at the
same time an important and essential part of the general
system. Hence it is impossible that any morbid con-
dition of the lungs should long exist without inducing
a diseased state of the other functions of the body,
which together constitute the general system ; neither
is it likely that any continued diminution of the general
vital powers sjiould occur without the lungs enter-
ing into the community of suffering. Strictly speak-
ing, there must be a period in acute conditions in which
the one may be diseased whilst the other is sound, but
in chronic states, of which the prime moment of depar-
ture from health cannot be ascertained, and in which
the changes towards disease proceed slowly and in-
sidiously, there is no period in which it may be safely
affirmed that the one suffers whilst the other is free.
Both alike are under the influence of general causes,
and they suffer simultaneously, although it may be in
very various degrees. Hence, whilst in the disease in
question, w^e have a localised disease of the lungs, and
such a variation of the general functions of the body as
to represent a diminution of the vital powers, we can
neither dissociate one from the other, nor assign a
precedence in time to the one or the other. They are
co-existent conditions, and react upon each other. It is
therefore rather in this belief than with a view to prove a
dependence of one upon the other, that we shall now
proceed to consider in detail the conditions of the
46 GENERAL OBSERVATIONS.
system generally, and of the lungs and other local
organs m particular. Neither do we wish it to be
understood that there is any clearly-defined line of
demarcation between the lungs and the general system
in their functional character, and it is only in their
anatomical and physical relations that we shall consider
them separately.
GENERAL EXPRESSION OF DISEASED ACTION.
With evidences derived from the many functions
which constitute the general system, there must he a
common expression either as to the nature or the tendency
of the changes induced.
It will be evident that no general changes can occur
in the functions of the body without having debility as
their issue. The due and harmonious working of the
body constitutes health, and whilst there may be
degrees of health, there can be no variation in the
vital actions which shall exceed the condition known
as health, for the most perfect functional condition is
health. Whenever changes occur there must be a
disturbance of the balance of the vital actions, and as
a result, a condition of disease in that particular func-
tion which is primarily changed, and in the whole
system of functions which is more or less dependent
upon it. Derangement of function must, therefore,
induce less vital power, or, in other words, less health ;
and, as a consequence, the system is less able to
supply its own wants, and to defend itself against
adverse influences, and debility or lessened vital power
is established. Hence there are not any true general
.VAKIATIONS OF THE TYPE OF HEALTH AND DISEASE. 47
sthenic conditions, if the standard of health be regarded
as our basis, since health is the natural condition of
the system, and nothing stronger or higher in degree
can occur ; yet, if we compare healthy with diseased
conditions, we find them relatively sthenic and asthenic ;
but the latter is essentially below, whilst the former
cannot be above health. The general expression which
we seek as indicative of the first stages of phthisis is
asthenia or lessened vital power.
VARIATIONS OF THE TYPE OF HEALTH AND DISEASE.
The separate conditions, which together constitute the
general expression, must he variable in degree as the
type of health varies.
It is important to bear in mind that unless the type
of health, as evidenced by the general organism be
identical in all persons, the variations from that type
cannot be universally the same. In our desire for
simplicity and uniformity in the diagnosis and treat-
ment of unhealthy conditions, we seek for general
descriptions and directions which shall be an universal
and infallible guide ; but as such a desire confounds all
the varieties which nature has established, it is evident
that it is the expression of limited knowledge. As we
must admit the existence of various types of health,
each having its own peculiarities, although all possess
outlines in common, so when we consider changes
from disease in their earliest manifestations, we are
compelled to admit variations in its evidences, and must
seek to classify them as we have already classified types
of health under the heads of temperaments, races and
48 GENEEAL OBSEEVATIONS.
climatic conditions, until the diseased changes have
proceeded so far that they have implicated the condi-
tions upon which life itself depends, when they will
assume aspects of greater similarity.
As we have in the first stage of phthisis the earlier
deviations from a state ,of health, we must he prepared
to admit much variation in the evidences of the disease,
and yet not thence assume either that the disease is
protean in its character or the description of it inexact.
Moreover, as these conditions are common with others
which are found in the course of other diseases, it
must not he assumed that they have no definite relation
to the one under discussion, for the generalsystem may
he similarly influenced, whilst other and local conditions
may vary.
The sanguineo -nervous and the lymphatic may he
regarded as the extreme types of temperament, as seen
in this country.
By the sanguineo -nervous temperament we mean one
in which there is great activity of the whole organism,
as seen in the high flow of spirits, the excitahle nervous
system, rapidity of circulation and respiration, readi-
ness for exertion, rapidity of digestion and transfor-
mation, and as externally marked hy a hody of medium
development, a form a little given to rotundity, a
coloured complexion, bright aspect, light coloured eyes,
and hair varying in shade from brown through sandy
and auburn to flaxen. The tendency of such a system
is to excess of action, and therefore to waste.
The lymphatic temperament is represented by com-
parative inactivity of all the mental and vital actions.
VAKIATIOI^S OF THE TYPE OF HEALTH AND DISEASE. 49
This is shown by slower mental appreciation, tendency
to low spirits, soft and not rapid pulse. Feebler and
slower respiration, lack of desire to make exertion, some-
what spare habit, or if fleshy, the flesh is loose and
flabby ; assimilation slow and imperfect, eyes brow^n
or dark, aspect dull, soft, pasty, and expressionless ;
complexion pale or sallow, and hair variable, from light
brown to black. Such a system is deficient in the
power of reproduction of tissue, and tends to exhaustion
by faihng to supply.
Without discussing this subject more minutely than
our present purpose demands, it will, we believe, be
admitted that the evidences of the early deviations from
health must be very different in the two classes of
cases, and the admixtures of them which abound in
society ; and that although in both alike the tendency
of the system is to deficiency of vital power, that condi-
tion is brought about by very different means, requires
very different modes of investigation, will vary greatly
in the rate of downward progression, and offers very
different chances of restoration to health.
There is no one temperament ivhicli is exclusively
found in phthisical patients ; hut the two extreme types
are largely diffused amongst them.
We have largely inquired' into the relative frequency
of these types of health, as seen in phthisical persons,
at least so far as refers to the respectable class who are
the out-patients at the Hospital for Consumption, and
who represent the masses of the community. In this
investigation we have determined the questions which
are usually included in the idea of temperament ; such
60 GENERAL OBSERVATIONS.
as the colour of the hair, eyes, and complexion, the
rotundity of the hody, and the degree of excitability of
the nervous system ; and, in doing so, have expressly
excluded the period during which the disease has
existed, and have ascertained the natural or healthy
conditions of the individuals. "We will now cite the
results in the order just given.
The Hair. — The variations of colour of the hair
which we have recorded are black, chocolate, dark
brown, brown, sandy, light brown, light, and flaxen ; and
in arranging the results of 1000 cases for analysis, we
have taken the medium brown colour as the standard,
and have compared the whole of the darker and lighter
shades respectively with it. Of the whole number of
cases, male and female, 32' 1 per cent, exhibited the
medium tint, whilst 34*7 per cent, had darker, and
30* per cent, light coloured hair. The instances of
the extreme colour were few, so that black hair was
found in only 1*4 ; chocolate, in 5*7 ; sandy, in 4*1; and
flaxen, or nearly white, in '33 per cent. ; and hence the
various shades of brown were almost universal. In
reference to the influences of sex, we may remark that
the medium and the darker colour were more frequent
in the females, whilst the lighter greatly preponderated
in the males. Thus, in reference to each of the three
divisions, medium brown, dark, and light, the per-
centage of frequency in females was 34, 41, and 19,
whilst in males it w^as 31,30, and 38. Black and sandy
hair was, however, more frequenth^ found in males than
females.
The Eyes, — We recorded three colours only, viz..
YARIATIOKS OF THE TYPE OF HEALTH AND DISEASE. 51
black, hazel, and grey, with the darker and lighter
shades of the two latter, so that blue was included in
the grey. The number of investigations was 1000, and
of these 74*0 per cent, had grey ej^^es, 23'0 per cent, had
hazel, and not 1 per cent, had black eyes, so that the
preponderance of one colour was very marked. The
grey colour prevailed in the men, and the hazel in the
women ; the per-centage of the two colours being, in
women 69 and 26, and in men 77 and 20.
The Complexion. — The colour of complexion in the
phthisical patients is not that which had existed in the
same person in health, but we found no difficulty in
ascertaining whether the natural tint of the complexion
had been coloured or pale, and the replies of 1000
persons were arranged under these two heads. The
coloured complexion was found in 58'3, and the pale
in 40 per cent. There was also a considerable pre-
ponderance of the florid complexion in females over
males, whilst the pale was noticed reversely in nearly
an equal proportion. The actual frequency was :
florid, 65 per cent, females, and 53 per cent, males ;
pale, 34 per cent, females, and 44 per cent, males.
The Habit of Body. — The inquiries were made from
1000 patients under the four heads of rounded, spare,
muscular, and bony; but for this analysis we have
arranged the answers under two only, viz., fleshy and
spare. The general returns showed singular equality,
for 45*8 were fleshy, and 51*9 per cent, were naturally
spare ; but there was a marked difference in the two
sexes, since 60 per cent, of the women had been fleshy,
and 37 per cent, spare, whilst of the men 33 per
B 2
52 GENERAL OBSERVATIONS.
cent, only had been fleshy, and 61 per cent, had been
spare.
The Degree of Excitability. — We sought to elicit this
fact by ascertaining if in good health the patients had
exhibited evidences of an excitable, firm, or languid-
temperament, and as the first greatly preponderated, it
will suffice if we quote the returns. Of 1000 persons,
71 per cent, exhibited the excitable or susceptible tem-
perament, and the proportion was nearly equally dis-
tributed in the two sexes, since in females it was 75,
and in males 68 per cent.
We have thus endeavoured to epitomise the results
of this part of a very laborious inquiry into the
etiology of phthisis, to which we shall have to recur
on numerous occasions. As a general expression of
the whole, it may be stated, that there is the greatest
diversity in all the points of inquiry in phthisical per-
sons in this country, but there is a preponderance of
cases with grey eyes, florid complexion, fleshy habit
of body, and excitability of temperament. Whether
however, they differ in these respects from the com-
munity at large has not yet been determined. In
reference to the sexes, the females constituted the
greater proportion of the cases with dark hair, hazel
eyes, florid complexion, and fleshy habit, whilst there
was much equality in reference to pale complexions and
excitability of temperament.
In the following chapters we shall consider the state
of the several functions of the body in the two classes
of cases just indicated, and shall have occasion some-
times to refer to them separately.
CHAPTER V.
MENTAL AND NERVOUS OEGANISATION.
The general condition of the nervous system in
the sanguineous cases is marked by sensibility and
excitability. The spirits are greatly elated under
pleasing circumstances, so that the vivacity is beyond
that of health, whilst at other times there is sudden
and unaccountable depression, rapidly alternating
with the former and becoming more marked by con-
trast. The elation is chiefly found after the break-
fast hour and until the afternoon, whilst the depres-
sion follows fatigue, precedes the meals, and is com-
mon in the evening and the early morning, before and
at the hour of rising. In the middle hours of the day
the spirits readily answer every call, but in the evening
they are not only low% but they do not readily obey the
impulses which at other periods excite them.
The same remarks also apply to the general nervous
organism so far as relates to its increased excita-
bility, for it is unusually sensitive to all impressions,
whether pleasing or painful. The influence of sudden
impressions, whether of mental emotions or of physical
occurrences, is increased, so that shock, whether of the
mental or general nervous organism, is more easily
54 MENTAL AND NERVOUS ORGANISATION.
induced. Fear more certainly paralyses, pleasure ex-
hilarates, pain exhausts, and cold revulses than under
ordinary conditions. The influence of the period of the
day is different from that which is found in reference
to the spirits, for the increased excitability is the
greatest in the evening, night, and early morning, and
the body is then the most liable to be injured by
adverse agencies.
If we now turn to the patients of a lymphatic
temperament, we commonly find that the spirits are
depressed under all conditions and at every period of
the day, whilst the degree of sensibility of the general
organism remains unchanged.
Hence in a large number of cases it will be found
that there is much diversity in the sensitiveness of the
mental and general organisation ; and when we add to
this the influence of the events of life upon the masses
of the community, we shall readily admit that, whilst
there may be much diversity in degree, there will be
great uniformity in the occurrence of the fact of
depressed spirits and disturbance of the general
sensibility.
CHAPTER VI.
ALIMENTATION,
The tvhole of the processes concerned in the function
of alimentation are commonly lessened in vigour.
This proposition we believe to have the widest
application, and yet at the same time to have only a
limited force.
APPETITE.
The appetite seldom remains naturaly hut is some-
what lessened in respect of food in general and of some
foods in particular^ and is commonly ivayioard and
uncertain.
There are, doubtless, many cases in which no notice-
able change of the appetite has occurred, for, since
men usually take more food than they strictly need,
and the appetite falls into a routine course, there may
be a certain diminution in and variation of it before
the change is noticed, but we venture to affirm that on
careful inquiry it will be admitted that the appetite is
not so good as was formerly the case. The period of
the day when it is in the greatest defect is the morning.
Whilst pursuing an inquiry into certain circum-
stances met with in phthisical patients, we thought it
would be of interest to ascertain in what degree the
56 ALIMENTATION.
ordinary articles of diet were disliked by phthisical
patients before their disease commenced, in the hope
that by the aid of a similar inquiry to be made upon
healthy persons we might determine if there were any
constitutional peculiarities in this respect in this large
class of persons. This investigation is incomplete,
but we have abstracted the returns from about 400
patients, of whom 276 were cases of phthisis. The
inquiry included acids, sugar, tea, coffee, vegetables,
fruits, bread, meat, milk, and fat, and the question asked
w^as whether they had liked or disliked them in health.
The combinations of so large a series precludes the
possibility of giving the results in detail, but we shall
quote the principal facts which have been obtained.
The number of cases in which one of the articles
was the sole food disliked were few, except in refer-
ence to fat, viz. : acids, 2*1 ; sugar, 2*8 ; tea, *7 ;
coffee, 2*; vegetables, '3 ; fruits, 1*; bread, '7 ; meat,
•3; and fat, 23'4 per cent., and there was not an
instance in which milk was solely objected to.
When, however, we refer to the combinations of the
several foods we find large numbers who disliked
them. Thus acids were objected to by 29*; sugar, 25' 7;
tea, 11*6; coffee, 17*3; vegetables, 2*1; fruits, 5*;
bread, 6*1 ; meat, 4*3 ; milk, 6*1 ; and fat by 66*6 per
cent. Acids and fat alone were objected to by 10;
acids, sugar, and fat alone by 3*2 ; sugar and fat alone
by 5*4 ; coffee and fat, and tea and fat, each by *7 per
cent. ; and bread and fat alone by 1 * per cent. The
various other combinations amount to 66 in number,
and offer much interest.
APPETITE. 57
We further sought to ascertain if there were an}'
differences in those cases in which the perspiration
was usually free and in those who were commonly
liable to have perspirations of an acid odour, and the
following results were obtained : —
Of those who disliked acids, 36" 6 per cent, were
liable to much perspiration, 31 "8 per cent, had acid,
and 37*1 per cent, had not acid perspirations. Of
those who disliked fat, 78-8 per cent, had much
perspiration ; in 69-2 per cent, the perspirations were
acid, and in 58*5 per cent, there was no perception
of the acidity. Of those who perspired with unusual
readiness or to an unusual degree, 35*2 per cent, dis-
liked sugar, 15*4 per cent, disliked tea, and 28' 1 per
cent, objected to coffee. Those who experienced acid
perspirations and disliked sugar, tea, and coffee, were
37*3, 14-2, and 24'1 per cent.
There was a great similarity in these particulars
to those obtained from persons in whom general
asthenia was the leading feature, but great dissimi-
larity to those found in chronic bronchitis. Thus the
dislike of fat with much perspiration was in phthisis,
debility, and bronchitis 78*8, 78*5, and 42'8 per cent.,
and the same dislike associated with acid perspirations
was in the three diseases 69*2, 72*4, and 38*4 per cent.
There was a larger proportion of cases of debility
which disliked acids, with much perspiration and with
sour perspirations, than in phthisis.
In reference to the dislike for sugar, tea, and coffee,
there was not absolute uniformity in the results, as may
be seen by the following table : —
58
ALIMENTATIOJT.
TABLE No. 1.
Showing the Per-centage of thosh who dislike Suoar, Tea, and
Coffee, with certain Conditions op the Perspiration.
Perspire much —
Dislike Sugar
„ Tea ... .
,, Coffee
Have Acid Perspiration —
Dislike Sugar . ...
„ Tea ....
■„ Coffee . . . .
Phthisis.
Debility.
Bronchitis.
35-2
15-4
28-1
37-3
14-2
24-1
35-
7-
14-
so-
lo-
37-
41-
14-
35-
34-
15-
21-5
The dislike for sugar was nearly equal in the three
diseases. Tea was less frequently disliked by the
cases of debility than by those of phthisis and bron-
chitis, whilst there was a want of uniformity in the
taste for coffee.
We also instituted another special inquiry into the
prevalence of a distaste for the various kinds of fat,
and of meat and milk, and now proceed to quote the
results.
DISTASTE FOR FAT.
The prevalence of a distaste for fat was determined
by an inquiry made upon five hundred cases at the
Hospital for Consumption, of persons suffering from
phthisis in the several stages, bronchitis, debility, and
derangement of the liver. The fats selected for
inquiry were fat of meat, butter, suet, milk, and
fat of bacon, and the results obtained are inserted in
the following table : —
DISTASTE FOR FAT. 6d
TABLE No. 2.
Showing the FREQuENcr with which Fat Food, in various
Combinations, is eaten in Disease.
F signifies fat meat, B butter, S suet in puddings, Mk milk, and Ba fat
bacon. The italics show that the fat was liked little, whilst the small
capitals indicate that it was liked much.
Kind of Fat
Phthisis.
^
1
S m
Out-patients.
eaten.
.11
'rS
tT
g
t-
13 fco
1 §
3 i
w
►3
«^
<s
<X) '-tJ
C3 -<-*
3 03
>^
KH «
02
«
6-^
46
15
6
F B S Mk Ba
...
62
27
24
11
i^ B S Mk Ba
...
17
9
5
3
5
5
F B S Mk Ba
1
1
1
1
F ^ S Mk Ba
...
1
F B S Mk ^a
...
"3
i
2
1
F B SM.k Ba
2
2
F B S Mk 5a
...
2
1
1
...
...
F B S Mk BA
1
1
...
F BSMk Ba
...
3
1
i
"i
i
7? 5 S Mk Ba
...
2
1
1
i5' B S Mk BA
...
1
i? B S Mk Ba
...
...
"i
...
FB S Mk Ba
...
...
1
...
i? 5 S MK Ba
...
1
...
F B S UK Ba
...
...
*i
FB SMkBa
1
...
F B S Ba
i
2
"i
1
F B S Mk
52
12
4
2
"1
P B S Mk
1
FB S Mk
...
...
"i
F B SMk
i
"2
"2
i^ B S Mk
18
8
3
"2
i
F B S
1
...
FB S
1
...
...
...
FB S
1
...
...
F Mk
...
1
...
...
...
F B Mk
i
...
...
...
FB Mk
1
...
...
...
...
F B Mk
Carry forward .
...
...
...
"i
60
ALIMENTATION.
Table No. 2 — continued.
Kind of Fat
eaten.
Phthisis.
1
1
If
Out-patients.
1
1
1
1
1
02
li
Brought forward
¥ S Mk
F S Mk Ba
F S Mk 5a
F S
5 S Mk Ba
5 S MK Ba
B S Mk Ba
B S Mk £a
£ S Mk Ba
5 -S Mk 5a
B S Mk Ba
B S Mk BA
£ S Mk £a
B S Mk
£S Mk
BS Mk
5S Mk
5S MK
B S Mk
5^Mk
£ MkBa
B Mk Ba
£ Mk
B Mk
B 3Ik
B S
£S
B
S MkBa
S Mk Ba
S MkBa
S Mk
MkBa
Mk
'l
i
34
"i
12
1
1
1
3
"i
"3
i
7
1
17
4
1
2
2
1
23
1
2
2
1
3
2
1
2
2
3
2
1
"i
1
1
"2
1
3
"5
I
I
1
12
I
1
1
"i
"2
1
i
1
1
"2
"2
i
'4
2
"2
1
"7
"2
1
"i
i
1
"i
i
4
1
"i
4
i
1
'i
1
"i
"2
1
i
"i
"i
"5
1
"2
"i
"i
"i
1
'i
1
1
2
i
"f
1
7
1
2
1
i
*i
1
i
Total number
examined
137
213
99
71
45
72
51
18
DISTASTE FOR FAT. 61
TABLE No. 3.
Showing the Per-centaqe op the Cases in which the various
Fats were taken in Disease.
Kind of Fat
eaten.
Phthisis.
a
P
1
1
If
Out-patients.
< ^
3rd.
2nd.
1st.
fQ
Q
1-4
\-i
M
Fat .
56-1
58-3
55-5
65-2
53-5
79-1
58-8
33-3
Bacon . .
...
66-8
76-6
66-6
65-1
84-7
60-7
50-
Suet .
83-5
93-3
94-
95-6
88-
98-6
64-7
95-
Butter . .
94-2
95-7
95-
97-1
95-3
95-8
94-1
100-
Milk .
92-8
98-1
98-
98-5
97-6
97-2
98-
100^
5 Elements
46-4
72-2
47-
38-8
4 „
...
28-4
...
...
16-6
1-7
16-6
3 „
18-0
...
...
•7
2*7
38-8.
2 „
•52
...
...
...
•55
1 „
•19
t
Of the 213 phthisical out-patients, 46 per cent, ate
all the kinds of fat; 28 per cent, ate four kinds; 18
per cent, ate three kinds ; J of 1 per cent, ate only two
kinds ; and not -j^ of 1 per cent, were limited to one
kind only. By way of parenthesis, we may state, that
if milk be regarded as one of the fats, only three
patients ate milk exclusively, and hence some of the
other fats were taken by 210 of 213 cases. The
number of cases by which each of the fats was taken,
w^as in the out-patients as follows : — Fat meat was
taken by 58 per cent. ; bacon fat, 66 per cent.; suet,
93 per cent. ; butter, 05 per cent. ; and milk, 98 per
cent. The quantities are in each case a little higher
€2 ALIMENTATION.
than those obtained from the in-patients ; but we rely
upon them, since the in-patients, being asked the
question in parties, were somewhat influenced in their
answers each by the other, as shown by a tendency to
uniformity in the answers of each party of patients ;
whereas the out-patients were asked singly. It is also
quite possible, that their tastes may have been slightly
changed during their residence in the hospital, and
thus fewer persons liking suet may be owing to the
surfeit which some of them get with the milk and suet
supper.
We have inserted the results obtained from other
conditions than those under discussion, both from
their own interest, and as facts with which those
observed in the early stages of phthisis may be com-
pared. The highly important fact was elicited that fat
is less commonly liked in phthisis than in other diseased
conditions of the system, and that this dislike is more
general in persons afflicted with the disease in its early
than in those suffering from the subsequent stages
of the disease. Thus, 58*3 per cent, of those in all
stages of phthisis liked some form of fat, but in the
early stage alone the number was reduced to 63*5 per
cent., so that nearly half of all cases of early phthisis
have a distaste for fat. In reference to the kind of fat
which was most disliked at this early period, we re-
mark that only 37'7 per cent, liked all the kinds of
fat ; 28"8 per cent, disliked fat bacon ; '23 per cent,
disliked milk; 6*6 per cent, disliked butter ; 44*4 per
cent, disliked fat of meat ; and 9 per cent, disliked suet
in puddings.
DISTASTE FOR MEAT AND MILK. 0S
DISTASTE FOR MEAT AND MILK.
The diminution in the relish for meat is much less
than that for fat, but it is more evident in the early
than in the advanced conditions of the disease. In
this particular there is doubtless much diversity, but
it will commonly be found that in the conditions in
which there is any material diminution of appetite, the
distaste for meat is greater than for other prime
articles of food. In the advanced conditions, there is
still a tolerable and in some cases a good appetite for
flesh meat. In an inquiry in which we noted all the
ingesta and egesta of fifteen phthisical cases for ^
month in the summer season, it was found that the
average quantity of cooked mutton without bone which
the several cases ate was as follows, in ounces : 3*7,
3-6, 3-, 3-6, 5-9, 4*6, 5*4, 5*4, 5'4, 6*, 6-9, and 4-5,
or a total average quantity of 4*83 ounces. In all these
instances the supply of meat was unlimited, and as they
were all men, and belonged to the working classes, it
must be admitted that whilst the quantity taken was
considerable, it was below that which healthy men
similarly situated would have eaten.
The diminution in the relish for milk is ordinarily
not very great, and when there is a distaste for that
article of food, it is frequently found that it had existed
in a state of health. The foregoing table (No. 3)
shows in how few cases there was an entire dislike
to . milk in this early stage of the disease ; but when
large numbers of cases are considered, we believe that
^ dislike has been acquired much more commonly than
64 ALIMENTATIOiT.
the table indicates. It is, however, to be observed,
that when a dislike occurs, it is almost always based
upon a belief that the milk does not agree with
the system, and that it scarcely ever occurs that
there is any true dislike to milk when made into
puddings.
DIGESTION.
There is commonly some derangement of the function
of digestion^ hut it is frequently small, and in such cases
is not important.
The evidences which we would adduce in support of
this proposition are that the tongue is more or less
discoloured, or loaded with a buff-coloured coat, and
presents enlarged and projecting papillae, and is not
unfrequently large and flabby. Also that there is a
sense of oppression after meals, and tenderness over
the epigastrium on pressure, at most periods of the
day ; a sour taste in the mouth, and flatulency. These
conditions are more commonly found with the lymphatic
temperament, whilst in many of the sanguineo -nervous
temperament the tongue retains its usual size and colour,
and remains clean. It is very frequent in dressmakers,
tailors, shoemakers, and others of sedentary occupa-
tions; in printers and others living in foul air, and
engaged in night work ; and in the poor, who live
chiefly upon bread, potatoes, and tea ; and in all such
instances it is a prominent symptom, and demands
prime attention. In a majority of such cases there is
much intolerance of fat, and occasionally we have met
with instances in which fat caused pain at the stomach.
AMOUNT OF FOOD TAKEN. 65
AMOUNT OF FOOD TAKEN.
The amount of food taken is commonly somewhat
lessened.
In the inquiry referred to at page 63, it was found
that in the various stages of phthisis combined, there
was a diminution in the total quantity of solid food
consumed. The quantity taken by the several cases
in ounces was as follows, on the average of a month
in May and June: 18-9, 19-5, 18-7, 26-4, 247', 26'9,
28-8, 21-4, 22-1, 81, 32-2, 41*5, and 22, or a total
average of 25*5 ounces. The average amount of solids
eaten in health, as deduced from our own inquiries, is
from thirty-five to forty ounces, and hence it is mani-
fest that, notwithstanding the existence of a tolerable
appetite for food, there was a considerable diminution in
the total weight of food taken. We have reason to
believe that there is the same proportionate diminu-
tion in the food taken in the early stage, at least in a
majority of the cases, — a diminution beyond that
which the patient is aware of, until closely ques-
tioned upon the subject.
ASSIMILATION.
The assimilation of food is commonly defective.
The degree of assimilation of food is chiefly to be
proved by the weight and general condition of the
system, and as we shall show that they are usually
reduced whilst there is a moderate quantity of food
taken, it will follow that there is lessened assimilation
of nutritive material. This fact is capable of deter-
ee ALIMENTATION.
mination in a more exact way, by ascertaining the
proportion of the elements of a given quantity of food
which remains in the bowel as compared with that .
which occurs in health, for we have proved by our ex-.
periments in prisons* that, under conditions in which
there was lessened assimilation of food, there was an
unusual quantity of nitrogenous matter remaining in
the bowel, and which consequently had not entered the
blood. We hope to find opportunity to determine this
fact experimentally in phthisis. In the absence of
these inquiries we must fall back upon the external
evidences of mal-assimilation, and shall be able to
show that the general system is not well nourished.
WEIGHT AND BULK OF THE BODY.
The weight and hulk of the body are almost uni-
versally lessened.
We believe this proposition to be true in the great
majority of instances, and when it appears to be
otherwise we would counsel a careful inquiry into
the facts at all the jDeriods of the disease. It is
quite true that cases of isolated tuberculous masses
have been found after death, which were un-
connected with any known change of health during
life, but that is not satisfactory evidence, — and
we know of instances in which there are the evi-
dences of deposition, and yet the person remains in
apparently sound health ; but we contend that in
almost all instances careful inquiry will show, that at
* Phil. Trans. 1861.
WEIGHT AND BULK OF THE BODY. 67
the period of origin of the disease there was loss of
flesh and weight extending over some months. This
diminution of weight and bulk is often only temporary-
even in those cases in which the disease slowly pro-
gresses ; and either by the unassisted powers of nature
acting in the cycle of the seasons, or by more careful
attention to hygienic conditions, it passes away for a
time, and the weight again becomes nearly normal. So
general, however, is this loss of weight, that we should
expect to find it in every case.
But the fact being admitted, it is necessary to con-
sider what importance should be attached to it. As
ordinarily understood, it is referred to the solid struc-
tures of the body, and to the muscular or nitrogenous
tissues in particular, and hence great importance is
commonly attached to this sign as an evidence of
defective nutrition. Upon this point recent experi-
mental inquiries have thrown much light, and we will
endeavour in a few words to explain the position of
this question at the present moment.
The weight of the body depends upon the amount of
food and excretions contained within the body, of the
fluids in the circulation and in the tissues, of the more
solid parts of the soft tissues, and lastly of the heavy
and comparatively unchangeable bones. Hence, varia-
tion in any of these numerous sources will influence
the total weight of the body.
The errors due to the food and excretions may be
almost removed by taking the weight of the body before
breakfast, and after faeces and urine have been passed ;
but this cannot be eff'ected at any other period of the day.
F 2
68 ALIMENTATION.
The variations in the amount of fluid in the body
which occur under normal conditions are exceedingly
great, and refer to the water contained both in the blood
and in the tissues. It is evident that there will be
more fluid 'in the blood withii^ an hour and a half after
a meal than will be found immediately before the fol-
lowing meal. We have also shown elsewhere* that as
the excretion of fluid is lessened in the later part of
the day, there must be an increase in the quantity of
blood at that period ; and this in our own case is so
constant and to such a degree, that we usually weigh
from one pound and a half to two pounds more at
11 P.M. than at 8 a.m. We have also shown that the
excretion of fluid is materiallj^ influenced by tempera-
ture and barometric pressure, when acting suddenly ; so
that increased atmospheric pressure induces increased
elimination of urine on the same day, and increased
temperature the contrary effect, either on the same or
the following day. With a falling thermometer and a
rising barometer, as in frosty weather, there is great
increase in the elimination, whilst with a rising thermo-
meter and a rising barometer the effect is scarcely per-
ceptible, since in the former case two co-ordinate actions
reinforce each other, whilst in the latter two opposed
actions neutralise each other. Hence variations of
meteorological conditions exert great influence upon
the bod}^, and vary its weight greatly, so that it in-
creases in the summer and diminishes in the winter.
Moreover, whenever from any cause there is a large
♦ Phil. Trans. 1861.
WEIGHT AND BULK OF THE BODY. Qd
elimination of urine, there will be on tlie following
days, or there was on the preceding day, a correspond-
ing diminution, as the following examples in health
prove : —
Alternations
64, 40, 71, 44, 66, and 33 fl. oz.
57, 37, 62, 44, 60, and 46 fl. oz.
Waves . . . 73, 50, 41, 41, 57, 52, 54, and 63 fl. oz.
Increase . . 44, 38, 60, 62, and 74 fl. oz.
Decrease . . . 68, 49, 49, 40, 42, 37, and 26 fl. oz.
Hence, whilst these variations in a long period neu-
tralise each other, and thus tend to keep the body of
uniform weight, they disturb the weight in each direc-
tion when regarded for short periods.
The elimination of fluid is also influenced greatly by
the quantity of fluid ingested, by the kind of food, and
by exertion. Thus, a quantity of fluid taken upon an
empty stomach before breakfast, causes the emission
of about thrice its own weight within three hours ; but
if food be taken, the emission is greatly reduced, and
a large portion of the water becomes fixed in the body.
In the latter case the food prevented both the emission
of the water which had been drunk, and the further
quantity which would have been otherwise educed by
the fluid taken. With much food, much water is fixed,
and vice versa; and hence, when the appetite is les-
sened and food is diminished, the emission of fluid is
thereby increased.
In reference to kind of food, we believe ourselves
justified in stating that fat, flesh, and animal foods have
the greatest power to prevent the elimination of fluids ;
whilst, on the other hand, starchy food allows the elimi-
70 ALIMENTATIOK
nation. This is observed in practice ; for those who
live well on animal food often retain a larger bulk
than the ill fed. Hence, when the appetite for fat
and flesh is lessened, there will be an increase in the
elimination of fluid, and the weight of the body will be
thereby decreased.
We have also proved that when in ordinary condi-
tions of health there has been a day of comparative
fasting from both fluids and solids, there was much less
elimination of fluid on the following day, when the
usual quantity of fluid and solid food was eaten, than
would have occurred under normal conditions.
Rest preceded by exertion always tends to prevent
elimination of fluid on the day of rest, upon the prin-
ciple which w^as active in all these researches, viz., that
during the period of exertion there was an unusual
emission of fluid, and during the subsequent rest nature
restored the balance by temporarily fixing a larger
quantity of fluid.
We need not stay to prove that a variation in the
quantity of fat in the body will cause a considerable
variation in the weight, and have only to remark, that
this applies not only to the fat deposited in the skin,
but to that in muscle, to the extent of fifty per cent.,
if we may quote experiments made upon well-fed ani-
mals. We believe that so long as fat is abundantly
supplied from without and duly assimilated, or there is
an excess of fat in the body which may be consumed,
so long is there a power to withhold the extreme emis-
sion of fluids; and therefore, when a person is losing
fat, he not only loses weight pari passu with the loss of
WEIGHT AND BULK OF THE BODY. 71
■fat, but when the store of fat is exhausted, he loses
weight in a rapidly-increasing ratio from the more rapid
elimination of fluid, until that bulk and weight are
attained which are consistent with the existing state of
health and the kind and amount of food supplied.
Thus, in the case of persons in training for violent
exertion, or in that of prisoners on the tread-wheel,
where the amount of animal food supplied is abundant,
the weight lessens only as the fat and superfluous
fluid disappear ; but after no long time an arrest of this
process occurs, and the muscles retain their bulk. In
conditions in which there is not a sufficiency of animal
food, or, as in the disease now under consideration,
there is defective assimilation of food, the loss of weight
continues after the fat has been removed. Hence it
follows that loss of appetite for fat and flesh has far
greater influence over the weight of the body than the
loss of weight of these substances will account for.
We have now seen how many sources of loss of
weight there are, without having any reference to the
nitrogenous elements of the body. In reference to the
muscular tissues, we must further observe that they
consist of from twenty to fifty per cent, of fat, accord-
ing to the condition of the body, and that in the lean
of muscle alone there is about eighty per cent, of
water. Every housewife knows how much more lamb
will shrink in cooking than mutton, and the diff'erence
between a grass-fed and stall-fed ox is well seen in the
greater loss of weight which the flesh undergoes in the
process of roasting. We are also familiar with the
fact that some flesh is soft, compressible, and flabby,
72 ALIMENTATION.
whilst other is hard and resisting to the touch. All
these prove that bulk and weight of flesh do not imply
uniformity in nitrogenous elements, but are largely
influenced by the fluids which are contained in the
tissues. Hence therefore, on the one hand, as by
exertion, we may have an unusual emission of fluid from
the muscles, and their weight and bulk be lessened with
a relative increase of their nitrogenous elements, so on
the other the weight and bulk of a muscle may be main-
tained whilst the nitrogenous elements are reduced and
the contained water increased.
We have thus shown in how great a degree the com-
ponents of the body may vary with change of weight
and bulk ; and it may well be asked if, with such diver-
sity of cause, loss of weight in th^ early stage of phthisis
means anything of general interpretation.
It follows that the diminution in weight and bulk
which occurs in early phthisis is no necessary evidence
of loss of nitrogenous tissue, much less that it is
altogether explained by it. But when, as we have
shown, there is some diminution in the food taken,
when there is less perfect assimilation of food, and
when fat is disliked, it will follow that the store of fat
in the body will be lessened, that the elimination of
fluid will be increased, that the nitrogenous parts of
the body will be less perfectly restored, and that the
tone of the tissues will be lowered. Hence, in such
cases, loss of weight indicates numerous conditions
of great importance.
CHAPTER yil.
ELIMINATION.
The fixation of fluid in the body is lessened, and the
elimination of it increased.
We have already referred to this condition under the
preceding heading, but shall now analyse it somewhat
further.
We have shown the relation between the fixation and
elimination of fluid on the one hand and the quantity
and kind of food on the other, and stated that there is
lessened ingestion of fat and flesh, and a correspond-
ingly larger elimination of water. The immediate
result of this is to lessen the bulk of the body, and
by diminishing the fulness of the tissues and the
blood-vessels to give the sense of atonicity or flabbi-
ness to the limbs. It also indicates and is co-ex-
istent with lessened nutrition of the body. It is.
probable that this result is partly physical and partly
vital, and commonly proceeds to a moderate degree
only. It is also to be noted that whilst there is some
diminution in the quantity of food, there is no diminu-
tion, but often an increase, in the quantity of fluid
taken, and that this tends to increase the elimination
of fluid.
74 ELIMINATION.
We will now offer some remarks upon the two prin-
cipal eliminators of fluid, viz., the skin and the
kidneys.
THE siaN.
The action of the skin is commonly increased, either
absolutely or relatively to the vital transformation.
In a majority of cases of early phthisis the skin is
thin, fair, and very sensitive, and we believe it to be an
indisputable fact, that at the early period of the disease
as it is usually seen, apart from any evident inflammatory
action, the skin is soft and cool, and tends easily to
perspire, and to this we attach the utmost importance.
The function of the skin is almost entirely that of
the heat-regulator of the body, and in that capacity
it rules almost every vital function. It is not, as
is commonly supposed, an organ which, in case of
need, may act vicariously for the lungs, for in our
experiments, in which the whole body, except the
head, was enclosed in a caoutchouc dress, through which
a current of air was first passed, and then carried over
a solution of potash, we only obtained six grains of car-
bonic acid per hour, or about 1*25 per cent, of that emitted
by the lungs ; and by similar experiments made on the
Continent it has been proved that the quantity does
not exceed 2 per cent. Hence it is manifest that,
whatever may be the source of this carbonic acid, the
quantity bears no such proportion to that which is
emitted by the lungs, that the one organ can act vica-
riously for the other. Moreover, the structure of the
two organs is so totally dissimilar that, a priori, it
would be impossible to admit identity of function.
THE SKIN". 75
The skin acts as the heat-regulator of the body by-
radiating heat into and absorbing it from the atmo-
sphere, and by the conversion of the fluid into vapour,
which occurs upon its surface. We do not need to refer
further to the two former processes, but shall offer some
remarks upon the latter only.
It is well known that insensible evaporation or per-
spiration from the skin occurs at all times, and that,
under favourable conditions, the quantity of fluid
vaporised is so greatly increased, that being condensed
in the air surrounding the body it becomes evident to
the sight, or being condensed upon the body it rushes
down the skin in streams. In this act of vaporisation
a large amount of heat is rendered latent, so that a
given quantity of fluid being converted into vapour,
the latter will require nearl}^ one thousand times more
latent heat than the former. The heat thus absorbed
and rendered latent must be abstracted from the sur-
rounding substances, and therefore chiefly from the
skin upon which the process is proceeding. This
explains the cooling effect of perspiration which all
have noticed to follow exertion, or exposure to heat,
or the ingestion of certain hot fluids, as tea, or the use
of the hot air, vapour, or water bath.
It is chiefly by this means that uniformity of the
temperature of the body is effected, under varying
conditions. Thus after a meal, when vital actions are
proceeding vigorously, and heat is being abundantly
generated, the skin, as every other part of the body, be-
comes hot, and if this proceed to any great extent, and
it be also dry, there is a sense of oppression induced.
7j6 ELIMINATION.
because the body cannot rid itself of its superfluous
heat; but after the lapse of an hour or two, and especially
after taking tea, the skin becomes soft and active, and
vaporisation cools the body. So when the vital actions
are increased by exertion, and heat is abundantly gene-
rated, we know that the normal result is increased
evaporation and perspiration ; and the same explanation
avails us to account for the power which the body has
of keeping itself cooler than the surrounding air in the
burning regions of the East. For these purposes it is
necessary that the skin be in a condition in which
evaporation may proceed, and that the circulation supply
a sufficiency of fluid to the skin to meet this constant
drain.
In the contrary condition of cold the skin becomes
less active and is dry, so that evaporation is reduced
to a minimum, and the refrigeration of the body
depends mainly upon radiation, and is regulated chiefly
by clothing.
Hence it follows that the skin is almost omnipotent
in preventing excess of heat, and acts as a self-regula-
tor quite apart from our care, but it is almost powerless
against the effect of cold, and we are then left to our
discretion in protecting the body by clothing and
shelter.
In the cases now under consideration this beneficial
action of the skin is converted into an evil by being in
excess of the requirements of the system, and its
tendency is to cause too free elimination of the fluid
from the body, to unduly reduce the temperature of
the body, to injuriously interfere with the force of
THE SKIN. 77
the heart's action, as we shall have hereafter more
particularly to point out, and lastly and most impor-
tantly to waste the hody hy demanding an excess of
vital transformation in order to maintain a supply of
heat from within — a demand which cannot be supplied.
Hence we have an explanation of the ill health and of
the occurrence of phthisis in persons who exchange
a hot for a much colder climate.
The amount of fluid which is thus lost by the skin
may be approximatively ascertained by the series of
experiments which we made upon fifteen phthisical
patients in May and June (already referred to at
page 65).
The table No. 4, page 78, contains a number of facts
to which we may hereafter have occasion to refer to
supply the information which we now seek.
The part of this table to which we wish now to
refer has reference to the relation of the egesta to the
ingesta.
In the various cases referred to the total fluid and
solid egesta varied daily from 65*3 oz. to 143'1 oz.,
with an average extending over the whole month of
92*7 oz. The weight of the faeces, sputa, and urine
varied in the different cases from 29'7 oz. to 67*7 oz.
or a total average of 48*04 oz. The excess of the
ingesta over the egesta varied from 32-6 oz. to 75"3
oz., with an average quantity of 44*66 oz., and if we
deduct from that amount the carbon exhaled by the
lungs, nearly the whole remainder will represent the
fluid which passed off by the skin and lungs. The
amount of carbon evolved was not ascertained, but
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•S IS S
THE SKIK 79-
from our inquiries upon persons in health we find
that 194 grs. of carbon are expired daily in quietude
to each pound of body-weight, and as the average
weight of these patients was 135 lb. the total daily
elimination of carbon in health may be estimated at
6 oz. daily, and in a state of disease at five-
sixths of that amount. Hence the amount of vapour
eliminated by the skin and lungs was about 40 oz.
per day, and this abstracted from the body nearly
40000 times as much heat as was held latent by
that quantity of fluid when within the body.
Hence in the class of cases now under consideration
we find the skin unusually active and abstracting heat
rapidly from the hodj, when, at the same time, there
is less transformation of nutriment than occurs in
health, and consequently less heat produced within the
body. As a necessary result the temperature of the
body is reduced, the hands and feet become cold, and
the depression and exhaustion of the nervous power
ensues which is known to occur with excess of cold of
the body. In an inquiry made upon 1000 phthisical
patients, we found that 54 per cent, were constitu-
tionally liable to coldness of the extremities. Of these
4'8 per cent, suffered from coldness of the hands, and
19*1 per cent, from coldness of the feet alone; whilst
in 30*2 per cent, that condition aftected both the
extremities in the same • person. This was observed
in states of so-called health, but it must be much
in excess of the frequency occurring in robust con-
stitutions.
80 ELIMINATION.
UPtlNE.
The amount of urine evolved is perhaps equal to that
in healthy hut varies with the activity of other outlets of
tlie body.
We have shown in inquiries which were prosecuted
upon ourself throughout the year, that there is very great
variation in the amount of urine evolved in health at
the different seasons of the year, and also that there is
a relation between the amount of fluid evolved through
this and other outlets. The experiments in phthisical
cases just referred to, although extending over a long
period, may not be taken to represent the quantity of
urine which would be evolved at all seasons of the
year, and must, therefore, be accepted with a certain
amount of reservation. Moreover, we have shoAvn
that in these cases there was a very active state of the
skin, and consequently a large amount of fluid passed
away from the body by that outlet, and less would
remain to be eliminated by the kidneys. The daily
amount of urine varied from 21 oz. to 64 oz., and
the average of all fourteen cases was 38*8 oz. during the
whole summer month. The amount of urine in health
varies greatly in different persons, and it is very
difficult to obtain a standard with which it would be
just to compare any individual case, or a few cases,
but it is probable that the average now obtained is
not less than occurs in health.
SPECIFIC GRAVITY.
"We do not purpose to enter into a consideration of
THE URmE—SPECIFIC GRAVITY. 81
the quality of the urine evolved in phthisis, but as an
American observer* has made the unaccountable obser-
vation, that *' in phthisis, as a general thing, its
specific gravity does not exceed 1010," we think it
right to cite the specific gravity in the cases of phthisis
now referred to. The specific gravity was determined
with great care, by means of an instrument with a
large bulb, and graduated to a quarter of a degree,
and at the same time the exact temperature of the
urine was determined.
The inquiry was made in the day and night urine
separately, and as the whole returns are too voluminous,
we insert in the following table a copy of the record in
the first eight cases.
It will be observed that there was much diversity
in the returns of the specific gravity, so that on one
occasion it was so low as 1007, and in several others
as high as 1030. Usually that of the night urine
(9 P.M. to 8 A.M.) was less than that of the day.
We cannot determine the true average specific gravity
in these cases without the laborious process of multi-
plying each return by the number of ounces of urine of
the day and night separately, and adding the totals,
but it will sufiice if we represent the number of occa-
sions on which certain specific gravities were found.
Thus,
A specific gravity of 1030 and upwards was found in 4-3 per cent.
„ 1020 „ „ 650 „
,, less than 1010 ,, 2*4 „
* Extracted from the "Phil. Med. Reporter," Sept. 21, by "Dublin
ELIMINATION.
TABLE No. 5.
Showing the Specific Gravity + 1000 in the Day and Night Urine in
Eight Cases of Phthisis daily during One Month.
Case.
No.
90.
No.
93.
No.
95.
No.
88.
No.
79.
No. 75.
No. 73.
N.
"d?
N.
^
N.
^
N.
^
IT"
^
"nT
D.
N.
D.
May 15
26-
30-
11-
14-
18-
28-
14-5
24-
16-
30-3
17-
16-5
15-
30-
„ 16
25-
28-
12-5
21-2
31-
21-5
26-2
16-8
31-
18-2
19-
25-
25-
„ 17
21-
25-
12-
14-5
20-
27-3
18-5
24-
17-
29-
20-
12-
25-
26-
„ 18
25-
27-
14-
16-
22-
28-3
22-
26-
18-
13-7
16-3
12-6
25-
23-6
„ 19
26-6
28-5
14-8
17-5
15-
29-
9-
23-
17-6
29-5
18-5
15-
7-
27-6
„ 20
27-
26-5
16-5
15-5
31-
40-
26-
21-
25-5
31-
15-
13-8
27-5
25-
„ 21
25-
27-
14-5
17-
28-
30-2
12-6
23-5
16-6
27-
10-5
10-
25-2
28-
„ 22
22-7
29-5
12-6
13-3
26-3
30-5
18-3
21'
14-5
52-
17-
15-8
22-3
28-
„ 23
25-8
28-2
14-8
20-4
25-
24-
22-
21-
17-5
27-
13-
11-8
25-5
26-
„ 24
24-
28-5
13-
14-
12-
28-
14-7
21-8
25-8
29-
15-5
19-7
17-
18-5
„ 25
16-8
25-5
11-
12-
25-
27-
15-
23-5
27-5
23-8
15-
22-5
9-6
26-
„ 26
24-
27-5
10-7
11-
25-
28-
16-5
13-5
22-
27-
14-
19-3
15-2
26-
„ 27
27-5
25-
9-
11-5
28-
29-5
20-5
23-
27-3
26-5
14-2
15-4
223
24-5
„ 28
25-
25-3
11-
11-5
26-5
29-
18-8
24-6
24-
29-
18-
17-
24-5
28-5
„ 29
24-
26-5
8-5
11-5
23-
29-
17-5
23-
28-
26-
No. 77.1
25-
24-
„ 30
26-5
28-6
9-5
11-
19-
27-5
16-5
22-
29-
37-
18-7
22-3
12-
25-6
„ 31
24-8
25-
9-6
11-6
23-5
27-
17-
20-2
25-5
33-5
20-6
24-
12-2
26-5
June 1
24-
28-6
9-5
9-5
16-5
27-
21-5
16-
24-
26-8
25-
24-
21-5
27-5
,, 2
„ 3
26-
25-5
24-
25-
8-
9-8
7-5
12-5
24-3
27-5
17-
25-8
25-
22-5
26-5
25-
34-
24-5
18-6
18-6
22-6
22-5
23-
20-3
26-
23-5
„ 4
25-2
28-
22-
29-
22-3
25-
12-9
27-
16-
24-
20-5
26-
„ 5
17-8
25-
15-8
27-
17-5
10-6
14-
30-
15-5
20-5
22-4
24-
!, 6
28-
23-5
17-8
31-3
12-5
19-7
14-8
27-3
10-
23-
22-
27-
„ 7
25-8
28-
18-5
22-
22-3
24-6
16-6
25-7
20-3
24-
20-
25-
„ 8
25-8
26-5
12-6
27-5
25-
19-
16-5
31-
20-5
23-5
24-
28-3
» 9
25-5
25-5
19-
28-
12-
18-6
22-
17-4
20-
26-5
25-
28-5
„ 10
27-
21-5
20-
26-
20-
21-8
34-
32-
20-
23-
23.8
23-
„ 11
24-
27-
17-8
26-2
11-5
21-
14-8
13-8
18-2
20-
21-6
25-2
and hence it is quite clear that the specific gravity
was certainly not less than in health.
As we intend on a future occasion to analyse the
returns of two large series of inquiries which we have
made, into the chemical and other qualities of the
urine in phthisis, we shall not enter more fully into
this question on the present occasion.
PERSPIRATION. 83
PERSPIRATION.
Perspirations are common in the early, as in the
later stages of phthisis, and oftentimes have a sour
odour.
Of 177 cases of phthisis we found 40*1 per cent, had
constitutionally a tendency to perspire much, 46*7 per
cent, perspired as is usual, and 27 '3 per cent, were
believed to perspire less than others in health. In
cases of debility and bronchitis there was a somewhat
greater tendency to perspire. In a comprehensive
inquiry, including one thousand phthisical persons,
we recorded that 25*4 per cent, had been ascertained
to perspire with unusual freedom in health.
It is common to regard the occurrence of considera-
ble perspiration as a mark of the advanced stage of the
disease; but in this we think there is an error. It
cannot be doubted that profuse perspirations occur in
the exhaustion of the later stage, and more commonly
than at any other period ; but it is equally true that
they are met with, in a less degree, in a majority of
cases in the early stage. This may be inferred from
the remarks already made (p. 74), but they occur in an
intermitting manner, and chiefly in the evening and in
the early morning, whilst the patient sleeps. They
also are observed whenever the heat is suddenly in-
creased, as also with the sudden occurrence of cold
weather in the autumn, upon any unusual exertion, and
on the occasion of sudden surprise. The cause of
this occurrence is to be found in the preternatural
G 2
84 ELIMINATION.
action of the skin, and particularly with that low state
of the vital powers, which we have shown to occur at
night, hoth in health and in disease. We are unable
to explain the precise mode by which the degree of
activity of the skin is regulated ; but in reference to the
latter, we have ascertained the rate of pulsation and
respiration, and the amount of carbonic acid evolved
at each hour of the day and night, and have proved that
the vital actions are reduced during the night to a point
not higher than from one -half to two- thirds of that
which is found during the day. Whether, therefore, a
state of atonicity occurs in the night, which leads to the
more rapid elimination of fluid by the skin, we perhaps
cannot prove, but the correlation of the two facts quite
corresponds with other observations both in health and
disease, viz., that with debility, or a diminished degree
of vital power, there is commonlj^ increased tendency
to perspire. We have also noticed that perspirations
occur in feeble persons who sleep when lying upon
the back, and in whom the tongue, falling back into
the pharynx, induces increased dyspnoea. In such
instances the patient sleeps uneasily, and wakes
bathed in perspiration; but on awaking, the respira-
tions become more natural, and the perspirations
gradually cease.
We have also observed two conditions of the perspi-
ration which must have a significance both in reference
to the condition of the system and as an indication for
treatment. Normally, the perspiration is slightly acid,
— a condition due, we believe, not to secondary changes,
as some chemists are inclined to think, but to the fixed
PERSPIRATION. 85
and volatile acids which have been detected in that
fluid. The amount of acid varies at different periods
of the day, so that before breakfast it is the least, and
if much exertion be then made, it will be found that
the perspiration is perfectly neutral, whilst after meals,
and particularly in the afternoon, the degree of acidity
is increased. We have noticed that in numerous cases
of phthisis the acidity of the perspiration is so in-
creased, that the odour has attracted the attention of
the patient, and particularly in the more marked perspi-
rations which occur in the early morning. In some
it is so pungent as to be perceptible, and sometimes
very offensive, in every part of the room, whilst in other
cases there is no acid odour, however profuse may be
the perspiration. In the former case, we have con-
stantly taken pains to prove that it occurs in cleanly
persons, and after daily washing of the whole body, and
when using clean linen, and is therefore not resulting
from the circumstances too commonly found in the
working classes. Of 177 cases of phthisis, 5 6 '4 per
cent, had a constitutional tendency to acid perspira-
tions; whilst of those who perspired much, 70'7 per
cent, had sour perspiration, and of those who perspired
less than is usual, 54 '2 per cent, had remarked the
acidity of the excretion. Hence phthisical persons
appear to be constitutionally predisposed to an acid
state of the perspiration.
We do not attempt any sufficient explanation of these
conditions, but that which most readily occurs is the
deficiency of alkali in the blood, whereby the final
transformation into carbonic acid is prevented, and
86 ELIMINATION.
which must lead to, as it would be indicative of, les-
sened respiratory changes. "We shall subsequently
show that this inference is to a great extent supported
by the effect of treatment. In many of these cases the
linen is stained of a yellow colour, after having been
worn but a day or two. The impression has been
conveyed to our mind that in the cases in which there
is considerable perspiration without any acid odour,
there is very marked debility of system.
CHAPTER YIII.
TEMPERATURE OF THE BODY.
There is a general tendency to defect of temperature of
the body.
We have already referred to this subject in
chapters YI. and VII. The temperature of the body-
bears a relation to the formation and supply of heat on
the one hand, and the dispersion of heat on the other.
In reference to the supply of heat we have already
shown that those vital processes upon which the pro-
duction of heat within the body is dependent are in a
greater or less degree lessened. With lessened trans-
formation of food and lessened nutrition of the body
there is diminished production of heat. In this climate,
where the temperature of the external air is at all times
below that of the body, there can be no gain of heat
from without, since the loss will exceed the supply;
but, on the contrary, there will be a loss, and particu-
larly at the seasons of the year when the temperature
is low and the air damp. In hot countries, however,
the temperature of the external air approaches to or
exceeds that of the body, and therefore there may be
an abundant, nay, even an excessive supply from with-
out which shall make good any defect in the produc-
88 TEMPERATURE OF THE BODY.
tion of heat within, and hence the condition now under
consideration is far less powerful in hot than in cold
climates, and in hot than in cold seasons. But in this
country, if there be defect in the production of heat
within, there must be absolute defect in the whole
supply. The dispersion of heat chiefly depends upon
the action of the skin and the protection of the body
by clothing and shelter. It is quite evident that as
there is a relation between the supply and the disper-
sion of heat, if the dispersion could be lessened in
a degree commensurate with the diminution in the
supply, the effect upon the system would be the same,
so long as the total diminution was not so great as to
act injuriously upon the system; but we have already
shown that not only is there a lessened supply of
heat but there is no diminution in the dispersion
of it ; nay, it often happens that there is both les-
sened supply and greater dispersion proceeding at the
same time, and a marked total defect must follow.
The action of the skin is, no doubt, the root of this
evil, and is not under the control of the untaught
individual, but there is an important subsidiary ele-
ment, viz., the clothing of the body, which is within
the control of those who may be able to obtain it. Of
the former we will not now say more ; but, in reference
to the latter, it is notorious how ill clad are many, both
of the poor and sick, and how passively they submit to
coldness of the hands, feet, and other uncovered parts
from day to day.
These conditions are more frequently found in the
young, in whom there is naturally great activity of the
TEMPERATURE OF THE BODY. 89
skin, and to whom activity of the vital functions is
relatively of greater importance than at other periods
ofHfe.
The importance of this condition is both demonstra-
tive and inferential. There can be no doubt that the
maintenance of a certain degree of temperature is
essential to the due performance of the vital actions, as
is well seen in those who suffer from long exposure to
cold. The long continuance of cold, moreover, reacts
upon the body, and tends further to lessen the frequency
of the circulation and the activity of the vital processes,
and thus, in the conditions under consideration, it exerts
a most injurious influence.
The occurrence of coldness of the hands and feet,
and a general tendency to defect of heat, must at least
imply that there is an inadequate supply of heat to the
body, and should lead us to infer that the .processes of
nutrition are insufficiently performed, for, in the con-
ditions in which we live, to be ill nourished is to be
cold, and a continuance of these states must lead
to deficient growth, and a depression of all the vital
powers, inimical to health and dangerous to life (p. 79).
CHAPTER IX.
MUSCULAR POWER.
The muscular power is commonly lessened.
It is not at all times easy to prove this proposition,
whilst in other cases the truth of it is very manifest.
Many, and especially the young, mistake will for
power and ambition for capability, and with the mode-
rate exertion made by females in the middle classes, it
may often seem that the capability for walking and
other ordinary modes of exertion remains unchanged.
But in all cases there is an earlier sense of fatigue than
occurs in health, and this is especially seen if there be
unusual or somewhat laborious exertion, as going up
hill or carrying weights. The muscles have also lost
something of their tone, and feel less resisting on
pressure. The thinner layers of the muscles become
relaxed, and dependent parts seem to hang more loosely.
The pupil is not uncommonly enlarged, so as to give
a bright and somewhat staring appearance to the eyes,
and the muscles of the face do not so completely
respond to the stimulus as to give full contractility
and expression to the features. The eye kindles
and the lips smile whilst there is vivacity of spirit,
but there is a languor imprinted upon the features
MUSCULAR POWER. 91
by the absence of the due contraction of the muscles
of the face.
Such, indeed, must be the case if what has already
been advanced have previously existed, for it is impos-
sible that there should be full muscular tone and power
with defective nutrition, innervation, and nitrogenous
food, and with a tendency to defect in the temperature
of the body. The condition of the muscular system is
the sum of the conditions of health, just as the muscular
system itself is the sum of the vital powers in a body,
the essential feature of which is action and capability of
motion. The least reflection shows that the muscular
system is in truth the body, for the bones simply offer
points of attachment and resistance to the levers, and
the vital organs are employed in supplying it with food,
and removing effete matters. The muscles are the end
of the system, whilst the lungs and other organs are
means to the end. Hence it follows that the condition
of the muscular system is the true measure of the vital
state of the system, and it cannot be perfect if any
essential parts of the vital actions are imperfect.
CHAPTER X.
THE CIRCULATION.
The circulation is commonly enfeebled, and somewhat
quickened.
We are accustomed to regard tlie circulation in
two aspects, viz., the force and the rapidity of the
current.
The force of the circulation is clearly dependent
upon two conditions, viz., the vis d tergo and the vis d
fronte. The propulsion of the current is due to the vis
a tergo and the vis insita, if the latter exist ; and if
they be lessened, the force is lessened until it ceases.
When fluid is impelled through smooth and partially-
filled channels, there is but little resistance to the
current, and the flow will be gentle and easy. As the
channel becomes fuller, so the resistance is increased,
assuming in all cases that the walls of the channel are
not extensible ; and in proportion as there is pressure
made upon the walls, so will the resistance be further
increased. If, with increasing resistance, there is no
increase in the propelling power, the force of the cur-
rent will become less ; and, on the other hand, if the
resistance be uniform, and the propelling power be
increased, the impulse will be stronger. Hence, with
THE CIRCULATIOK 93
much pressure, or vis a fronte^ there must he much
propulsion from the vis a tergo, and the greater the vis a
f route, the greater must be the vis d tergo, in order to
maintain the circulation. Upon these principles we
show the cause of the feeble circulation in early phthisis,
and its importance upon the whole phenomena of
nutrition.
If, as we have seen, the power of the muscular system
be reduced and innervation be lessened, it follows that
the vis a tergo of the heart upon the circulation is dimi-
nished also ; and if, as is believed, the vis a tergo which
maintains the circulation in the veins be the action of
the surrounding muscles, it again follows that the vis d
tergo is lessened. On the other hand, if the various
outlets of the capillaries be so increased in action that
the contents of the blood-vessels pass through with
unusual readiness, it follows that that the vis a f route is
lessened. If the vis a tergo were lessened, the pulse
must become softer ; how much more, then, when both
the propulsion and the resistance are lessened ?
This argument, we believe, to apply to all cases in
which there is rapid discharge of water from the blood,
as in the case of dropsical effusions, great emission of
urine, or perspiration ; but it is particularly applicable
to the case of the active skin, with its immense net-
' work of capillaries, and its special apparatus for the
elimination of water. With a soft and active skin, and
a normal power of the heart, there must be a soft pulse ;
then, how much more so when there is a soft and active
skin, a feeble heart, and a feeble muscular power to
maintain the venous current. Hence there is a chain
94 THE CIRCULATIOlJr.
of events, all of which hang together, and are amenable
to one prime condition.
The importance of this condition, in reference to
nutrition, is very evident. That a certain fullness of the
capillaries generally is necessary to good nutrition may
be inferred from the facts that vital actions are the most
powerful after meals, when the blood-vessels are nor-
mally in their highest state of repletion, and lessen as
the repletion lessens ; and also that vigorous vital action,
or nutrition, is not found with a feeble circulation and
soft pulse. Hence we infer that in this condition there
is not robust nutrition, whether the cause of it be pri-
marily in defective nutrition of those structures upon
the action of which the force of the circulation is
dependent, or upon the diminution of the vis dfronte,
or upon both conjoined.
We affirm, therefore, that in the early stage of
phthisis a somewhat enfeebled circulation and soft
pulse must be associated with the other conditions to
which we have referred.
The rapidity of the circulation varies under every
act which can affect the organism, and particularly with
exertion and food. As we have fully discussed this
elsewhere,* we will not here refer to it further than to
state that a meal will increase pulsation 15 to 30
beats per minute, that exertion will increase it from
15 to 130 per minute, according as we carry the
body, at the rate of 1 mile to 8 miles per hour;
* " Health and Disease, as influenced by the daily, seasonal, and other
Cyclical Changes in the Human System." (Walton & Maberly).
THE CIRCULATION. 95
that sleep in the daytime will lower the pulse 10 per
minute, and in the night, with the other conditions of
the night, will lower it to the further extent of 10
heats ; and that ordinary idle rest will lower the pulse
throughout the day to a considerable extent. It has
been regarded as an established rule, that a rapid
pulse indicates waste, and, if rapid beyond the normal
standard, that it indicates debility. In the early
stage of phthisis, the pulse is commonly either not
quickened, or it is quickened in a moderate degree
only ; and there are cases in which it is, on the one
hand slower, and on the other greatly quickened.
In the inquiry to which reference has already been
made, in which the rate of pulsation was determined in
each of the three postures of lying, sitting, and stand-
ing, at two periods of the day, viz., 8 a.m., before break-
fast, and 4 p.m., before tea, on the large average of 1500
observations in one month,* it was found that the average
rate of pulsation in the different cases varied from 73
to 125 per minute in the morning, and from 79 to 131
in the evening, as shown in Table No. 6, p. 96.
Of these 15 cases in different stages of phthisis,
one had a morning pulsation under 80, and nine under
90 per minute ; a rate beyond, but not greatly beyond,
that of health; but in numerous instances in the early
stage, and particularly in those of the lymphatic
temperament, we have found a rate of pulsation below
that of health.
What, then, is the significance of this fact ? If there
* " Bri. and For. Med. Chi. Review," April 1856.
96
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THE CIRCULATION. 97
be unusually free elimination of fluid from the blood
by any outlet, as, for example, the skin, and thereby
the volume of the blood be reduced and the force of
the circulation lessened, it is evident that, in order
to maintain a due amount of vital action in the tissues
of the body, the blood must be more rapidly distri-
buted to them, or otherwise they cannot receive a due
supply of that fluid. So, on the other hand, when
the supply of blood is not thus interfered with, but is
abundant, the rapidity of the circulation must be
lessened, or the supply would become excessiye.
Hence feebleness and rapidity of pulsation are as
naturally associated as are a full and slow pulse, and
to alter the rapidity, if that were desirable, we must
begin by changing the force. What, then, must be
the condition in which a feeble and slow pulse is
found ? If a rapid and feeble pulse be indication of
debility, how much more a slow and feeble pulse?
And hence it is scarcely possible to attach too much
importance to the latter as indicative of a system
depressed and difficult to elevate.
The normal condition of the circulation in early
phthisis is a certain amount of feebleness, with some
increase in the rapidity, and so long as the rapidity
is not very great, the conditions are as favourable as
they could be when allied with the disease. This is
due both to lessened f is a tergo and vis dfronte, and the
latter chiefly in connection with the skin.
Hence we do not consider that in early phthisis a
moderate rapidity of circulation indicates an increase
of vital action, whether destructive or otherwise, and,
W THE CIRCULATION.
therefore, does not cause, nor does it show increased
waste ; but, doubtless, there are cases in which
there is marked rapidity of the circulation, which
indicates increased vital changes of an inflammatory
nature, but these are exceptional ones, and have a
condition superadded to the phthisis. So there are
many instances in highly sensitive young females, of
sanguineo-nervous temperament, in whom there is
almost perpetually increased rapidity of the circulation,
due to emotional and similar influences, which must
cause, and be indicative of, increased waste ; but
however numerous these may be, they also must be
classed apart from ordinary cases. The large mass of
cases do not present either of these two conditions,
when they are in their ordinary state, and examined
under proper conditions.
CHAPTER XL
RESPIRATION.
The respiration is shorter^ shallower, feehler, and
perhaps quicker.
When first questioned, it commonly occurs that the
patient is unaware of any shortness of breathing ; but
he subsequently admits that on any unusual exertion,
as ascending stairs or running, his breath is short. He
also frequently finds that this state of the respiration is
increased after a meal ; and if he eats heartily or there
be much dyspepsia, there is marked dyspnoea.
The shallowness of respiration is determined both
by the general movement of the chest and the amount
of air inspired as shown by the spirometer.
On carefully looking in front of the exposed chest, it
will commonly be seen that the breath motion is
lessened over the whole thorax, but particularly at the
upper part of it. This is well seen in women, in whom
there is normally much motion at the upper part of
the chest. It is not compensated by unusual abdomi-
nal respiration, as is found in conditions of disease in
which there is an impediment to respiration, but the
whole respiratory movement is lessened. When the
spirometer is used (such an one as that arranged by us,
H 2
100
RESPIKATION.
wliich is capable of measuring even to one cubic inch
of air, without offering any important impediment to
respiration), it is found that the quantity of air which
is inspired per minute is considerably lessened, so
that if the person were in good health he would in-
spire, in the sitting posture, at rest, 400 to 450 cubic
inches per minute; while he only actually inspires
from 250 to 350 cubic inches in his ordinary mode of
respiration. When this defect is multiplied by the
twenty-four hours, it will be more clearly shown how
great it is ; but the whole loss is not ascertained until
the effect of exertion is imported into the question.
"We have elsewhere given, in a tabular form,* the
results which we have obtained in our experiments
upon the effect of various kinds of exertion over the
quantity of air inspired in health, and from these we
learn that, taking the quantity inspired when lying
and at rest as unity, the effect of ordinary exertion is
as follows : —
TABLE No. 7.
Showing the Inplukncb of Exertion over the Quantity op Air
inspired.
1. Lying . .
2. Sitting ....
3. Standing .
4. Singing, and reading aloud
5. Walking, at 1 mile per hour
6. , , 2 miles per hour
7. „ 3
8. „ 4
9. Horse exercise— Walking
10. ,, Cantering
11. ,, Trotting
12. Running, at 6 miles per hour
1-0
1-18
1-33
1-26
1-9
2-76
3-22
5-0
2-2
3-16
4-05
7-0
Edinburgh Med. and Surg. Jour.," Jan. 1859.
RESPIRATION. 101
Hence all men in health occupy a large portion of
the day in exercises which increase the respiration
from two to four fold during the period of exertion,
and when this is added to the respiration at rest, it
greatly increases the total daily quantity. But in the
cases now under consideration, not only is there inahi-
lity or indisposition to take the exercise which is com-
monly taken in health, and thereby a large part of the
ordinary increase is omitted, but during each moment
of the day, whether at rest or with exertion, there is
less respiration than occurs in health. Hence, when
these two causes of decrease are considered together, we
are enabled to form some conception of the importance
of even a small but constant diminution in the respi-
ration.
The feebleness of respiration is seen both in the
ordinary and in forced respiration. In ordinary respi-
ration, not only is the breath motion small, as it is
also in chronic bronchitis, but the effort is feeble, and
without that violence which is found in bronchitis.
There appears to be not only less respiration, but less
power to respire, as is evident to the most careless
observer. In forced respiration it is, however, better
marked, for it is much more difficult to train such an
one than one in health to perform deep and slow respi-
ration, both because the habit of shallow and feeble
respiration prevents him from duly apprehending what
is required, and from his inability to inspire deeply.
Such a person, when required to breathe deeply, per-
forms quick and short acts of deeper inspiration, ana-
logous to the short actions of a pair of hand-bellows
102 RESPIEATIOK.
when suddenly snatched open or suddenly pressed
down. The deep and slow inspiration which alone
would fill the bellows (to continue the illustration), he
does not easily apprehend and cannot readily perform.
This we believe to be in part due to a forgetfulness of
the proper habit of breathing, from the long continuance
of an abnormal mode of breathing, and partly to inability
to perform easily what is required. Moreover, it very
often occurs, that when such an one is taking a deep
inspiration, the inspiratory muscles too soon cease to
act and the chest suddenly falls to a certain extent,
whilst he believes that he is still inspiring. This is
most commonly seen in persons who are much en-
feebled, and who, having led a very sedentary life, have
not frequently evoked the full power of the inspiratory
muscles. We have also found many cases in which
the attempt at deep inspiration was frustrated by a sense
of choking. This is readily accounted for, since in
ordinary cases the sides of the pharynx, at the
epiglottis, approach closely at the end of a deep inspira-
tion, and when the sensibility is increased, such an
effect is yet more likely to follow. We have seen the
free edge of the epiglottis greatly contracted in such
cases.
Feebleness and shallowness of the respiration are com-
monly associated, and w^e think that these two qualities
must be taken together when considering their nature
and effects, and that there is such a dependence of the
one upon the other, that feeble breathing will induce
shallow breathing.
The causes of this must be referred to those which
EESriRATION. 103
ordinarily control breathing, viz., the muscular power
and the nervous influence. Nothing need be advanced
to prove that a feeble person does not breathe so power-
fully and deeply as one in a vigorous state of health.
This is seen universally, whatever may be the general
disease in which the debility occurs, so that it would
seem unnatural to find a feeble person breathing vigo-
rously, and it is, in fact, due to the condition of the
muscular system. We have already shown that in the
conditions now under consideration there is a defec-
tive state of tonicity and power of the muscular system,
and some amount of emaciation. But if we examine
the chest of one not in the habit of using the lungs
powerfully, it will be observed that both the pectoral
muscles have lost some part of their bulk, and are
become more or less thin and soft. Such is also the
condition of the muscles of the back and the inter-
costals ; and hence it is evident that, so far as the act
of respiration depends upon the action of these mus-
cles, it will be less efficiently performed ; and inasmuch
as we find a general condition of the muscular system
which is exemplified in certain respiratory muscles
which are external to the chest, so we may infer that
the internal muscles have a similar defect of tone and
power. Well-developed pectoral muscles and a vigo-
rous state of the muscular system in general would be
incompatible with feeble and shallow respiration ; and
although in the state of disease now under considera-
tion they do occasionally co-exist, they are exceptional
conditions, and due to exceptional causes.
The association of shallowness and feebleness of
104 RESPIRATION.
respiration is seen in the most marked degree in tailors,
shoemakers, clerks, and others who follow very seden-
tary occupations, and sit with the chest bent forwards.
In such persons the act of respiration is at all times
defective, and they are known to be very prone to the
recurrence of phthisis. *The stooping posture during
employment is, however, far more common than the
limits of this class would indicate ; for in the in-
quiry upon 1000 phthisical persons engaged in a great
variety of occupations, we found that 20 per cent, con-
sidered that it had been injurious to them.
Dyspnoea is not present in ordinary respiration.
It is well known that even in advanced cases of
phthisis, dyspnoea is seldom complained of, except by
those who are required to make muscular exertion,
whilst at the same time the amount of air which is
actually inspired and the power of respiration is consi-
derably diminished. This is, no doubt, due to the facts
that there may be great diminution in the vital capa-
city of the lungs without interfering with the small
quantity of air which is inspired in ordinary respira-
tion, to the lessened vital changes already referred to
at page 46, and to the accommodation which the system
has effected to the lessened capacity of respiration by
the gradual diminution in the capacity of the lungs.
Hence, a fortiori^ we shall not expect to find dyspnoea
in the early stages of phthisis, except when much re-
spiratory effort is required, as in ascending steps, or
running, or lifting weights. There are cases in which
the respiration is aided by the patient locking his arms
or hands behind his back, which gives increased power
KATE OF RESPIRATION. 105
in the act of respiration by placing the relaxed pectoral
muscles on the stretch, and enabling them to exercise
their full power as levers.
RATE OF RESPIRATION.
The rate of respiration is commonly somewhat in-
creased^ but, like that of pulsation, it is greatly influ-
enced by the temperament of the patient. In the
inquiry at the Hospital for Consumption before referred
to, it varied in the different cases, on an average of
1500 observations, from 16 to 31 per minute, as re-
corded in Table No. 8 (page 96), in which the cases
are arranged in the order of the rate of respiration.
These refer to the disease in its various stages ; and
whilst there is not so great diversity in cases in the
early stage, there is yet considerable variation.
The importance of increased rapidity of respiration
in conditions in which the respiration is shallow and
feeble, is very evident, and analogous to that of rapidity
with feebleness of circulation.
It is well established by the experiments of both
Vierordt and ourself that, with lessened inspiration of air,
there are lessened vital changes, and as the pulmonary
circulation is in a great degree dependent upon the ex-
pansion and contraction of the lungs in the thoracic
cavity, it is also certain that the diminution in the chest
movements will physically render less free the pulmo-
nary circulation directly, and the general circulation
indirectly. Both of these actions proceed pari passu,
and have equal importance. But when the respiratory
movements are quickened, there is an increased quan-
106 EESPIRATIOK
tity of air inhaled per minute, which will increase the
vital changes, and, in a certain degree, sustain the cir-
culation. Increased rapidity of respiration, when that
function is performed in a feeble and shallow degree
only, is the greatest advantage of which the condition
is capable ; and, like increase in the rate of pulsation,
is beneficial, and only to be interfered with by increas-
ing the completeness of the respiratory act. But there
are cases in which the respiration is both incomplete
in character and slow in repetition.
There is, as is well known, a correspondence between
the rapidity of the respiration and that of the circula-
tion ; and whilst this is quite true when applied to cases
in which the difference in rate is well marked, it does
not admit of very close appKcation. In our experi-
ments in health we found, in an hourly inquiry through
seventy-two consecutive hours in five persons,* the fol-
lowing number of pulsations to one respiration : — ^t.
6, 4-5; set. 8, 3-9; set. 33, 4*; set. 36, 4*1; ^t. 39, 3*4;
and in another sett of investigations, carried on through
eighteen hours of the day, the relation was — set. 26,
4-63 ; set. 33, 5' ; set. 38, 5*25 ; and set. 48, 5*72. In the
inquiry in reference to phthisis (page 65), we arranged
fourteen cases in the order of the rate of respiration
and pulsation, and Table No. 9 (page 96), shows that
the relative position under the two heads was, with
one marked exception (86), somewhat similar. The
numbers refer to the number of the cases in the
hospital books.
* " Med. Chi. Trans." 1856.
■ t "PhU. Trans." 1869.
VITAL CAPACITY. 107
VITAL CAPACITY.
This is, perhaps, a convenient occasion to refer to
the vital capacity, or that amount of air which may be
inspired from the extreme point of inspiration to the
most complete expiration, or, if inspiration be tested,
from the most complete expiration to the most complete
inspiration. We would first remark, that this depends
not only upon the condition of the lungs, but upon the
power of respiration, the tact to perform the act per-
fectly, and the degree of action (spasmodic, perhaps)
of the resisting muscles. We shall discuss the state of
the lungs hereafter, and shall here only refer to the
other condition.
The vital capacity of the lungs is diminished even
when there are no evidences whatever of the presence of
tubercular deposits.
We have tested this question with every care, and in
many persons, and believe the proposition to be true
in every period of the early stage of phthisis. No one
will deny that the vital capacity is lessened where there
is a material impediment to inspiration, such as occurs
with deposited tubercle, but many may question it in
the absence of this deposition, and affirm that, if it
exist, there must also be the tubercle. We shall discuss
this part of the subject in a future chapter, but here
we affirm that there is a considerable diminution in the
vital capacity, when there is no evidence whatever of
the existence of any deposit.
The amount of diminution varies with the duration
of the disease, and other conditions ; but we have known
108 RESPIRATIOK.
females, set. twenty, who could inspire only 100 to 120
cubic inches, and men of medium height whose capacity
did not exceed 150 cubic inches. To render these
statements of value, it is necessary to compare them
with the healthy standard; but here we meet with a
serious difficulty. Drs. Hutchinson and Balfour, and
others, have ascertained the average vital capacity
with different heights of body, and we are invited to
compare our cases with their returns. But their
averages were derived from great numbers of persons,
some of whom necessarily presented a vital capacity
much above, and others as much below, this average
quantity ; and we compare an individual case, not with
an individual high, medium, or low case in each class,
but with the average derived from the high, medium,
and low combined. If we had an equal number of
cases of disease, with the number taken in health, and
we simply desired to determine the average in both cases,
the results might be comparable ; but it is evidently
a fallacious course to apply an average from various
quantities to an individual quantity. This is doubt-
less the fallacy of all averages, when they are applied
as a test to any individual case ; but it proves that the
system of averages is not suited to such a purpose. It
is quite evident that if in a case of disease we find a
small vital capacity, we should be at liberty to compare
it with those cases in the great average which offered a
small capacity ; but if we should find an identity in the
results, it would be of no avail, for by the proposition
the one case is one of disease, and the other of health.
Hence we advise the greatest caution in comparing
VITAL CAPACITY. 109
the results of individual cases with those obtained
from large averages ; and by this source of error we
explain so much of that which all persons who practise
spirometry have found fallacious in the system.
Eegarding the cases under discussion absolutely,
we find a small vital capacity, and a smaller one than
occurs in health, but what value must we attach to this
fact ? It is too much the habit to regard lessened vital
capacity as a permanent condition, whilst we venture
to assert that it is often a temporary one, and one
existing wherever there is long- continued lessening
of the vital powers. We must not infer from the
fact that the patient inspires only a given quantity,
that the lungs could not admit a larger amount of air,
for we have shown that the capability to inspire as
fully as the lungs would admit depends upon important
causes, apart from the structure of the lungs, some of
which are irremediable for the moment, but remediable
subsequently, whilst others show an improvement even
during the examination. The power to inhale belongs
to the former, and whilst it may be increased, it must
increase by slow degrees. The appreciation of the right
method of inspiring or expiring air, or, as it may be
termed, the knack of respiring, maybe acquired more and
more perfectly during each examination ; and so much
is this the case, that no one would take the first attempt
as indicating the true vital capacity. It is constantly
found that the result will vary 10 to 40 cubic inches
at different efforts, and as we teach the patient, and he
clearly apprehends what is required, we find evidence
of larger vital capacity. The same observation will
110 RESPIRATIOK
also apply to the action of the muscles which impede
extreme movements of the chest, whether in expiration
or inspiration. No one can have been largely engaged
in examination of his own respiration without being
conscious of a sense of constriction at various parts of
the chest, and especially about the diaphragm, when
attention is given to the respiration, and it is quite
impossible to overcome that resistance by any effort of
the will. It is only removed when the attention is
withdrawn, or, in other words, when the person has
acquired the free and natural method of breathing. If
this be so with persons in health, who understand what
is required, and who have had large personal expe-
rience, how much more will it apply to persons in
disease, who are nervous and untrained in this kind of
inquiry ?
Hence we feel that there are so many sources of
variation in the results of spirometry, that until the
case presents features which, in the hands of competent
men, render spirometry unnecessary, we can seldom go
beyond the fact of having ascertained the amount
inspired, and must infer the cause of the supposed
diminution with caution.
SPIBOMETEES.
This would be a favourable opportunity on which to
refer to the various instruments which are in use for
the purpose of measuring the amount of air inspired,
but as we do not attach great value to this inves-
tigation in cases of disease, when the case is under
the observation of those well-trained in the physical
SPIROMETERS.
Ill
examination of the chest, we shall not occupy much
space in doing so.
A. Mouthpiece.
C. Inverted Receiver.
E. Scale.
P, Counterpoise.
R. Wheel.
S. Chain.
T. Tube, open above the
water-line inside, and
ending at A outside.
Y. Cistern to contain water.
M. schnepf's spikometer.
The air-holder of Hutchinson is now familiarly
known to the profession, and that of Pereira (which
was devised after the apparatus arranged by Sir H.
Davy) is of a similar nature, and both have the same
112 RESPIRATION.
merits and defects. They are arranged to measure
expiration, and are graduated to 400 or 500 cubic
inches, which is more than enough for the largest
expiration. They are so counterpoised as rather to
favour the ascent of the inverted holder as it rises from
the water, but there is no sufficient attempt to exactly
balance the weight of the holder at different eleva-
tions. Hence, whilst they are sufficiently accurate for
the purpose now under consideration, they cannot
be regarded as instruments fitted for exact scientific
research.
A modification of this spirometer has been made
by M. Schnepf, so that by varying the weight of the
chain in its different parts, it becomes a travelling
counterpoise ; and the weight of the holder is so exactly
balanced in every part of its course, that stop-cocks
and corrections become unnecessary. We insert a
drawing of this, the least imperfect of this kind of
spirometer. (See preceding page.)
Dr. Lewis, of Caermarthen, has recently introduced
a very simple and cheap instrument, which fulfils the
required indications with a sufficient degree of accu-
racy. The principle of its construction is the displace-
ment of a volume of water equal to that of the air
expired. The apparatus consists of a large glass jar,
placed on its side at an angle, so as to favour the removal
of the fluid, and furnished with an index, large tubes,
and mouthpiece. When the graduation of such an
instrument is carefully made, it becomes so far a
perfect instrument, and the only defect to which we
need to refer is the resistance which the mass of water
SPIROMETERS.
iia
offers to the expiratory force ; and althougli this is very
appreciable at the end of expiration, when the force is
greatly reduced, we are of opinion, after careful trial,
that its indications are as reliable as those of much
more expensive instruments. The following drawing
has been kindly furnished by Dr. Lewis : —
The spirometer which we have used in our various
inquiries, is an inverted dry gas meter of improved
construction, which has been adapted to measure the
air in inspiration, and to register from one to one
million cubic inches. It will, therefore, indicate the
quantity of air inhaled at one full inspiration, as required
in the determination of the vital capacity, or it will
register the number of cubic inches inspired during
ordinary respiration in an hour, or indeed for any
114 SPIROMETERS.
period however long or short. It is manufactured
by Messrs. CroU, Kait and Co., Kingsland Road, N.E.
For the further discussion of this subject, we must
refer to a series of papers on the Spirometer published
by us in the " Medical Circular " of 1857.
CHAPTER XII.
INNERVATION.
Innervation is commonly lessened.
We are not able to enter at any length into the ques-
tion of innervation, since the subject is at present too
much involved in mystery to enable us to do more than
indicate the general principles involved in that act.
There can be no doubt that, whilst there may be
certain powers inherent in tissues, as, for example, in
the muscular and fibrous tissues, there is a separate
controlling influence, which not only calls forth the
full power of action of each tissue and organ, but co-
ordinates movements, and enables the body to act in its
various parts simultaneously and as a harmonious
whole. This, whatever it may be, acts through the
nervous system, and hence a primary and controlling
power is given to that system.
The amount of power which may thus be exerted
varies with different conditions of the system, so that
at one time the nervous force appears to be efficient,
and the responses of the tissues which it calls into
action are ready and effectual, whilst in others one or
both of these conditions of force are weakened, and the
resulting action is below the standard of health, without
i2
116 INNEEVATIOJS^.
there having heen any serious injury inflicted upon the
nervous centres. This is seen particularly in condi-
tions of mal-nutrition from any cause, and as nutrition
is doubtless greatly under the control of the nervous
influence, we are brought to argue in a circle, and to
show that nervous influence sustains the nutritive act,
and is itself in part dependent upon the degree of
efficiency of nutrition.
So far as the defective nutrition, with its host of
consequences, may be a sure guide, it is safe to affirm
that there is lessened innervation in the early stage of
phthisis, and as that condition carries in its train nearly
every feature of the disease, we think we are warranted
in affirming that it is the ordinary condition of the
nervous system. With lessened appetite for food,
lessened accumulation of food, more ready elimination
of fluid, mal-nutrition, lessened muscular tone and
force, lessened cardiac force, and feeble respiration,
there must also be lessened innervation, whether we
regard the latter as a consequence or a cause of some
of the former.
We have now discussed some of the larger and more
general questions which affect the health of the body
and are concerned in the production of phthisis, such
as mental activity, assimilation, calorification, elimina-
tion, circulation, respiration, and innervation ; and now
proceed to discuss others of a subordinate and less
general character, and which cannot be arranged under
any common heading.
CHAPTER XIII.
THE MENSES AND LEUCORRHCEA.
The menstrual function is frequently disturbed, hut
probably not in a greater degree than occurs in health.
There is much liability to leucorrhoea.
When we consider the large mass of cases in the
disease now under discussion, we think that this pro-
position is true ; but for a due estimation of the import-
ance of the irregularity, it is essential to ascertain the
frequency of its occurrence in health. We can scarcely
enter upon the consideration of the menstrual function
beyond the statement of the facts, for the physiology is
at present too obscure to enable us to afford the explana-
tions which we desire. It is well known that, in the
advanced stages of the disease, it is usual to find that
the menses have ceased ; and, on the other hand, in
young women, in whom the functions of the body are
not vigorously performed, whether temporarily or for a
long period, it is very common to find a deficiency or
an arrest of the menstrual flow ; but in neither case can
we afford a sufi&cient explanation of the fact. To say
that they are associated with general debility and ener-
vation, or are dependent in part upon the degree of
activity of the body in the occupation of life, is simply
118
THE MENSES AND LEUCORRHCEA.
to state co-ordinate facts, and does not in the least
explain them, and yet such is nearly all that we can
adduce in reference to this matter.
We have thought it would be of interest and import-
ance to inquire into the natural tendencies of the
system in reference to this function in phthisical
persons, with a view to ascertain if any special pre-
disposition existed in them, and particularly to inquire
as to the age at which the menses first appeared, and
the general degree of regularity of the menstrual func-
tion during health, and we therefore instituted an
inquiry upon 1000 out-patients for that purpose. The
result showed that the epoch of menstruation occurred
at from" seven to twenty -four years of age, and the pro-
portionate appearance of the menses at each age was
ascertained to be as follows : —
TABLE No. 10.
Showing the Age at the First Appearance op the Menses.
iEt. years.
Per Cent.
^t. years.
Per Cent.
7
•26
16
15-1
10
•53
17
8-0
11
4^4
18
6-0
12
6-2
19
3-9
13
11-4
20
1-3
14
18-2
21
•26
15
18-2
24
•26
It therefore appears that set. 14 and 15 was the most
frequent period of the appearance of the menses, and
that there was a progressive increase from aet. eleven,
and a decrease until aet. twenty years. It is impro-
THE MENSES AND LEUCORRHCEA. 119
bable that so large a number as 11^ per cent, of
the women in this climate have the menses previous
to or at set. twelve, and hence, perhaps, there may-
be a slight preponderance in favour of the phthisical
patients ; but since more than 60 per cent, of the latter
commenced to menstruate at thirteen, fourteen, fifteen,
and sixteen years of age, it is highly probable that no
important peculiarity existed in them. We also ascer-
tained that in 4*0 per cent, the menses had never
appeared, although they had all passed the usual period
of the commencement of that function.
The same patients have also furnished us with infor-
mation as to the degree of regularity with which this
function had been performed in the course of the life
previous to the commencement of phthisis, and we
found that there was a tendency to deficiency in the
menses. The menstrual discharge was excessive in
6*0 per cent., and too frequent in 2*52 per cent., but
it was deficient in quantity in 29*0 per cent., and with
the intervals too prolonged in 6*7 per cent. In refer-
ence to the combinations of these conditions in the same
person, it may be of interest to remark, that in 16*2
per cent, the discharge was insufficient and too seldom,
in 1*2 per cent, it was excessive and too frequent, in '5
per cent, it was excessive and too seldom, and in '25
per cent, it was insufficient and too frequent.
Hence we are entitled to state that the menstrual
function has been well established in the great ma-
jority of cases of phthisis, and is performed with
tolerable regularity during the period of health. It
evinces a distinct tendency to deficiency in quantity,
120 THE MENSES AND LEUCOREHCEA.
and in only a few cases is there an excessive discharge.
We have also met with many instances in which there
is much suffering at, or immediately preceding the
monthly recurrences of the menses, and in such the
discharge was commonly deficient, and the duration
restricted to one or two days. In others, gastralgia
of a severe kind has occurred at the same periods,
and in many instances haemoptysis has preceded the
monthly period, or has appeared during the week when
the menses have heen deficient.
Whilst, therefore, we find that there are numerous
evidences of a disturbed state of the menstrual function
existing during health in cases of early phthisis, we
cannot at present affirm that they occur more fre-
quently than in other enfeebled organisations. We
are, however, convinced that there is no further dis-
turbance induced by the disease in question in its
early stage, but whenever, and to whatever, degree it
occurs, it demands a remedy.
The pre-disposition to the occurrence of leucorrhcea
is certainly marked. In the period preceding the
development of phthisis, not less than 45*6 per cent,
of the cases already referred to, had been liable to the
discharge, and this disposition is stiU further increased
by duration of time and the occurrence of the phthisical
symptoms. It is also very common to find this state
associated with deficiency in the menstrual function,
and particularly in unmarried women of sedentary
habits and lymphatic temperament.
CHAPTER XIV.
MUSCULAR PAINS.
Muscular pains about the chest are very common.
There is another local condition to which we must
direct attention, which often precedes any evidence
of the early stage of phthisis, and very frequently at-
tends its course, viz., myalgia both in the front and
back of the chest. The most frequent seats of this
affection are the pectoral muscles and the muscles
attached to the base and inferior angle of the scapula.
The former are very variable in degree and seat, and
seldom remain fixed in any place. They are commonly
uninfluenced by exertion, but sometimes the movement
of the arm causes pain. The latter are more com-
monly found between the shoulders and at the inferior
angle of the scapula than at any other part ; and whilst
the former are far more common in men, the latter are
far more frequent in women.
The nature of these pains has been more correctly
understood of late years than formerly, and we owe it
in no small degree to the vigorous mind and acute ob-
servation of Dr. Inman, whose treatise upon this sub-
ject is worthy of careful study. These are not attended
by any febrile disturbance of the general system, and
122 MUSCULAK PAINS.
are not usually acute, but sometimes the pain is very
urgent, and is much increased on deep inspiration. In
the latter cases we should formerly have diagnosed
pleuritis ; but whilst such might be correct in some
instances, it is more probable that it is a muscular pain,
induced by calling the muscles into action. In the
disease now under discussion we need not entertain
much fear as to the diagnosis ; for whether it be in any
severe case localised pleuritis or severe myalgia, the
effect of treatment will be equally satisfactory.
The relations of this myalgia are often obscure, but
so far as we have been able to apprehend them, they
are very important. The connection with exertion, and
the atonicity of the muscle, which is commonly found
in the early stage of phthisis, may be excluded from
these observations, for they are commonly plain ; but
there are other causes of very frequent occurrence. In
reference to men, we have often found them in persons
addicted to onanism, or who have been so in former
years. In such persons myalgia of the chest is a most
frequent occurrence, and although not severe, it attracts
the attention of the patient, and leads him to fear more
important mischief. We shall recur to this subject at
a future page.
In other cases, in which this cause cannot be disco-
vered, we have found chest mj^algia of the moderate
degree, and intermitting, before any other condition of
the early stage of phthisis has occurred ; and as such
often remain long under treatment, we have had the
opportunity of tracing the addition of symptom to
symptom, until the evidences of the early stage of
MUSCULAR PAINS. 123
phthisis are before us. Whether this is simply one of
the numerous conditions which are due to pre -existent
influences, or whether it may be regarded in any way
as inducing other evidences of early phthisis, we cannot
determine ; but there can be no doubt that persistent
or often-recurring myalgia of the inspiratory and expi-
ratory muscles will tend to a diminution in the action
of these organs, either by rendering inspiration ineffi-
cient or by unduly limiting expiration, and thereby
lessen the chest movements ; a condition which, as we
shall show, is essentially connected with the early stage
of phthisis. We incline to the latter view, and in doing
so shall err on the safe side ; for it will at least show
us how important it is to adopt every method which
may cause their speedy removal.
CHAPTER XV.
THE THROAT.
The form of the throat in phthisis is peculiar, and
differs much from that seen in chronic bronchitis.
We discussed the conditions of the throat in phthisis
and bronchitis in a paper published in the " Liverpool
Medical Journal " for 1857 — a journal which is now de-
funct. In that communication we pointed out that
there is ordinarily a condition of the throat in phthisis
quite different from that which is found in chronic
bronchitis.
On inspecting the throat in an ordinary case of
phthisis, it will be seen that the fauces are generally
narrow and small, and the anterior arch has nearly dis-
appeared, whilst the posterior remains largely developed.
The cavity between the arches is large and deep, and
the tonsillar mucous follicles are frequently enlarged.
The whole structures are attenuated, and present a
sharp outline. The pillars of the posterior arches are
commonly large, and project into the cavity of the
pharynx during forcible expiratory efforts. The move-
ments of the throat in inspiration and expiration are
normal, but those which attend the contraction of the
pharynx at its lower part seem to be increased in vigour,
for the lateral contraction which they induce about the
THE THROAT. 125
epiglottis is very considerable. But in ordinary cases
of old bronchitis the cavity of the fauces is very wide ;
there is no attenuation of the parts, and the respiratory
movements of the throat are greatly diminished, as
may be seen during forced expiration, in the manner
exliibited in the drawing on page 130.
There is commonly a state of hypercesthesia of the
throat.
We believe that but few cases occur in which there is
not some complaint made of the throat, such as is re-
presented by the word tickling, or irritation. This, in
many instances, is very slight, so that it is ascertained
only after inquiry ; and in nearly all cases it is a con-
dition which varies in intensity, and is oftentimes
entirely absent for a certain period.
The conditions of the throat which are commonly
found are two : —
First, — A state of pallor of the whole mucous mem-
brane, with an attenuated state of the arches and the
pillars of the pharynx, and an evident sulcus in the
intervals between the pillars. It also frequently occurs
that the pharynx is contracted at its upper part, either
antero -posteriorly, or laterally, or in the whole circle,
so that the posterior wall of the pharynx seems to be
brought very near to the root of the tongue (when the
latter is well depressed and inspiration is effected by
the mouth), and the uvula seems to fall nearly upon
the posterior wall, or the whole aperture is greatly con-
tracted, and with difficulty can the patient be persuaded
to inhale a full volume of air by the mouth. In all
cases of this class the uvula is not elongated, but, on
the contrary, if at all changed, it is rather retracted :
126 THE THROAT.
and when the sense of irritation is very considerable,
there will be found more or less froth or foam over the
whole throat. In this condition there is a sense of
constriction in breathing, and sometimes in swallowing,
and great sensitiveness to excitants as the spatula, finger,
or cold air. When the whole aperture is contracted, the
cough is oftentimes of a spasmodic character, and noisy.
Second, — The condition now known as follicular
disease, in which the simple epithelial glands, which
are abundant on the posterior wall of the pharynx,
become enlarged and vascular, and present the appear-
ance of small flattened red currants. In this condition
there is not unusually, but yet not necessarily, some
elongation of the uvula, and a little sujffusion of the
mucous membrane of the whole fauces, with enlarged
vessels upon the back and sides, and sometimes also
some enlargement of the tonsils. There are not,
however, in these signs any evidences of inflammatory
action, neither is the sense of irritation, or of choking,
so acute and urgent as in many cases of the anaemic
throat, but there is a moderate degree of irritation, and
it is persistent. It also frequently happens that the
tongue is loaded in this condition of the throat, both
in health and disease, whilst in the anaemic throat the
tongue is usually clean, or covered only with froth, or
a very thin white covering.
In a few cases, we find a little thickening of the
whole mucous lining of the throat, without any exal-
tation of colour, and with diminution rather than
increase of sensibility ; but these are conditions which
belong to the scrofulous diathesis rather than to the
disease which we have now under consideration. In
THE THEOAT. 127
the condition of the throat common to the early stage
of phthisis it may he affirmed that exaltation of
sensibility is usually met with.
On examining the throat in either of the above-men-
tioned conditions, it is essential that the patient be
placed before a good light, that the throat be below the
level of the observer, that the tongue be well laid down
by the broad spatula pressed firmly, but without any
approach to violence ; and, above all, that the patient
inspire by the mouth and not by the nose. Some of
these conditions are difficult of attainment ; for it very
often happens that the patient cannot be induced so to
expand the lips as to allow the light to freely enter the
throat, or the presence of the spatula near the root of
the tongue excites irritation ; or, lastly, that the patient
will persist in holding the breath during the examin-
ation instead of breathing at the normal rate, and thus
limits the duration of the examination, and induces a
sense of sickness. The opening of the lips may be
effected, and the presence of the spatula be tolerated
by a little care and perseverance ; but until the patient
can be induced to open the throat, and breathe quietly
with the spatula in the mouth, it will be impossible
to make a satisfactory examination. For the latter pur-
pose, it is advisable to close the patient's nose, so that
being compelled to breathe through the mouth, the
back part of the tongue may fall from the velum palati,
and the patient be conscious of the air passing down
the throat by the mouth, and when this has been
attained, it will generally occur that the patient can be
induced to continue the respiration by the mouth ; or
it may sometimes suffice to induce the patient before
128 THE THROAT.
the spatula is used, to inhale deeply by the mouth, so
as to feel the presence of the current of cool air in
the pharynx when entering by the mouth in a large
volume, and so learn what it is to inhale by the mouth
and not by the nose. It is needless to say that so long
as inspiration is effected by the nose, the tongue is
raised and closes the mouth, and no investigation of
the pharynx can be made.
It is also to be commended so to depress the tongue
as to expose the upper edge of the epiglottis, — not that
there is commonly a condition about that part of the
pharynx which is not seen somewhat higher,^ — but to
expose the epiglottis implies that the pharynx has been
well explored. It is not to be understood that there
is any real difficulty in seeing the upper edge of the
epiglottis in ordinary cases ; but, on the contrary, if
the head be held moderately backward, and the back
part of the tongue pressed firmly downwards and
forwards, the epiglottis is at once exposed. There are,
however, some cases in which the sensibility of the
parts, or the wilfulness of the patient, prevents the use
of the necessary pressure, at least for a time ; and there
are others in which the epiglottis is so low in the throat,
that, with every facility and effort, it cannot be well seen.
The last case is, however, rare, and the second is not
by any means common, so that the former cases are
those which will ordinarily engage attention.
The importance of a condition of hypersesthesia of
the pharynx has no reference to the structure of the
throat itself, or to the due performance of its functions,
but in its relation to the occurrence of cough, and the
action of cold air in inspiration.
CHAPTER XVI.
COUGH.
There is commonly only a small or moderate amount
of coughing.
Coughing is essentially a reflex act, and is due to
eccentric irritation, but the irritation may be applied
directly to the true seat of the act, or be transmitted
from distant organs. In the act of coughing, the
following conditions must exist. 1st. Closure of the
larynx at its upper orifice. 2nd. Suspension of the
respiratory movements. 8rd. Tension of the thorax
by contraction of the muscles, and particularly of the
diaphragm and the abdominal muscles, during which act
the air is displaced, and the upper lobes are distended
by pressure from below. And, 4th, Sudden opening
of the larynx, and forcible ejection of the previously
confined and compressed air. As a subordinate action,
the circulation, both pulmonic and systemic, is inter-
fered with, and during a fit of coughing the pulsation is
much accelerated.
The importance of the pharynx in the act of coughing
may be seen in the immediate production of that act on
the application of any irritating body to the posterior
and lateral walls, and also by the rapid and violent con-
130 COUGH.
traction of the cavity wHcli occurs in the first part of the
act of coughing. When the pressure upon the lungs from
below is exerted by the abdominal muscles and the
diaphragm, the larynx is simultaneously raised about
half an inch ; the root of the tongue is carried upwards
and backwards, and the posterior wall of the pharynx
is brought forwards, so that the posterior aspect of the
epiglottis is in approximation to the anterior aspect of
the posterior wall of the pharynx ; and this, together
with the circular contraction of the pharynx about the
epiglottis, closes the apertures both of the pharynx
and larynx. This was shown by us in 1857, and the
engraving opposite was i)ublished afterwards in the
Journal de Physiologie.
It has also been affirmed that during this action the
chordae vocales are brought into apposition and the
chink of the glottis is closed; but that the true closure
of the larynx during the act of coughing does not take
place there, or at least is not entirely there, may be
proved by the circumstances attending ulceration of
the free edge of the epiglottis, when, as is well known,
the patient cannot cough at all, and the sharp sound
accompanying- the emission of the air is lost, and a
dull sound of air rushing through an imperfectly closed
aperture attends the attempt to cough. This inability
is due to the absence of the elastic substance which,
when present and applied to the wall of the pharynx,
closes the aperture of the larynx. It is also of great
interest to remark that, immediately before free inspi-
ration is effected, during the choking which follows the
application of the strong solution of caustic to the
COUGH. 131
pharynx, there is commonly a sudden eructation of air
from the oesophagus, proving that with the apnoea there
was closure of the pharynx at its lower extremity, as
ahove described. Hence, there is reason to believe that
the pharynx is the essential seat of cough.
DRAWING OP THE PHARYNX IN ITS CONTRACTED STATE, AS DURING THE
FIRST PART OP THE ACT OP COUGHING.
1. Uvula contracted, and drawn upwards.
2. Tonsils drawn forwards and inwards.
3. Pharynx drawn forwards and inwards, and corrugated into folds.
4. Upper edge of epiglottis rendered convex, and applied to tlie posterior
"wall of the pharynx.
But it is believed that irritation set up in other and
distant parts produces cough also, as, for example in the
bronchi, the pulmonary structure, or even in the stomach.
It is, however, to be borne in mind that the degree of
irritation as a cause of cough which is observed when
foreign bodies have passed through the larynx into the
bronchi is by no means so great as is observed when
irritants are directly applied to the pharynx; also,
K 2
132 COUGH.
tliat the amount of cough bears no relation to the
amount of irritation existing below the larynx, and that
stomach affections usually exist without producing any
cough. When cough is owing to these causes it occurs
through reflex action upon the pharynx, and hence in all
cases it is proper to regard the pharynx as the true seat
of this expiratory act. The importance of this ques-
tion is evident, both with regard to the causes and the
treatment of cough, and to these we shall have further
occasion to refer.
As we have already shown that there is hyper-
sesthesia of the pharynx in a large number of cases of
early phthisis, it follows that there will be a tendency
to the occurrence of cough, and the amount of cough
will (within certain limits), be in proportion to the
amount of the hyperaesthesia. As a general observa-
tion it may, however, be stated, that at the period in
question the amount of cough is not usually a distress-
ing feature in the case.
The nature of the cough is commonly short, and
repeated a few times at each attack. It is not usually
violent or causing much succussion, but sometimes it is
spasmodic. It more frequently occurs on moving into
a cooler atmosphere, as on going into the haU from the
warm sitting room, or out of doors, or into the bed-
room at night, and is consequently more frequent on
taking out of door exercise, and at night. It is also
immediately excited when, with a hot and perspiring
skin, the clothes are suddenly removed, or cold air gains
access by any means. It is not infrequently irritable
in the early morning, and especially soon after rising,
COUGH. 133
and doubtless from a similar cause, for at that period
of the day the temperature is commonly low. It is
also worse in the colder seasons of the year, as the end
of autumn, the winter, and the early spring, and is
then more frequent throughout the day. A dry frost,
however, although it causes cough, is not so constant
a cause as a cold and raw atmosphere, and particularly
one in which there is fog and smoke, and the latter
condition is perhaps the most injurious of any in
which such a patient could be placed. All these influ-
ences seem to have one common mode of attack,
namely, the inhalation of air which irritates by the
temperature or other qualities, and the effect is always
greater in proportion to the volume of air inspired,
the intensity of those qualities, and the sensibility of
the mucous surface over which the air passes.
There are also numerous cases in which the cough is
increased after meals. Such are commonly instances
in which there is much general sensibility of the nervous
system, and of the pharynx in particular, and in which
the vital capacity of the lungs is much diminished ; but
in many instances it is due to food which produces irrita-
tion as it passes over the pharynx, or remains in small
particles attached to it, or excites the reflex action from
the stomach to which we have referred. The cause of
this cough is not at all times easy of detection, but we
have been accustomed to seek it in two directions : —
.1st. It will manifestly arise if the food mechanically
irritate the sensitive mucous membrane of the pharynx,
whether by being in large lumps from imperfect masti-
cation, or containing condiments, as pepper, salt, or
134 COUGH.
mustard, or possessing inherent stimulating qualities,
as spirits, or remain adherent to the membrane froin
an imperfect deglutition, or from the absence of fluid
following the deglutition of solid food; and all these
conditions are remediable. 3nd. It has appeared to
us to have some connection with a diminution of the
capacity of the thorax which follows a full meal, by the
distended stomach pressing the diaphragm upwards,
and impeding respiration ; or it may be in part due to
the fulness of the blood-vessels, and the increased
innervation which follows a meal, in which the pharynx
partakes in common with other parts of the internal
organs. The point to which we desire especially to
call attention is, that the cough is not usually or neces-
sarily associated with the condition of the lungs, to
which we shall have hereafter to particularly refer ; but
whatever may be the immediate source of irritation, the
seat of the cough is for the most part located within
our reach.
CHAPTER XVII.
EXPECTORATION.
There is commonly a small amount of expectoration.
In referring to the nature and quantity of the expec-
toration, it is necessary to premise that we discuss only
those which commonly occur in the course of the dis-
ease, and not such temporary conditions as may be
found in persons in health, or in every condition of
disease.
The quantity of secretion expectorated is very small,
and does not exceed from one-quarter to one-half ounce
in the twenty-four hours. It usually occurs in the early
morning and after meals, and follows a certain amount
of cough which then prevails. During the other periods
of the day its appearance is quite uncertain, and does
not attract attention ; but it is always associated with
cough.
The nature of the expectoration is very uniform,
except in the temporary condition of cold, &c., which
we have excluded from consideration. It is semi-trans-
parent, or only very slightly opaque, and not unfre-
quently shows lines or small masses of darker colour.
It is never uniformly yellowish, greenish, or pinkish,
and when these colours are found they are due to other
136 EXPECTOKATIOK
conditions. There is no form to tlie sputa, but it is
glairy and irregular in shape, according to the place in
which it is deposited, and sometimes is very tenacious.
A frothj^ condition is not necessary, but when it is
found* it is due to irritation of the pharynx, with much
cOugh, or is associated with bronchitis.
On microscopic examination, it is found to consist of
a glairy, semi-translucent matrix, in which are found
tesselated epithelial cells, whole or in parts, and fre-
quently with large cells of a black colour, filled with
nuclei and granules. There is not, we believe, any of
the yellow elastic structure of the lungs found at this
stage, for we are now concerned with an earlier condi-
tion than that of destruction of the lung tissue; and
although the expectoration of lung tissue may be asso-
ciated with the signs and symptoms which belong to
the early stage of phthisis, there will usually be other
evidences which prove that the disease has progressed
further than the point under inquiry. It is believed
that cases occur in which destruction of the lung tissue
is found in a very small part of the lung only, whilst all
the other parts retain their normal structure and func-
tion ; but to this we venture to demur. We believe that
all such cases exhibit, and have long exhibited, in the
lungs, the signs of an earlier stage, and that with such
general signs there will be superadded, in progress of
time, deposition, and then destruction, and both may
be localised in a small space ; but such are truly cases
of more advanced disease.
The cases in which there must be doubt as to the
existence of localised destruction of lung are very few,
i
EXPECTOKATIOK IZT
comparatively, except those which are complicated with
other diseases, which cause respiratory sounds fitted to
prevent a careful examination of the chest for the detec-
tion of the softening in question, as, for example, in
cases of continued bronchitis ; but, without enl^ring
further into the argument, we exclude the cases in
which yellow elastic tissue is found in the sputa, with-
out acute inflammatory action, from those now under
discussion.
The chief sources of the secretion in the early stage
of phthisis are the fauces and pharynx. The tonsils
emit a secretion of a glairy nature, and having the
characters above described. When there is much sen-
sibility of the pharynx, and cough, the surface of the
mucous membrane is covered with minute bubbles of
air, enclosed in a very small quantity of mucus, which
are ejected from time to time ; and when there is en-
largement of the mucous follicles, each hypertrophied
body secretes a glairy fluid with detached epithelial
scales, which is abundant according to the number and
activity of the follicles. But, besides these, it fre-
quently occurs that secretions, passing over from the
nares, rest upon the pharynx, cause cough, and are
expectorated by the mouth. It is scarcely possible to
examine the upper part of the pharynx frequently
without being struck with the amount of secretion
which is often found lying upon the membrane. This
has a character different from that which we have
described, since it is opaque, and contains many mucous
cells and some granular matter. Ciliated epithelium
will also be often found in this secretion, for that
135 EXPECTORATION.
form of epitlielium lines nearly the whole nares, and
covers the nasal aspect of the soft palate and the
nasal end of the pharynx ; but it gives place to the
tesselated epithelium above mentioned in the lower
part of the pharynx. The secretion from the nares is,
we believe, often mistaken for that which is presumed
to occur from the bronchi, trachea, and larynx, in which
places the ciliated epithelium again appears. It must
be borne in mind that in many persons the nasal secre-
tion is very abundant, and a large portion of it passes
into the pharynx ; and all persons are conscious that a
certain amount is thus disposed of in perfect health.
It may be again remarked, that the seat of cough is
particularly that part in which there is tesselated
epithelium, and in w^hich there are but insuflGicient
means whereby either particles of food, or such accu-
mulation of secretion, may be detached from it. Hence
cough is the natural remedy for the defect.
CRETACEOUS EXPECTORATION.
There are cases numerous, yet few comparatively,
in which we find the expectoration of white chalky-
looking particles which, when taken between the fingers
in the fresh state, rub down, and make an opaque
granular fluid, such as would occur when a small
portion of softened chalk was rubbed with mucus.
When they have been separated from the sputa and
allowed to dry, they appear to be small roughish
granules of a white color, opaque, and resembling
chalk somewhat disintegrated. They vary in size, but
usually are twice or thrice the size of a pin's head, and
CRETACEOUS EXPECTOEATION. Ut
sometimes they are equal in size to lialf a split pea, or
even larger.
Since the comparatively recent researches into the
nature of tubercle and of tubercular phthisis, it was
common to notice substances in the sputa of con-
sumptives which resembled particles of boiled rice, and
to describe them as portions of eliminated tuberculous
matter in some of its secondary processes. As know-
ledge has increased, we have looked with increasing
distrust upon the relationship of these matters to
tubercle, and, indeed, their importance has almost
passed away, either from the small attention which is
now paid to the expectoration in relation to the daily
examinations which were made thirty years ago ; from
the small importance which is attached to such matters,
either in elucidating or in treating the disease ; or from
the grave doubts which are entertained as to their con-
nection with tubercle. We think that, perhaps in the
present day we err in giving so little attention to the
sputa, and thus allow matters to pass unnoticed which
should excite interest, but we fully partake in the
general doubts which are now extended to these
substances.
The cretaceous matters which are expectorated seem
to rest upon more tangible grounds, inasmuch as we
do not see any other source for them than that to
which they are referred. Yet it must be borne in
mind, that as yet we have no proof as to their nature.
When they are placed under the microscope they
exhibit simply a mineral character, without any vital
structure whatever, except epithelial scales. It is true
140 EXPECTORATION".
that, admitting their nature to be as assumed, such
would be the case, because they have passed through
the stage in which they were vital structures, and are
become secondary degenerations with mineral matter.
There are some prima facie objections to this reasoning,
since in no case do we find precisely similar bodies in
the lungs, whilst they are not unfrequently found in
the glands ; and although there may be a probability
as to their origin, it rests not upon established facts.
It is also worthy of note that these matters^ are rarely
expectorated in cases in which the disease proceeds to
a fatal termination, but in such as offer none or but
very questionable evidence of the disease, or in which
the presumed disease is manifestly connected with
bronchitis. They are regarded as the evidence of a
healthy process in parts of the lungs which are pre-
sumed to have been afflicted with tubercular depo-
sition. Now, in the absence of proof as to the pre-
existent condition of the lungs, — proof which can
rarely be obtained, — and bearing in mind the few
instances in which they occur, and also the rarity of true
tubercular disease being arrested after destruction of the
tissue has begun, it will become us rather to look out
for some other source of this matter than an ordinary
tubercular deposit in the tissues which commonly
proceeds to a fatal termination. We are not able to
give further information as to them, but we entertain
doubts as to their nature and supposed site in the
lungs. Assuming them to be of the nature assigned
to them, we think that they must be admitted to occur
in the class of cases under discussion, for there can be
CRETACEOUS EXPECTORATION 141
no doubt that many cases with this kind of expec-
toration, are in apparent health, or regain their health ;
and it is no answer to this statement, that in others
tubercular disease does manifest and pursue its fatal
course, because the very great frequency of tubercular
disease renders it probable that it will occur occa-
sionally, or even frequently in every condition. We
have met with them in every stage and condition of
the disease, — in the advanced cases, with profuse
expectoration, in which there is no hope of arresting
the disease, in cases in which the phthisical symptoms
were marked by co-existent and long- continued bron-
chitis, and in instances in which the most minute and
careful examination of the lungs led to the belief that
no disease existed, but it would be of no value to cite
the cases in detail.
CHAPTER XVIII.
HJIMOPTYSIS.
In a majority of cases there has been hcemoptysis in
some degree, but not necessarily proceeding from the
lungs.
There is mucli want of uniformity in the cases of
early phthisis as to the occurrence of haemoptysis, the
frequency of the occurrence and its supposed cause ;
but there is more uniformity as to the quantity of
blood which is expectorated. It is well known that
there are many cases in which the disease proceeds
to a fatal termination without haemoptysis having
occurred, and others in which there is very consider-
able destruction of the lung tissue, and no discharge
of blood appears until a yet later period. In the
inquiry upon 1000 patients in the second and third
stages of phthisis, we found that one-third, viz., 82'2
per cent., of the females, and 33 per cent, of the males,
had never had the slightest haemoptysis. Such cases
are, however, the exceptions to the general rule, that
haemoptysis is common at some period in the i)rogress
of phthisis.
There may be a difference in opinion upon this point,
according as we include the appearance of very small
HAEMOPTYSIS. 113
streaks of blood, even at distant periods, or only such
quantities as have attracted the attention of the patient,
and which, from the proximity of the occurrences to
the supposed period of the commencement of the dis-
ease, may be more closely associated with it. We are
accustomed, in our inquiries into this matter, to notice
the occurrence of haemoptysis in two degrees, viz., slight
or streaks, and large quantities, but to note only, or
chiefly, the period of its first occurrence ; and whilst
believing that the impression to be produced upon the
mind in reference to the prognosis should vary with any
great difference in the quantity of blood lost, we believe
that the most important period to be noticed is that of
the first occurrence, from whatever cause ; and that it
will not avail us, or it will beg the question, to attempt
to exclude all occurrences which, in our opinion, had
no connection with the disease.
Commonly, the quantity of blood expectorated is
very small, and amounts only to a streak in one or only
a few quantities of the sputa. It is usually noticed
on one occasion only at a time, and may have appeared
on one, two, or three occasions. Sometimes the first
occasion of it is somewhat sudden, and there is a so-
called mouthful of blood spat at once, and probably no
return follows; but in a few cases there is profuse
haemorrhage on one or perhaps two occasions, amount-
ing to some ounces, or, as is stated, to a pint, and oc-
curring with coughing, but without any noticeable effort.
The latter accident is so impressed upon the memory
in such cases, that the patient commonly dates the
commencement of his disease from that period ; and it
lU HEMOPTYSIS.
not unfrequently happens that it occurred some years
before, and the health was believed to have been subse-
quently quite restored. These, although the most
noticeable of all the cases, are yet few, and quite ex-
ceptional ; and it may be affirmed as a general rule,
that whilst haemoptysis occurs in a majority of the
cases of early phthisis, the quantity is very small, and
does not exceed a few streaks or specks.
This fact has long been admitted, and because it is
general and well established, great importance has been
attached to it in the diagnosis of the disease. Let us,
therefore, inquire what is the precise value of such an
occurrence, what is its seat, and to what is it usually
owing ?
Those who attach importance to the occurrence of
this small amount of haemoptysis, do not now do so on
account of the loss of blood, although CuUen, in his
Synopsis, page 83, introduces the alarming sentence —
" The consequence of haemoptysis is phthisis, ema-
ciation, debility, cough, hectic fever, and, in general,
purulent expectoration."
Whether profuse haemorrhage was more common in
his day than now, we cannot affirm; but we believe
such to have been the case, from the greater prevalence
of inflammatory complications ; and we must not forget
that errors in diagnosis must have then been much
more frequent than now. Certainly the amount of
blood which is usually lost is too small to have the
least significance. Such persons are divisible into two
classes, 1st, Those who believe the blood to proceed
from the lungs, and to indicate mischief already com-
HEMOPTYSIS. 145
menced ; and 2ndly, Those wlio regard it as an indi-
cation of a condition of system in which phthisis will
most probably occur. The determination of the site of
the haemorrhage is the most important part of this
inquiry.
It is presumed that the haemorrhage, when in small
quantity, necessarily proceeds from the lungs, but, as
we believe, without any warrant. There is no pretence
of being able, by any kind of examination, to find out
the site of the haemorrhage ; and it is only because the
blood appears with the expectoration, and both are
induced by cough, and that there is a presumed con-
nection of them with chest diseases, that that assump-
tion has been arrived at. But when we even cursorily
investigate the facts of the case, we shall admit that it
is in the highest degree improbable that it could pro-
ceed from the lungs.
We have already seen that in the early stage of the
disease the sputa is usually derived from the mucous
surface of the pharynx and fauces ; and, therefore, the
fact of its being accompanied by blood, would be no
evidence that the latter came from the lungs. More-
over, the blood is not mixed up with each portion of
the sputa, as we find in pneumonic expectoration
(which, doubtless, proceeds from the structure of the
lung), but is simply a streak, lying upon or within the
small sputum. Its small quantity, and its appearing
only on one or a very few occasions at a time, and quite
apart from the sputum, renders it in the highest degree
improbable that it could have been produced in the
lung. Then add to these facts that it was first noticed
146 HAEMOPTYSIS.
with a somewhat severe temporary cough, and that the
pharynx is often highly irritable, that enlarged and
vascular follicles frequently co-exist, that enlarged veins
are frequently seen upon the posterior wall of the
pharynx, that specks of blood may also be seen there
after severe coughing, that a violent cough so acts upon
the pharynx as to render the surface quite sore — to
scrape it, as patients often remark — and we are led to
believe that the seat of the haemoptysis, is almost always
in the pharynx in the early stage of phthisis.
It may be more difficult to discern the seat of large
emissions of blood, which are sometimes said to occur.
We must, however, bear in mind how certain it is that
the quantity is less than it seems to be, from the dis-
coloration of a large quantity of mucous which a small
quantity of blood will effect, from the impossibility of
estimating the two separately, even when carefully
examined, and the natural disposition which exists to
magnify an alarming occurrence, and we shall arrive at
the conviction that in these cases the quantity expecto-
rated was much less than it appeared to be. But we
have seen numerous cases in which there was large
and even repeated haemoptysis, without any evidence
whatever, on the most careful examination, of any
destruction of the lung tissue, and in which the pro-
gress of the case during many months proved that
the diagnosis was correct. In these cases also there
can be no doubt that the seat of the haemorrhage
was the mucous membrane either of the pharynx or of
the larger bronchi, and more probably the latter. We
venture to affirm that very large emissions of blood may
hj:moptysis. 147
occur in persons in the early stage of phthisis without
any inflammation or marked local congestion of any part
of the lungs, and he due to the rupture of a small vessel
upon the mucous lining of the pharynx or larger air-
tubes.
What, then, is the true significance of haemoptysis ?
1. It is not necessarily indicative of disease of the
lung such as would imply any destruction of parts, or
any local interference with the circulation in the part,
as by the deposition of tubercular or other matter.
2. It most commonly indicates a state of local con-
gestion, or increased vascularity of the pharynx, induced
by numerous causes from without, in which the lungs
may possibly not share, and of which they certainly are
not the cause. The most common of these causes are
doubtless the temperature of the inspired air and the
congestion of parts, and then the violent action of a
current of air suddenly and violently rushing over a
delicate surface in coughing. It is, therefore, com-
monly local and apart from the lungs, and due to causes
acting locally.
This statement is further supported by the frequency
with which haemoptysis is met with in chronic bron-
chitis. We have not made a special inquiry to deter-
mine this question, but on examining the records of
3000 of our patients, we find 459 cases to which we
may now refer. It is recorded that of that number, 131
had spat blood, and 155 had not spat blood; whilst in
173 cases the fact was not recorded, and hence we can-
not be certain that the question was asked. This last
aspect is a very common one in hospital statistics, but
L 2
148 HEMOPTYSIS.
it nearly invalidates the whole inquiry ; for we are not
at liberty to infer that such cases had not spat blood.
If we compare those who were recorded to have spat
blood with those recorded not to have spat blood, the
per-centage of the former will be 45*8 ; but if we add
the cases in which no record was made to those which
are recorded not to have spat blood, the proportion of
those who spat blood is reduced to 28*5 per cent.
3. There can be no doubt that the interference with
the circulation which follows from lessened breath-
motion of the lungs must induce a tendency to conges-
tion, both of the pulmonary and bronchial system of
vessels, and therefore so far tend, on due cause being
given, to effusion of blood ; but as the change in the
respiration proceeds slowly, and this disturbance begins
by small degrees, it is probable that in ordinary cases
this is not an important cause of haemoptysis imtil a
later stage than that which we are now discussing.
There are, however, numerous instances in which severe
haemoptysis has immediately preceded the occurrence
of phthisis, and which was readily traced to local con-
gestion of the lungs.
But whilst the foregoing may be admitted, the ques-
tion is still left unanswered, " Why does haemoptysis
so frequently occur in the early stage of phthisis ?" and
to this we will now endeavour to give an answer.
It may be remarked that there are but few per-
sons, however healthy, who have not had slight hae-
moptysis at some period of their life — a mere streak
or speck — which, at the time, they attributed to sudden
cough or violent exertion ; and it is no answer to say
HJIMOPTYSIS. 149
that such were probably predisposed to phthisis, and
may ultimately fall into it, because the occurrence may
have taken place years before, and no change in the
health have since appeared.
Again, we believe that slight affections of the pharynx
are far more common than has hitherto been believed ;
and whilst Horace Green and some other distinguished
men have done much to call general attention to the
diseases of the throat, they have rather led us to look
for more important signs of mischief than mere irrita-
bility with congestion of vessels, and therefore have not
supplied this defect. There are few persons in whom
there is not found some suffusion of the mucous mem-
brane, and one or more enlarged vessels, if a few exa-
minations of the pharynx be carefully made.
Further, we must recollect that phthisis is the most
prevalent of all mortal diseases, and destroys one -sixth
to one-eighth of the inhabitants of these islands, and
far exceeds in frequency any other condition of disease.
If then we have two conditions which are very pre-
valent, what otherwise could occur but that both will
be present together in the larger proportion of cases ?
The marvel would be, if they did not so occur ; and yet
it by no means follows that there is any true dependence
of the one upon the other. We hear of physicians
finding scrofula or rheumatism in almost every con-
dition of system ; and since these affections are
capable of considerable extension, according to the.
views of the individual, and are doubtless prevalent,
what so certain as that they will find them in a large
proportion of any cases? So, indeed, would it be
150 HAEMOPTYSIS.
with indigestion and disordered state of the bowels,
which are universal, and yet not necessarily associated
with, or indicative of, any particular form of disease.
But we are led by these considerations to the
opinions of those who attach importance to hjemo-
ptysis, simply, or chiefly, as indicative of a state of
system in which phthisis is apt to arise, and we think
that they have grounds for this belief. It is quite
within belief that the local causes of haemoptysis may
be more potential in certain persons than in others,
precisely as we find variation in the influence of all
agencies whatever. But it is a fact, we believe, that
there is a preponderance in this country of a certain
form or forms of constitution in which phthisis more
commonly shows itself; and as this is the prevalent
kind of system, any other disease which largely prevails
must appear in it also. Hence, whilst it may be true
that haemoptysis and phthisis both prevail in the
community, and are both commonly found in certain
forms of constitution, it does not foUow that there is
any connection between them, except that they may
be more or less due to a common cause — a cause,
however, which is subjected to much disturbance by
the action of temporary influences.
CHAPTER XIX.
VOMITING.
A tendency to vomiting not unfrequently occurs.
We do not know that in the instances in which
vomiting occurs there are evidences of any especial
disorder of the stomach, and hence we do not think
that the primary cause of it is associated with indi-
gestion. We have already mentioned, that in many
cases of early phthisis there are some evidences of
dyspepsia — more frequently than is found in an equal
number of persons in moderate health — and, therefore,
if vomiting occur in any large number of such cases,
it will be associated with dyspepsia, but we believe that
usually the former is not due to the latter.
As a general rule, the vomiting or retching is due to
the act of coughing, and is therefore truly pharyngeal.
The cough in such cases is commonly irritable, and
possibly spasmodic, and the patient continues to cough
until he retches. It also not unfrequently occurs after
a meal, but even then it is always associated with
cough. In such cases the food excites the cough either
by its quality, its presence on the pharyngeal mem-
brane, or by the distension of the stomach preventing
the usual descent of the diaphragm, and in such con-
162 VOMITING.
ditions as we have already stated there is commonly
increased sensitiveness of the mucous membrane.
Hence, there is a favourable conjunction of circum-
stances for the occurrence both of the cough and the
retching, quite apart from any primary action from the
stomach.
The proportion of cases in which this symptom occurs
in early phthisis is but small, and is almost restricted to
such as evince much sensibility of the pharynx and
the general system, or who have the habit of eating
quickly, or of taking too much fluid or solid food at
once. It is a symptom which, in the stage now under
discussion, is never permanent, but passes away in a
few days. During its continuance it is, however, a
symptom of urgent character, and occasionally produces
much prostration of the system.
J
CHAPTER XX.
THE LUNGS.
THE RELATION OF THE LUNGS TO THE GENERAL SYSTEM
IN PHTHISIS.
We have now concluded our observations upon the
state of the general system in the early stage of phthisis,
and proceed to inquire into the condition of the organs
which may be concerned or more essentially implicated
in the disease in question ; but, before doing so, it may
be well to define the relations which exist between these
two parts of the body in reference to the production of
phthisis.
It is evident, as we have already shown, that the
lungs must share in any change in the general condi-
tion of the system, and also that they may have their
own local deviations from health, which will implicate
the general system in proportion as they are more or
less extensive. Hence, whether the general system
suffer first, the lungs will suffer also ; or whether the
lungs are affected first, the system will be affected also ;
so that whilst any disease may be said to be local, it
might with equal truth be affirmed that no disease is
local. What, then, is the state of the case in reference
to phthisis in its early stage ?
154 THE LUNGS.
In reference to phthisis in an advanced condition, we
have no doubt as to its presenting local evidence of
disease in the lungs, for the changes of structure are
marked, and attract attention. In regarding the dis-
ease step by step in a yet earlier stage, we find less and
less evidence of the existence of the material which is
regarded as pathognomonic of phthisis, until it may be
found only in a small portion of one lung, instead of
its wider distribution over larger portions of one or both
lungs. Having thus arrived at a point at which only
the smallest amount of this recognised evidence of the
disease exists, it is commonly presumed that we have
found the earliest evidence of the lung disease — the
commencement of the local disease ; but knowing that
there are conditions of the general system indicative of
ill-health existing even prior to this period, we transfer
our attention from the lung, where the disease would be
regarded as local, to the general system, and connect
this state of the general system with the local condi-
tions, not by any necessary tie, but by an accidental
one, and regard the general conditions as predisposing
causes, from which the local disease may or may not
issue. Hence the general conditions of the system are
regarded as only predisposing to the local mischief, and
the local disease is believed to begin, not during the
whole period of action of these predisposing influences,
but only after a certain duration has occurred, and a
new substance has been deposited in the lung, which
has been seized upon as the origin and essence of
phthisis. So that, strictly speaking, phthisis is at no
period a general disease, and as a local disease it com-
THE LUNGS. 155
mences only when certain morbid products have been
deposited in the lungs.
This is, we believe, a correct statement of the belief
at the present day ; and it will be observed that it makes
no account of the fact, that the general conditions
which early occur, and which are called predisposing,
are precisely those which are found through every sub-
sequent stage of the disease, varying only in intensity ;
and also that the matter which has been deposited in
the lung, and which marks the commencement of the
local disease, must have had a source whence it was
derived, and an antecedent morbid action by which it
was created. How, then, can we regard a condition of
the general system which exists throughout the whole
course of the disease as a predisposing condition only,
and in what way are we entitled to affirm that the local
disease commenced in the lungs with the deposit of
tubercle, when that deposit must have been due to pre-
existent changes. We ask if the distinctions which
have been drawn as to predisposing and local conditions
are not purely arbitrary, and have arisen from the de-
fective knowledge of former times, by which tubercular
deposit was regarded as the essence of the disease, both
because it was the condition of the lung readily de-
tected, and because it having been found in some, it
was affirmed to exist in all stages of phthisis. Such a
view might have been the best possible one under these
conditions of knowledge, but now it must be admitted
that, until we have satisfied ourselves that there is not
an earlier condition of disease in the lungs than that
marked by the deposition of tubercle, we are not
156 THE LUNGS.
warranted in stating that tubercular deposition is the
commencement of the local disease. Neither — as it is
shown that there is a morbid state of the general sys-
tem, which is known to precede the tubercular depo-
sition, and which, in an unbroken line, continues
throughout the course of the disease — are we entitled
to dissociate this state of the general system from the
local condition of the lungs, and say that the one is
simply a predisposing series of events to the other.
We admit the occurrence of predisposing causes and
conditions on the one hand, and the deposition of
tubercle as a local condition of the lung on the other ;
but it has been our endeavour to prove that the so-
called predisposing condition is co-ordinate and alike
in nature with the condition of the lung ; and we now
hope to show that there are conditions of the lung
which precede the deposition of tubercle, and are co-
existent with the change which takes place in the
general system.
There has, however, been an indirect admission of
the fact that tubercular deposit cannot be the first stage
of the disease, and, in consequence, we find a casting
about for a general condition of the system which may
be proved to directly lead to the production of the
tubercular matter ; but nothing has yet been adduced
to show why the tubercular matter, if formed at a dis-
tance from the lungs, should select those organs as its
depositary, nor any tangible method by which it could
be carried into them.
The part of the general system which has naturally
engaged the attention of inquirers into this matter has
THE LUITGS. 167
been the blood ; and as there must be different states
of that fluid under many conditions, and particularly
in different constitutions, it has been affirmed that
there is a peculiar crasis of the blood applicable to the
production of tubercular matter, and found in phthisical
cases. Whilst admitting the general principles involved
in this argument, we assert that there is no evidence of
any known condition of the blood necessarily or even
usually found in phthisis. In a course of lectures pub-
lished by us in the Association Medical Journal for
1856, we endeavoured to controvert the statements
made by Kokitansky, and must refer to them for the
arguments which may be used against such a theory ;
but it is unnecessary to discuss the subject here at any
length, since the author of the theory has withdrawn it
from his subsequent editions. There is, therefore,
nothing before the profession, but the general statement
or belief that the origin of tubercular disease is in the
blood, without any attempt to isolate the morbid pro-
duct, or to define the nature of the change in that fluid
from the conditions of health. Hence, whether the
statement be true or false, it is not supported by any
evidence, and is mere assertion, and, at the most, a
parallelism of facts. Yirchow has recently drawn atten-
tion to the fact, that there is no necessary connection
between the morbid action known as tuberculous and
phthisis.
We do not need to offer here any remarks upon the
absence of information in reference to the selection of
the lungs for this deposit, since we are not aware of
any attempt to explain the fact beyond the general
158 THE LUNGS.
statement, that we do not know much as to the cause
of the selection of certain other organs as the depo-
sitaries of secretion; as, for example, the liver and
lungs in pyaemia, and the joints in gout. The latter
assertion is doubtless too true, but it cannot be the
less true that there may be some special cause within the
organ itself to which it is due, and which it is our duty
to carefully investigate. Hitherto, no special cause in
the lungs has been generally admitted, but one has
been pointed out which we believe to be in the
highest degree probable, and which we shall presently
discuss.
As to the transmission of the diseased product to
the lungs, we may remark that there are two sets
of opinions upon this point — one * affirming that the
debris of effete tissue, and the products of ill-
organised nutritive matter, ar6 deposited in the
lungs, and these must of necessity have passed bodily
through the capillary walls previous to their depo-
sition. By this theory, parts of epithelial scales,
tubercle cells, &c., must have not only been admitted
into the blood, but have found their way out of the
blood-vessels through the capillary walls. This view
is very modern, but it seems to carry its own refu-
tation so clearly with it, that we may dismiss it from
the discussion with the remark, that if the blood cor-
puscle does not pass through capillary walls under
ordinary conditions, we can scarcely expect epithelial
scales and tubercle cells to penetrate them ; and that
if the latter could pass, it would of course follow,
* Timms on Consumption.
THE LUNGS. 159
that the smaller blood corpuscle would pass, and that
a large effusion of red blood would occur with the
white tubercle.
The other one is the more philosophical one, viz.,
that a blastema of a morbid character is thrown out
from the blood into the lungs, and after deposition
takes on the cell growth, which constitutes tubercle.
This blastema has not been detected, nor its charac-
ters proved.
CHAPTER XXL
EXTERNAL PULMONARY EVIDENCES OF PHTHISIS.
We now proceed to discuss the conditions which are
connected with the lungs in the early stage of phthisis.
LESSENED MOVEMENT OF THE CHEST.
If the observer place himself immediately in front of
a patient whose chest has been uncovered, he will not
fail to notice a diminution in the chest movement.
The patient should sit at ease, and yet with the back
tolerably erect, and with the arms hanging naturally
at his side, and not resting upon any extraneous
support. The ordinary mode of respiration should
then be attentively watched whilst the patient is quite
quiet and at his ease, and it will be noticed that the
anterior and lateral elevation of the chest proceeds to
a less degree than in health. This will be particularly
seen in the upper and anterior parts, where the whole'
movement can be grasped by the eye, and where
the ordinary amount of movement in health is more
commonly observed and studied than at the lower part.
It will also be frequently observed that there is flat-
tening below the clavicles, and a falling in above the
clavicles at the site of the apices of the lungs, although
LESSENED MOVEMENT OF THE CHEST. 161
the clavicles may be in their lowest position, and not
raised and fixed as in severe cases of bronchitis. It
will also often occur that this flattening, or falling in,
and the lessened breath movement will be less on
one side than on the other, indicating generall}^ that
the progress of the disease has been greater on one
side than on the other ; but, in forming this opinion,
it will be necessary to consider the relative size of the
pectoral muscles of the two sides of the chest, for
they commonly differ somewhat, and in persons who
employ the right arm in laborious occupations they
vary very considerably. It will also frequently be seen
that the intercostal spaces do not exhibit their normal
fullness, and particularly if the patient be thin ; and
although this does not usually strike the unpractised
eye at first, it is occasionally so marked as to show
distinct depressions.
If we now turn to the back aspect of the body,
it will be seen that the motion is indistinct, so much
so as to require attention to detect it with certainty.
It is also common to find a little tendency to round-
ness of the shoulders, and also to an increase of width
between the scapulae. The flatness above the trans-
verse process of the scapulae is also usually evident.
With these various changes it will be noticed that
there is no increase in the abdominal movements, nor
any unusual expansion of the thorax at its lower
part.
When considering these circumstances, it will be
readily understood that their due appreciation wiU
depend upon the amount of knowledge which the
162 EXTERNAL PULMONARY EYIDENCES OF PHTHISIS.
observer has as to the movements and form of the
chest in health, — information which must include not
only the average movement in all persons in health,
but also the peculiarities of the individual, as to height,
width of chest, and sedentary or active habits : — all of
which exert a material influence upon the normal
amount of chest-movement. It is also requisite to
recognise the broad distinction in the chest-movement,
which occurs in the sexes. It is well known that in
women there is usually much more breath-movement
at the upper part of the chest than is found in men ;
a difference due, doubtless, to the unequal pressure
exerted by the stays, which constringe the lower part
of the chest, but allow the upper part to act freely.
Hence, there may be much diminution in the chest-
movement in women, and yet the amount remaining
be equal to that which occurs in men ; and a reduc-
tion to the amount observed in men shows far greater
diminution of breath-movement than could be inferred
from an equal diminution in men. It is important,
therefore, to bear in mind, that small breath motion
has very different significance in the two sexes, and
as it is normally so much greater in women than in
men, the smaller variations are more readily recognised
in the former. Hence, in studying this condition of
the chest, it is better to select women than men.
To one whose eye has been well trained to appre-
ciate minute changes in the chest-movement, no other
test is required, but there are many who seek other
means of admeasurement. For this purpose some
place the fingers of the hand upon each shoulder, to
LESSENED MOYEMEJiTT OF THE CHEST. 163
obtain a tolerably fixed point, and then, stretching out
their thumbs to various parts of the chest, attempt to
measure the amount of motion. This method has
but little that is rigorous in it, and would scarcely at
all aid the practised eye.
The two instruments which are now commonly used
for this purpose are Sibson's and Quain's chest mea-
sures, and with either of them a moderate amount of
accuracy may be obtained. Sibson's instrument, con-
sists of a metal lever, connected with a pointer and
graduated dial, by the intervention of a silk thread
and spring. One end of the lever is placed upon
the chest, or upon the finger when laid upon the
chest, and the dial being held firmly in the hand, the
lever moves up and down, and varies the position of
the pointer as the movements of the chest vary. It
requires much practice to be able to hold the dial so
firmly that, on the one hand, no pressure shall be made
by it upon the end of the lever which is in contact
with the chest ; and, on the other, that the contact of
the lever and the chest shall always exist ; for it will
readily be understood that the lever will rise and the
pointer move by pressure downwards of the hand, as
well as by pressure upwards of the chest ; and also
that, if the contact be not well sustained, there may be
a degree of movement of the chest which will pass
unregistered. . In the hands of one well practised in
its use, — as, for example, in those of its inventor, — we
cannot doubt the accuracy of the results ; but in other
hands insufficiently practised, it will as certainly cause
error.
u 2
164 EXTERNAL PULMONARY EVIDENCES OF PHTHISIS.
But the least fallacious experimental method is that
of measuring the amount of inspired air, and by this,
as we have already stated, it may be proved that in
the stage of disease now under discussion, there is a
marked diminution in the amount of air which is
inspired at each inspiration.
It is scarcely necessary to state that the amount of
variation in the chest-movement, and in the form of
the chest, will be proportioned to the amount of devia-
tion from health, and therefore will vary with each
person examined. We affirm that there is a diminu-
tion in the breath-movement in every case, and that
as time progresses, it increases and leads to other
abnormal conditions.
EXPANSIBILITY OF THE LUNGS.
The structure of the lung facilitates expiration but not
inspiration.
During the expansion of the chest the capacity of
that cavity is increased ill all directions at the same
time, so that the lung increases in size, both in its
perpendicular and transverse diameters ; but, as the
central part or root of the lung remains fixed, the
greater portion of the expansion takes place in front
of, above and below the root. The lungs are com-
posed of two principal structures, and it must be by
the expansion of one or both of these structures that
its enlargement is effected. Of these two there is no
evidence to show that the tubular structure has any
power of elongation, although, from the arrangement of
its muscular fibres, it has a power of contraction and
EXPANSIBILITY OF THE LUNGS. 16S
expansion within very narrow limits around its own
axis. Neither is there any evidence of any method
whereby the tubular structure may be folded, so
that at one time the peripheral extremity of the tube
may be more distant from the central tube than at
others, although this may probably occur in a small
degree. There is also a small amount of movement in
the lower part of the trachea and the large bronchi
during the movement of the chest, but it is not in the
direction of the long axis of the tube, and is only an
undulating movement from behind forwards. Hence,
it follows that the whole expansion of the lung is due
to the structures of those parts which lie between
and at the extremities of the minute bronchial tubes,
and which constitute the vesicular structure of the
lungs.
Let us, therefore, ask by what mechanical arrange-
ment this vesicular structure is enabled to expand
in both uniform and diverse degrees during a long
life. The structure of these organs, as commonly
described, is that of a basement membrane, having in
its walls yellow elastic tissue, lying chiefly in bands,
and lined on the surface with tesselated epithelium.
There is, therefore, nothing in this structure which
will facilitate expansion, and the power by which the
expansion is effected must be from without; in the
muscles attached to the parieties of the chest, which
draw the yielding structures in such directions as will
enlarge the capacity of the cavity, and in this act the
air enters and fills the newly created space. The
structure of the lung offers no aid whatever in this
166 exter:n"al pulmonary evidences of phthisis.
movement, but it must possess within itself a capabi-
lity of being - expanded, and that must be at least
co-equal with the power to enlarge the cavity of the
thorax from without, or an impediment to the expan-
sion would be offered by the vesicular structure. The
capacity for expansion is therefore proportionate to
the size of the vesicles above that which is required at
their point of least expansion, and their ready expan-
sibility will depend partly upon the force of the
expanding power, and partly upon the amount of
resistance which their own structures possess. Hence
it is seen that, whilst the structure of the lungs offers
no aid in the expansion of those organs, it may
offer a degree of resistance to the expansion, either by
congenital or other defects, by which the capacity for
expansion is unequal to the chest movement, or by
varying degrees of resiliency or elasticity, by which
the structures vary in the degree of opposition which
they make to their expansion.
When, therefore, we find that there is a lessened
degree of expansion of the chest, we may seek for its
cause — without the lung, either in the degree of power
by which the chest is expanded, and the expansibility
of the walls of the chest ; or within the lung, in the
lessened capacity of the vesicles to expand, or in the
increased resistance of their structures to the act of
expansion. And, further, in reference to resistance to
expansion in a given time, with a certain degree of
freedom, we must recollect that the tubular structure
may play an important part.' The capacity of tubes
to transmit fluids in a given time, varies with the square
EXPANSIBILITY OF THE LUNGS. 167
of their diameters, and therefore, with the immense
number of tubular ramifications in the lungs, each one
becoming smaller, there is increasing resistance to the
current of the air through them, and increase of time,
or of force, is required to convey the air as the tubes
become smaller. It is, therefore, a question worthy
of close observation, if there is in all lungs a sufficient
area in the small tubes to allow the air to pass with
the required freedom under the influence of a given
power, and this would be especially valuable in those
cases in which there is such an impediment to respira-
tion from birth, that it is perceptible in ordinary
respiration, or at least with a small amount of exertion,
and requires an inspiratory force beyond tha^ which
men ordinarily employ. It is also now believed that
the circular fibres which the small bronchial tubes
possess have the power to further contract the diameter
of the tubes, and thus to offer another mode (and in
bronchitis an effectual mode) of resistance to the
expansion of the lung.
If such, then, are actions concerned in the expansion of
the lung, what are those which attend the return of the
expanded lung to the volume which it normally retains
in a state of rest ?
It is evident that less power is usually required for
expiration than for inspiration, for expiration chiefly
occurs by the mere withdrawal of that force which pro-
duced the expansion, and in this act the structure of the
vesicles is fitted to play an important part. This is no
doubt due to the retractile power of the yellow elastic
fibres, which at all times seek their normal condition at
168 EXTERITAL PULMONARY EVIDENCES OF PHTHISIS.
rest. These fibres are arranged in two principal direc-
tions ; first, in longitudinal bands, passing from the
termination of a bronchial tube to the peripheral extre-
mity of the vesicular structure into which it leads.
These bands lie near to each other, so that in a pre-
paration of vesicular structure placed in acetic acid
it often occurs that more than one band may be seen
in the field at the same time with a two -third or one-
quarter object-glass. There are also isolated fibres
passing transversely from one band to another in a
direct line, but at irregular distances ; and other bands
of circular fibres, which are seen to project into the
interior of the intercellular passages. The latter are
shown*" in the following figure, extracted from our
lectures alreadj^ quoted. On looking into the interior
of any vesicle or intercellular passage, it will be seen
that there is a free edge around the opening, and by
lowering or raising the focus, it will be evident that
this does not occupy a plane, but the circumference of
a circle, with a descending plane, so that, as the focus
descends, the different portions of the free edge come
into focus successively, until the whole may be traced,
more or less, around the circumference of the cell, and
descending after the manner of a spire. This may be
seen in any vesicle, but it does not follow that the
spiral arrangement can be traced far in every specimen,
since the section of a vesicle is much more likely to be
made obliquely across the tube, or at some angle in the
direction of the tube, than directly across it, and in
such instances the fibres which pass round the tube
would be cut across, and a number of half spires, rather
EXPANSIBILITY OF THE LUNGS. 169
than one whole turn of the spire, would be observed.
The drawing below was taken from a fortunate section,
in which the cut at one extremity was made at right
angles to the tube, and therefore embraced the whole
circumference of the tube ; whilst at the other extremity-
there was an opening by which light was admitted
through the whole length of the vesicles or passage.
In that section, which is the best that I ever obtained,
there are five spires seen, and the continuity of the
spire from the top to the bottom may be traced almost
without interruption. The sketch was made from the
microscopic preparation magnified 400 times ; but as
the drawing was a work of much complexity, the free
edge only has been represented, and that appears in a
rough and inartistic manner. This section was shown
to Prof. Sharpey in 1855.
SPIRAL ARRANGEMENT OP THE AIR-CELLS.
In the contracted state of the vesicles after expira-
tion, it follows that there must be some arrangement
whereby they occupy a less space than occurred in
their state of expansion. We might suppose this
170 EXTEENAL PULMONARY EVIDEN"CES OF PHTHISIS.
arrangement to be, — 1st, A confused crushing of
them together ; 3nd, A condition of intussusception,
whereby the elongated extremity is drawn within the
vesicle or passage; 3rd, An arrangement used in
telescopes, whereby several parts in the length of the
passage would be retracted within those nearer to the
centre ; 4th, An arrangement similar to that of a spiral
spring, whereby each part, from the peripheral to the
central end would become folded, as when the spires
of a spring press closely together.
It is clearly a condition of this folding up that the
air shall be discharged from the vesicles as they con-
tract, and that all the parts when folded shall occupy
such a position that they may again be expanded with
facility, or otherwise impediments both to expansion
and retraction would occur. These conditions seem
impossible in any arrangement by which the expanded
parts should be simply crushed together, for the air
would certainly be retained in the folds, and the folds
would re-open with very varjdng degrees of facility.
It is also highly improbable that these conditions
would be compatible with any modification of intus-
susception; and, moreover, there is no arrangement
of the structures which appears to indicate such an
action. But the spiral arrangement to which we
have drawn attention fulfils all the indications, since
it admits and provides for the most orderly me-
thod of expansion and retraction, and allows the
structure to be folded in the quickest manner, and to
occupy the smallest space when retracted. It also
requires that the air shall be removed from its peri-
EXPANSIBILITY OF THE LUNGS. 171
pheral extremity first, and then progressively to the
central part, and permits of the most ready expansion
when that act is required. When it is recollected that
the alternate expansion and retraction must occur at
the rate of about 1000 times per hour throughout life,
and be subject to great and sudden variations of
expanding force and rapidity of action, as in the
case of violent exertion, it is clearly necessary that
the most perfect mode of elongation and retraction
should be employed. We therefore think that the
anatomical arrangement which we have pointed out
comports well with the requirements of the organ, and,
in all probability, gives a sufficient explanation of this
remarkable action. It may also be observed, that for
this action it is not essential that the spire shall be
in all its parts single, as in the bell spring, but the
fibre may have a dichotomous or other arrangement,
as in plants ; and since the vesicles certainly commu-
nicate with each other, it is manifest that the unifor-
mity of the spiral arrangement will be broken, in order
to allow of the junction with other vesicles. In the
figure above given, the spire was single, and nearly
uniform in its arrangement : but in the sections which
will commonly occupy attention, there is much less
regularity than is there depicted.
Hence, on a review of the foregoing observations,
we find that the structure of the lungs in no degree
aids in the expansion of these organs, yet normally
passively permits the expansion whilst possessing a
certain power of resistance; but it is well fitted to
aid in the act of retraction. It also appears that no
172 EXTEENAL PULMOl^ARY EVIDENCES OF PHTHISIS. •
congenital change could confer upon it any power to
aid expansion, but an abnormal arrangement might
increase the natural tendencj^ to resist expansion, and
the ordinary power to effect retraction. Such also
must be the effect of disease ; and hence we arrive at
the general conclusion that all abnormal conditions of
the lungs whatever must be adverse to inspiration,
and with the exception of emphysema, be favourable
to expiration or both.
In the conditions met with in the early stage of
phthisis, there is, as has already been shown, dimi-
nished expansion of the chest, which also implies
lessened elongation, and general expansion of the
air vesicles of the lung, without any diminution of the
power of retraction attending expiration. It has also
been shown that with this lessened amount of expan-
sion there is also feeble inspiratory effort, and whilst
the effort to expand the chest fully is less than that
required to expand it to a less degree, there is a corre-
spondence between short and feeble inspiration, and,
in all probability, a more feeble motion of the air in
its passage through the lungs.
CHAPTER XXII.
INTERNAL PULMONARY EVIDENCES OF EARLY PHTHISIS.
FEEBLE BREATHING.
The earliest and therefore the most universal condition
is that of lessened force, and fulness of the respiratory
murmur and diminished length of the ordinary inspira-
tory act.
Dr. Stokes remarks in reference to feebleness of
respiration, " of the different signs of incipient phthisis
there is none more important than thig," and " may
occur as the sole phenomenon/' In giving three
causes for its production, he believes with M. Rey-
naud that it is commonly due to obliteration of the
minute bronchical tubes. He, however, still associates
it with deposition of tubercle ; and it is probable from
his definition of the cause of it, that he does not
mean the same thing as that referred to by us. It is
not necessary that there should be an irregular kind of
respiration, such as would be perceived by the ear, if
some of the air vesicles were pervious and others
closed, as after the deposition of tubercle, but an
uniform feebleness of the sound issuing from all the
air vesicles equally. The condition referred to by Dr.
Stokes refers, we think, to a later period.
174 INTERNAL PULMONARY EVIDENCES OF PHTHISIS.
We believe it to be a universal condition in the
earliest stage of phthisis that the vesicular murmur is
less strong than occurs in health. The examination
may be conducted by testing both ordinary and forced
inspiration. On the patient being quietly seated, and
the respiration proceeding naturally, it will be found
that the vesicular murmur is but indistinctly audible,
and quite different from that general gentle buzzing
which is so perceptibly present in health. At the
same time it will be noticed that the apparent distance
to which the inspired air is carried, or, in other words,
the length of the inspiratory current, is shortened, and
the act of inspiration is short and feeble, whilst that
of expiration is perhaps shorter and quicker than is
natural. On the patient inspiring forcibly the respira-
tory sounds are of course increased considerably in
intensity, but they are more or less tubular, and the
vesicular sound is much less distinct than occurs with
forced inspiration in health, and there is still the same
evidence of feebleness of inspiration. It also frequently
occurs that the patient is unable to take a long, deep,
and slow inspiration, until his attention has been
repeatedly called to it, and he has been in some degree
trained. Usually when he is required to inspire
deeply, he makes a quick and short inspiration, and
when he has overcome that source of error, the inspi-
ration will still be feeble, and only with difficulty can
he be induced to inspire deeply, and to fully expand
the lungs.
It usually occurs that whilst feeble and short vesi-
cular sounds are extensively present, they are more
FEEBLE BREATHmG. 175
perceptible on one side tlian on the other (Dr. Stokes
and others affirm that the vesicular murmur is naturally
more feeble on the right side), for it very rarely
happens that the disease proceeds at an equal pace in
all parts of the chest, and as the disease advances to a
certain point the vesicular sounds progressively dimi-
nish in force and fullness.
It may here be demanded in what respect this
change varies from that found in ordinary debility on
the one hand, and from a tubercular condition on the
other, and we will endeavour to answer these questions.
In ordinary cases of debility there is no doubt feeble
breath-motion, as there is feebleness of every other
vital act, and there are also many healthy persons in
whom the breath-motion and breath sounds are less
strong than is found in the majority of cases. Yet, to
an ear well trained to this enquiry, there is no difficulty
in the diagnosis, for the degree of feebleness is far less
than is found in that stage which immediately precedes
tubercle, and in all cases of mere dehility the vesicular
sounds and the trajet of the air become normal in deep
inspirations. This latter we hold to be the true
diagnostic sign ; and although the state of the ordinary
respiration is often a sufficient guide, it is better for
every observer, whether peculiarly trained or otherwise,
to examine the condition in forced inspiration also.
i' . . . .
In practising the latter examination, it is highly
important that the inspirations be not made in a rapid
and jerking manner, but with ease, regularity, and
moderate force, for in all conditions of the lungs
in which the inspiratory effort is very forcible and
176 INTERNAL PULMONAEY EVIDENCES OF PHTHISIS.
rapid the tubular; sounds predominate over the
vesicular.
But as the general evidences of early phthisis are
chiefly those of continued debility, it is evident that
in states of chronic debility, from whatever cause, the
chest should be frequently examined, and the progress
in the diminution of the breath-sounds and chest-
movements carefully ascertained ; for, as the cases of
phthisis number one-eighth of all our patients afflicted
with fatal diseases, it follows that the states of debility
leading to phthisis will be most abundant, and form a
large proportion of cases of debility from all combined
causes.
PROLONGED BREATH CURRENT.
The earliest evidence of the deposition of tubercle is
that ivhich indicates a localised and isolated obstruction
to the current of the air.
There can be no doubt from the structure of the
lungs, that as these organs are expanded by the enter-
ing current of air, they always offer an obstruction to
its entrance ; but this is general, and the degree of it
is included in the perception of the respiratory sounds
and movements which we learn as constituting health.
It can scarcely be said that this degree of obstruction
is increased in the earliest stage of phthisis, for the
defect is then rather in the inspiratory power than in
the expansibility of the lung. Yet it is quite possible
that as the disease advances to the period when
tubercle is deposited, and particularly if the progress
be slow, the expansibility of the lung will diminish in
PEOLONGED BREATH CURRENT. 177
proportion to the lessened expansion, and increased
obstruction will be offered to the entrance of the air.
But whilst this may be so theoretically, we do not find
in practice any sign by which its existence may be
distinguished from the mere diminution of inspiratory
power or effort.
When, however, a foreign body of an appreciable
bulk is deposited within the air cells, and lessens their
capacity, it is evident that in its degree it lessens or
prevents the entrance of air into, and the expansibility
of, the particular vesicles. In this condition, it is clear,
that there is increased obstruction to respiration, and
the earliest indications of the deposition will be the
evidences of the obstruction. The obstruction will be
opposed both to the ingress and egress of air. There
must be a period when the first alone is present, since it
occurs within the air vesicles affected, but practically
after a period both occur together. After a few vesicles
have become partially filled with the deposit, they press
upon the adjoining terminal branches of the bronchial
tubes, or of the air passages leading to other air vesi-
cles, and become an accumulating cause of the closure
of the air vesicles. In the earliest condition the signs
are those of further diminution of vesicular expansion,
and, consequently, greater .prominence of tubular
breathing, and these may continue for an indefinite
period ; but when the second condition above-mentioned
occurs, the impediment to breathing may be parti-
cularly shown by the prolonged respiration, or a lag-
ging behind in the current of air at the parts affected.
This, doubtless, occurs in both the inspiratory and expi-
178 INTERNAL PULMONARY EVIDENCES OF PHTHISIS.
ratory acts, but chiefly in the latter ; and it is at least
in part due to the fact, that as the volume of air in the
vesicles beyond the obstruction is small, and can only
be forced out by pressure conducted from the parietes
of the chest to the more deeply seated parts of the
lungs, it cannot overcome the resistance with the same
rapidity and force as occurs in inspiration, when the
volume of the air behind it is large, the muscular effort
greater, and the force is applied to that particular cur-
rent in a more direct manner. Hence, the obstruction
is more easily overcome by inspiration, and any sound
which it might produce is lost in the louder tubular
sounds, and is soon checked by the immediately suc-
ceeding act of expiration ; whilst in expiration the
power is more feeble and less direct, and the interval
of rest following the act of expiration allows much
time, during which the air may continue to pass out-
wards, and the sounds of expiration be heard.
WAVY OR JERKING RESPIRATION.
We do not think that wavy or jerking respiration is
evidence of the deposition of tubercle or of any other
material, nor, indeed, essentially of any obstruction
within the lungs, but at the same time its presence in
early phthisis deserves attention. We have seen nume-
rous instances, and particularly in persons who breathe
feebly, in which it has evidently resulted from an
irregular mode of breathing, and was connected directly
or indirectly with muscular action. In a few cases we
have found this sign present in every part of the lungs ;
but usually it is more restricted in extent. In many
DULNESS ON PEECUSSI0:N". 179
others we have found it in cases of chronic bronchitis,
without any evidence whatever of deposition, but with
much obstruction to the current of air. In a third
class we have found it associated with tubercular depo-
sition in every stage of the disease, except that it was not
heard in the parts of the lungs in which the process of
excavation was present. Hence, we believe it to occur
under two perfectly distinct sets of conditions, in only
one of which is there obstruction within the lungs to
the entrance of air, and in that it may be due to con-
traction of the air tubes whether of a bronchitic or
tubercular kind. The conditions under which we think
its presence of value, as indicating the presence of
tubercle, is where there is an absence of bronchitic
contraction and irregular breathing, and where it is
localised in a space of one or two inches and passes
away as the deposit increases. Hence, whilst we would
attach value to this sign when conjoined with others of
a more trustworthy character, we do not, upon the
whole, think that its presence or absence is of much
importance in the diagnosis of this particular disease.
DULNESS ON PERCUSSION.
Dulness on percussion is a sign of great importance,
hut it occurs in very different degrees and under very
different conditions.
It is impossible for two persons to arrive at the
same idea of the value of this sign, unless they are in
the habit of attaching the same value to degrees of
dulness, and of eliciting the sound in the same
manner. There are many who do not recognise the
180 INTERNAL PULMONARY EVIDENCES OF PHTHISIS.
fitness of the term until the degree is so considerable
that it may be readily recognised at a distance from
the patient, and who elicit the same by violent thumps
of the ends of several fingers, or the knuckles, or by a
hammer. Such cannot be expected to recognise those
lesser degrees which require the ear to be brought
near to the patient, and the most sensitive of the two
ears to be directed to the side percussed, nor such
sounds as are elicited by a quick and smart, but not
heav}^ blow, by the index finger upon the back of a
finger of the other hand well pressed upon the chest.
There can be no doubt that in most cases, both light
and heavy percussion should be made, but we maintain
that it is impossible to appreciate minute changes
without the gentle yet firm kind of percussion", an ear
quick at the perception of sound, the direction of the
ear to the chest, and the earnest attention of the mind
to the enquiry. Hence, with all these necessary con-
ditions, it is very manifest that many will never be
able to appreciate the minute changes, and that others
will confound all the degrees of dulness under the
marked expression of that sign.
But to these we must further add the natural varia-
tions of sound on percussion in healthy persons, due
no doubt in large measure to the thickness of the
chest parietes, and to the age of the patient, and not
yet fully explained. Other things being equal, the
sound on percussion is much clearer in the young than
in the old, and in spare than in fat and muscular per-
sons, and as this must be duly allowed for, and yet its
degree be not capable of absolute determination, it will
DULNESS ON PERCUSSION. 181
under all circumstances be a small source of error.
As a general expression, we may state that the ex-
aminer with the most delicate sense of hearing, the
power of abstracting his attention, and the greatest
practice both in health and disease, carried on in a
careful manner, is the most likely to appreciate the
earliest deviation from health in reference to percussion
and other auscultatory phenomena.
In the early stage of phthisis, before there is any
evidence of the deposition of tubercle, there is an
appreciable degree of dulness on the clavicles, and,
indeed, over the chest in general. This is not found
in the earliest condition, but only after the diminution
in the expansion of the lung has been long continued.
It arises no doubt from the absence of the full amount
of air in the lung tissue, which was common in health,
for in such cases we cannot doubt for a moment that
the solid tissues bear a larger proportion to the volume
of the lung than occurs when the air vesicles are
usually expanded. Some may think this to be over-
refinement, and question its truthfulness ; but let such
examine the percussion note of the clavicles in old
cases of bronchitis, and the doubt will be removed, for
no one believes that in such cases there is the deposi-
tion of solid matter in the lungs, or any large accumu-
lation of blood there in the absence of the winter
increase of dyspnoea, and yet the percussion note is
duller than is found in conditions of phthisis far more
advanced than those now under consideration. There
is also in long-continued bronchitis a state of collapse
of the apices of the lungs, as is evident by the depres-
182 INTEENAL PULMONARY EVIDENCES OF PHTHISIS.
sion which is found above each clavicle even when the
arms are pulled down ; and without entering into the
question as to the precise causes of this, we may
remark that the fact is commonly the same in old
people.
The degree of dulness observed in the absence of the
evidences of tubercular deposition, varies and increases
as the disease is prolonged, and whilst it may be
equally present on both sides, it more commonly pre-
ponderates on one side. Hence, up to this point, and
without the evidence of impeded respiration, dulness
on percussion is not evidence of the existence of
tubercle. When the deposition of tubercle begins,
there is a more permanent and evident cause of dul-
ness ; but if it proceed slowly and be greatly limited in-
extent, the addition to the degree of dulness is not
considerable. The form of deposition in which the
dulness is the most pronounced, is that in which the
deposit is widely distributed, and increases with mode-
rate rapidity. Speaking generallj^, as the deposit
increases in each cell, and in the mass of the cells
from the surface to the more remote parts, so will the
dulness also increase ; yet there is so much diversity
in the degree of dulness found with tubercular deposit
that the amount of deposit can be inferred in only a
general manner, from the degree and extent of the
dulness alone.
SUMMARY.
Having thus considered the evidences which the
external examination of the lungs furnishes in re-
SUMMARY. 183
ference to phthisis, we think it may be convenient to
sum up in a few words the truths which they re-
present.
1. When there is less breath-motion, less length of
inspiration, and feeble yet tolerably even vesicular
sounds, both with ordinary and forced respiration over
the whole chest, or particularly at one or both apices,
with or \\^ithout slight dulness on gentle percussion of
the clavicles, and without rales or any sign of bron-
chitis, we believe that there is the early or the pre-
tubercular stage of phthisis.
2. When there is dulness at least moderately pro-
nounced and localised, and prolonged expiration, with,
but sometimes without, flattening of the chest at the
part affected, and with or without wavy or jerking
respiration, and with unevenness of the respiratory
sounds at the part affected, in addition to the signs
of the first stage, and still without rales or other
evidences of bronchitis, we consider that tubercle is
deposited, and the disease in that part has passed into
the second stage.
3. When general bronchitis is also present, the
diagnosis from the examination of the chest is almost
impossible, and whilst the progress of the general
symptoms may aid us, a correct opinion can only be
formed after the signs of old bronchitis have disappeared,
or the general evidences of phthisis both in the lungs
and system have increased.
4. The state of the general system is substantially
the same, whether before or soon after the first de-
position of tubercle, but the degree of variation from
184 INTEENAL PULMOKAEY EVIDENCES OF PHTHISIS.
health will have increased in the latter with lapse of
time. Hence, whilst this state must be considered in
forming our diagnosis of phthisis, it is equally indica-
tive in the two stages, except perhaps in degree.
CHAPTER XXIII.
PATHOLOGY OF THE FIRST STAGE OF PHTHISIS AND OF
TUBERCLE.
We now proceed to consider the evidences of the
disease which are found in an internal examination of
the lungs up to the limits of the period embraced by
this work.
The only parts to which inquiry has hitherto been
directed are the minute divisions of the bronchial
tubes and the air cells. The distribution of the blood
vessels has also been examined — not with a view to
show any connection between them and the occurrence
of the disease, but to ascertain whether they penetrate
the tubercular masses, and to what extent they remain
pervious.
We have already shown that the structure of the
minutest bronchial tubes is quite different from that of
the air-cells, since the former consists of a series of
coats of various structures, lined by ciliated epithelium,
and, so far as is known, varying little in length during
the acts of respiration, whilst the latter have a base-
ment membrane, with a delicate tesselated epithelium
on the inner, and bands of yellow elastic tissue on the
outer surface, and submit to elongation and retraction
186 PATHOLOGY OF PHTHISIS AND OF TUBERCLE.
witli every act of respiration. Hence there is a prima
facie objection to any identity of diseases to which they
may be subject, and the former will more commonly
exhibit diseases allied to those of mucous, and the latter
to those of serous surfaces.
The universal belief of the present day is, that the
bronchial tubes are not primarily concerned in the
disease in question, and that they become implicated
by extension of diseased products outwards from the
air vesicles, or from the pressure of lateral masses.
In the former case they can only be regarded as depo-
sitories or, as it may be, channels of transit of diseased
products elsewhere generated, whilst, in the latter, they
may seriously add to the mischief by interfering with
the ingress of air to the vesicles to which they lead,
and thus cut off portions of the lung from the per-
formance of their functions.
Hence, we turn primarily to the air vesicles of the
lung, with a view to ascertain in what manner these
organs exhibit evidences of phthisis.
FIRST STAGE.
There have not as yet been any inquiries made as
to the state of the air vesicles in the stage preceding
that of deposit, and, indeed, such would, in the present
state of science, be nugatory, for so long as there is a
difference of opinion as to the existence of a layer of
epithelium, and the normal arrangement and structure
of the air cells is matter of dispute, it is impossible to
educe anything in reference to their minute changes
in disease which shall be worthy of attention. Hence,
FIRST STAGE. 187
those who oppose the view of a precursory or pre-
tubercular stage have the advantage of this negative
evidence.
But satisfactory and complete evidence is not attain-
able in inquiries into any vital action until those
inquiries have been long continued ; and, in the mean-
time, it is permitted to adduce such presumptive
evidence as the existing state of knowledge affords.
It is an established law in the animal economy that
a structure retains its full healthy vitality when in the
full performance of its functions, and that, cceteris
paribus, it tends to disease whenever these actions are
unduly increased or decreased. This is well esta-
blished in reference to the action of the heart, the
muscles of the limbs, and the functions of the liver
and brain, as indeed of every organ and tissue in the
body. Hence, as we have shown that in cases of early
phthisis the actions of the lungs, both physical and
vital, are diminished, and that commonly this dimi-
nution has been long continued, we must admit that
they are brought into a condition removed from the
standard of health, and have become more liable to
put on the marks of disease, and, in accordance with
their conformation, to become the depositories of dis-
eased products. We cannot think that any one can
raise a valid obj ection to the statement thus made ;
and we may further add, that as the tissues of the
lungs are a part of the general tissues of the body, and
the nutrition of the lungs must be supplied from the
same source as the nutrition of the general system, it
follows, that with a state of the general system, in
188 PATHOLOGY OF PHTHISIS AND OF TUBERCLE.
which the evidences of lessened vitality exist, there will
be a corresponding state of the lungs themselves.
Dr. C. Radcl^^ffe Hall, in his interesting little work
on Torquay, when discussing the nature of consump-
tion, remarks : " But in order for tubercle to form in
the first instance, the portion of lung about to be
affected must be in an unhealthy condition, to begin
with ; and the blood brought to it must be unhealthy.
The earliest local deviation from health in the lung I
believe to consist in an atrophy of the delicate filmy
tissue which lines the walls of the air-cells. This
atrophy depends upon a diminution in the vital power
of nutrition in the part." Hence, we venture to assert
that in the early stage of phthisis, before the deposi-
tion of tubercle, there is a condition of lessened vitality
of the air vesicles of the lungs, and an unusual ten-
dency to the reception of morbid matters.
The chronological relation of this condition to the
other evidences of the disease may be variously re-
garded. There can be no doubt that such a condition,
however induced, is well fitted to lessen still further
the degree of vital action of the tissues, and thereby
to become an efficient cause in the progress of the
disease, but it can scarcely be regarded as the cause
of co-existent conditions, since we have assumed, that,
in a majority of cases at least, there was a period when
the vital actions were performed in the lungs in a
manner consistent with health ; and we must therefore
look to an anterior cause, or that upon which the
healthy state depends, to find the reason for this
departure from the healthy state. We have shown
FIRST STAGE. 189
that the step immediately preceding this is lessened
action of the lungs, and this must be due to the mus-
cular power by which the action is maintained, to the
vital changes in the tissues, which, as has been shown
by Dr. Flint,* are the cause of the hesoin de resjpirer,
and finally to that power upon which all vital action
primarily depends. Without being able to penetrate
into the latter, we have shown that the two preceding
conditions exist in phthisis, but in the present state of
our knowledge we cannot demonstrate such a sequence
in the order of events as to show clearly the period
when the condition of the general system had the
immediate precedence of that of the lungs. There
can be no doubt, however, upon the same reasoning,
that as in different persons the degree of health, or of
vital resistance, differs from their birth, those who
inherit or receive at their birth a system deficient in
vital power, are more prone to this condition of the
lungs than others having a more vigorous state of
health.
* "American MedicalJournal," Oct. 1861. The conclusions to which
Dr. Flint's interesting investigations led him are as follows : —
** 1. That the hesoin de respirer does not occur during the continu-
ance of artificial respiration. 2. It is felt when respiration is
impeded or arrested. 3. Also when the blood becomes black ; and
4. During the emission of blood, and whilst artificial respiration
is maintained, the hesoin de respirer occurs after a certain
quantity of blood has been lost and before general convulsions
supervene."
Hence he infers that it is due to the want of oxygen in the tissues, and
as an inference we may remark that it will be the less felt in proportion
to the less degree of vital action in the tissues, and consequently in
early phthisis.
190 PATHOLOGY OF PHTHISIS AND OF TUBERCLE.
SECOND STAGE — TUBEECLE.
We next proceed to consider the evidences of
phthisis after tubercle has been deposited.
In our historical sketch at p. 33, we have given
the outlines of the opinions v^hich were held by
Bailie, Bayle, Laennec, and Carswell, in reference to
the appearance of tubercle in its various stages, and
shall only now refer to such statements as may be
found in the works of the two latter authors. Laennec
refers to seven forms of tubercle, arranged under the
two heads of insulated and infiltrated matter.
Of the insulated forms the Miliary tubercle is the
most common, and resembles small grains which are
grey and semi-transparent, sometimes even transparent
and colourless. They grow in distinct bodies, but after a
period they increase and approach each other, and form
groups. There is a yellow speck observed in the
centre, or, as Andral affirms, in other parts of each
tubercle, and ultimately the whole body becomes
yellow ; and as at that period the group of tubercles
has become one homogeneous body of a whitish yellow-
ish colour, they acquire another designation, that of
Crude tubercle. The Granular tubercle of Bayle is
very rare, and is distinguished from the foregoing by the
fact, that the small millet-seed-sized granules always
remain distinct, and are transparent or semi-transparent,
and colourless or slightly grey. In the infiltrated
forms of tubercle, the whole of the part of the lung in
which they occur appears to be equally occupied by
the matter, as, for example, the parts around vomicse,
SECOND STAGE— TUBERCLE. 191
and in the interstices of the groups of miliary tubercle,
and after a variable period it consists of tubercular
matter, mingled with pus and other fluids, the result of
secondary changes. In some instances, therefore, this
matter will appear as a grey and consistent substance,
and then it is termed grey infiltration^ whilst in others
it assumes a gelatinous form, and in a third class it is
evidently purulent. In the opinion of Laennec and
his cotemporaries, tubercle of every kind is first grey
and semi-transparent, and the yellow character is due
to subsequent changes, but Carswell controverted that
statement, and affirmed that the former does not neces-
sarily precede the latter. The former commonly appears
in the air ceUs and on serous membranes. Eokitansky
has varied the nomenclature of these different conditions,
but it is not necessary to refer here to his excellent
work.
We shall not quote the opinions of Bailie, Bayle, and
Laennec, as to the precise seat of the tubercle, for they
had not the advantage of the microscopic knowledge of
our day, but we may simply state that they believed it
to be in the cellular tissue-^a term used then in a less
precise and restricted sense than now. Carswell, with
greater advantages, found it upon the surface of tissues,
and particularly of those of hollow organs. Neither
shall we enter minutely into the question of the site of
the commencement of softening of tubercle, but may
state that Laennec and his cotemporaries believed it to
begin at the centre of each mass in connection with a
blood vessel which they affirmed to be present there,
whilst Carswell affirmed that the softening begins at
192 PATHOLOGY OF PHTHISIS ANT> OF TUBERCLE.
the circumference, and that there only is there com-
monly a connection with the vascular system. Rainey
affirms that the softening hegins at the centre, because
it is the furthest removed from the blood vessels, and
Eokitansky's description of the process shows it to be
physical in its nature, and due to absorption of fluid
from the adjoining parts. Lebert is of opinion that
softening occurs both from the circumference and the
centre in different instances.
Such, then, is a brief outline of the appearance of
tubercle to the naked eye and the changes which it
undergoes, and in a few words it may be stated that
tubercle commonly begins at a point and increases in
quantity until it is as large as a small seed. This
occurs in many places about the same time, and at
length the small rounded or slightly angular bodies are
pressed together until a mass is formed. The deposit
is at first transparent and colourless or slightly grey,
but it subsequently solidifies somewhat and becomes
opaque, and finally by various stages liquefies and is
expectorated from a part in process of excavation.
We will now adduce the information w^hich the micro*
scope has enabled us to obtain, and trace the changes
somewhat more minutely.
The material in its earliest form consists of a number
of cells, varying in size, but commonly smaller than a
mucous cell, filled with granules, and also a quantity of
free granular matter and other non-cellular elements. At
a later period the cellular element is less abundant than
the granular, and pus cells and debris of tissues appear
in the softened mass. The chemical composition
SECOND STAGE—TUBERCLE. 193
shows the presence of an albuminous material and
mineral matter.
These substances are deposited on the free surface of
the air cells (but some affirm that they are also found
in the parenchyma of the lung, and in the minute bron-
chial tubes), and in each lobule the deposit may proceed
in several cells at the same time, until the further
extension of the cells is hindered by the inelastic
lobular membrane which encloses a number of them.
In progress of time the deposit having occurred in a
number of lobules, the cells of adjoining lobules be-
come filled up, and the two masses lie in close approxi-
mation, or it may be that the adjoining lobule remains
free, and then the masses remain disconnected and
projecting.
Eainey has expressed our view when he says that
the tubercle being deposited on the inner surface of the
air cell, the latter becomes distended, and after a time
the cell walls or the septa between two masses of
tubercle become compressed and the intervening blood
vessels obliterated. Every tubercle may, therefore, be
regarded as an air cell full of tuberculous matter, and
the amount of vital action remaining in the cells will
be in great part proportionate to the extent to which
the blood vessels lying outside the cell and between
adjoining cells remain patent. Hence the coloured
spot often found in the centre of a miliary tubercle does
not, as Mr. Ancell intimates, represent the remains of
the contents of the air cell, but the central point of
the mass which fills the distended (not compressed) air
cells.
194 PATHOLOGY OF PHTHISIS AND OF TUBERCLE.
As each air cell receives the deposit, its capacity and
capability of expansion is by so much lessened, and
after a period the air is admitted only to the end of the
bronchial tube, unless in the mean time the lobules on
the sides of the bronchial tube have compressed the
tube and prevented the ingress of air to the cells to
which it is directed. Hence with deposition there will
be solidification and immobility of the lung, and the
chief causes of variation are the extent of deposition
at first, the rapidity of the filling of the individual cells
and of the implication of other cells in the morbid
process. Commonly a few cells or lobules are selected
at first, and these are usually found in one of the apices
of the lungs.
NATURE OF TUBERCLE.
Let us now ask what is the true nature and source
of tubercle in the lungs ? It is necessary to limit our
observations to the deposit found in the lungs only,
for with that alone are we concerned ; and although
masses of matter similar in appearance are found
elsewhere, and are called tubercle, it is not certain
that their nature is identical with that of those found
in the lungs.
CELLULAR CHARACTER OF TUBERCLE.
The precise nature of the histological elements
which are found in tubercular masses is not yet settled.
They have been described as rounded or oval granular
cells, but these characters are not such as would
enable any histologist to determine the nature of
BLOOD ORIGIN OF TUBERCLE. 195
tubercle if examined alone and apart from the other
histological evidences of the mass.
GRANULAR MATTER OF TUBERCLE.
The precise nature of the free granular matter, and
of the various non-cellular elements which are found
in tubercular masses, is at present a subject of specu-
lation, but there is a presumption that the granular
matter is derived from the cells after the cell wall has
become ruptured, and that the debris may in part be
the ruptured cell wall.
BLOOD ORIGIN OF TUBERCLE.
It is commonly held that the morbid material is
derived from the blood. It is deposited in the amor-
phous form common to all deposits, but subsequently
undergoes the vital transformation necessary to the
production of ceUs, and differs from benign deposits
in having its vital development arrested at this first
step of cellular growth. Hence it is deficient in
plastic qualities, and instead of being convertible into
some of the tissues of the body, it remains as a foreign
body, and has a marked tendency to degenerate and
decay. It is also affirmed that the relation between
the deposition in the bronchial and other glands is
such that, as in Professor Alison's case, the matter
may be determined to the glands, and thus be averted
from the lungs, or, as is believed by Dr. J. C. B.
Williams, the tubercular matter may be removed from
the lungs and deposited in the glands. In considering
2
196 PATHOLOGY OF PHTHISIS AND OF TUBERCLE.
this blood theory we require reasons for the follow-
ing :—
1. Why the lungs should he selected for this deposi-
tion in so vast a majority of cases. There is nothing
known in their structure which will account for it, and
if it be referred to their great vascularity, we may
reply that tubercle is much less frequently found in
so highly vascular an organ as the liver, and is met
with on serous and mucous surfaces where the vascu-
larity is not greater than that of other tissues.
2. The depravity of the vital processes hy which this
matter is produced, and which is chiefly discernible in
this deposit only, if ice compare its frequency with that
of any other due to chronic conditions. It is arguing in
a circle to say that, because the system is not in good
health, the deposits will be unhealthy, and that the
deposits must be depraved because the system is un-
healthy. If the depravity be due to the state of the
health, then all deposits occurring in such a state
should be depraved ; but this is not strictly true, for, in
reference to inflammatory deposits, their nature is in
great part determined by the activity of the local
morbid process, which is only in a general manner
influenced by the general system; and if a matter
should be regarded as depraved and unhealthy because
the disease associated with it tends to death, the term
can have no special significance beyond the expression
of the condition of the general system, and thus we
are brought back in the circle to the proof of the con-
nection of this deposit with the state of the general
system. There can be no doubt that in early phthisis
BLOOD OKIGIN OF TUBERCLE. 197
the vital transformations are not so perfect as in health.
There can be no doubt also that, as the circulating
medium varies in its composition according to the
nutritive material taken into the system, the perfection
of the acts of transformation, and the amount and
nature of the effete matters removed from the tissues,
it must vary in every person hourly, and in every
variety of constitution, and in every disease ; but it is
evident that we gain no increase of knowledge by a
reference to this state, unless we can point out the
precise changes which have occurred, the conditions to
which they are due, and the evils to which they tend.
Whilst admitting the fact, we venture to state that
expressions respecting it are made loosely, and
without any precise idea, and in illustration we may
cite the case of an American critic who, in discussing
most ably the merits of Dr. Lawson's work,* objects
to the statement that tliere is a stage of phthisis
before tubercle is deposited, and remarks : " Before
the deposit of tubercle reveals itself by physical signs,
the health must be deranged, for these signs are indi-
cative only of a certain accumulation of morbid matter."
In this it will be observed that there is an explanation
based upon a gratuitous assumption, for he had not
proved the accumulation to exist, but assumed that,
because tubercle would be deposited, it must accumu-
late in the blood previously.
3. The fact that the amorphous condition of the effu-
sion has never been seen in phthisis, but, on the contrary,
* The American Medical Journal, July, 1861, p. 157.
198 PATHOLOGY OF PHTHISIS AND OF TUBERCLE.
that in the earliest stage, and in the most newly formed
tubercle, the cell structures are present. This statement
that tuhercle is deposited in an amorphous state is
based upon the assumption that, because in certain
other conditions an amorphous lymph is first effused,
and cell-formation is set up subsequently, it therefore
occurs also in this instance ; but setting aside the
non sequitur of the argument, it is to be observed that
such a statement at once begs the question, by assum-
ing that it is a deposition from the blood.
4. The sudden arrest of that vital action which had
been set up in the amorphous deposit, by ivhich cell or
nucleus growths have arisen, leaving the material as
inactifve or dead as if it were unorganised.
5. The fact that cells of the size of the tubercle cells
cannot pass through the tissues, and if the cells ' have
been disintegrated, and the matter absorbed in its
granular and amorphous state, how it is accounted for
that in the glands whither it has been carried it again
appears organised.
6. The almost entire immunity of early youth from
this disease, and the comparative infrequency of it at
and after middle life. If it be derived from a depraved
state of the blood, why is it not distributed over all
ages with some approach to uniformity, for at all periods,
and particularly in childhood, we find abundant evidence
of continued ill health, and innumerable instances in
which ill-formed lymph is thrown out on serous sur-
faces, and in external wounds.
EPITHELIAL ORIGIN OF TUBERCLE. 199
EPITHELIAL ORIGIN OF TUBERCLE.
Another theorj^ has been propounded, which has the
merit of simplicity and of avoiding many of the
difficulties which beset the blood theory. Shroeder
Van der Kolk, Addison, and many others have pointed
out the resemblance which exists between the enlarged
nucleus of the lung-epithelium and the cells of tubercle,
and have affirmed that the tubercle is effete and
accumulated epithelium of the air vesicle.
Dr. J. H. Bennett, who strongly advocates the blood
theory, confesses that the tubercle cell is really a nu-
cleus, but without a tendency to form cells. Hokitansky
asserts that nuclei are normally present, and Lebert
affirms that they rarely appear. Gulliver and Vogel
believe that at the early period nucleated cells are
formed in the tubercle, and Virchow asserts that
tubercle originates in the interior of epithelial or other
cells.
Our esteemed colleague, Dr. Walshe, in referring to
this important statement of Virchow, somewhat ridicules
such revelations of science, and thinks it better to
trust to that which is evident to the eye and to ordi-
nary observation, than to such vague results of histo-
logical science; but we mistake greatly if Professor
Virchow's views do not lend valuable aid to a theory
opposed to that adopted by Dr. Walshe, and probably
to be preferred to it, and if it be not a true advance of
knowledge. "Whether the tubercle cell be due to a
retrograde metamorphosis or not is a question of
theory; but that it resembles the nucleus of the
200 PATHOLOGY OF PHTHISIS AND OF TUBERCLE.
epithelium cells, with which it is almost invariably
found, is, we believe, a matter of fact ; and, further, it
is highly probable that the tubercle is derived from the
epithelium.
In this theory we find a ready explanation of the
selection of the lungs for the deposit (for the material
is naturally found in the place where the deposit
occurs) ; of the accumulation of the deposit (from the
peculiar construction of that part of the lungs, namely,
a large and expanded cul-de-sac, in which the deposit
occurs, having for its outlet a minute cone-shaped
tube, the narrow end of which terminates in a cul-
de-sac) ; of the origin of the granular cells (without
supposing the setting up and arrest of a vital process
in a homogeneous mass effused from the blood, which
has never been demonstrated) ; of the infrequency of
it in childhood (when the respiratory function is very
active, and the air vesicles immature) ; of the origin
of the debris (from the expanded part of the tubercle
cell) ; and of the wide dissemination of the matter
(from the universality of the same conditions). It
would still remain to show why the epithelium should
accumulate in disease and not in health, but that
offers no serious objection to the theory, for it is fully
believed that everywhere epithelium is subjected to
constant degradation and renewal ; and it would almost
certainly follow that the air-ceUs, having been long
inefficiently expanded, and the current of air intro-
duced and emitted with less force, there would be parts
of the unfolded cells in which the material might
lodge, and the debris would be less easily carried into
EPITHELIAL ORIGIN OF TUBERCLE. 201
the bronchial tube. Then, if we add to these facts
the lessened vitality of the structures consequent upon
the more feeble performance of their functions, we
have the conditions fitted for the production of an
epithelium of changed organisation.
According to the testimony of all observers, there is
but small evidence of mineral deposition in the tubercle
so long as it remains transparent and colourless, and
it is only in the secondary changes, which produce
discoloration and opacity, that it abounds. This
would comport as well with this as with the theory
of the blood origin of the deposit. It would also
readily account for the now established fact, that
tubercle is almost exclusively found on the surface of
membranes possessing an epithelial covering, and not
in the substance of tissues, where the blood vessels for
the most part abound ; and if it leave unaccounted-for
the source of the deposit in bones and other places
where there is no epithelium, we may well admit that
an erroneous opinion may exist as to the identity of
the deposits when such exceptional cases bear no pro-
portion to the number of those in which the deposit is
found with epithelium.
This view appears to us to have much to commend
it in a positive sense, and also negatively, by excluding
the difficulties which attend the consideration of the
blood theory. It also comports well with our view of
the first stage of phthisis, and the manner in which the
first leads to the second stage.
It is well known that the earliest seat of tubercle in
the lungs is almost invariably at the apex, and so con-
202 PATHOLOGY OF PHTHISIS AND OF TUBERCLE.
stant and singular a fact must be due to conditions
especially found in that locality. On examining the
apex, with a view to explain this peculiarity, we do not
find anything in the intimate structure in which that
differs from any other part of the lung; but in con-
sidering its function, there is something which has
engaged the attention of numerous observers, and,
amongst them, of Sir Robert Carswell. This acute
physician remarked that tubercle is rarely found in
moving organs, whilst it is so abundant in the parts of
the lungs — the apices — in which there is much less
motion than is found in other parts of the same
organ. Hence he associates this liability to the depo-
sition of tubercle with the small motion of the part ;
and it is singular to notice how well this view supports
the opinions recorded in the last paragraph as to the
origin of the tubercle ; for if lessened breath motion
lead to the deposition of tubercle, it will follow that the
parts of the lungs in which the breath motion is very
small in health, will be the first to put on evidences
of this disease. It well accords with the view that
tubercle is accumulated and transformed epithelium ;
but we have no explanation whatever of the reason
for the selection of these parts of the lungs if the
tubercular matter be deposited from the blood. In our
Lectures, already referred to, we pointed out another
fact which corresponds with the statement made by
Sir Robert Carswell — viz., that, from the direction of
the bronchial tubes and the inspiratory force, the
current of air is chiefly directed to the base of the
lung, and that it is only on the deepest inspiration, and
EPITHELIAL ORIGIN OF TUBERCLE. 203
when the base has become full of air, that the apices
can be completely distended. This is evident on the
mere inspection of the lung, but is demonstrated when
either the observer attentively examines his own in-
spiration or that of any other person. The lessened
degree of expansion, and, to a certain extent, the
lessened movement of the apices, may thus be ac-
counted for.
CHAPTER XXIV.
PROGRESS OF TUBERCLE.
It now remains to show in what manner the tubercle
deposited in the lung comports itself when the ten-
dency of the disease is towards death and towards
recovery.
We have elsewhere stated that tubercle does not
extend by a process analogous to the extension of can-
cerous deposits, viz., by infiltration and destruction of
the surrounding tissues, but simply by accumulation
of the same material in hollow cavities lined by the
epithelial cells. Hence, the tubercle already deposited
is in no degree an active vital agent, but must be
regarded as a foreign body, having its own tendency to
decay, and also tending to the decay of the parts in
which it is placed — the latter action not, however, by
any malignant virtue which it possesses, but by ex-
cluding the supply of blood to the parts and interfering
with the vital functions of the organs.
Hence, up to a certain point we have simply accu-
mulation of material, interference with the functions of
the part, and lessening of the vital properties of the
containing tissues.
AS TO THE TISSUES. 205
AS TO THE TISSUES.
The changes which proceed in the tissues may be
the most readily explained, and we will, therefore, first
describe them. The supply of blood being cut off
more or less perfectly, and the functional activities of
the tissues being more or less arrested, it follows that
the nutrition of the tissues will be diminished, and
there will be a constant tendency to decay. This decay
is evinced in two ways: 1st, By a shrivelling of the
tissues as the fluid which they contain becomes more
and more removed. This is observed in cases of
isolated tubercle, in which calcareous degeneration has
proceeded, and to which we shall again refer. 2nd, By
destructive disintegration. This process has been
almost universally regarded as inflammatory, both
from the fact that in other tissues destructive action
is for the most part inflammatory, and because pus cells
are found in the course of the destruction. This is a
subject which is, perhaps, incapable of such inves-
tigation as may decide the question; but when we
recollect, on the one hand, that the tissues involved
are simply composed of a basement membrane and a
number of closed capillary vessels, it is not easy to see
how true inflammatory action could be set up ; and, on
the other, that in true inflammatory action there is
commonly a blastema effused, in which organising
elements are produced, neither of which is necessarily
found in this process ; and, therefore, it is scarcely cre-
dible that this should be the process of disintegration in
the mass of cases. Moreover, in the action in question
206 PEOGEESS OF TUBEECLE.
there is no such tendency to spread rapidly as is found
in ordinary pneumonia ; neither does the general system
show evidences of inflammatory action proceeding in a
vital organ. Hence, whilst we do not deny that in
some instances, and those particularly in which the
tubercular masses are not closely compacted together,
true inflammatory action may occur, and induce the
softening of the tubercular masses ; we believe that in
the ordinary instances of the softening of tubercle the
disintegration of the tissue proceeds chiefly by the
absence of nutrition, and not by the action known as
true inflammation; nay, we venture to assert, that
commonly inflammation does not occur in the com-
mencement of the process of softening.
The process of softening is often regarded as an active
one. In the sense of progress towards decay, the term
action may not be inappropriate: and in numerous
instances in which the process commences from expo-
sure to cold, or other cause of inflammatory action,
such a term may fitly imply increased vascular
action, and be evidenced in many instances by the
occurrence of sudden haemoptysis and pain over the
region affected, and general derangement of the system;
but there is certainly a greater mass of cases still
in which nothing has occurred to mark the commence-
ment of the process. There are, as is well known,
many cases in which extensive destruction of the lung
has taken place without the patient having been
aware of the existence even of any mischief; but
setting aside those which may be regarded as excep-
tional cases, we do not commonly find anything to mark
AS TO THE TUBERCLE. 207
tlie first onset of this process in a tubercular mass.
Hence, we believe that there are two classes of cases,
in one of which there is increased vascular action com-
monly attended by dyspnoea, pain, haemoptysis, and a
feverish state of the system — the evidences of inflam-
matory action — whilst in the other the change attracts
no attention whatever in its onset, and offers neither
general nor local marks of inflammatory action. These
two conditions have been commonly regarded as in-
flammation of a higher or lower order, but it is only
with a view to apply our imperfect pathology (such as
unquestionably exists in our views of the various kinds
of inflammation) that we admit any identity in the two
processes, and nothing is gained beyond mere verbal
arrangement by applying the same term to both
conditions.
AS TO THE TUBERCLE.
In considering the changes which proceed in tubercle,
we must, in limine, bear in mind the natural distinction
of such a small mass as is enclosed in one cell, and
has therefore cell wall and vital structures only upon
its circumference, and such a mass of tubercle as is
made up of many smaller masses, and which, therefore,
has cell walls and enclosed tubercles in many parts of
the mass. There are also several other circumstances
associated with tubercle in its tendency towards health
or disease which we must, consider; but the two lead-
ing ideas involved are the removal of the tubercle
from the lungs and the isolation of tubercle in the
lungs.
208 PROGRESS OF TUBERCLE.
THE REMOVAL OF TUBERCLE FROM THE LUNGS.
It has in all ages been believed that the removal of
tuberculous matter by expectoration was the natural
course for the cure of this disease. This arose, no
doubt, from the analogy of ordinary abscesses ; for in
the time of the early fathers the tuberculous exca-
vations were regarded as abscesses, and the natural
way to cure an abscess is to evacuate its contents.
But although in our day a distinction is drawn between
the breaking up of tuberculous masses and ordinary
abscesses, it may not be denied that tuberculous matter
is removed by expectoration. This process must be
confined to two conditions of the disease; viz., the
early accumulation of tubercle in each cell, and the
period of the formation of a cavity. It is quite con-
ceivable that when tubercle is first deposited, and
begins to accumulate, and whilst yet the bronchial tube
is open, that portions will escape into the bronchus,
but, with the exception of a cheesy appearance, we
doubt if the material would in that stage be recog-
nisable ; and we believe that it has never been recog-
nised.* There can be no doubt that the epithelial
cells constantly undergo destruction and emission, and
hence, if tubercle be transformed epithelium, there
seems no reason to doubt that this process may still
occur, although diminished in activity, by the gradual
closing up of the cells and the bronchial tubes, and the
* Dr. Radclyffe Hall, in some admirable papers published in the Brit,
and For. Med. Chir. Review for 1855 and 1856, speaks of the discovery of
degenerated epithelium in the sputa, but he treats of it hypothetically.
THE EEMOVAL OF TUBERCLE FROM THE LUNGS. 209
diminislied vital and physical actions of the cells. If,
therefore, plans be a,dopted which maintain the patency
of the air cells, and increase the vital action of the
diseased parts, we see no reason why such accumu-
lation of matter may not be removed in this manner.
At the period of destruction of the lung, and the
connection of a cavity with large divisions of the
bronchi, it necessarily occurs that as th€ material dis-
appears and a vacuity is formed, it passes out by expec-
toration ; and as the tissue of the lung becomes de-
stroyed, portions of the yellow elastic fibre are readily
found in the expectoration.*
The change of the tubercle which leads to this state
is known as that of softening of the lung, and occurs
nearly always by the admission of fluid from the
adjacent portions of the lung, conjoined^'with changes
in the tubercle, and disintegration of the morbid tissue.
The softening, as we have elsewhere shown, begins at
the centre or the circumference of the mass, according
as the tissues in the centre retain pervious blood vessels ;
but if it were possible to isolate a single cell filled with
tubercle, there could not be a doubt of the softening
commencing at the circumference. With the soft-
ening, the tubercle undergoes physical changes, by
which the cell walls of the tubercle burst, and emit
their granular contents, and there are in addition
mucous and pus cells. The walls of the several cells,
and afterwards those of the loblular membrane, become
* It is impossible to entertain too high an opinion of the acuteness and
diligence of Prof. Van der Kolk and Dr. Andrew Clark in their researches
upon this subject.
210 PROGEESS OF TUBERCLE.
disintegrated, so that the matter contained in the newly
formed cavity, and afterwards in the expectoration, is
tubercular, granular, and cellular debris of cell walls,
and the tissues of the lung, with mucous and pus cells,
often derived from the bronchial mucous membrane,
and sometimes with the corpuscles of the blood. As the
excavation proceeds, the walls of the cavity become
lined with a thick and smooth membrane, secreting a
fluid, and called pyogenic membrane, and if the cavity
should cease to increase, its walls become thickened
by the infiltration of tubercular and other deposits.
After a period, the cavity may become empty, and no
further tubercular matter be found in it, whilst at the
same time it begins to contract in size, if the con-
ditions be favourable and tend to health ; but if there
be tubercle deposited in the surrounding tissues, the
process of excavation commonly continues, and the
cavity is less perfectly lined by a membrane, and does
not tend to contract, except from the falling in of the
walls. This process of contraction is also dependent
in part upon the non-existence of pleuritic adhesions
to that part of the lung, for it is manifest that so
long as the lung at that part is closely held to the
walls of the chest, a closure of the cavity is almost
impossible.
Hence it appears that expectoration of tubercle may
be presumed to occur throughout the whole period of
the disease ; for as air cells become newly involved in
the disease, they may emit tubercle, whilst other cells
have become full; and when the destruction of the
lung has begun, it is probable that in ordinary cases
OBSOLESCENCE, OR ARREST, OF TUBERCLE. 211
the expectoration of tubercular matter never ceases
until death.
THE ARREST OF TUBERCULISATION IN THE LUNG.
It has been often remarked that tubercular masses
have been found in lungs after death when there was
no previous suspicion of their existence, and such prove
that the deposition, which had been very restricted,
had ceased, and that the tubercular matter (always
assuming such masses to be tubercular) had undergone
some secondary changes. We do not stay to remark
upon the fact of the fewness of such cases in pro-
portion to those in which the disease progresses (so
that we must not infer that the condition is common),
nor upon the further fact, that as in such cases no
careful examination had been made for their detection,
we are not entitled to affirm that such conditions could
not have been diagnosed, since these questions have
been treated of elsewhere, but we take them as simple
evidences of the occurrence of one form of cure of
tubercle.
OBSOLESCENCE, OR ARREST, OF TUBERCLE.
In this form of arrest of tuberculisation we find
that a few or many cells have been lost to the lung,
and have become filled with, and closed up by, mate-
rial, whilst the tissues immediately adjoining remain
pervious and useful. The tubercle itself has com-
monly become quite opaque, dry, and calcareous, and
the cell walls in which it is inclosed have become dry
p 2
212 PEOGRESS OF TUBERCLE.
and detached. In such cases the tubercle, as an irre-
gular nodular mass, may commonly be turned out of
the lung, leaving behind it a small irregular cavity.
How far such a condition is due to a diseased action
localised to these few cells at the time of the deposition,
cannot be determined ; but since whatever disorder may
affect the whole, may likewise affect a part of the lung,
and since such masses are found commonly in the centre
of the apex, or at the part of the least mobility of the
lung, it is possible that such a localised action may
occur. It is, however, more likely, we think, that at the
period of deposition of the tubercle in those particular
cells, there was a tendency to its deposition in the
adjoining cells also, but that the action was thus
arrested by the removal of the conditions to which it
was owing. It [is in this way that we believe the
beneficial action of voluntary inspiration proceeds, for
whether we consider with M. Piorry that this remedy
facilitates the absorption of deposited matter or not,
we can have no doubt that its power to maintain the
patency and increase the physical and vital action of the
cells would tend, at this period, to prevent the exten-
,sion of the disease, and to give bounds to that then
existing. In this state the material may remain
without change, or without inducing change, for an
indefinite period.
The expectoration of cretaceous tubercle results
from such an accumulation of matter, associated with
destruction of tissue and the formation of a communi-
cation with a tolerably large bronchial tube, and before
its expectoration : it becomes again partially softened
ABSORPTION OF TUBERCLE. 213
by the introduction of fluid, so that portions become
detached, and are spat up in sizes of from a pin's head
to a half a grain of wheat, accompanied usually with
an imperfect emulsion of the same material, looking
like chalk and water. In such expectoration there will
be necessarily the debris of the yellow elastic and other
tissues; but as the process commenced at a distant
period, and the tissues have been long shrivelled, their
character is far less evident than is observed in recent
softening. Yet it may be that recent softening is pro-
ceeding in an adjoining part, and the expectorated
matter may contain both products.
Tubercle is also subject to other transformations, as,
for example, fatty transformation and the production of
cholestrine, but these conditions either precede the
cretaceous formation, or they are found in such
tubercle as tends to softening and destruction of the
tissues.
ABSORPTION OF TUBERCLE.
We have just referred to the opinion of so eminent
an authority as Piorry, in reference to the promotion of
absorptiqn by a particular mode of treatment ; to this
we may add the well-ascertained fact of the absorption
of inflammatory exudations, although it occurs slowly
and seldom quite perfectly, as presumptive evidence of
the absorption of tubercular matter; but it must be
recollected that commonly, perhaps, the exudation in
inflammation occurs rather between the cell walls than
in the cells themselves, that is to say, in the paren-
chyma of the lung, where it cannot be doubted the
214 PROGRESS OF TUBERCLE.
more direct vascular actions occur. Yet there is
strong evidence in favour of the absorption of tuber-
cular matter from the air-cells themselves, in the fact
that degenerated epithelium in closed cavities must in
health be removed by absorption ; and also that under
our observation the evidences of the deposition dis-
tinctly disappear in a stage so early, that the matter, if
removed by expectoration at all, must have passed out,
not by a cavity and large bronchus, but by the minute
opening of the ordinary bronchial tube.
PART III.
TREATMENT.
CHAPTER XXV.
RESTORE THE BULK OF THE BODY BY LESSENINa
ELIMINATION.
THE SKIN.
In discussing the methods of treatment which are
adapted to this disease, we purpose first to consider
the indications for treatment, and the best method of
fulfilling them, and then to give, in an empirical and
categorical manner, a detailed statement of the whole
plan which we recommend. It will also he necessary
to subdivide the former into those conditions which
apply to the system as a whole, including the lungs,
and those which refer to the lungs and other organs, &c.,
as local affections. To these we shall also add chapters
upon certain questions which could not be fully treated
of under those heads.
We have already shown that we have to do with d,
disease in which there is commonly diminution of the
appetite, flesh, and strength, and increased elimination
of fluid and loss of heat ; and that these conditions
216 RESTOEE BULK BY LESSENING ELIMINATION.
have arisen almost insensibly, have stealthily increased,
and have been long continued. The indications for
treatment are, therefore, to restore the bulk of the
body, to increase vital action, to regulate muscular and
mental labour, and to increase innervation; and to
these points we shall give attention in their order.
We have also shown that the term " waste of flesh "
comprehends many questions, and particularly those
relating to the amount of fluid and fat, as well as the
nitrogenous tissues of the body, so that in an attempt
to restore the bulk of the body, we must have reference
to all these elements. The methods proper for this
purpose may be classed under two heads, viz., such as
will lessen elimination, and those which increase
supply ; and of these we will first consider the method
whereby elimination may be lessened. The elimina-
tion of fluid by the skin can be diminished by numerous
methods of treatment.
INUNCTION OF OILS AND FATS.
The practice of inunction of the body is very ancient.
It was used as a method of healing diseases, as we
learn from the Scriptures, and was common^ employed
by the Romans and various Eastern nations after the
use of the hot bath. It is still employed in both very
hot and very cold climates ; in the former, when the
naked body is exposed to the fierce rays of the sun ;
and, in the latter, when it is closely enveloped in furs.
It is also the practice amongst uncivilised nations to
smear the skin with colouring matter and fat ; and in
reference to the dirty state of the skin in such persons,
INUKCTIOK OF OILS AND FATS. 217
as well as in those living in cold climates, and with
insufficient shelter, it has heen remarked that they
could not afford to be clean.
In some of these instances it is possible that the
use of the fat may have been simply a matter of luxury;
but, generally, we beheve it to have had a much deeper
meaning, however little it might have been so regarded
by those who used it. Thus, inunction after the hot bath
would have the effect of lessening the perspiration
which followed the bath, and which tended to the injury
of those who used the bath excessively, and there-
fore strictly corresponded to the cold wet sheet used
in hydropathic establishments, and the cold douche
and cold currents of air practised in Turkish baths
after the hot bath. When applied to the skin of those
whose naked bodies are exposed to the sun, it protects
that organ from the chemical rays, by interposing a
layer which would be equivalent to an article of
clothing ; and since the thick and loose clothing which
is frequently worn by the Turks and other nations
when the external temperature is higher than that of
the body, protects the body by preventing the access
of the rays of heat, and tends to cool the skin, although
it prevents the rapid dispersion of heat from the skin,
so, in like manner, will a layer of fat, with or without
mineral colouring matter, protect and also cool the
skin. Ijlfie free use of oil and fat externally, and the
want of cleanhness of those who live in very cold
climates, have also the power to lessen the insensible
perspiration, and to offer a non-conductor of heat,
which would retard the dispersion of heat, and at
218 KESTOEE BULK BY LESSENING ELIMINATION.
the same time prevent the irritating effects of a dry,
frosty air.
Both of the actions thus described are, we believe,
physical. Of the latter action there can be no doubt,
since it is demonstrated by the existence of the inter-
posed laj^ers; but with regard to the former, there
are many persons who have not so considered it. It
is well known that when a little oil is rubbed over the
spiracles, or breathing pores, of an insect, the creature
dies, because the oil closes the openings and prevents
respiration. So it is with the skin, in which the
openings of the sweat ducts are closed by the oil or
fat, except that, as the air must enter the body of
the insect by respiration, whilst the perspiration must
pass out of the body, the former action will be more
complete, and the respiration be arrested, whilst the
latter action will be only lessened. This action is
capable of easy determination, for if we cover any part
of the skin with a thick layer of ointment, we know
that neither fluid nor vapour can pass through ; but
when we reduce the thickness of the layer until it is
rendered imperfect, we find that fluid will at length
be emitted. Hence we believe that there can be no
doubt of the fact, that in both cases alike the principal
action of the oil or fat is physical.
Then, again, there are many who believe that the
fat becomes absorbed by the skin, and plays ^ part in
the general and local * nutrition of the body ; and in
* Dr. F. W. Mackenzie stated at the Medical Society of London that he
had known deposition of fat about the chest to follow the local external
use of cod-liver oil ; but if morbific putrid matters applied to the skin do
INUNCTION OF OILS AND FATS. 219
proof, reference is made to the disappearance of the
oil or ointment after friction. We admit the latter
as a fact, but do not equally admit the former as an
inference. Fat or oil disappears, in great part at least,
because it is rubbed oiff by the clothing, or runs off by
the liquefjdng effect of the heat of the body, and, of
necessity, a certain portion will enter every opening in
the skin, and thus temporarily disappear ; but it will
be observed, that there is no anatomical arrangement
of the skin whereby the oil can be carried into the
general circulation; neither is there the presence of
the alkali which, in the bile and pancreatic juice, is
understood to be essential to form an emulsion of fat.
The only openings upon the skin are those of the
sebaceous glands and sweat ducts, whilst all the surface
is covered by a material which is non-vascular, and the
perspiration is either neutral or slightly acid. Hence
there are grave doubts as to the true absorption of fat
by the skin, and of its conversion into nutritive material,
to be employed either locally or through the general
system.*
In the disease now under consideration, the inunc-
tion of oil is useful when there is excessive elimination
of fluid by the skin, by restraining that action, and
not gain entrance into the circulation unless there be abrasion of the skin,
it is not easy to see how fats would find admission ; and if they should be
admitted, it yet remains to be proved in what manner they are deposited
locally in the place near to which they were externally applied.
* This is practically admitted by the absence of all attempts to nourish
the system through the skin in cases in which deglutition is almost
impossible. If the skin can absorb fats, there is a presumption that it
could absorb other aliments, as milk and wine — practically a reductio ad
absurdam.
220 RESTOEE BULK BY LESSENmG ELIMINATION.
also by offering, in some degree, a protection against
external agents acting upon a highly sensitive structure.
These actions are mechanical, and will therefore be
more or less efficient as the fat more or less completely
covers the pores of the skin. Hence in the employ-
ment of inunction it is requisite to find a material
which will not readily be removed from the skin, and
to use it in such a manner that a layer of fat shall
always cover the skin. In reference to the material,
we may cite the employment of olive oil, cod-liver oil,
neat's-foot oil, and lard.
Olive oil has the great advantage of not offering an
offensive odour, and of being a substance of ordinary
use to some part of the body, and one therefore with
which the public is familiarly acquainted ; but it has
the disadvantage of rarefying by the heat of the body
to so great an extent, that it runs off the skin, and is
most readily wiped away. Hence it is impossible to
keep the skin covered with a layer of it, unless some
plan be adopted whereby it may be almost constantly
re-applied. Cod-liver oil and neat's-foot oil possess the
great advantage of viscidity, and remain upon the
warm skin for a much longer period than olive oil.
Hence they are much more fitted for the object which
we have in view, but the odour which arises from them
prevents their general use.
Lard, being solid fat, is better adapted for the
purposes of inunction than liquid oils, and possessing
but little odour, it is but slightly offensive. The
addition of a portion of mutton suet renders it less
liable to be removed by the heat of the body, and the
INUNCTION OF OILS AND FATS. 221
ordinary spermaceti ointment is an excellent remedy.
Hence, of the substances named, olive oil and lard are
those to which the least objection is advanced by
patients, whilst the former is the least and the latter
the most fitted for the purpose in a physical point of
view.
In the method of inunction it is important to attend
to the following rules : — 1st. That the ointment shall
be rubbed over every part of the body not less than
twice a day, and so rubbed that the aim shall be, not to
induce the largest amount of absorption, but to cover
the skin in the most perfect manner, and to leave a
layer of fat upon it. Snd. When thus covered, the
layer would remain for many hours if the skin could
be left uncovered and free from contact with external
objects, but as this cannot be, at least in our climate, a
considerable portion of it will be removed whenever
any clothing is put on. Hence it is necessary that
there be a dress worn which shall cover nearly the
whole skin in one piece, and worn so long a time
without change, that the inner surface becoming oily
may the less tend to absorb the fat from the skin.
Perhaps the best material for this purpose is a tolerably
thick twilled calico, without a nap, and it may be worn
either as a long chemise or be made to fit the body as
vest and drawers. 8rd. The plan should be pursued
for a number of days, say seven or ten, without any
intermission, or for as long a time as the patient will
tolerate it, if the skin still require it. It is desirable
to allow a few days to elapse after the treatment has
been discontinued, lest the patient should become
222 EESTORE BULK BY LESSENING ELIMINATION.
weary of it, and then the inunction may be renewed
and repeated in like manner for a long period, if it
should be necessary. 4th. Care must be taken not to
allow the body to remain long uncovered during the
inunction, unless it be summer weather, lest cold be
taken; but if the application be rapidly performed,
time will not be allowed in which injury may occur,
and the ointment itself will tend to prevent cold.
It has been affirmed that persons who handle oil and
fat daily are less frequently afflicted with phthisis than
other persons, and whilst such general statements can
never be admitted as grounds for theory, it is probable
that the constant oiling of the exposed parts of the
body — as the hands, arms, face, and neck by cloth-
workers, butchers, and others, may prevent the skin of
these parts being too active. In the cases of butchers,
it is well-known that the ordinary tendency is to an
inactive state of the skin, as shown by the colour, heat,
and moderate dryness of that organ, whatever may be
the causes to which that may be due.
THE APPLICATION OF COLD WATER.
It would appear at first sight that the application of
cold to a skin in which perspiration is proceeding, and
which possesses great sensitiveness to cold, would be
injurious ; but we have been taught of late years that,
within certain limits, these changes may be effected
with rapidity and impunitj^ The object to be had in
view, however, is not to lower the temperature of the
skin, although that may be a necessary condition to
the attainment of our object, but to remove the atonic
THE APPLICATION OF COLD WATER. 223
or relaxed state of the skin, with which an unusual
tendency to perspiration is always associated, and to
restore the skin to its normal tone. For this purpose
cold is very efficacious, from its known property of
contracting vital tissues, and the chief care must he to
apply it in such a manner that tone may he given without
materially lowering the temperature of the skin. In
exercising this care, it is hetter to use water of the
temperature of the air of the room, viz., from 50° to
60°, according to the season of the year, and either to
plunge the whole hody at once into it, or to apply a
small quantity of it as quickly as possible to the whole
surface. If the plunge bath be used, it should be
expeditiously effected, and friction be applied directly
afterwards, and this may be performed either in open
water or at baths. "When sponging is preferred, it
should be effected night and morning, and care be
taken that the sponge or towel does not retain so much
water that when pressed upon the body the water shall
trickle in streams over the skin. We prefer a towel
for this purpose, and after it has been dipped into the
water and pressed, so as to leave but little water in it,
it should be quickly applied and reapplied to all parts
of the body. The whole operation need not occupy
more than one minute and a half, and as the towel
becomes less cold after it has first touched the body,
the shock is not considerable. In order to produce
the effect which we desire, it must be dipped several
times into the water. It is customary with many
persons to bathe the chest, or some small part of the
body which is ordinarily covered with clothing, and to
224 EESTORE BULK BY LESSENING ELIMINATION.
leave the greater part of tlie body unbathed. We think
this both a useless and a dangerous practice in the
conditions now under consideration, for the object can
be attained only when the whole skin is influenced, and
there is much greater liability to take cold when the
temperature of one part of the skin is lowered and
that of the other parts remains high.
There is still some unfounded prejudice against the
free use jof cold water, on the ground of a supposed
liability to take cold under its use. We grant that if
only a part of the skin be so acted upon, and the naked
body be exposed to a cool temperature for some time,
this is very liable to occur ; but when the whole bod}^ is
acted upon at the same time, — as by the shower or plunge
bath, or by the wet sheet, — there is not the least danger,
and in proportion as the temperature of the skin has
been rapidly lowered, so will the glow of heat be felt
when the skin has been dried and, covered.
On the same ground there are many who use luke-
warm water, and others who, by the routine of the
hydropathic treatment, precede the use of cold by the
employment of the hot bath, but in the conditions in
question both plans are injurious. The use of the
warm water would not afford the contractile action
which we desire, and by the evaporation which would
be set up would be likely to give cold to a sensitive
skin, whilst the hot-bath cannot be useful in any case
in which the skin is ordinarily too active, and where
the sole design is to lessen the activity.
T'here is a common belief that the use of salt water
is attended with less liability to cold than that of
CLOTHING. 225
simple water, and, although this is based upon opinion
only, we attach value to it. It is also probable that
the salt itself possesses a stimulating action, and is,
therefore well fitted to diminish the atonicity of the sldn.
In our ordinary treatment we advise the use of a small
quantity of a cold saturated solution of either common
or rock salt, with a tow^l, as above directed, or the
use of the cold plunge bath, either of simple or salt
water. The former may be practised at every season
of the year, and the good effects which the patients
attribute to it are universal.
In the cases in which we employ inunction, we also
recommend the use of the salt and water sponging in
the intervals during which the inunction is omitted.
-I
CLOTHING.
In the conditions of the skin now under considera-
tion, we have to guard against unduly lessening or
increasing the temperature by clothing, and of in-
creasing perspiration. The rule to be observed is to
use so much clothing as will allow the skin to be
moderately cool, without the patient having the sensa-
tion of cold ; but in the cases in which the extremities
are cold, it is essential that the clothing of these parts
be abundant.
The period when excess of clothing is ordinarily
injurious is the night time, when it is often the habit
to protect the sensitive skin by much clothing, and as
the tendency to perspire is always the greatest when
the vital actions are the lowest, viz., from 3 to 5 a.m.,
it will necessarily occur that perspiration will follow^
Q
226 EESTOEE BULK BY LESSENING ELIMINATION.
and the skin in the early morning will be in its most
relaxed and sensitive condition.
Others have acquired the habit of unduly covering
the body during the day, whenever there is the least
exposure to cool air, either by wearing two flannel
shirts, or two waistcoats, or an overcoat, or by
several layers of flannel or skins on various parts of
the chest. Such persons are afraid to undress on
account of the shock which they experience when the
cool air comes in contact with their soft and sensitive
skin, and it not unfrequently happens, in the cases
in question, that when they are divested of their
clothing there is a cloud of vapour surrounding the
body.
Hence in both of these conditions there is excess of
clothing, and it is requisite that the bathing with
salt and water be employed, at the same time that the
quantity of clothing is lessened, so that the sensitive-
ness of the skin be reduced as the exposure to the
cooler air is enforced. It is also advisable that the
patient do not sleep on a feather bed, and that the bed
clothing be gradually lessened.
The use of flannel shirts is much more general than
•it was in former years, but it is yet very common to
find persons in the early stage of phthisis who have
never worn them. In an inquiry upon 1000 patients
we found that 14^ per cent, had never worn flannel
upon the skin, and that a further 10^ per cent, had
worn for periods not longer than six months. Hence
it may be affirmed, that 26 per cent, of the cases
of both sexes had not worn flannel upon the skin in
CLOTHma 227
health ; but if the women alone are considered, the
proportion was no less than 39 per cent.
We attach the greatest importance to the use of
flannel shirts, chiefly on the ground that woollen
being a bad conductor of heat, they prevent the imme-
diate accession of cold air to the chest under condi-
tions of sudden exposure. We regard them, therefore,
as preventives of disease, and in that light it is mani-
fest that a closely woven fabric is the most fitted for
the purpose, and that no amount of loose and more
open external clothing can offer the same protection
as an ill-conducting fabric which closely fits the body
and is applied immediately to the skin. The thickness
and weight of the material is of far less consequence
than its close manufacture, its good nap, and its tight
covering to the whole chest ; and hence, while the
wove shirts of the present day have the advantage of
more closely fitting the body, the fine Welsh flannel is
a more efficient material.
A woollen shirt, of whatever kind, which is worn
threadbare, or which does not closely fit the body is of
little value.
In connection with this part of the subject is that of
defective clothing. It rarely happens that defective
clothing is associated with an active skin, except when
conjoined with living in close, and therefore heated,
rooms, and with great exhaustion of system from what-
ever cause. Hence in such cases the problem is a
comphcated one, but if the skin be cool and the ex-
tremities cold, with deficient clothing, it is manifest
that the clothing should be increased, and the risk
q2
223 RESTORE BULK BY LESSENING ELIMINATION.
of inducing a more active condition of the skin be
averted by the use of the salt and water bath.
, It may be of advantage to introduce here a few
remarks on the use of clothing which is impenetrable
to moisture. "We think we are right in affirming that,
whilst the use of Indian-rubber goloshes has in-
creased, and that of waterproof coats has perhaps not
diminished materially, the periods during which they
are worn are now more restricted than formerly. It is
manifest that by so much as they are fitted to defend
the body from external wet, by so much do they
necessarily prevent the egress of the vapour from the
body, so that it is common to find that the smooth
Indian-rubber surface of the inside of a coat, which
has been worn when buttoned closely and during
exertion, is covered with moisture, whilst the under
clothing is more or less saturated, the temperature of
the surface materially increased, and the skin ren-
dered soft and very active. So, also, in reference to
the feet, when goloshes or patent-leather boots are
worn, as the wet state of the socks, and the soft,
shrivelled, and sometimes abraded state of the skin of
the feet wiU prove. The first effect of the use of these
articles of clothing is, therefore, to increase the action
of the skin, and, by retaining the heat, to increase the
temperature of the surface; but the effect at a later
period is to give a sensation of cold and to increase the
sensibility of the skin. All persons who wear goloshes
for lengthened periods find the feet cold.
Hence, in the conditions of disease to which we now
refer, it is injurious to wear waterproof materials
EXPOSURE TO THE ATMOSPHERE. 229
of clothing, except under urgent circumstances, and
then their use should be discontinued as early as
possible. When in use they should not thoroughly
envelop any part. Under the ordinary conditions of
life we regard them as injurious.
EXPOSURE TO THE ATMOSPHERE.
Eegulated, but yet free, exposure to the ordinary
variations of the atmosphere is to be commended.
Moderately free exposure to a cool atmosphere at all
periods of the day acts upon the skin in a manner
almost identical with that described under the head of
cold bathing. It will be in vain to attempt to increase
the tone of the skin by the infrequent use of cold water,
unless at the same time the patient be induced to quit
his room, where the air is stagnant and the temperature
high, and to seek the open air with its vigorous breezes
and lower temperature. We are of opinion that nothing
tends so much to induce the unfavourable condition
of skin now under consideration, as the state of the
atmosphere in close rooms and in crowded houses, and
that all such persons ought to spend a very large
portion of the day in the open air and in moderately
exposed positions.
It is highly probable that in former years the
disease in question offered more frequent evidences of
an inflammatory type than is now observed, and con-
sequently demanded a sheltered^ house and a residence
in a warmer climate ; but, however true this may have
been, we affirm that in the ordinary cases of the
disease there is now nothing whatever to forbid the
230 EESTOEE BULK BY LESSENING ELIMINATION
free exposure of the body to the external air. There
are many who deprecate exposure to all weathers, and
seek shelter whenever there is a little rain or the
wind blows somewhat cold. We, however, do not see
any ground for this, and if suitable clothing be used
and exertion made, we would place little restriction as
to the kind of weather. There can be no doubt that
warm and moist weather is the least to be desired in
the conditions now under consideration, and as little
that a dry and cool, and even frosty, air is the most
advantageous.
The universal objection which exists to the east
wind must be based upon truth, however difficult it
may be to assign a proper reason for it. There can
be no doubt as to that wind being a pre-eminently dry
and drying one, as the dry and harsh skin, and the
dry tongue and throat of many persons during its
occurrence testify. So far an easterly wind will clearly
be less injurious to the conditions of skin now under -
consideration, than in the ordinary state of that organ,
but otherwise it may be injurious.
FOOD.
The observations which have been commonly made
in reference to the action of food upon the skin, are
such as have followed its use when it disagreed with
the system, and hence have been attributed to a
diseased, and not to a healthy action. These observa-
tions were no doubt correct, and were due to the cause
indicated, but they also show the direction of the
action of foods under normal conditions, for it must
FOOD. 231
follow, that both in health and disease alike, the
direction of the action of food would be the same,
whilst the degree of the action might be so different
that in one case it would be compatible with health,
and in the other would so exceed the bounds of health
as to cause disease.
Thus it has been observed that alcohols dry the
skin, and particularly the stronger forms of them, as
brandy and rum, and, in our experiments, it was
recorded by one of the gentlemen under its influence,
that the effect was as drying as an east wind * This
occurs both with the ordinary and unusual doses of
the alcohol, but more readily on some occasions than
on others. It is also fully admitted, that in fevers,
when the skin is dry and parched, and in certain forms
of derangement of the liver, when the skin is commonly
dry, alcohols cannot be tolerated, whilst in conditions
such as those under consideration they are well borne,
-and are useful.
Fats, also, when they do not agree, but cause indi-
gestion, are followed by headache and dry skin, as was
known to Hippocrates, whatever may be the kind of
fat, and whether it be taken separately or in the
combination found in milk or in artificial cooking.
This was noticed by us in our experiments, and
also that the tendency of flesh meat in general was to
lessen the action of the skin. Coffee was invariably
seen to dry the skin in our experiments.
Hence, in the conditions now under discussion, some
* PMl. Trans. 1859.
232 RESTORE BULK BY LESSENING ELIMINATION.
of the forms of alcohol, coffee, fats, and milk, are
especially fitted for employment, and it is a familiar
and analogous fact, that they tend to induce constipa-
tion. The old and well-approved combination of rum
and milk, or brandy and milk, in the dose of two tea-
spoonfuls, or a dessert spoonful, of spirit to half-a-pint
of milk is very proper, and particularly in the early
morning, when the skin is commonly very active.
During the day no form is better than that of home-
brewed ale, when not too strong ; or, failing this, good
Dublin stout ; but the dose should never be so great as
to affect the head, nor the use of it continued after the
due effect upon the skin has been produced.
In reference to the night hours, when perspirations
more usually occur, we have found that food of almost
any kind will tend to lessen the elimination, but the
most suitable kinds are coffee and milk, together or
separately, and not unfrequently cold tea has been
equally beneficial. All these substances have the
common effect of increasing the action of the heart
temporarily, and at the period in question, the pulsa-
tion and all the vital actions are extremely reduced.
Whether the effect upon the skin is produced in this
manner we do not stay to inquire.
On the other hand, it is a matter of common obser-
vation that some other kinds of food do not lessen but
increase the action of the skin. This is the case with
warm water, tea, bread, and fresh vegetables, and whilst
the two latter must be eaten, the second should be
usually avoided.
MEDICINES, S33
MEDICINES.
The action of medicines has been ascertained for
the most part by the empirical method just referred to
when discussing the influence of food, and it is well
established that certain substances promote, and others
lessen the action of the skin. This has been proved
both by their ill effects when they have not agreed, and
by their unfitness in certain states of the system.
Thus it has been shown that iron and its salts, with
zinc and many other mineral preparations known as
tonics, with acids and vegetable tonics in general, lessen
the action of the skin, and are particularly fitted for
cases in which the skin is active, and cannot be
administered in febrile and other conditions in which
the skin is dry. Hence recently our friend Dr. Robert
Dickson has introduced the oxide of zinc as r remedy
for night perspirations. The action of iodine upon the
functions of the skin has not been well determined,
but it is highly probable it lessens the activity of that
organ, as is found in the cases of general struma, in
which it is very beneficial.
Hence in the conditions under consideration all
these remedies are applicable, and the ordinary com-
position of a preparation of iron, with acid and a
vegetable bitter, is manifestly the best with which we
are at present acquainted. There is much difference
in practice as to the precise form of a metal which
shall be given, and much ingenuity has been exhibited
of late years to provide salts of iron to meet these
views, and also the supposed requirements of practice.
234 RESTOEE BULK BY LESSENING ELIMINATION.
We cannot but think that the differences of action are
in a degree rather matters of opinion than of fact, and
in practice one or two forms seem to fulfil almost every
indication. Such, for example, as the sesquichloride
of iron, and the citrate of iron with quinine ; but, of
the two, we ordinarily prefer the former in doses of
15 to 25 minims thrice a day.
Lead is also a powerful agent for the purpose now
under consideration, as may be inferred from its
power to arrest sanguineous and alvine discharges,
although it has not hitherto been employed with the
express object here indicated. It is an old remedy in
the treatment of phthisis, but within the last few years
only have its merits been brought clearly before the
profession. M. Beau, the present distinguished physi-
cian to La Cliarite, following the observations of
Hildebrand, has very recently recommended its employ-
ment in all stages of the malady.* His data are
purely empirical, for the idea was derived from the
alleged fact that persons engaged in the operations of
lead mines and white lead works are not very liable to
phthisis, and as such persons are liable to the affec-
tion known as lead colic, M. Beau believes it to be
essential to produce a similar condition in every
phthisical patient. This condition implies lessened
elimination, and constipation, with great diminution
of the power of the cerebro -spinal system of nerves,
for such a condition is indicated in the distended state
of the bowels in painter's colic, and demonstrated in
* Journal de M6decine et de Chirurgie, Nov. 1861.
MEDICINES. 235
the hanging wrists and other evidences of paralysis
which occur in more advanced cases of the lead
poisoning.
We must be exceedingly cautious how we admit
such statements as grounds for treatment in any, but
particularly in so important a class of cases as
phthisis, since the very basis of the infrequency of
phthisis in the class referred to is not by any means
established, and since all empirical observations are
liable to error, both in their interpretation and in the
extension of the class of persons in which they are
observed. The most that could be fairly inferred from
the facts already known is, that in some persons the
influence of lead may be beneficial as a prophylactic
of phthisis, and it would remain to define the charac-
ters of that class. Our own belief of the action of the
lead, and of the class of persons in which it would be
useful, has already been expressed, and hence we
regard it in no wise as a specific remedy in phthisis,
but as one which may be advantageously employed in
a selected class of cases in the early stage with a view
to remove certain collateral conditions.
We do not recommend the adoption of M. Beau's
plan of treatment, neither do we think that any
physician to a public charity in England would feel
himself justified in inducing consequences so serious
as those pointed out by M. Beau, or in so expending
the precious time afforded for the treatment of the
case within the walls of an hospital. M. Beau con-
siders, as w^e have above stated, that in order to obtain
the good effects of the lead, it is necessary to continue
236 RESTORE BULK BY LESSENING ELIMINATIOK
it until constipation and lead cliolic are obtained.
Within that degree he states that the action is rather
unfavourable, since it lessens the appetite, is liable to
disorder the digestion, and, when given by the stomach,
produces diarrhoea. Moreover, he adds gastralgia,
gastric cough, and dyspnoea to this list of preliminary
evils. But after the constitutional influences of the
lead have been attained, M. Beau asserts that there
is improvement in the cough and all the general
symptoms, and the change in the lung disease may
amount almost to a cure. He states, also, that of
twelve persons so treated, the disease was checked and
the physical signs improved in four, the disease had
almost disappeared in four, and two others were
apparently altogether cured. He prescribes the car-
bonate of lead in 2 grains doses, daily adding 2 grains
on each succeeding day until 12 grains daily are given,
or the lead poisoning is effected.
AVe believe the remedy to be useful in the class of
cases where there is emaciation, due chiefly to a con-
stitutional disposition to excessive elimination, and
where, as a consequence, there is a diminution in the
heat of the body and the vital powers ; but it should be
given rather in an intermitting than a continuous
manner.
There is, however, a temporary condition of the
perspiration, which in our judgment modifies the kind
of treatment here advised, and which it may be proper
to refer to here, viz., the acid odour of the perspiration
w^hich is observed in many cases. This condition is
oftentimes very marked, and on inquiry it will be found
MEDICINES. 237
that it has attracted the attention of the patient. It
is also more common in the night than in the day-
perspiration. It suffices to divide the class of cases
now under consideration into two classes, so far as the
treatment is concerned ; for we have noticed that those
on whom perspirations, whether by night or day, are
profuse, acids and mineral tonics do not diminish the
action of the skin, whilst in such cases the use of the
ordinary saline medicine containing acetate of ammonia,
or of a combination of salts of soda and potash, soon
remove the sour odour and the perspirations together.
There is some variation in the cases, so that in one
class the ammonia salt is more efficacious than the
soda and potash ; and such for the most part are those
who experience chilliness and severe sense of alterna-
tions of temperature, as in a common cold, whilst in a
few cases the plan now indicated is of no avail. Our
ordinary plan is to administer the alkalies or neutral
salts in cases where the perspiration possesses the sour
odour, and when there is much debility, we have
commonly found that the ammonio-chloride of iron is
the best of all the tonic preparations. This condition
is temporary, and after a period the treatment required
is that which is fitted for those in whom there is no
acid odour ; but we have known many cases in which
the continued use of a saline for several weeks was
attended by much comfort and increase of strength.
As an instance of marked improvement from the plan
of treatment here recommended, we cite the following
case of early phthisis.
There was constant and excessive elimination of
238 EESTORE BULK BY LESSENING ELIMINATION.
acid by the skin, without other symptoms than exces-
sive and general exhaustion and wasting, and it did
not progress satisfactorily during three or four months.
Under the influence of the combination of potass and
soda, he had a very profuse sweating, accompanied by
an exceedingly acid and acrid odour ; and obtained
immediate and almost marvellous relief.
J. E,, a young, single man, aged twenty, engaged
in a grocer's shop in the country, had complained for
three months of bad appetite, with brown tongue, foul
breath, and slight emaciation. There was slight
haemoptysis occasionally, with slight dyspnoea. There
was scarcely any cough, but the throat had been sore
from the commencement of his disease. The general
expression of the symptoms was nervous exhaustion
and muscular debility. The chest presented the
slightest shade of dulness on percussion, and lessened
respiration on the left side.
On August 21st, he began to take iron, with a
mineral acid and quina. Cod-liver oil was added on
August 28th. In September, he continued in the same
state, but with a little increase of cough and debility.
In October, the cough continued, but he felt a little
general improvement. There was also a little pain in
the left breast. His state was becoming more anaemic;
and the iron, being intermitted for a time, was renewed
in November. During all this period he took out-of-
door exercise, used salt-and-water ablutions, and was
directed to take milk and other nutritive kinds of food
at short intervals during the day and night.
Thus three months passed away without any
MEDICINES. 239
visible improvement ; and the progress of the lung-
disease appeared imminent. At the end of November,
however, he had a most profuse sweating during four
nights, in frosty weather, accompanied by an exceed-
ingly sour and acrid odour, which appeared to be the
crisis of his condition ; for, under the influence of
bicarbonate of potass and gentian, he improved most
rapidly, and the increase of perspiration, with its acid
state, ceased in December. Throughout January he
continued to improve, and became again cheerful,
active, and strong; and the cod-liver oil being again
prescribed at the beginning of February (it having
disagreed with him in the early part of his attack),
caused so much improvement in a fortnight, that he
was led to look upon it as the principal means of his
restoration to health. It is very probable that, had the
alkaline treatment been begun earlier, we should have
been spared some anxiety.
Cases are also met with in which the perspiration is
profuse and of a very sour odour, and does not yield
to treatment, and in such the disease commonly pro-
gresses rapidly. When the perspiration is not acid,
the ordinary forms of mineral and vegetable tonics,
with acids, are well fitted to lessen the action of the
skin.
CHAPTEH XXVI.
RESTOEE THE BULK OF THE BODY BY LESSENING
ELIMINATION.
THE KIDNEYS AND BOWELS.
Theee is undoubtedly a close relation between the
action of the skin and the kidneys, so that any increase
or decrease in the elimination by the skin will be
attended by the converse condition in the kidneys.
Hence in the condition of disease now under considera-
tion, in which there is commonly increased action of
the skin, the quantity of urine evolved is seldom in
any marked excess.
There are, however, periods when the kidneys
eliminate large quantities of urine, either from a sudden
change in the relations of the skin to the kidneys, or
from some other cause acting directly through the
latter organs. There are also numerous instances in
which the amount of urine is unduly increased by
drinking large quantities of water or weak tea, and
since the ordinary effect of drinking fluids alone is to
cause an elimination of more fluid than they have
afforded to the body, the result is to produce excessive
elimination. Moreover, many persons indulge in the
THE KIDNEYS AND BOWELS. 241
use of gin or other alcohols, which tend directly to
increase elimination by the kidneys.
In the treatment of the early stage of phthisis, it is
very desirable that the fluids taken should be duly
restricted, that they should not be of a nature to in-
crease elimination, and that they should be administered
with solid food, which may require them for its solution,
and will temporarily fix them in the tissues. It is
highly probable that the evil effect of gin-drinking is
evident in this manner before the further condition of
diseased kidneys is induced, and is thereby one of the
causes of phthisis. It must also be admitted that the
indiscriminate use of large quantities of Spa waters
before breakfast tends largely to injury in this direction
in persons suffering from the condition now under
discussion, since at that period of the day, and when
taken without food, simple water is a most powerful
diuretic*
The patients frequently express a desire for much
fluid to satisfy thirst, and so far it is indicative of
excessive elimination, for both perspiration and diu-
resis, when in large excess, induce thirst. In such
cases the plan of treatment is to lessen the elimination
of fluid, and then the thirst will disappear.
When the excessive elimination of fluid by the
kidneys is associated with disease of the kidney, its
prevention is seldom within our reach ; and as it is
rarely found in the early stage of phthisis, and has
no necessary relation to that disease, we do not pur-
pose to enter upon its discussion.
♦ Phil. Trans., 1861.
242 EESTOEE BULK BY LESSENING ELIMINATION.
There is mucli variation in the habits of men as to
the frequency with which dejections from the bowels
naturally occur, and consequently as to the quantity of
alvine excretion. There is also very great tolerance of
these variations, so that we have known many persons
in good health who have been accustomed to only one
dejection in ten or fourteen days, whilst others have
alvine evacuations twice or thrice a day. It is, therefore,
impossible to lay down any rule which may be considered
as necessary to health, or to affirm that the ordinarily
daily evacuation is much more natural than a less fre-
quent one. It is no doubt, in fact, dependent upon the
amount and kind of food eaten, and the amount of
food which has been transformed ; for the larger the
amount of refuse and unused food in the bowel, the
more necessary it is to have a frequent dejection. But
in the disease in question, where the appetite is some-
what diminished, there is perhaps less than the
ordinary necessity for a daily evacuation. "When the
food is habitually long retained, it may be inferred that
its nutritive qualities are more perfectly extracted than
would have occurred in the same person with a daily
evacuation ; whilst frequent evacutions always contain
a large amount of nutritive material. Hence, in ordinary
cases, we would not advise a rigid conformity with the
ordinary rule of a daily evacuation. In this matter the
ordinary habits of the patient must be duly considered,
and it not unfrequently happens that frequent dejections
have been the rule, or that this condition has existed
for some time ; but even then, unless other circum-
stances contra-indicate it, we would rather lessen the
THE KIDKEYS AND BOWELS. 243
frequency of the act ; and where there are frequent
dejections, to which may be in part attributed the
condition under discussion, the first object should be
to arrest it.
We do not here refer to the conditions of the bowel
which commonly give rise to diarrhoea, since they
belong to a later period of the disease than we purpose
to embrace.
11 2
CHAPTER XXVII.
RESTORE THE BULK OF THE BODY BY INCREASING THE
SUPPLY.
DEFICIENCY OF NITROGEN IN ADOLESCENCE.
Having now shown the degree of activity in the
eliminating actions of the body, and the methods
whereby it may be restrained, and thus arrest the loss
of weight and bulk of the body, which is a common
feature in this disease, we now proceed to show how
far the emaciation may be lessened by a positive in-
crease in the amount of food supplied.
It will be well understood, in limine, that it is one
thing to place food in the stomach, and another to have
it duly digested and transformed, so that only a little
may pass off by the bowel; but there is, nevertheless,
a close relationship between the appetite for food and
the power of the system to transform the food, and, as
a practical rule, if the patient can be induced to
increase the quantity of food taken, we may be sure
that there will be an increase in the quantity trans-
formed, although not necessarily in exact proportion
to the increase of the food. The former question we
shall hereafter consider more at large when speaking
of the increase in the vital actions, and shall here refer
DEFICIENCY OF NITEOGEN IN ADOLESCENCE. 245
only to the latter, or tlie increase of the quantity of
food.
We have already stated that there is commonly
some diminution in the amount of food eaten, and
in addition to this, we may affirm that, whatever
may be the relation of the present to the usual
quantity of food, there is in the cases in question
very commonly an absolute defect in the required
quantity. It is impossible to lay down any general
rule which shall be applicable to individual cases,
and therefore, to some extent, each case must be
determined by itself, and a comparison made be-
tween the present and the usual quantity of food ;
but yet there are certain general grounds which are
widely applicable.
We have elsewhere shown that the nitrogenous ele-
ment in food* is necessary both for the supply of mate-
rial to be fixed in the nitrogenous tissues, and for the
true transformation of the hydro-carbons ; and there is
the most serious reason to believe that this element is
commonly deficient in the food of the persons to whose
condition we are now referring.
At the period of life when youth is passing into
adolescence, and when so large a portion of mankind
fall into phthisis, there is such a change in the dietary
that the amount of nitrogen supplied is greatly
lessened in proportion to the weight of the body, and
the greatest liability to a diminution below that re-
quired by the system at this period of growth. Thus
taking the amount of urea evolved to represent the
♦ Phil. Trans., 1859.
246 RESTORE BULK BY mCREASING THE SUPPLY.
amount of nitrogen ingested, we have shown, in our
work on the cyclical changes of the human system,
that there are 5, 6, or 7 grains of urea to each pound
weight of body, at three, four, or five years of age ; but
it is reduced to 2, 3, or 4 grains at sixteen or eighteen
years of age. This is chiefly to be attributed to the
diminution in the supply of milk without a corre-
sponding increase in the supply of other nitrogenous
foods, and at the same time there is an increase of the
hydro -carbon starch, which, as above mentioned, de-
mands the addition of nitrogen for its due assimila-
tion. The proportion of nitrogen to the carbon in
bread is 1 to 23, but in milk it is 1 to 11 ; so that, for
every pound of milk omitted, there should be two pounds
of bread added. The addition of meat which is made
when the supply of milk is lessened is generally quite
inadequate to meet the loss thus occasioned; for if a fair
proportion of fat and lean meat be taken, the quantity
of nitrogen per ounce s(^rcely exceeds 8 grains, whilst
that in good bread is nearly as much, and it would
require 5i oz. of good uncooked fat and lean meat
to supply as much nitrogen as is found in one pint
of good new milk.
We know that at the period in question, when the
quantity of milk is reduced one or two pints daily,
there is not commonly an equivalent increase in meat
and bread, and hence this most essential vital excitant
falls into defect. This we believe to be the case in all
classes of society, and to constitute one of the most
common causes of this disease. In the rich it is
customary for tea and coffee, which offer scarcely any
DEFICIENCY OF OTTEOGEN IN ADOLESCENCE. 247
nitrogen, with but a small portion of milk, to consti-
tute the breakfast of the young man or woman, who a
few years earlier ate one pint of milk at that meal, con-
taining 44 grs. of nitrogen, and a quantity of bread,
scarcely less than that eaten in adolescence ; whilst the
children of the poor are frequently compelled to live
throughout the day upon little but tea and bread.
As a general rule, it may be laid down that the
quantity of nitrogen supplied for each pound weight of
body, from fourteen to twenty years of age, should not
be less than Ij grs., and that of carbon 25 grs. ; so
that, if we consider the weight of the body to vary
from 90 lbs. to 150 lbs. in that period, the total daily
quantity would be 135 grs. to 275 grs. of nitrogen,
and 5 oz. to 8J oz. of carbon.
The dietary which should be supplied may be thus
stated. Three pints of milk ; 1^ lbs. of bread ; 6 oz.
of uncooked meat (equal to 4 oz. of cooked meat) ;
f lb. of potatoes ; Ij oz. of butter and 3 oz. of uncooked
bacon, or 4 oz. of eggs. This would give the follow-
ing quantity of nitrogen : —
Nitrogen.
3 pints of milk, new and good, grains . . . 132
6 ozs. of meat (fat and lean) . . . . . 48 .
20 ozs. of bread 155
12 ozs. potatoes 9
344
Hence we would supply upwards of 300 grs. of
nitrogen per day, and thus be in excess of the daily
requirements of the system, and allow a considerable
quantity to be fixed in the tissues of the body as
248 EESTOEE BULK BY INCREASING THE SUPPLY.
they increase in bulk. In order that this large
quantity of food may be taken and duly digested, it
is requisite that it be wisely distributed over the
twenty-four hours, and to this we attach the greatest
importance.
But there are very many cases in which the patient
is unable to take sufficient food to supply so large a
quantity of nitrogen, and it is of great consequence to
meet this deficiency. This is largely effected by Bou-
chardat's various preparations of glutenized foods re-
cently introduced into this country by G. Van Abbott
and Co., which we have extensively used in our expe-
rimental researches and in the dietary of phthisical
patients. These preparations are^ — gluten bread, which
is prepared in slices, and must be toasted and eaten
hot ; semola, the ground gluten bread containing 80
per cent, of gluten, and chocolate, the best quality of
which contains 10 per cent, of gluten.
In our experiments we found that Ij oz. of gluten
bread, when taken alone, increased the emission of
carbonic acid to the maximum extent of 1*04 and 1*7
grs. per minute, and maintained the effect for fully three
hours. Two ounces of gluten bread, taken in the morn-
ing, caused an increase of 62 grs. of urea during the
day; Ij oz. of the best gluten chocolate caused an
increase in the quantity of carbonic acid evolved of
2 grs. per minute, with the increase enduring for about
3 hours.
As gluten contains about 16 per cent, of nitrogen, it
is evident that if the gluten bread and the semola con-
tain 80 per cent, of gluten, there will be as much nitro-
SCHEME OF DAILY DIET. 249
gen supplied in 1 oz. as is contained in 1 J pint of milk
or 7 oz.of ordinary bread, and that we have in them
most valuable agents. The gluten bread may be eaten
like ordinary toast with any meal, whilst the semola
may be prepared with milk, and taken separately or in
puddings. In the treatment of consumptive patients
we attach very great value to the use of these substances.
Their action is to increase the activity of all vital func-
tions, since, by so largely increasing the evolution of
carbonic acid, they must aid in the transformation of
starchy and other hydro-carbonaceous foods, and at the
same time the nitrogen supplies the element requisite
for the formation of the tissues of the body. Hence
they increase assimilation.
In cases of consumption and general debility, it is
our practice to recommend the daily use of 4 ozs. of
gluten bread or semola and two quantities of gluten
chocolate, in addition to, or to supply a deficiency in,
the quantity of nitrogenous food just referred to ; and
we are able to affirm that the results have been highly
satisfactory.
SCHEME OF DAILY DIET.
We have already shown that the vital actions are
greatly reduced during the night, and that in phthisis
the night depression far exceeds that observed in
health. Hence it is of prime importance to supply
food in the night as well as in the day, and the
following is the scheme which we ordinarily recom-
mend : —
1. Immediately on awaking in the early morning.
250 RESTORE BULK BY INCREASING THE SUPPLY.
i a-pint of milk (hot if possible), alone, or with
chocolate added, with bread and butter.
2. For breakfast : f pint of milk, with coffee, choco-
late, or oatmeal, and eggs or bacon in addition.
3. At 11 A.M. i a pint of milk, or of good beef tea,
made from ox heads or shins, with bread and
butter.
4. An early dinner, with plenty of meat, and milk
and egg pudding.
6. An early tea, consisting of milk with coffee or
chocolate, and bread and butter.
6. An early supper of f pint of milk with oatmeal
or chocolate, and bread and butter ; or two eggs
with bread and butter, and milk to drink.
7. During the night a cup of milk and a little bread
and butter to be placed by the bed side and to
be eaten if the patient should awake.
By this mode a much larger quantity of food maj^
be taken than would be possible if the food were given
only at the usual meal hours, and as it will be taken
in small quantities, the system wiU not be oppressed
by it, and the vital actions will not be allowed to
subside. It is a dietary which allows a considerable
quantity of nutritious material, both nitrogenous and
hydro-carbonaceous, to be stored up in the system,
since it is rich in both classes of nutriment.
SPECIAL ARTICLES OF FOOD.
We think it of great importance that there should
be a considerable amount of fat taken, whatever may
be the quantity of starch supplied, since it is manifest
SPECIAL ARTICLES OF FOOD. 251
from common experience that starch alone cannot
meet the requirements of the system in reference to
this class of food. The dietary just recommended
supplies nearly 3 oz. of hutter in the milk, and this
added to the butter eaten with the bread, would
amount to 5 oz. daily. The meat, when well fed,
offers upon the whole beast from 25 to 50 per cent, of
fat, so that with 6 oz. of fresh meat we shall supply
about 2 oz. of fat, giving a total daily supply of fat
of 7 oz.
The essential consideration in the dietary for
patients in early phthisis is abundance of nitrogenous
and fatty foods, with such an addition of starchy foods
as may be necessary for admixture with the fat, and
this we would in the most serious manner urge
upon the attention of all having the charge of such
cases. There are, doubtless, many other articles of
food which enter into ordinary dietaries, and which
might be properly introduced into this one, besides
these now indicated ; and amongst these we may
mention gelatin, isinglass, Irish moss, and various
modern preparations of grain, as corn-flour and semo-
lina.
There is a prevalent belief amongst scientific men
that gelatin does not aid in the work of nutrition.
This has been derived from the results of the inquiries
of the " Gelatin Commission " in France, which showed
that animals could not live on bones, however well
prepared; and also from the observations of many
physiologists, that as the excretion of urea is greatly
increased after the ingestion of gelatin, it implies that
252 EESTOEE BULK BY INCREASING THE SUPPLY.
the gelatin did not enter into the composition of the
tissues, but was transformed in the blood, and emitted
as urea. We think that it would not be difficult to
adduce arguments against these views, and particularly
the facts that in our experiments gelatin caused as
large an emission of carbonic acid as followed the
employment of flesh meat, and also that nitrogenous
matters have two actions which are useful in the
economy, namely, that of forming nitrogenous tissue,
and of €xciting vital action. The last action cannot
be denied to gelatin, however much we may question
the former ; and hence, whilst we do not attach such
value to the use of gelatin as would warrant us in
including that food in our scheme of dietary, we believe
it to be a useful adjunct. Iceland and Irish moss act te
by their mucilaginous property, and are therefore
rather medicinal than dietetic substances. We believe
that the use of the new farinaceous preparations is of
much value.
We do not attach importance to the employment of
alcohols as articles of food under ordinary conditions,
but we cannot doubt that there are circumstances in
which these are called for. If we consider that alcohol
is the chief component of these fluids, we cannot
employ them under the heading of these observations,
viz., the increase in the supply of food, for it is impos-
sible to affirm that it is a food in the ordinary accepta-
tion of that term. There are doubtless some elements in
ales which supply a small amount of nutritive material,
but with the conviction which we have endeavoured
to establish that alcohol is not transformed in the
SPECIAL ARTICLES OF FOOD. 253
system, we cannot extend the same remarks to spirits,
and only in a very small degree will it be applicable to
wines. But we have shown * that indirectly this class
of substances exerts a large influence over nutrition,
and we purpose to describe this action when considering
the mode of increasing vital action.
It will be remarked that we have not admitted tea as
an article of dietary for consumptives, whilst we have
recommended the use of coffee and chocolate. The
reason for this omission is the power which tea
possesses of increasing the action of the skin, and
whilst there may be some cases in which this action
wou^d not be injurious, we believe that in the majority
the tendency of it would be hurtful. Coffee and
chocolate have an analogous action over the respira-
tory function, and over nutrition, whilst they lessen
rather than increase the action of the skin.
It is not unusual to recommend fish as an article of
dietary in this class of cases, but we submit that in the
cases in which the appetite fails somewhat, and it is
desired to increase nutrition, it is much more useful to
give animal flesh, with its rich juices, which offers a
larger amount of nutriment in a smaller volume, and
to add to it the combination of nitrogenous and hydro -
carbonaceous compounds found in milk as the diluent.
Without offering any very strong objection to the use
of fish, we think it better to avoid it, and to supply a
stronger food. There are but very few cases in which
the appetite refuses a moderate quantity of flesh meat,
♦ Lancet, 1861 ; British Med. Journal, Nov. 16, 1861.
254 EESTORE BULK BY INCREASmG THE SUPPLY.
and in which the fi:ee use of milk will not form a better
substitute than fish.
The two general rules to be obeyed in supplying food
are, to offer the largest amount of nutriment both nitro-
genous and hydro-carbonaceous in the smallest bulk,
and to supply it in small quantities at short intervals.
CHAPTER XXYIIL
INCREASE THE VITAL ACTIONS.
GENERAL OBSERVATIONS.
We have in a former part of this work shown that
in many cases of early phthisis there is a small
increase in the rate of pulsation and respiration, and
when this is considered in connection with the emacia-
tion which in some degree occurs, it may appear to
contra-indicate an increase in the vital actions, as a
remedy in that disease. But we venture to affirm that
this wasting of the body is no evidence of increased vital
action, but rather on the contrary indicates a diminu-
tion of that vital force by which tissue is formed and
the due bulk of the body is maintained, and it has long
been admitted that increase in the rate of the action of
the heart is per se evidence of feeble vital force. Hence,
as the condition met with in early phthisis is truly one
of lessened vital power, the increase in these actions
which indicate vital power and which also maintain it,
must be called for.
There are two effects of vital action which embrace
all that we would affirm under this head, viz., the
increase in the heat of the body, and the deposition of
tissue material.
256 INCREASE THE YITAL ACTIONS.
In reference to heat, we have already shown how far
the waste of it may be prevented by lessening the
action of the skin and the quantity of the excretions,
and by this action alone the total heat in the body
must be increased. But whilst it is of the first con-
sequence to lessen the waste of heat, it is of the next
importance to increase the supply of it, and then by
increased production the evils of excessive waste may
be altogether removed. This is effected whenever the
chemico-vital changes in the body are increased, but
particularly when food of whatever composition is
transformed within the body.
The deposition of tissue material must also be a vital
act, and to increase it considerably we must ordinarily
increase the vital actions. This we conceive to be essen-
tially the case with the nitrogenous tissues, but only
partially in reference to the deposition of fat. There can
be no doubt that the production of nitrogenous tissues
demands the final and the highest transformation of
nutritive elements, but it is not necessarily so of fat,
for whilst that substance is produced within the body
from other elements in food, there is no reason to
suppose that fat which is taken into the body and laid
up there is necessarily first transformed. Hence there
are numerous instances in which increasing deposition
of fat is indicative of lessening respiratory and other
vital actions. Such is observed in cases of chronic
bronchitis, in which it often occurs that the approach
of an attack may be predicated by observing a recent
increase in the deposition of fat. In phthisis, however,
this increase in the quantity of fat in the body is more
INCREASE OF APPETITE. 267
indicative of increase of vital action than in that of
bronchitis, since it implies that the appetite for fat
has been increased, and that foods containing fat in
some form have been eaten more abundantly. Hence,
as a general expression in cases of early phthisis, it
will be correct to affirm that increased deposition of
tissue elements, and of the fat contained in tissue,
indicates increased vital action.
We will now proceed to consider in detail the
methods whereby vital action may be ordinarily
increased.
INCREASE OF APPETITE.
Whilst there is commonly a real diminution to a
moderate degree in the desire for food, it is almost as
common to find that caprice or imfounded belief or
habit is largely concerned in that diminution. The
dislike to fat and milk are patent illustrations of the
fact. On inquiring into the habits of those persons
who say that they have a dislike to fat, it frequently
occurs that they refer only to one kind of fat, as, for
example, that of meat, and the dislike may be further
restricted to special kinds of fat of meat, as suet, or
even the fat of beef, when that of mutton or pork
will be tolerated. In this matter there is a certain
amount of fact; for as different kinds of fat afford
different flavours, we know that persons in perfect health
prefer one kind to another ; but there is also some
fiction, for it will be found that in many cases there has
been no change in the appetite, but that the present
dislike is one which has been induced by habit and
258 INCREASE THE VITAL ACTIONS.
education, as is seen in families in whom it is the habit
to purchase only the leanest meat and to set the
example of leaving uneaten every small portion of fat.
So, in reference to milli, in a majority of instances in
which there is a dislike to the food, there has been no
change of recent date ; but, either in early life it was
nearly withheld, or since the period of youth its use had
been almost entirely discontinued, until the absence of
desire for it has been construed into a distaste for it.
There are, however, a few cases in which, with some
relish for it, evil effects follow its use, as for example
sickness; but in many of these instances it will be
found that the milk is taken cold, and drunk in a tole-
rably large quantity at a time, so that there has been a
large accumulation of casein within the stomach.
In nearly all the instances in which there is a declared
dislike to these two important articles of diet, it will
be found that encouragement and due regulation will
nearly overcome the objection. Thus, when one kind
of fat cannot be taken, another, as for example bacon,
butter, suet in puddings or milk may be substituted, or
it may be eaten in smaller quantities at a time and with
the addition of starchy food. "When milk is disliked, it
may be eaten when cooked as pudding, or alone when
taken hot and with bread or other farinaceous food in
small quantities at a time ; and when new milk cannot
be retained upon the stomach, skimmed milk may be
borne.
Hence, the first duty in reference to the improve-
ment of a defective appetite for particular kinds of food,
is to ascertain how much is due to false impressions,
INCEEASE OF APPETITE. 259
to habit, or to injudicious quantities, or admixture of
foods, and to regulate the habits and encourage suitable
efforts to remove the distaste ; and when this has been
effected, and the mind of the patient impressed with the
essential importance of increasing the appetite for food,
the whole difficulty will in many persons have been
removed. But there will yet be many cases in which
the desire for food will still be below the requirements
of the system, and then the following rules may be
applied : —
1. To allow of no improper, useless, or bulky article
of food, and to select those kinds of food which
approach to a proper dietary, and are the least
distasteful to the particular patient.
2. To supply the food in small quantities at frequent
intervals, so that the total quantity may be
unconsciously increased. The amount of the
interval must necessarily vary with the food
supplied ; but if the food consist chiefly of milk,
the interval need not exceed two, or at the most,
three hours.
3. To supply the food as warm as it may be com-
fortably eaten, and cooked in different ways, but
in those the most agreeable to the patient. The
exhibition of food at a temperature higher than
that of the body is commonly practicable when
food at a temperature but little below that degree
would be rejected, and the application of the
heated fluid to the stomach is fitted to increase
nervous and vascular action.
Within certain limits the appetite will vary as the
s 2
260 INCREASE THE VITAL ACTIONS.
general vital actions of the body vary, and hence will
increase as exertion is made or cold is applied to the
body. Exertion directly causes increased vital action
and increased waste, and in^the ordinary course of events
increases the desire for food to supply the defect ; and
the application of cold, whether by the inhalation of
cool air or the application of it to the skin, acts in a
similar manner, but in a much less degree. Hence the
general plan of treatment adopted in this class of cases
tends directly to increase the appetite.
The mode by which medicines increase the appetite
is not very clear. In some instances a stimulant suf-
fices to increase the nervous action of the stomach, or
a bitter or acid, constringesthe mucous coat, or an alkali
removes disordered secretions ; but our knowledge upon
this point is almost exclusively empirical. We are,
however, aware by experience that condiments, carmi-
natives, bitters, and acids, have this influence. We
have also already referred to the stimulating influence
of heat when locally applied to the stomach; and to this
we may add the action of alcohols.
The action of alcohols as an excitant of the appetite
is very well known in India, where, with the exhaustion
induced by the climate and the low state of the vital
force which occurs in the early morning, it is found
almost impossible to enjoy the breakfast or the lunch
without prefacing the meal with bitter beer or some
other alcoholic compound. The like conditions do not
naturally occur in this climate ; but in many cases of
early phthisis the same degree of vital exhaustion is
met with, and a small quantity of ale, wine, or a little
IMPROVEMENT OF THE DIGESTION. 261
spirit and water, when taken immediately before the
meal, increases the appetite for food. But whilst
affirming the value of alcohols in numerous instances
in the condition in question, we would add that com-
monly an increase of appetite would be gained without
their use.
IMPROVEMENT OF THE DIGESTION.
The evidences of defective digestion are commonly a
sense of fulness and load at the stomach after meals,
sometimes extending to the degree of compelling the
patient to desist from eating after having taken only a
few morsels ; acidity occurring in the early morning,
but chiefly after meals, and a foul state of the tongue
with a disagreeable taste.
The condition in which the patient feels full after
having eaten only a very small quantity of food appears
to present a state of h3^per8esthesia of the stomach. In
such a case there is great liability to vomiting if
cough occur at that period, and there is commonly some
tenderness or pressure at the epigastrium. There can
be no doubt that this condition being long continued,
induces a contracted state of the organ such as occurs
when the bulk of the food is permanently reduced.
This state is relieved by abstinence from tea, coffee,
and condiments, and by supplying food prepared with
milk, in small quantities, frequently ; but if it have been
long continued, and the cavity of the stomach have been
reduced in capacity, a considerable period must elapse
before the stomach will exhibit the natural tolerance to
the presence of a full quantity of food at a meal.
262 INCREASE THE VITAL ACTIONS.
The most efficacious remedy in this condition is the
administration of hydrocyanic acid with an alkaline
carbonate and a bitter, a short period previous to the
dinner and tea meals ; and it but rarely happens that this
plan of treatment, added to that which belongs to the
general treatment of the disease, fails after a few days
or weeks to allow the food to be increased in quantity,
and a large quantity to be borne during the digestive
process. When, however, cases present themselves in
which this condition of the stomach is a permanent
feature, or where it is unusually intractable, it is
advisable to apply and renew blisters to the epigastrium ;
and it should be borne in mind that there is no condition
which so powerfully tends to obstruct the treatment in
the direction now under discussion.
The dyspepsia in which there is an excess of acidity
is frequently conjoined with that now mentioned, but
in perhaps a majority of instances the acid eructations
and the heartburn are more prominent evils than the
sense of fulness after meals. However the excess of
acidity may be explained, it will be found that its effect
is to induce a certain degree of irritability of the mucous
membrane, and in process of time it becomes essentially
connected with a diseased state of the pharynx. In
cases of heartburn the sensation is felt at the top of
the pharynx, in the part covered by tesselated epithelium,
and as we have already seen, essentially associated with
the act of coughing. It is also highly probable that the
inferior opening of the oesophagus into the stomach does
not close, or that a certain quantity of fluid food is
retained within the cavity, as is proved by the frequent
IMPROVEMENT OF THE DIGESTION. 263
ejection of food into the upper part of the pharynx
which attends the act called "heartburn." During the
existence of heartburn, if a warm fluid be drunk, it causes
pain in the pharynx. We believe that in a large portion
of such cases the condition complained of is truly
pharyngeal, and is not only an impediment to the
reception of food, but excites cough.
It is common to find, on examining the pharynx, that
portions of food remain attached to the mucous
membrane. This is the case in that part covered by
the tesselated epithelium ; but whether it occurs in the
lower part which possesses vibratile epithelium we
cannot tell; yet, notwithstanding the beneficial action of
the ciliae, it is very probable that particles of food often
remain upon the membrane. This will be the case
particularly when bread or similar food is eaten alone,
and the deglutition of it is not followed by a fluid.
There is also reason to believe that the eructations to
which we have referred have in many instances become
habitual, and are due either to an unnatural action in
the oesophagus, or to an abnormal formation of that organ ;
but, whatever may be the immediate cause, if they have
been long continued, they will not readily succumb to
treatment.
In this class of cases we advise that the deglutition
of solid food be always accompanied by a fluid, and that
fluid be drunk after the solid food has been taken. It
frequently happens in health that when dry and solid
food has been eaten, and particularly when it has not
been well masticated, it accumulates in the lower part
of the oesophagus, causespain and perhaps hiccough, and
264: INCREASE THE VITAL ACTIONS.
requires a large volume of fluid to be drunk before
the mass can be carried into the stomach. Hence, if
the patient be subject to this accumulation, it is the
more necessary that he should use sufficient fluid after
the deglutition of solid food. The use of brown bread
in this state is very inappropriate, since the particles of
bran readily adhere to the mucous membrane, and induce
irritation and acidity. We also advise the use of bread
prepared with baking powder in preference to yeast,
having a little excess of the alkali, since it has a less
tendency to become sour, and certainly corrects acidity
upon the points over which it passes. In this state,
also, the use of tea, coffee, alcohols, and condiments
should be interdicted, whilst antacids, either in the
form of a caustic or a carbonated alkali, will be very
beneficial, both at the period when the heartburn is
distressing, and at other periods of the day.
We have endeavoured to connect the class of cases
in which there is excess ofacid secretion in the stomach
and pharynx with those in which there is acid perspira-
tion, but have not yet found any essential connection
between the two conditions.
The conditions in which there is foulness of the tongue
are very various, as indeed are the degrees and character
of the foulness. When the tongue retains its usual
size and form, and is pale, and more or less covered
with a thin white layer, it may be found with any
condition of dyspepsia ; but the state to which we more
particularly refer is one in which the tongue appears
enlarged and the upper surface rounded ; the papillae
enlarged and the whole organ presenting a yellow (not
IMPKOVEMENT OF THE DIGESTION. 265
the ordinary pale red) tinge. There is also a thick
crust over the surface, varying in thickness, but usually
increasing towards the root ; and there is a foul taste in
the mouth, and often a foul odour in the breath. This
condition we have noticed to be common in compositors
and others who live in foul air and are engaged in night-
work ; but it is not uncommon in shoemakers and
tailors, and in the poor and ill-fed. It is always
accompanied by marked evidence of dyspepsia, and is
usually very intractable. As we regard it rather as
evidence of mal- assimilation, we shall again refer to it.
Cases of apparently pure atonic dyspepsia are not
common — that is to say — conditions in which the
stomach and the function of digestion simply partici-
pate in the general atony of the body ; but whilst an
atonic condition is observed in all the forms of dys-
pepsia met with in phthisis, it is commonly associated
with evidence of disordered action. "When, however,
the atony is the leading feature, the general use of
tonics, alcoholic stimulants, tea and coffee, condiments
and pepsine, are the appropriate remedies.
CHAPTER XXIX.
INCREASE THE ASSIMILATION OF FOOD.
This, although the most important part of this branch
of inquiry, is one about which but little is certainly
known as to ^its intimate nature ; it is quite clear that
the food must undergo a process of final change after
it has left the stomach and duodenum, and before
it is deposited as tissues. It is also well known that,
unless this change proceed in a due order and degree,
the material which is produced is unfit for the full
purposes of life, and it is termed unhealthy. This is
the change which at present is hidden from our know-
ledge, and we are obliged as yet to be content with
knowing the two extreme limits of the chain, and the
causes which influence the whole process.
In the disease now under consideration there is
reason to believe that this process is not healthily
carried on ; not so much from the production of new
and unhealthy matter, as from the fact that the tissues
are ill-nourished beyond what occurs in other states of
the system when an equal amount of suitable food is
taken. It is true that we have seen that the two
anterior processes of taking and digesting food are to
a certain degree in defect also ; but it is probable that
EXERTIOF. 267
the deficient nutrition is still more than that defect
will account for.
The circumstances which are known to have the
power to increase this final transformation of food, as
evidenced hy the elimination of the products of trans-
formation, are exertion, food, respiration, pulsation,
temperature, and certain intimate chemical changes ;
and to these we will refer in their order.
EXERTION.
We have elsewhere shown that not the least amount
of muscular exertion can be made without producing
an increase in the quantity of air inspired, and of
carbonic acid evolved. Change of posture even from
lying to sitting caused in our experiments an increase
of one-sixth, and to the standing posture of one-third
of the quantity of air inspired ; whilst walking at the
rate of one, two, three, and four miles per hour, in-
creased the quantity to 1*9, 2*76, 3'0, and 5*0 times that
inspired at rest in the lying posture (page 100). The
quantity of carbonic acid evolved during the exertion of
walking at the rate of two and three miles was 1*85,
and 3*64 times that evolved at rest in the sitting
posture.
The effect over the elimination of nitrogen remains
singularly mysterious. We have shown from prisoners
working the tread- wheel, and BischoiBf and Voit from a
dog working a spit-wheel, that there is scarcely any
increase in the elimination of that product under the
most severe exertion ;* yet, under the theory which has
* Phil. Trans. 1861.
268 II^rCEEASE THE ASSIMILATION OF FOOD.
of late years influenced professional opinion, the pro-
ducts of heat-formation were said to be eliminated by
the lungs, and those of tissue-waste by the kidneys. It
is, however, true, paradoxical as it may appear, that in
a general sense both the observations and the theory
are correct, for it has now been proved that urea is a
combined product of conversion of food and degrada-
tion of tissue ; and as the loss of nitrogen by the tissue
during exertion is supplied by nitrogen from the food,
there can be no increase in the elimination of urea
from the body unless the bulk of the muscle be
lessened. It must, therefore, be admitted that, with
increased muscular exertion, there will be a larger
emission of nitrogen from the tissue, and that the
urea emitted from the body will be in a greater degree
derived from the tissue than could occur in a day of
rest.
In the condition of disease now under discussion,
we perceive that if we increase muscular exertion, we
shaU increase the excretory products, and the excretory
products are evidence of an increase in the metamor-
phosis of matter. If with this we supply suiB&cient
and proper food, there will be both increase in the
metamorphosis of the tissue, and in the final trans-
formation of the food; and as the quantity of food
transformation should be in excess of the tissue
wasted, we shall cause further tissue-deposition or
growth.
The due regulation of the exercise to be taken by
the patient is hence of i)rime importance, and there
are two rules which must be observed : — 1st, To take
EXERTION. 269
as much exertion as can be borne without noticeable
fatigue; and 2nd, To associate the exertion with
sufficient food.
In selecting the most suitable kind of exercises, we
are compelled to bear in mind the strength, sex, and
convenience of the patient. Athletic exercises are no
doubt the best, when they are practised for a short
period twice daily, and when the powers of the body
are not too severely taxed. Running and jumping are
suited to men, and skipping to women ; and whilst the
first of these sometimes causes alarm in the minds of
patients, lest haemoptysis should be induced, there need
be no fear of its occurrence at the stage of the disease
under consideration, since the inability to breathe
freely will limit the exertion, and if any haemoptysis
should occur, it will proceed only from the enlarged
vessels of the pharynx. We feel assured that this
matter may be left to the patient, with the conviction
that commonly he will make too little rather than too
much exertion. In reference to women, we attach
great importance to the practice of skipping, and direct
that the rope be thrown from before backwards, and
that a considerable amount of exertion shall be made
during the ten or fifteen minutes' practice at one time.
The conventional habits of society have so limited the
kinds and degrees of exertion which females of seven-
teen years of age and upwards may make., that this is
almost the only one which they can be induced to
adopt as a remedial agent, and it is only after much
persuasion and explanation as to the importance of
it that many will undertake it.
270 INCREASE THE ASSIMILATION OF FOOD.
But as these exercises both for males and females
are presumed to task the respiration, and will also
largely determine to the skin, they must be limited to
very short periods of duration, and hence cannot
supply all that we desire. We have therefore to turn
to that of walking, as the exercise which may be the
most continuously pursued, and it is highly desirable
that it should be employed during two to four hours
daily. If the patient rise so as to leave the bedroom
before 8 a.m., and take a cup of milk or chocolate,
with bread and butter, it will be proper to walk in the
open air briskly for half or three quarters of an hour
before breakfast, and during the forenoon before
dinner, and again, in the afternoon, from one to two
hours should be spent in exercise in the open air.
The want of strength, and the previous habits of the
patient, will, in many instances, limit the amount of
exertion more narrowly than we could desire, but it is
important that the amount of exertion should approach
as nearly as possible to that now recommended. It is
not however to be understood, that whilst walking
during two hours, considerable or even continuous
exertion should be made during the whole period, but
such an amount of exertion should be made, and such
intervals of rest allowed, as may be practicable and
agreeable to the patient. In ordihary cases the dis-
position and capability for exertion wiU increase by
practice, and particularly if it be made in a cheerful
spirit, with a pleasant companion, in new and agreeable
scenes, and with an exhilarating atmosphere. The
exertion of walking, moreover, causes a more general
FOOD. 271
use of the muscles of the body than any other mode-
rate exercise, and is less liable to be followed by cold
than when violent exertion of particular muscles is
made, as in rowing, or when taken in closed rooms,
as in various athletic exercises. It is also capable of
variation in degree.*
FOOD.
As food is the material to be transformed, it may at
first sight appear paradoxical to look to it as an agent in
its own transformation ; but whilst it is true that cer-
tain kinds of food seem to be passive in this transform-
ation, it is equally true that there are other kinds
which aid in the transformation, whilst a third class
are devoted almost exclusively to the latter actions.
Amongst the passive agents we may mention the
* We are tempted to insert here a copy of a placard which was recently-
exposed in the -window of a bootmaker and coi-ncutter in one of our
principal "West-end thoroughfares, not on account of the original manner in
which science is turned to commercial account, but of the talent exhibited
in the composition, and the excellence of the advice ! It is as follows : —
" The best medicine ! Two miles of oxygen three times a day. This
is not only the best, but cheap and pleasant to take. It suits all ages
and constitutions. It is patented by Infinite "Wisdom, sealed with a
signet divine. It cures cold feet, hot heads, pale faces, feeble lungs, and
bad tempers. If two or three take it together, it has a still more striking
effect. It has often been known to reconcile enemies, settle matrimonial
quan-els, and bring reluctant parties to the state of double blessedness.
This medicine never fails. Spurious compounds are found in large towns ;
but get into the country lanes, among green fields, or on the mountain-top,
and you have it in perfection as prepared in the great laboratory of
Nature.
" Before taking this medicine * ■* * * should le consulted on the
understanding that coi-nSf bunionSf or lad nails, prevent its proper
effects:'
272 INCREASE THE ASSIMILATION OF FOOD.
hydrocarbons, which, so far as we know, possess no
power to aid in their own transformation, whilst the
active agents are the nitrogenous elements. This latter
fact has not been hitherto so fully admitted as it will be,
since on the chemical theory, which has ruled our views
of nutrition, it has only been regarded as an element of
tissues, and fitted to repair the waste of tissue ; but
the experiments of Lawes and Gilbert, ourself and others,
have shown that the fattening properties of fodder are
in proportion, not to the carbon, but to the nitrogen
contained in them ; that manures- containing an excess
of nitrogen beyond that required to be fixed on the
plant, produce better crops from the same amount of
carbon in manure ; that nitrogenous foods increase the
elimination of carbonic acid, and that the very large
amount of nitrogen which is taken into the body
beyond that which is necessary to supply waste of
tissue, must be regarded as useless, if its whole duty
were to supply tissue waste. Hence we have endea-
voured to prove that nitrogen in food exerts the double
action of promoting directly or indirectly the trans-
formation of other food, and at the same time of
supplying the wants of the nitrogenous tissues attend-
ing their degradation.
In a former part of this work, p. 245, we have urged
the great importance of giving an abundant quantity of
food, and particularly of the nitrogenous kind, and we
have now given our reasons for that advice. It is also
to be observed that there are but few instances in which
nature has separated the two great classes of food ; but
with the hydrocarbons has supplied the nitrogenous.
FOOD. 273
This is the case with bread and flesh — the two gi'eat
elements of nutrition — and nature has moreover given
to us a relish for the combination of the latter with the
former, and of the more highly nitrogenised with the
less nitrogenised substances ; and when we find the two
elements separated, it is chiefly the work of man, as
Avhen he separates the starch from flour or potatoe, and
fat from flesh.
The class of substances which, considered as food,
are devoted almost exclusively to the duty of aiding in
the transformation of other foods are tea, coffee, and
beer. We have elsewhere * shown how each of these
substances causes the elimination of carbon to a greater
degree than it supplies that element ; and hence must
be the means of causing its elimination from other
substances. "We have not determined to which of the
elements of tea and coffee this influence is due, since
we have experimented only upon the substances as a
whole ; but in reference to beer, it is doubtless due to
the nitrogenous elements, and the sugar, which they
possess. It is, however, evident that these substances
cannot be ranked as true foods, and that they will
nourish or waste the body, not simply according to
their own action, but in proportion to the amount of
nutriment which is otherwise offered to the system.
When the plan which we have recommended in the
treatment of phthisis is pursued, and an abundance of
food is supplied, these substances will aid in the nutri-
tion of the body ; but it will nevertheless be true that
♦ Phil. Trans. 1859.
274 INCEEASE THE ASSIMILATION OF FOOD.
as milk contains so large an amount of nitrogenous
matter, conjoined with the hydrocarbons, it more per-
fectly meets all the indications of the system than the
class of substances to which we now refer.
RESPIRATION.
Eespiration in its widest sense is an act which
results from rather than causes vital transformation,
and yet, in several important respects it modifies the
transforming powers. The former fact is proved by
Davy's experiments, which show that when pure
oxygen was inspired there is no more chemical
change induced than occurs when atmospheric air is
breathed ; and although we think from our own experi-
ments that this statement will now require some
modification, yet the law is established that, let the
vital actions be a constant quantity, the addition of
oxygen to the inspired air does not materially increase
vital transformation. Hence, if we could cause an
increase in the consumption of oxygen, we must begin
by causing an increase in the vital actions, as by exer-
tion and food, and in this sense the respiration obeys,
and does not control, vital transformation. Allowing
this statement to be true, we are led to believe that the
action of the compressed air-bath must be null in
this direction, for if it be in vain to offer pure oxy-
gen in place of atmospheric air, it will be not less so
to offer an increase of the quantity which is found in
the air at the ordinary pressure, p. 279.
But, on the other hand, it has been proved abundantly
by Yierordt and ourself, that the voluntary inspira-
EESPIKATIOK. 275
tion of an increased quantity of air is followed by an
increase in the evolution of carbon. This is primarily
due to the physical action of the admixture of gases,
and to the fact that the air in the central parts of the
lungs is richer in carbonic acid than that found in the
larger tubes, and hence deep inspiration followed by
deep expiration causes a larger amount of the air,
richer in carbonic acid, to be exhaled. From this it
will probably follow that increased chemical change
will result, for if the carbonic acid be removed from
the air-cells, its place will be filled by quantities of the
same gas, which will escape from the blood, and it is
highly probable, that if carbonic acid be removed from
the blood by any cause, it will lead to an increase of
that chemical change by which it will be again sup-
plied. Hence, whilst this train of results does not rest
upon experimental proof, it is based upon physical
laws which are well established.
Thus it follows that if the quantity of air expired
be increased from whatever cause, there will be an
increase in the vital transformation of the body ; and
if that be conjoined with abundant food, it will aid in
the process of nutrition.
There is, however, a modifying power due to the
degree of purity of the air. It has been now abun-
dantly proved by many observers, as by De Saussure,
Prof. Frankland, and Mr. Welch, that the composition
of the air at the highest attainable altitude is identi-
cally the same with that found at the level of the
earth ; but at the level of the earth it has been shown
that there is very great diversity in the constitution
T 2
276 mCEEASE THE ASSIMILATION OF FOOD.
of the air in town and country, and in well and ill-ven-
tilated dwellings. Prof. Eoscoe published a series of
researches in the "Chemical Quarterly Journal" for
1858, in which he proved that in certain dwelling-
houses, barracks, crowded schoolrooms and theatres,
the quantity of carbonic acid in the atmosphere was
from 1*1 to 3-3 volumes in 1000 volumes — the latter
being nearly ten times the normal amount. It has also
been proved that in the densely-populated parts of
London the proportion of carbonic acid in the air is
much increased. Now as it is known that carbonic
acid depresses the vital functions, and that air can-
not support life after it has obtained a certain per-
centage of carbonic acid, it follows that the air of
densely-populated and ill-ventilated localities is less
fitted to support vital transformation than the pure
air of the fields and country. Dr. Angus Smith has
also published some very interesting and valuable re-
searches which establish similar facts. We ma}^ also
add to this the facts, that the presence of foul air gives
us an inevitable repugnance to inspire with the ordi-
nary depth and freedom and thus lessens the effort
of respiration ; but the result might not appear
after we had by custom become unconscious of its
foulness.
But in every aspect air which is unduly loaded with
carbonic acid, and which is also foul to the sense of
smell, is much less fitted to promote and support vital
transformation than pure air.
In the treatment of the disease in question, we have
very good ground for insisting upon the patient in-
PULSATION. 277
spiring pure air, and therefore of his seeking the open
air of the fields and the country in preference to
that of the bedroom or sitting-room in the crowded
town.
The influence of exertion over the increase of respi-
ration has been already pointed out, and the effect of
food has also been hinted at, so that we need here
only to state that the hydrocarbons — fat and starch —
do not promote respiration, whilst that function is
always increased in efficiency by nitrogenous food.
Tea and coffee are the most powerful respiratory
excitants amongst food, and it is singular to add, that
sugar, which is a hydrocarbon, also largely increases
the activity of that function.
PULSATION.
The relation of pulsation to vital transformation
seems to be such that, with an unusually rapid or un-
usually slow pulse, there will be emaciation — the stan-
dard rate of pulsation of health in the individual in
question being ascertained — and that in reference to
rate, the normal is that which is the most compatible
with the maintenance of the bulk of the tissues. It is
also admitted that a certain degree of fulness of the
pulse is requisite to the due performance of vital acts,
for a feeble and soft pulse, whether rapid or slow, is
incompatible with perfect nutrition, and, as a rule, that
is the condition met with in early phthisis. A nor-
mally full pulse is therefore a circumstance of much
importance, and, whilst feebleness and rapidity of
pulsation are normally associated, fulness and slow-
278 mCEEASE THE ASSIMILATION OF FOOD.
ness as in the ordinary rate of pulsation are commonly
found together. Hence, in treatment, the prime ques-
tion seems to be, to cause an ordinary degree of fulness
of the pulse, and in doing this the change in the rate
will probably follow.
We have already referred to the conditions which
modify the fulness of the pulse, whether it be with the
vis a tergo or the vis a fronte, and will now refer
only to the remedial agents to be employed to restore
fulness.
The prime question, no doubt, is to increase the
vis a fronte, whether that be by lessening the action
of the skin, the kidneys, or the bowels, and thus offer
greater resistance to the column of blood, and to this
we have fully referred. The next question is to in-
crease, if need be, the vis a tergo, by increasing the
vigour of the heart, and by causing a free supply of
blood to the heart through the veins of the general
circulation, and through the pulmonary circuit.
The chief agents to be employed are an abundant
supply of food, which, during its immediate transfor-
mation, always fills the pulse, and to administer
alcohol and tonics, which tend to increase both the
vis a tergo and the «;is a f route, the former by acting
upon the muscular fibre of the heart, and the latter by
lessening elimination. In this respect we think that
the compressed air-bath may be of great advantage,
page 274. It is evident that there will be a physical
effect upon the body with the increase of the pressure,
and although the pressure will be exerted both within
and without the body by the air admitted within the
TEMPERATURE. 2^9
lungs, yet it is not tlie less true that the pressure is
increased. It will not materially affect the question
whether a pressure of 100 lbs. be made upon the
hand whilst it is laid flat upon a plane, or it be exerted
on both sides by placing it in the jaws of a vice, for in
either case there will be a degree of compression
effected. So, in the compressed air-bath, we think it
to be clear that the increased pressure will tend to
sustain the soft structures, and particularly to support
the circulation by pressure through the soft structures,
both upon the surface and within the lungs. Hence,
its first effect will be to give more firmness to the
pulse, and it will lessen the rapidity of pulsation if
the rate has been beyond that which is natural, or
increase it if it have been unduly languid and feeble.
Its action upon the circulation is indirect, through the
intervention of the structures surrounding the vessels,
and is analogous to that which, w^hen applied to
minute structures, is called tone in its influence over
the capillaries.
By the courtesy of Dr. Grindrod, of Malvern, we
have twice tried to determine the effect of this agent
over the production of carbonic acid, and through the
kindness of Dr. M'Leod, of Ben Rhydding, we have
ascertained its influence over the quantity of air
inspired, but at present the results are not ready for
publication.
TEMPERATUKE.
The influence of temperature in modifying vital
transformation is very marked. When the temperature
280 INCREASE THE ASSIMILATIOlSr OF FOOD.
is low, as during the winter months, tlie excretion of
carbonic acid is so largely increased that, considering
the permanence of its action, the influence of this
agent is probably more powerful than that of exertion.
At the same period the skin is rendered less active ;
there is a less free distribution of blood to the surface ;
a large amount is retained in the central vital organs ;
the blood has greater capacity to retain gases, and the
I)ulsation is somewhat slower and more vigorous.
Moreover, unless the temperature be very low, the
cold is favourable to exertion, and to the desire for
abundant nitrogenous food. Hence, in all the points
of view in which we have hitherto regarded the ques-
tion of vital transformation, it is evident that cold is a
most potent agent. But it is necessary that the degree
of cold be such that the patient may readily tolerate it,
that there be sufficient clothing and shelter to maintain
the requisite temperature of the body, and abundant
food to aiford material for the vital transformation,
and, if such be the case, there can be no doubt that
the winter half year is pre-eminently suited to sustain
a vigorous state of the nutritive processes in this
disease.
High temperature exerts the opposite influence to
that now recorded in reference to cold, since, with
increase of heat, above that at which we habitually
keep our dwellings, there is a rapid subsidence of the
respiratory changes, and the same result also occurs with
any degree of temperature, provided there be a sudden
and rapid elevation of it. The pulse is commonly
feeble and rapid, the blood is largely distributed to the
TEMPEKATURE. 281
surface, and has less capacity to hold gases in solu-
tion, the skin acts freely, the appetite for certain kinds
of food fails somewhat, the tissues hecome relaxed,
a^d the whole state indicates that there is a depression
of the vital powers, and a diminution in the vital trans-
formation. This condition is, however, not unfavour-
able to the deposition of fat in the tissues, provided
the defect in the vital powers be not excessive ; for we
have already shown that a state in which the appetite
for food is not greatly lessened, whilst the respiratory
function is somewhat diminished in activity, is favour-
able to the storing up of fat within the system.
Hence, in cases of early phthisis, it is a prime re-
quisite to avoid high temperature, and to permit the
patient to live in an atmosphere not above sixty degrees,
if it .be possible to do so. This, of necessity, depends
upon the period of the year, and will be the most
difficult of attainment in the summer season. In the
winter there is very little danger to be apprehended
from the cold, if suitable precautions be taken, except
in the cases in which there is inflammatory complica-
tions, or an irritable condition of the larynx, and hence
no special precautions are needed, but in summer,
when the temperature exceeds 65°, it is desirable that
there be shelter from the sun during the heat of the
day, that the day and night rooms have a free circulation
of air admitted from the shady side of the house, and
that the residence be in such a position as, by its
elevation, northern latitude, or proximity to deep
water may reduce the temperature to a medium degree.
It was made clear by our own experiments that a medium
282 INCREASE THE ASSIMILATION OF FOOD.
temperature, sucli as that at which we seek to keep
our houses through the year, permitted everj^ varia-
tion in the degree of vital action according to the other
conditions of season, but that as the temperature rose
or fell from that central point, the effects of heat were
rapidly demonstrated.*
CERTAIN INTIMATE CHEMICAL CHANGES.
This part of our subject is too indefinite and exten-
sive to warrant a lengthened consideration of it on the
present occasion, and we purpose only to point out one
or two facts which it may be interesting to consider in
the treatment of the varied conditions found in early
phthisis.
It is important to bear in mind the observation
which Baron Von Liebig has so often placed before
us as to the importance of a due quantity of alkali in
the blood, to enable that fluid to absorb the largest
amount of carbonic acid. He has shown that the
blood carries carbonic acid by virtue of two qualities,
viz., its property of chemical combination, and its
power to hold the gas in solution, and it is evident
that, in reference to actions of a rapid nature, the latter
is by far the most important property. The capacity
of solution varies with the nature of the fluid, and the
alkaline carbonate, and the phosphate of soda very
greatly increase this capacity of solution in the blood.
Hence the free administration of alkalies is in many
cases well suited to excite or support chemical changes,
* Phil. Trans. 1859.
CERTAIN INTIMATE CHEMICAL CHANGES. 283
and thereby to sustain vital transformation. This
may possibly be one of the explanations of the bene-
ficial action of alkalies in cases where there is marked
acidity in the stomach, the perspiration, and the other
excretions.
On the other hand the tissue fluids are invariably
acid in their reaction, which seems to indicate that the
formative process proceeds under the influence of an
acid, and it is very possible that the numerous instances
of early phthisis, in which the mineral acids are found
to improve nutrition, may receive a part of the benefit
in that direction.
M. Fernet * has shown that the excessive use of
chloride of sodium will lessen the power of gas-absorp-
tion by the blood, since with excess of that salt in
the blood the absorbing or carrying power of that
fluid is lessened. This may be familiarly seen by the
change of colour of black blood, which occurs on the
addition of chloride of sodium, when by the disengage-
ment of a portion of the carbonic acid the colour becomes
red, and the blood is no longer enabled to retain so
large an amount of carbonic acid as before. Hence
the use of chloride of sodium in excess is clearly
antagonistic to nutrition.
* ThSse, Paris, 1858.
CHAPTER XXX.
EEGULATE MENTAL AND BODILY LABOUR.
MENTAL LABOUR.
The influence of mental labour over the functions of
the body must be beneficial if practised within mode-
rate limits, since without wasting the body it engages
the attention, and satisfies some of the highest desires
of our nature. In the abstract then, as it induces no
evil, we have no remedy to offer. But when carried to
excess, so that the body is constrained in posture and
kept in a closed room during many hours daily, its ten-
dency must be to exhaust the vital power, to prevent
due muscular exertion, to lessen the force of the circu-
lation, to render the skin too active, to lessen the
functions of assimilation and digestion, and to diminish
the appetite for food. Hence in this degree it is pre-
cisely fitted to induce the conditions which are observed
in the disease under discussion, and demands most
serious attention. There is no class of cases in which
remedial agents appear to have so little influence, or in
which a more decided method and long continuance of
treatment are called for, as in those induced by exces-
sive mental work, but not, as we believe, because mental
labour increases the elimination of nitrogenous pro-
MENTAL LABOUE. 285
ducts, but because there has been long continued
neglect of all the conditions upon which the healthful-
ness of the body depends. Such a state is one essen-
tially of low vital energy.
Hence we would encourage cheerfulness of spirits
and occupation of the mind in every degree compatible
with the due exposure of the body to sanitary influ-
ences ; and so important indeed do we consider this,
that we believe it almost impossible to restore the poor
man to health, who, without actual inability to labour,
beheves himself unfit for it, and avoids it, or the
young lady who, from depression of nervous energy and
bodily feebleness, is allowed to spend the day in a listless
manner. A prime condition in an attempt to increase
the bodily strength is the happy and moderately con-
tinuous occupation of the attention, which at the least
permits the hours to pass away during which the body
is regaining strength without despondency or querulous
regrets ; and commonly, in addition, tempts the patient
to go into conditions more favourable to health.
But in the same degree do we deprecate that state of
mental anxiety which renders persons at all times un-
happy, leads them to shun society and the open air,
and to court solitude, seclusion in the house, and
distressing forebodings. Many there are suffering from
early phthisis who may trace their disease to this con-
dition, and who have been in part led into it by the
adverse occurrences of life, to which all are more or
less subject ; and in other part by allowing their anxie-
ties to prevail over their faith and reason; and it
frequently happens that the adverse circumstances
286 KEGULATE MENTAL AND BODILY LABOUR.
continue during the disease and negative the effects of
treatment. In 1,000 phthisical patients of both sexes
22*2 per cent, attributed their disease to anxiety, and
the proportion was so great in women as 32' 5 per cent.
It is often in vain to point out the uselessness of such
regrets and anxieties in reference to any attempt to
remove the causes, or to show that they only aggravate
the evil, and whilst kindness and courtesy may in a
small degree lessen the evil, it is only as the mind can
be induced to trust in Him who controls all human
affairs, that the calmness can be attained, which is
so necessary to the use of all the means calculated to
insure a return to health. Excessive anxiety, whether
in reference to the prognosis of the disease or any other
subject whatever, is the most formidable foe to treat-
ment.
The effects of excessive labour are, as we have inti-
mated, rather indirect than direct, and if they have
not been too long continued, we may hope to remove
them by causing the labour to cease, and by instituting
the habits which we have already commended. Long
continued mental labour must be opposed to the con-
ditions upon which health of body depends.
BODILY LABOUE.
We need not insist that there is an amount of
bodily labour which is not only compatible with health,
but upon which health depends, and that when it is
associated with a due amount of food and intervals of
rest, it is our best aid in the treatment of the disease
in question. The habits of mankind are in general
BODILY LABOUR. 287
based upon this knowledge, and the labour of the day
is presumed to be proportioned to the power of the
body to effect it. But there are many who from cir-
cumstances which they might control, and others from
circumstances which they cannot control, allow the
exertion of the body to be in excess of their power of
endurance, the supply of food and the duration of rest.
There are also many who labour far into or through the
night, and such cannot remedy the evil by seeking
repose through the day. Of these classes, we may
mention the postman, the in-door man-servant, the shop-
man, the night cabman, the baker, the compositor, the
sempstress, the ballet-girl, and the framework knitter,
all of whom have often come under our notice. In
such cases it is necessary that the hours of labour, and
the amount of walking, or other kind of exertion, be
duly restricted before any attempt be made to regain
the bulk and vital energy of the body. This course is
expecially necessary in reference to tall persons, since
they demand the horizontal posture more than persons
of short stature. We have elsewhere insisted upon the
necessity for a periodical day of rest, and have given
the physiological grounds upon which the injunction is
based ; and we shall only remark here, that in the cases
in question no considerable good can be effected unless
this requirement be rigorously enforced.
There is another class of persons to whom it is
necessary to allude, viz., such as by sedentary habits
or occupations, do not make sufficient general exertion
with the whole body. Such are tailors and shoe-
makers, in whom there is usually a deficient bodily
288 REGULATE MENTAL AND BODILY LABOUR.
development, and a state of very low vital power. We
are accustomed in such cases to enforce violent general
exercise at two periods of short duration daily, and by
suitable posturing of the chest to remedy the evils
attending the pursuit of the sedentary occupation. We
attach the greatest importance to the pursuit of some
laborious occupation or exertion in the treatment of
this disease.
CHAPTER XXXI.
INCREASE INNERVATION.
This is either the sum of all our efforts at treatment,
or it is the evidence which we seek that our efforts have
been successful, precisely as we regard innervation as
the cause or the consequence of vital actions. It is
quite true, that if we can increase the general inner-
vation of all the parts of the body, we shall increase the
vigour of the vital processes and raise the standard
of health ; and on the other hand we are assured that
when we have increased the healthful action of the
vital organs we have increased the general innervation
of the body. This is indeed reasoning in a circle, but
we do not think that at present our facts carry us much
beyond it.
Without, therefore, entering further into the question
of the origin of innervation, we may affirm that the
direct tendency of all the plans which we have recom-
mended in the treatment of this disease, is to increase
innervation at the same time that they act through the
various vital organs and processes of the body. In
this way only do we believe that increase of innervation
is practicable ; and any attempt to act primarily upon the
nervous system, and through the nervous system upon
290 INCREASE INNERVATION.
the vital organs will, in the present state of knowledge,
be futile. Just in proportion as the vital processes and
the transformation of nutritive matter can be increased
to the standard of health, and the waste of material
lessened, so shall we find the evidences of increased
innervation.
Dr. Churchill has proposed the use of the hypo-
phosphites for a purpose very similar to that discussed
in this place, and Mr. Taylor, of Liverpool, has
supported his views in a paper published in the Lancet
of October 30, et seq. 1861. Dr. Churchill's theory is
based upon an assumption, viz. : that the excessive
discharge from, or the deficient supply to, the body of
oxydizable phosphorus, is the cause of phthisis, through
the loss of nervous force and diminution of the vital
properties of the blood. We say that this is an
assumption, for it is not based upon any experimental
inquiries, actually showing that there is an increased
excretion of phosphorus in the period preceding the
occurrence of phthisis. Hence we should be justified
in declining to lend an ear to Dr. Churchill's state-
ments; but as it does not follow that his remedy is
not beneficial because the grounds of his theory are
defective, it will be right to try the effect of the remedy
quite apart from any theory. Dr. Churchill claims that
the hypo -phosphite of a base, is the best form of admi-
nistering phosphorus, since it is more soluble than the
phosphite or the phosphate, and also that it is capable
of a higher degree of oxidation. He affirms that they
increase the nervous force and promote blood formation,
and he regards them as both prophylactic and curative
THE HYPO-PHOSPHITES. 291
of phthisis in every stage; but in this he evidently
affirms more than any remedy can possess, since in the
advanced stage of the disease no remedy can reinstate
the destroyed or useless lung. His own words are, " If,
as I assert, the hypo-phosphites be the specific remedy in
phthisis, because one at least of the essential conditions
of that disease consists in the want or undue waste of the
oxydizahle phosphorus in the animal economy, it follows
that consumption will be prevented simply by taking
care to keep the system supplied with a due amount of
that element. The best time for administering it is
at breakfast along with the food." But whilst declining
to accept the whole statement, i£ may not be wrong to
inquire if the remedy have not some virtue which may
be serviceable in the treatment of the disease.
Mr. Taylor calls attention to the facts, that much
impure salt is sold, that of the pure salt only 3 grains
can be taken for a dose, and that it is quite necessary
that even such a dose should be administered with a
tonic or a carminative. He affirms that in this quantity
it increases nervous and muscular force, animal heat, and
the power of assimilating both nitrogenous and hydro -
carbonaceous foods. But on looking carefully at his
observations, it is evident that he attaches so much
importance to the adjuvans and corrigenSy as he terms
various excellent foods and medicines, that it may be
doubted if the action of the remedy could be eliminated
from them.
Opposed to his view are the statements of three
physicians to Hospitals for Consumption, who, after
trial, have affirmed that this remedy is nearly inert.
u 2
292 INCREASE INNERYATIOK
Two of these gentlemen, viz., Drs. Bennett and Quain,
have prolonged its use in a few cases for several
months, and whilst all ascertained that a few cases were
improved during its use, and with the advantageous
conditions of an hospital, there was no result which in
the least indicated that the remedy excited any curative,
much less, specific action. "We do not, however, think,
that the manner in which the inquiry has been made,
is such as would be admitted in physiological research,
to prove the precise degree and mode of action of the
substance ; for there has not been such a rigid selection
of cases as would admit of parallel results, nor such
elimination of attending influences as would leave the
effect of this remedy evident, nor, except in a few cases,
so long a duration in its use as may be demanded in
the treatment of a disease which so thoroughly affects
the general constitution, and which may be said to
resist all treatment. We conceive the following to
be the only mode by which this question could be
answered : —
1. The patients to be selected should be those in the
early stage of phthisis, in whom the injury done
to the system is not excessive.
2. They should be treated at home, and in the con-
ditions in which they have lived for some time
previously.
3. The conditions in which they are placed should
tend to health, but they ought not to be
materially changed from those which have
previously existed.
4. All existing causes of disease, whether within or
THE HYPO-PHOSPHITES. 293
without the body, should have been previously
removed or be kept in abeyance.
5. The experiments should be continued uninter-
mittingly during several months, and at periods
of the year when there are not great atmospheric
changes.
6. The aim should be to determine the effect over
the elimination of important products as urea,
phosphorus and water ; also the amount of nitro-
genous material ingested, and the proportion
of that which remains in the bowel unused.
At the same time the general condition of the
system as to weight and innervation could be
determined, and the degree of progress of the
lung disease ascertained. As a basis of com-
parison, such inquiries should have been made
upon the same person and under the same
conditions during 10 days previously.
7. Six patients would be quite sufficient to prove the
degree of influence of the remedy if the inquiries
were thus carefully conducted.
But since we have to treat a disease which is in the
long run fatal, it would be important to ascertain if the
use of the hypo-phosphites were attended by results
better than could be obtained from other known remedies,
although they also might fail in curing the disease.
Such an inquiry would be one of great difficulty, since
it would imply the co-ordinate employment of other
agents, the effect of which could not be isolated, but it
might be pursued at least as definitely as with any other
remedy. We certainly commend its employment as an
294 INCREASE INNERVATION.
adjunct to other treatment, until further experience has
demonstrated its worthlessness.
Whilst being unable to affirm that the remedy is very-
valuable or otherwise, we must, I think, admit in general
terms, that phosphorus, when combined with iron, is a
good remedy in such conditions as are induced by or
accompany spermatorrhea, so frequently found in the
early stage of phthisis; but that it has any specific
influence over the disease such as quinine in ague,
and vaccination against small-pox, as Dr. Churchill
claims for it, is in the highest degree improbable, and
has not been in the least proven. *
* Since the above was in the press, Dr. Cliurcliill has published some
papers on this subject in one of the London medical journals, and has given
directions for the preparations of the salt ; but we do not find that he has
adduced any new proofs of the correctness of his theory.
CHAPTER XXXII.
THE LUNGS BEFORE THE DEPOSITION OF TUBERCLE.
Having tlius concluded our remarks upon the indica-
tions for, and the details of treatment of the general
system in the early stage of phthisis, we proceed to con-
sider such local deviations from a healthy state as
demand especial attention in the treatment of this
disease ; and of these the most important is that of
the lungs themselves.
It will be convenient to adopt the artificial arrange-
ment of stages of the disease, and separately consider
the periods before and after evidence of the deposit of
tubercle.
The prime condition of the lungs in that stage
which precedes the deposition of tubercle, is manifestly
lessened action or lessened expansion, and conse-
quent upon it diminished vital changes, a less free
distribution of blood to the intimate structures of
these organs, and a proclivity to local disease. When
tubercle has been deposited, there is the presence
of an extra-vascular and foreign body which must still
further impede the action of the part of the lungs in
which it is situate.
The deficient expansion of the lungs in its earliest
296 THE LUNGS BEFORE DEPOSITION OF TUBERCLE.
condition is, no doubt, a part of the general defect of
vital energy which is then existing ; for it is of common
observation that when there is debiUty of the vital
powers there is also feeble respiration; but after a
period there can be no doubt that there is a local con-
dition induced which further enfeebles the respiratory
act, and which consists in a deficient expansibility of
the lungs, the result of long continued diminution of
action.
Hence we have to treat both a general and a local
condition, but both are so connected that the same plan
of treatment is adapted to both conditions.
PROMOTE EXPANSION OF THE LUNGS.
The prime object in the treatment of this condition is
fin addition to the general treatment already recom-
mended J, to produce more perfect action of the lungs —
perfect in frequency and in extent of action.
For the attainment of the end here proposed we have
usually to lessen the frequency of respiration, since we
have seen that feebleness and frequency commonly,
but not invariably, exist together ; and if we induce a
deeper respiration, the duration of each act being in-
creased, the frequency must be in the same proportion
decreased.
One of the most acute and learned physicians of our
day. Sir Henry Holland, Bart., in his classical work
entitled '* Medical Notes and Eeflections," has the fol-
lowing highly valuable remarks upon this subject : —
"Might not more be done in practice toward the pre-
vention of pulmonary disease, as well as for the improve-
PEOMOTE EXPANSION OF THE LUNGS. 297
ment of the general health, by expressly exercising the
organs of respiration ? — that is, by practising according
to some method those actions of the body through
which the chest is alternately in part filled and emptied
of air ? Though suggestions to this effect occur in
some of our best works on Consumption, as well as in
the writings of certain continental physicians, they
have hitherto had less than their due influence, and the
principle as such is little recognized or brought into
general application. In truth, ^mmon usage takes,
for the most part, a directly opposite course ; and, under
the notion or pretext of quiet, seeks to repress all
direct exercise of this important function, in those who
are presumed to have any tendency to pulmonary dis-
orders. Yet, on sound principle and with reasonable
care, it is certain that much may be done in this way
to maintain and invigorate health, even in constitutions
thus disposed. Omitting some points of controversy,
particularly as to what regards the mechanical influ-
ence of respiration on the circulation through the heart
and lungs (points meriting, however, much attention
from their importance), the free and equable expan-
sion of the latter by full inspiration is beneficial ; —
first, in maintaining their healthy structure by keeping
all the air passages duly open and pervious ; — secondly,
in preventing congestion in the pulmonary circulation ;
— thirdly, in providing more completely for the neces-
sary chemical action in the blood, by changing at each
act of respiration a sufficient proportion of the whole
air contained in the lungs, and giving it more complete
access to the vascular tissues ;—^all objects of great
298 THE LUNGS BEFORE DEPOSITION OF TUBERCLE.
importance, and all capable of being promoted more or
less by the means in question/' P. 422.
The same observer further remarks, " of actual mus-
cular exercises directed to this function, that of full and
repeated inspiration in the free air, is perhaps the best.
The exercises which open the chest, as it is termed, are
salutary, provided they are not such in amount as to
hurry the circulation, oppress the breathing, or occasion
too large and sudden expenditure of the muscular
power." Again " thQ,» breathing, therefore, may best be
exercised in these cases by full inspiration when the
body is otherwise at rest, or in slight and easy move-
ment. The lungs will thus be more completely filled
than by hurried respiration, and without any evil to
countervail the good." After remarking upon the bene-
ficial influence of exercises on foot and horseback. Sir
Henry adds, *'but there are cases where neither mode
of exercise is practicable ; yet, where the gentle exer-
cise of inspiration by voluntary effort, so as to bring
more air into the lungs than is done by the common
act of breathing, is advantageous even to those who
are deeply under the influence of pulmonary disease."
P. 428.
These observations, made many years ago, and
before the precise influence of exertion over the res-
piration, had been determined, exhibit rare practical
sagacity.
The methods by which we may increase the expansion
of the lungs are few, viz., by increasing general inner-
vation, by food, by exertion, and by deep voluntary
inspirations.
PROMOTE EXPANSION BY EXERTION. 299
BY GENERAL INNERVATION AND FOOD.
We need not here advert to the first, since we have
already discussed the various plans hy which innerva-
tion may be increased, and shall only affirm that the
expansion of the lungs in the act of inspiration will
proceed pari passu with the increase of innervation.
The influence of foods over the expansion of the lungs
has also been in j)art pointed out, and it is very pro-
bable that they act by a modification of the innerva-
tion of these organs. Thus we have stated elsewhere,
that tea, coffee, cocoa, chicory, sugar and nitrogenous
foods increase the expansion of the lungs, and also the
amount of chemical change — the former being fami-
liarly shown by the ease and lightness of respiration,
foods which follows the tea meal, and the latter by the
increase in the carbonic acid evolved. But the amount
of the increase of expansion due to their influences is
but small — seldom exceeding 10 cubic inches at each
inspiration, and as a mechanical action it cannot be
regarded as very important.
BY EXERTION.
The effect of exertion is very considerable according
to the degree of it. During ordinary quiet respiration
we inspire from 35 to 45 cubic inches at each act, but
when we run at full speed, or on working the tread-
wheel, the quantity is increased to upwards of 100
cubic inches at each inspiration, and the inspirations
are increased from 12 to upwards of 30 per minute,
until the increase of the pace prevents the amount of
lung action which is necessary to accompany it, or
300 THE LUNGS BEFORE DEPOSITION OF TUBERCLE.
until the duration of the more moderate pace has
wearied the muscles both of the general system and of
the chest. The difference in the amount of expansion
requisite to admit 40 and 100 cubic inches of air is
very great, and the amount of vital force exerted to
make the greater effort, and to perform it with a speed
24 times as great at each inspiration, and with twice as
many respirations in a given time, must be greatly
increased. Hence we have in this degree of exertion
a most powerful agent for the purpose in hand. More
moderate degrees of exertion are attended by less
increase of respiratory action, but yet cause an in-
crease of very great value. Thus, in walking at the
rate of 1, 2, 3, and 4 miles per hour, the depth of
inspiration was increased in our experiments to 52
C. L, 60 C. I., 75 C. I., and 91 C. I. at each inspira-
tion, and the frequency of respiration was 18, 18i, 22,
and 25 per minute. The sauntering pace of two miles
per hour causes an expansion of the lungs, and a rate
of respiration of 4 more than that observed at rest,
and is far more powerful than we are accustomed to
believe. When, therefore, the patient is enabled to
take a moderate amount of exercise, we must admit
that in doing so he is placed in very good circum-
stances to produce the mechanical as well as the
chemical effect which we desire ; but if, in addition,
running, jumping, or skipping be performed for short
periods, the effect is greatly increased. He should
also be informed of the object which the medical
adviser has in view, and reminded that it is desired
to produce complete expansion of the chest. He should
PROMOTE EXPANSION BY EXERTION. 301
endeavour, during the exertion, to breathe lightly and
freely, and with as much depth of inspiration as may
be convenient to him.
In numerous cases it will be necessary to encourage
the efforts of the patient to the performance of any
required degree of exertion ; for it is not infrequent to
meet with those who, from a sense of weakness, dysp-
noea, and pleurodynia on exertion, or defect in the
previous habits, believe themselves unable to make so
much exertion as is required. To this end it is advis-
able that such exercises be selected as are convenient
to the patient, and that the amount be gradually
increased ; but in whatever degree it may be made, it
must be carefully limited in time. Any degree which
induces true fatigue is in excess, but by judicious
management this degree may be gradually increased
without inducing a sense of fatigue. In a case of
early phthisis we advised, in addition to other exer-
cises, the use of the skipping-rope within doors, in the
middle of October, and at that time it was found that
she was unable to skip more than three times without
inducing so much pleurodynia and dyspnoea as to
compel her to rest ; but, by careful continuance twice
a day, she was able in the course of a month to skip
more than 100 times without resting and without
fatigue. In a similar manner, ladies who have not been
accustomed to walk one mile per day out of doors may,
by gradual increase, and the use of a hand-chair when
tired, become able to walk 5 or 6 miles daily with
comfort.
302 THE LUXGS BEFORE DEPOSITIOIT OF TUBERCLE.
BY DEEP VOLUNTARY INSPIRATION.
Considering the duration of exertion and the apti-
tude which all have for it, it is prohable that we possess
no agent which is equally powerful for the purpose now
under discussion; but in reference to short periods
of action, we find deep voluntary respirations yet more
efficacious.
These are performed by inducing the patient to
breathe as deeply as the lungs will allow, with the view
of expanding the chest to the utmost possible limits.
To this we attach the greatest importance, and having
advocated it for some years past, we are much gratified
to find that so distinguished a physician in diseases of
the chest as M. Piorry has arrived at the same views,
and recommends this plan of treatment as unreservedly
as we do, and with the higher authority which attaches
to his name and fame. It is true that the object sought
by M. Piorry and ourself does not appear to be iden-
tical, since his primary aim seems to be, the difficult
and important one of producing the resorption of
deposits, and in this he affirms that he succeeds ; whilst
our chief aim is to increase the expansibility or
patency of the lungs, and thus increase chemical
change and prevent the occurrence of deposits ; but
there is such an analogy between these two objects,
that the treatment of each may be regarded as practi-
cally the same.
The production of this complete expansion of the
chest is oftentimes a circumstance of extreme difficulty,
and sometimes it cannot be effected ; but the difficulty
PROMOTE EXPANSION BY DEEP INSPIRATION. 303
lies not in any impediment to the entrance of the air,
but in the defect of muscular power to expand the
chest, or in the impossibility of inducing the patient
to comprehend the method by which it is to be effected.
Hence, however great the difficulty, it lessens by prac-
tice, if the practice be carefully and intelligently made.
The plan which we adopt is as follows :
The patient is placed in the sitting or standing
posture, with the trunk erect, the shoulders drawn
downward and backward, and the chest thrown for-
wards. The mouth is then kept a little open, and the
patient is directed to inhale gently whilst he very
evenly expands the chest to its utmost limits; and at
the end of the inspiration he is directed to make
increased effort, and then to retain the chest in its
expanded state for two or three seconds before expira-
tion is commenced. If the mouth be shut, the nostrils
cannot admit the volume of air with sufficient freedom ;
and if, instead of an even and somewhat gentle inspi-
ration, the air is drawn in quickly and forcibly, like
suddenly snatching asunder the handles of a pair of
bellows, it is impossible for the lungs to become per-
fectly expanded. If, at the end of the inspiration, there
be not increased effort made, the mechanical act of dis-
tension is materially lessened, and the good which is
effected is imperfect ; whilst there is a manifest advan-
tage in keeping the lungs fully expanded for a few
■moments, and afterwards in preventing a collapse of
the chest by a sudden and rapid expiration. The
posturing of the chest is also important, not only by
inducing that position in which the cavity may be most
304 THE LUNGS BEFORE DEPOSITION OF TUBERCLE.
completely enlarged, but, by placing the relaxed and
elongated pectoral muscles upon the stretch, and hold-
ing the shoulders firmly backward, the greatest amount
of muscular power may be obtained.
There are two of these conditions which it is very
difficult to fulfil, viz., the prevention of a rapid and
gasping inspiration, and the final effort at the end of
inspiration to effect the complete distension of the
lungs. The former is more common in cases where
the respiration is short, and the person is nervous and
defective in readiness of apprehension, and in such
cases is very difficult of attainment ; whilst the latter is
chiefly associated with much atonicity of the muscular
system, and in the most intelligent and painstaking
person is only perfect after long practice. Its increase
is, however, a good measure of the improvement of the
patient.
On deep inspiration we find that the apex of the
lung is not filled until the very end of inspiration, and
we have explained this at page 202, by the common
direction of the Bronchi, which carries the current
downwards, and also by the great extent and direction
of motion of the lower ribs, so that whilst in inspira-
tion the air is admitted into all permeable parts of the
lung, the lower part is first filled by voluntary effort,
and then the upper. Hence, for various reasons, we
see the importance of the effort to inspire at the very
end of the act of inspiration, with a view to cause the
complete expansion of the apices of the lungs.
We have fotind it always necessary to have the chest
uncovered, and to watch carefully the movements of
PROMOTE EXPANSION BY DEEP INSPIRATION. 305
the parts during this procedure, so as to appreciate any
defect in the performance ; and moreover, it is com-
monly needful that the physician should show the
action upon himself. It is needless to state that it is
an easy process to those who can do it ; hut as its entire
value rests upon the degree of perfection with which
it can be effected, it demands that the physician be
enabled from time to time to inspect the movements and
correct their defects.
It is also evident that deep respirations cannot be
continuous, since their duration is incompatible with
the ordinary rapidity of respiration, and therefore we
direct that after each complete expansion of the chest
there be one or two ordinary inspirations effected, and
that with these alternations the practice be continued
for ten minutes at a time, and be renewed once or twice
in the day. It may also be performed in the house, if
the air be pure ; or out of doors, if the air be warm.
It is a method of treatment which is attended with a
rapid increase in the expansibility of the chest, so
much so that the practice of a few weeks will cause
the front of the chest below the clavicles to advance
and project on deep inspiration, when before it was
flattened. It has also the advantage of amusing the
patient, and of finding an occupation for the mind in
the search for health; and any other general and
local treatment may be adopted at the same time.
If this complete expansion of the chest be daily
effected, and at the same time the vital actions of the
whole body be invigorated, and the various plans to
which we have referred have been effected, we affirm
X
306 THE LUNGS BEFORE DEPOSITION OF TUBERCLE.
that if tubercle be not already deposited, it is fitted
to prevent its deposition ; and if already existing in a
small degree, it will in all probability prevent its
increase, and the parts of the lungs not thus occupied
will regain their normal condition. This improve-
ment, or cure, will of course be dependent for its
continuance upon the maintenance of a due degree of
vigour of system, and will pass away if at any time the
conditions which first led to it shall be renewed.
Hence we consider that up to the poiat under
discussion, phthisis is as curable as any other condition
of an organ in which an equal deterioration in the
function or structure has occurred.
CHAPTER XXXIII.
THE LUNGS AFTER THE DEPOSITION OF TUBERCLE.
ORDINARY LIMITS OF REMEDIABLE CONDITIONS.
As we have limited ourselves to a consideration
only of those conditions in which phthisis is a re-
mediable disease, it is necessary here to determine
the amount of disease which we believe to be remedi-
able. This is a task of no ordinary difficulty, for, on
the one hand, the term may be held to require that all
the conditions of the disease shall be removed, and, on
the other, that we shall be able rigorously to limit the
extent of the disease. As to the former we may
remark, that we shall fulfil all that can be desired, if
in many cases every trace of disease be removed, and if
in others we can arrest the disease so that there shall be
no longer any danger of its progressing ; and as to the
latter, we shall be satisfied to confine ourselves to such
conditions as are commonly determinable on the most
careful examination.
We think, therefore, that after tubercle has been
deposited, the case is remediable under the following
conditions : —
1. When the amount of tubercle is small, its site
X 2
308 THE LUNGS AFTER DEPOSITIOIT OF TUBERCLE.
capable of careful definition, and the other parts
of the lung free from disease.
2. "When the deposit is found in only one lung, even
if it have proceeded to a somewhat greater
extent.
3. When the vital powers of the general system are
not greatly depressed, and where there is no
complicating disease.
4. When the progress of the deposition has not been
rapid.
5. In cases where there is a small isolated cavity
surrounded by healthy lung, without pleuritic
adhesion, and one lung quite sound. When the
cavity is empty, and has remained so for some
time, the case is more hopeful.
6. When the patient can and will adopt all the
plans which are necessary for his restoration to
health.
Such are the conditions in which there may be hope
of restoration to health, and either of true cure, or of
complete arrest of the disease so long as the patient
live under healthful conditions ; but we do not wish to
intimate that, occasionally, arrest may not occur in a
more advanced state of the disease. We shall again
refer to this subject under the head of Prognosis.
DEEP VOLUNTARY INSPIRATION.
In each of the above conditions we still advise the
most careful use of the method of deep voluntary
inspirations, with a view to maintain the patency and
vital activity of all the parts of the lung at present free
EEMOYAL OF TUBEECLE. 309
from disease, for in so doing it is higlily probable that
tbe further progress of the disease will become im-
practicable.
REMOVAL OF TUBERCLE.
The aim, in reference to the tubercle deposited, must
be either to promote its removal, or to isolate it, and
induce the cretaceous degeneration.
In reference to the removal of tubercle we do not
think that anything can be done to promote it by
the expectoration, since it may be doubted as to how
far any expectorant has effect upon the air-cells them-
selves, however much it may have upon the bronchial
mucous membrane; and as a rule we should dis-
countenance the use of expectorants at that period,
lest they should tend to induce a state of congestion
and irritation of the tissues. For the same reason we
do not advise the employment of inhalations which have
an irritating tendency. The efforts at removal must
certainly be directed to the absorbents by which the
material may be disintegrated and altogether removed,
or the fluid parts removed and the solids left in a state
to which we shall presently refer. For this purpose
it seems to be necessary that the tubercle should
either have been recently deposited and have un-
dergone no secondary changes, in which case the
promotion of its absorption is the direct road to the
cure; or after having been long deposited in small
quantities only, it has degenerated, and finally softened
without inflammatory action, in which case the capa-
bility of being absorbed has occurred as a secondary
310 THE LUKGS AFTER DEPOSITION OF TUBERCLE.
result. It is, however, to the former that we par-
ticularly refer at present as the condition in which
the aim may reasonably be to cause its removal by
absorption.
We have already referred to the opinion of M. Piorry,
that the voluntary and deep inflation of the lungs
directly tends to promote the absorption of deposited
matter. This is[ highly probable, both from the fact
that such treatment directly tends to the increase of
vital action, and also from the pressure which it
mechanically affords, and which in certain conditions
is known to be favourable to the absorption of fluids.
Hence the plan already recommended receives another
sanction.
Of the medicinal agents to be employed for this
purpose, we attach great value to the administration
of iodine in small doses, and of all forms that of
the iodide of iron has appeared to us to be the most
efficacious. The syrup is an agreeable preparation,
but the iodide of iron in pills is, we think, to be
preferred for adults, and of this 2 grs. should be
taken thrice a day, for a period of six or eight weeks
without intermission. We have not found the use of
iodide of potassium so fitting in these cases as in those
of deposits from chronic pneumonia, and generally
because the system does not gain strength under its
use, and does not well bear it. It is possible that in
some cases the inhalation of iodine may also be
serviceable, but generally its action as a local irritant,
and particularly where the fauces exhibit much irri-
tability, has prevented our employing it extensively.
ISOLATION OF TUBERCLE. 311
The application of the iodine paint to the walls of the
chest cannot, we think, act in this manner with any
degree of certainty, since the anatomical disconnection
of the parts renders the action upon the lung- structures
almost impossible. We need not here advert to the
fact, that the tendency of all the remedies previously
advised is to promote this absorption, since they
tend to improve the tone of all the vital powers.
We have already referred to the conditions of tu-
bercle in which this action may be looked for, but it
is necessary further to add, that in a majority of the
cases it is probable, that only the fluid and the un-
organized animal parts will be removed, and that there
will remain whatever is truly solid, whether in the
horny state to which Laennec and his school often
referred, or in the mineral matter which occurs with
secondary changes.
ISOLATION OF TUBEECLE.
This result is almost as valuable as the former, for
although the material remains, it is placed in circum-
stances which are comparatively harmless.
This is effected when, after a small amount of depo-
sition, the further progress of the disease is arrested ;
for in nearly all such states the tubercle, in process of
time, puts on secondary changes which tend to its
permanent isolation. This end is promoted by what-
ever improves the general health, but particularly by
the full inflation of the lungs, the first by tending to
remove the general, and the second the local con-
ditions upon which the deposit depends. The latter
312 THE LUNGS AFTER DEPOSITION OF TUBERCLE.
remedy acts no doubt both by maintaining the patency
of such cells as are free, or nearly so, from the deposit,
and by promoting the closure of those which are nearly
filled by it, for as the healthy air vesicles which
surround a small mass in which the deposit has oc-
curred are fully distended, they must cover and press
upon those which are incapable of inflation, and thus
soon cut off any communication between the latter and
the external atmosphere. This we believe to be a
most important effect of the agent in question, and a
mode whereby the isolation -of the tubercle is most
readily effected. It is also to be borne in mind that
the lobular arrangement of the lung aids this result,
since by it small aggregations of air-cells are enclosed
in an inexpansible membrane, and connected with the
air by one minute ramifying tube only, which after a
period may become impervious.
Hence there can be no doubt that the cases of iso*-
lated calcareous tubercle are commonly cases of true
arrest and cure, but calcareous tubercle is very fre-
quently found in the sputa of persons, in whom, if
there have been arrest, it has been only temporary,
and who suffer from destruction of the lung-tissue of
greater or less importance.
ISOLATION AND POSSIBLY CLOSURE OF A CAVITY.
From the period of Bayle it has been noted that
puckered conditions of the lungs have been found which
more or less resemble a cicatrix, and that on carefully
cutting into it the structures have been found tough
and solid, and sometimes resembhng cartilage. These
ISOLATION AND POSSIBLY CLOSURE OF A CAVITY. 3X3
were, therefore, regarded as evidences of the prior ex-
istence of an ahscess or a vomica which had gone
through its course of destructive excavation, followed
by emptying and contraction, and had ended by
simply inducing the loss of a large number of air-
cells. Such is a ready, and probably in many cases
a true explanation of the appearances, and hence we
find a certain amount of warrant for the. belief that
cavities may entirely disappear. Moreover we find
in practice a certain small number of cases in which
there is a small and isolated cavity at the apex of the
lung, which readily empties itself, does not tend to
increase, and in which there is no further deposition
of tubercle, whilst watched over a period of months or
one or two years. There are also other instances in
which, with more extensive mischief, we find evidences
of a dry cavity which has existed for years, and in
which there has been little or no accumulation of
secretibn. Such may add to the presumption of cure,
but doubtless they are rare when compared with the
mass of cases, and must be included in a category of
curable conditions with a certain reservation.
When, however, we find a small isolated cavity with-
out tendency to increase, and without further tuber-
culous deposition, our aim should doubtless be to
induce its closure. How may this be efi'ected ?
Those cavities appear the most fitted for this process
which are small, and have not any quantity of infiltrated
tubercle in the tissues which bound them, that is to say,
such as have thin and still elastic sides. It has been
presumed that closure occurs partly by the filling up
314 THE LUNGS AFTER DEPOSITION OF TUBERCLE.
of the cavity with exudations, and partly by the collapse
of the sides. The former is scarcely possible in any
case in which the cavity is of size to deserve the name,
both from the impossibility of accounting for the deposi-
tion of layer within layer more and more distant from
the blood-vessels, and from the fact that the remains
of cavities exhibit the marks of compressed tissues
rather than those of accumulated foreign material.
The collapse of the sides of the cavity of the nature
above-mentioned must certainly occur, and if it be
placed in the apex of the lung, and be free from
pleuritic adhesion, the upper part will fall downwards
so as to tend to obliterate it from above.
In reference to this mode of closure voluntary in-
flation of the lung is very useful, for as the adjoining
cells become fully expanded, they must press upon the
sides of the cavity, and as there will be less resistance
in that than in other directions, the air-cells will
the more readily tend to expand at the superficies of
the cavity. It may be objected that in such conditions
the forcible expansion of the lungs will be likely to
induce haemoptysis, but in the course of extensive
experience we have not found that result, and, indeed,
when we recollect how much less force is used in the
expansion of the lungs by the inhalation of air with
the trachea open than by the effort of coughing, when
with the trachea closed there is violent and sudden
compression of the air from below, so as to forcibly
expand the air-cells of the upper and the least re-
sisting parts of the lungs — we shall see that there is
much less probability of haemoptysis occm-ring with
COLLAPSE OF THE AIR-CELLS. 815
tills act than witli coughing. It may also be objected
that an emphysematous condition of the air-cells
abutting upon the sides of the cavity may occur by
forcible inspiration, and it is possible that both by
this act and by coughing this may occasionally follow,
yet it does not complicate the case adversely, but
rather favourably, for in so doing it must tend further
to lessen the cavity.
To these various acts we must add that of the natural
contractibility of the yellow elastic tissue of the lung,
and of the membrane lining the cavity when the cavity
remains empty, and whilst we do not think that this
would greatly tend to advance the required end by
itself, we must admit that it is an important condition
with which the other agents may act. It is also clearly
an essential preliminary condition that the cavity either
be empty or have a free outlet for all secretions.
COLLAPSE OF THE AIR-CELLS.
Having thus treated of the relation existing between^
the puckered cicatrices found on the lungs and the
closure of cavities, we think it needful to add that such
appearance would be readily accounted for by mere
collapse of a mass of air-cells, by which a depression
in the lung would occur, and the tissues be compressed
together and lose their configuration. That such a
state should occasionally occur must be admitted, since
it only needs that the minute bronchial tubes should
become impervious, as by local pressure of internal
deposits, after which the air would become absorbed,
the cells would collapse, and the adjoining cells would
316 THE LUNGS AFTER DEPOSITION OF TUBERCLE.
partly fill the space thus vacated. That it does often
occur in the lungs of infants is well known. We would
therefore venture to suggest that such cicatrices cannot
be accepted as indisputable evidence of the pre-ex-
istence of a cavity.
CHAPTER XXXIV.
THE THROAT.
We have intimated that there are two principal con-
ditions of disease of the throat met with in numerous
cases, in the early stage of phthisis, and that they are
important, less in themselves than from the cough
which they occasion. The two conditions may be
termed anaemic and congestive respectively.
In the anaemic throat the leading indication, as a
local condition, is to lessen the hyperaesthesia, which
is commonly present ; and the most satisfactory reme-
dies are the strong solution of nitrate of silver, or an
admixture of chloroform and neat's-foot or cod-liver
oil. In both applications it is better to use a large
camel's-hair brush, quite as large as the end of the
little finger. The patient should be seated before a
light, and the tongue being carefully depressed by the
spatula, whilst the patient is breathing through the
mouth, the brush having been dipped in the applica-
tion and drained a little upon the edge of the vessel,
must be weU swept round the fauces, so as to apply
the solution to the posterior wall of the pharynx, as
low down as the epiglottis. The only difiiculty in
this process is to induce the patient to breathe through
318 THE THROAT.
the mouth (not through the nose), and thus raise the
velum palati from the tongue, and to breathe with
freedom and ease, so as to prevent the act of vomit-
ing and allow time for the careful application of the
remedy.
There is with either remedy a certain amount of
choking induced by the approximation of the epi-
glottis to the pharynx from reflex action, but it is never
alarming or long-continued with the chloroform. In
reference to the application of the nitrate of silver,
however, we have seen the most alarming spasm, and
so severe a sense of choking as to prevent inspira-
tion, and so continued as to induce discoloration of
the face and great terror to the patient. After half
a minute, perhaps, this passes away, and commonly
at the moment when there is an eructation of flatus
which had been pent up in the contracted oesophagus,
when the larynx and pharynx were temporarily closed.
We have never met with any untoward results, but the
danger appears imminent in some of those cases in
which the hypersesthesia is considerable, and hence we
commonly, on the first occasion, apply the caustic to
the tonsils and uvula only, where there is not the
power to excite the reflex movement which closes the
larynx and pharynx. If this application be well borne,
the next step is to apply the solution sparingly to a
part of the posterior wall of the pharynx ; and if that
should be tolerated, it may be safely applied over the
whole surface of the pharynx on the next occasion.
In this condition of the throat, notwithstanding the
general bloodlessness of the mucous membrane, there
THE THEOAT. 319
are commonly a few large and superficial veins tra-
versing the surface from above downwards, and from
which the blood in haemoptysis often proceeds. It is
apparently of importance to cause contraction of these
vessels, and this will be effected by the application of
the solution of caustic, or, failing that, by a touch of
the solid caustic in some spot in the course of the
vessels.
This is the condition of the throat which, par excel-
lence, belongs to phthisis, and whilst the state of
congestion or suffusion is also met with, it is much
more rare, and is commonly due to conditions apart
from phthisis. Thus it may oftentimes be traced to
the use of neat ardent spirits, to the free indulgence
in tobacco, and particularly when used with a foul
pipe, or to the inhalation of irritating fumes, as those
in charcoal burnt in a stove without free ventilation,
or on the open hearth in certain manufactures, or
those proceeding from the combustion of impure gas
in badly -ventilated rooms. Hence the treatment of it
is almost apart from phthisis ; but we have found the
application of chloroform and oil, or the frequent use
of warm suet and milk in small quantities, or the
taking of cod -liver oil alone, or made into an emulsion,
with an alkali, the best remedies. It is also requisite
to remove internal obstructions to the circulation by
purgatives or alteratives, or to determine to the skin,
as the case may require ; and as there is usually ten-
derness, on pressure over some part of the throat, it
is very useful to apply, and re-apply, small blisters
as near to the part affected as possible. When there
320 THE THEOAT.
is much relaxation of the throat, or the colour of the
mucous membrane is 'deepened by the duration of the
disease, it frequently happens that the application of
the strong solution of caustic is attended with benefit ;
but we do not advise it in the earlier stage, or when
there is the appearance of acute desquamation of the
epithelium.
In both conditions of the throat it is well to employ
such remedies as by locally covering the membrane
will, for a time, prevent the immediate contact of the
air ; such are oily and alkaline emulsions, or gela-
tinous, albuminous, or mucilaginous fluids, and it will
also do good service if such a sedative as morphia, mixed
with thick Mist. Acacise or thick syrup of poppies, be
drank very slowly and taken in small quantities, so
that it may have an immediate action upon the mucous
surface. It is also true that sedatives and narcotics,
when taken in pills, or other form, so that they cannot
exert a local action as they pass over the sensitive
surfaces, yet lessen the sensibility through the general
system, but we submit that this is a very circuitous
mode of action, and very liable to disturb other parts
which do not need the sedative influence. It is cer-
tainly better to administer the remedy in such a form
that it may act directly upon the part affected, and
be administered in small quantities and frequently.
We venture, also, to affirm that cod-liver oil, when it
acts beneficially, often does so by the local action upon
the throat, producing the soothing effect, and reheving
the cough, to which so many patients ascribe its
utility.
CHAPTER XXXV.
HEMOPTYSIS,
The treatment of haemoptysis in phthisis always
demands careful consideration and preliminary investi-
gation, and the ordinary habit of repressing it by
styptics is often fraught with much danger.
In the majority of cases the amount of bleeding is
so small as not to attract much attention, and in
such any special treatment for its arrest would be
unnecessary ; but even in other instances in which it is
more profuse, its importance really lies in indicating a
condition of the circulating system, or some other
part of the body, than any mischief to which it may
give rise.
The first duty on the occurrence of hsemoptysis is to
examine the chest and the fauces. If there be evi-
dences of congestion of the lungs as a whole, such as
may be proved by diminished resonance and lessened
respiration, with a sense of constriction or dj^spnoea,
and with more or less disturbance of the general system,
or if there be similar evidences restricted to a part of
the lung, whether at the base or apex, and shown
more particularly after a certain amount of effusion
has occurred by crepitation or indistinct moist rales, the
322 HAEMOPTYSIS.
proper course will be to relieve the bowels, to deter-
mine to the skin, and to enforce the maintenance of the
horizontal posture. Unless the discharge be consider-
able, it is not advisable to employ cold, either by ice
or cold and comfortless food, or exposure to cold air,
since the aim is not repressent, but derivative. The
use of hot foot-baths and saline diaphoretics, the
application of blisters between the shoulders, or the
use of the croton oil liniment to a large part of the
chest, will be the proper course ; and unless active
inflammation should follow, the haemorrhage will soon
be arrested.
"When there is evidence of inflammatory action the
case assumes a character which cannot be treated of
here, and the severity of the antiphlogistic regimen
must depend upon the circumstances of the case.
When the haemorrhage can be traced from enlarged
vessels in the pharynx, the case may be left to general
treatment, unless it be urgent, when the local applica-
tion of a solution of nitrate of silver (30 grs. to an
ounce) by the aid of a large camel's hair brush, or of the
solid caustic, to any particular vessels which may be
seen, will be proper. The use of styptic gargles, as
those of alum, borax, and tincture of the sesquichloride
of iron diluted with water, may be employed in con-
tinuance of treatment.
There are, however, many instances in which it is
necessary to act upon the blood, either from the con-
dition of that fluid, or the fact of the haemorrhage being
probably a transudation through the membrane, or
from a vessel bursting into a cavity in the lungs beyond
HEMOPTYSIS. 323
our reach. In all of these cases we have found great
benefit from the use of an aqueous or a spirituous
solution of the perchloricle of iron, made in the pro-
portion of 5 drachms of the salt to 6 ounces of water
or proof spirit, and given in doses of twenty to thirty
drops in water six times a day. Warren's styptic,
made by the addition of 2 drachms of turpentine and
alcohol each to 5 drachms Acidi Sulph. Fort., and
then filtered through sand, is also a most efficient
remedy, and the dose may be 15 to 30 drops in
water. The employment of 1 scruple to half- drachm
doses of turpentine in mucilage is an old and very
valuable remedy, and to these may be added the
employment of gallic, tannic, and dilute sulphuric
acids, in doses of 3 grains of the two former, or 1
scruple to half-drachm of the latter. The use of ice
gradually dissolved in the mouth is very valuable.
We meet also occasionally with cases in which the
haemoptysis is clearly associated with the menstrual
function, and is erroneously considered vicarious. In
such cases the menses are greatly reduced in quantity,
and not infrequently changed in quality, and the hajmo-
ptysis occurs either at the period of their occurrence, or
at the usual monthly period when they are absent.
We have seen numerous instances of the former, in
which there was much uneasiness at the stomach for
two or three days -preceding, and on the day of the
occurrence of the insufficient menstrual discharge, so
that the cases assumed rather the features of ulcera-
tion of the stomach, until the periodicity and the
relation to the menses had been clearly established.
Y 2
324 HEMOPTYSIS.
It is always very difficult to decide upon the direct
plan of treatment in these cases, since the discharge
gives no relief, is attended by suffering, and occurs in
enfeebled persons, and jet there is no indication which
would justify the employment of styptics. The only
safe plan is to enforce the horizontal posture, to give
mild diluents as food, to regulate the general functions,
to use the mustard foot-baths, and to apply a mustard-
plaster to the lumbar region of the spine.
Hence, on a review of this subject, we venture to
affirm the following general rules : —
1. That commonly the haemoptysis is unimportant,
except as indicating a condition of the general
system, or of the pharynx or of some portions
of the lung.
2. That its repression by direct means is often highly
prejudicial, and tends to further advance in the
disease of the lungs, and that in no case is it
justifiable without a careful examination of those
organs.
3. That ordinarily the plan of treatment is tonic
and derivative.
CHAPTER XXXVI.
MUSCULAR PAINS.
The myalgia to which we have ah^eady referred as a
pre -existent and concomitant condition of early phthisis,
is that of the muscles about the chest, some of which
are connected simply with the arm, and others with
the acts of inspiration and expiration. The former
induce distress, and therefore demand alleviation, but
the latter limit the respiratory motions, and thereby all
the vital and mechanical actions i^hich attend them,
and more or less induce danger to health. The
indications for treatment are various, and include the
removal of any mechanical or vital cause, the improve-
ment of the general tone of the system, and the use of
local derivatives.
As the weight of the arm is borne by the muscles
attached to the neighbourhood of the shoulder, there
is a constant tendency in these muscles to the condition
known as weariness, and in order to avert or relieve
this, we direct that the arm be artificially supported, as
when leaning upon a table. But there are engage-
ments as those of a sempstress, in which, whilst one
arm may be thus supported, the other must remain
free for motion, and hence there is a cause of inequality
326 MUSCULAR PAINS.
of muscular effort, and of suffering on one side only.
This will illustrate numerous conditions in which
muscular pains arise, and the first duty is to limit the
period when the muscles of the shoulder must bear the
weight of the arm, and to render the support equable
on both sides. This will often suffice to remove the
pain, but if it should fail, or if it cannot be effected,
the most efficient remedy is artificial support by plasters.
We do not find that the nature of the plaster is material,
since we believe it to have a mechanical effect only, but
it is requisite that it be made upon a substantial
material, as very thick calico or leather, that it be much
larger than the extent of the pain, that it fit and stick
very closely, and be renewed as often as the support
which it affords fails. We cannot deny, in reference to
its mode of action, that there is also besides the
mechanical support a certain degree of irritation
induced, an excitement of the sweat ducts, and a most
potent protection against the accession of cold air, and
it is possible that one or all of these may be of some
value in the action of plasters under all conditions.
Indeed, in reference to the latter action, we frequently
advise the tise of several plasters when there is
indistinct pain and liability to cold of the front or back
of the chest, and believe them to be most efficient safe-
guards. The employment of stimulating liniments in
this condition has also been commended, but although
we have occasionally seen great relief afforded by the
use of strong turpentine or ammoniacal liniments, we
have been much more frequently disappointed than
when calefacient, belladonna, opium, or other plasters
MUSCULAR PAINS. 027
have been applied, and since both cannot be employed
at once, we are required to choose between them.
In the numerous cases in which the pain is restricted
to a small surface, and is very acute, we believe that
no remedy is equal to blisters. One application of the
blister commonly removes the pain, but occasionally
cases occur in which it is necessary to renew the appli-
cation several times. It may perhaps be an open
question as to whether the iodine paint or the Spanish
flies is the best mode of causing a denuded surface,
and whilst admitting that they are equally good in
many cases we prefer the blister when the pain is
very locahsed and very acute, and the iodine when the
pain is severe but less acute, and is experienced
immediately beneath the clavicle, where the figure of
the chest is uneven and not well adapted for the appli-
cation of blisters. When the iodine paint is freely
used, the pain to which it gives rise is greater than
occurs with blisters, and it produces a sore, secreting
pus, and sometimes not easily healed ; but when it is
lightly applied, the degree of irritation may be more
carefully graduated than can be effected with a blister.
The croton oil liniment is also a valuable agent, but
seldom so trustworthy as a blister in the treatment of
myalgia, yet when the pain is widely distributed over
the chest, it is more convenient to use this more
general remedy than the strictly localized blister. The
croton oil often causes irritation in the eyes, and it
frequently happens that the eruption extends to parts
which apparently have not been rubbed with the oil.
There is also much diversity in the effect produced
328 MUSCULAR PAINS.
upon different skins, so that occasionally a single
application will cause great irritation, whilst commonly
three applications must be made daily for two or three
days before the desired effect is produced. "When we
order this application, we direct it to be employed
thrice a day, and continued with short periods of inter-
mission for some weeks, unless the pain should have
in the meantime passed away. There are some cases
in which the myalgia has a rheumatic character,
although they are few in which this can be ascertained
with certainty. The history of the case is the best
guide, but in addition the intractable character of the
pain under the ordinary treatment may sometimes aid
us. In such cases we find that the exhibition of
colchicum in the form of the acetic extract, or the
powdered root conjoined with Dover's powder, is the
best remedy, in addition to the external application
already advised.
In the intractable cases which are connected with
spermatorrhea, we have found the improvement of
innervation and of the bodily functions in general,
with the use of cold bathing and occasional blistering,
to be the most efficacious. It is in such cases that the
phosphate of iron sometimes produces marvellous
benefit.
CHAPTER XXXYIL
CATEGORICAL STATEMENT OF THE WHOLE PLAN OF
^TREATMENT.
We purpose in this chapter to state, in as few words
as possible, and without comment, the details of treat-
ment which are suited to a case in the early stage of
phthisis, and which have been already discussed at
length ; but it will be understood, in limine, that any
general plan will require to be modified in reference to
the treatment of individual cases, as certain conditions
of the system are more or less pronounced in each
case.
FOOD.
The patient should take from two to three pints of
milk daily, prepared (and we also add thickened) with
chocolate, arrowroot, flour, gluten semola, oatmeal, or
bread, or made with eggs, &c., into puddings. In
cases where new milk does not agree, skimmed milk
may be in part supplied, and then, if fats be tolerated,
half an ounce of suet, cut finely, should be well boiled
in each pint of milk, and taken quite warm. The
milk should be eaten in somewhat small quantities, say
half a pint at a time ; one quantity is to be taken
330 CATEGORICAL STATEMENT OF PLAN OF TREATMENT-
immediately on the patient awaking in the morning,
others at breakfast and supper, the milk pudding for
dinner, and chocolate or coffee may be added to
the milk which is taken at breakfast and tea. Food
should further be taken at intervals of from two to
three hours, and the dinner should be supplied soon
after midday. Half a pint of good soup, with bread,
may be taken between breakfast and dinner, and,
if fats are not disliked, it would be better to prepare
the soup from ox heads or sMns, so as to supply
both oil and jelly in addition to the juices of the
meat, and the whole should be well thickened with
groats or corn flour. Eggs, bacon, or meat, should
be taken at breakfast, and abundance of fresh meat at
dinner, with soup, pudding, and a moderate quantity
of fresh vegetables, French beans, and bread. The
meat should be of the richest quality, and have at
least one-third of its weight of fat. If the patient like
salad oil, it may be eaten as freely as possible. A
small quantity of cheese should be added to the dinner.
An egg should be taken at the tea meal and also at
supper w^hen milk is not taken. There should also be
a cup of milk and bread and butter placed at the bed-
side of the patient, and eaten, if possible, during the
night. Beer or wine may be taken at dinner, and once
or twice at other periods of the day, if it be found to
agree with the system, and the dose be so moderated
that it may not in the least affect the head, or cause
heaviness in, and indisposition to move the limbs.
Usually, wine should be taken with hot water; but
when the progress of the case is satisfactory, alcohols
EXERCISE AND EMPLOYMENT. 831
are not necessary. All food should be taken hot, and
prepared so as to please the taste of the patient.
EXERCISE AND EMPLOYMENT.
The patient should rise at 7 a.m., and take a walk for
half an hour before breakfast at 8i a.m. Exercise in
the open air should also be enjoined for an hour or
more before dinner, and again before tea. When
engaged in business, half an hour or more must be
employed at two periods of the day in exercise in the
open air. He should retire to rest from 9 to 10 p.m.
If there be much debility and sense ,of fatigue felt
during the day, he should lie down on the couch before
and after dinner, and particularly if he be tall, either
absolutely or in relation to his age, and the action of
the heart be feeble.
The exercise should be apportioned to the strength,
but it should be carried as far as possible short of
fatigue. When it can be tolerably borne it should be
rough and free, as rapid walking, or moderate climbing,
or running, or skipping, each of which is to be per-
formed for limited periods at a time, and, if possible,
with unvarying regularity as to the period of the day
and duration. It should be made with a cheerful com-
panion, and with as much abandon and gaiety of feeling
as possible. Men should walk, run, and climb, whilst
women should walk briskly and skip, throwing the
rope from before backwards, and resting when fatigued.
Horse exercise is very proper for both sexes, unless
there temporarily be much exhaustion. Eidmg in
carriages is unworthy the name of exercise, except to
332 CATEGORICAL STATEMENT OF PLAN OF TREATMENT.
those who are very feeble. Deep voluntary inspira-
tions should be practised during ten minutes, twice a
day, at the periods of exercise or otherwise.
The occupation should not be sedentary, nor be
pursued in close or heated rooms, nor, in crowded
places ; but out-of-door employment, under certain
restrictions as to exertion and weather, is the most
proper. A sitting occupation, in which the chest
is leaning over a desk or the trunk is curved
forward, is very injurious, and should be exchanged
for the standmg posture, but alternated at intervals
with sitting. . An occupation, also, which requires
continuous standing should be avoided. Dust and
irritating fumes are also injurious. The period of
labour should be restricted to 6 p.m., and even to an
earlier hour if it is practicable. But whilst there is
commonly more to be feared than hoped for in the pur-
suance of the occupation of life by persons in this
state of disease, it is, at the same time, of imperative
necessity that the attention be moderately occupied
through the day, and with an occupation which is felt
to be profitable to the patient or to others, and within
the sphere of his duty. Listlessness and idleness are
particularly to be deprecated.
BATHING.
The patient should wipe the whole body over before
retiring at night, and on rising in the morning,
with a towel saturated with cold salt and water, and, in
order to prevent the cold water trickling down the
skin, the towel should be compressed a little before it
CLOTHmG. 333
is applied to the skin. The salt and water should be
made with water which has been in . the bed or other
room during the day or night, and should be applied
either immediately before or immediately after taking
the cup of hot milk and chocolate. A dry, and
perhaps rough, towel should be used afterwards with
moderate freedom. Care should be taken to prevent
much exposure, and particularly in cold weather, and
the whole process should not occupy more than a
minute or two. Men in tolerable health should use
the plunge bath, or bathe in open water, for a
few minutes every second morning. In the proper
season, sea-bathing should be pursued every second
day, but limited to three or five minutes.
CLOTHING.
The clothing should always be sufficient to maintain
a comfortable warmth, without causing a sensation of
heat or producing perspiration. Woollen vests and
drawers should be worn by both sexes, but of different
weights according to the season. They should not be
worn during the night. Both the upper and lower
extremities should be well clad, so as to prevent the
sensation of cold, but if, notwithstanding the use of
woollen clothing, they are cold, it is of the greatest
importance to use rough friction and to apply external
warmth, so as to induce the due amount of heat. The
use of Indian-rubber goloshes is to be avoided, except
whilst actually walking in the wet, and boots or shoes
with cork and leather thick soles are to be preferred.
We do not recommended patches of warm clothing
334 CATEGOEICAL STATEMENT OF MODE OF TEEATMENT.
with a view to render one part of the body hotter than
another, and therefore rather deprecate the habit of
loading the front of the chest with hare skins, chest
protectors, or layers of flannel. The daily and general
application of cold water will prevent local hyper-
sesthesia, and therefore the sense of necessity for this
clothing ; but, at the same time, the chest, both before
and behind, must be kept comfortably warm by flannel
shirts, high dresses, or double-breasted waistcoats.
The neck should also be covered. The night covering
should be moderate, and, if practicable, increased
somewhat from 4 to 6 a.m. It should be quite suffi-
cient to produce abundant warmth, but not perspira-
tion or oppressive heat, and should consist of blankets,
and not of heavy counterpanes. The face should not
be covered by the bed- clothes, and there should not be
any drawn bed-curtains. The proper place for the
bed is between the door and the window or fire-
place, and not in a corner. If there should be too
great a draught over the face, a curtain may be used to
moderate its efi'ect. The bed-room should be large
and lofty, and, if possible, the patient alone, or, if
married, the husband and wife should occupy the room.
The bed-room should have the air moderately dry,
and therefore it ought not to be on the basement or
grouiM floor. It should also be moderately cool, and,
except when there is irritable cough, or the air damp,
no fire should be lit in the room, and when a fire is
used, charcoal should not be burnt, unless there is a
good draught of air in the room.
EESIDENCE. 335
RESIDENCE.
The house should be so well built that draughts from
the windows and doors may be prevented. The roof
should be sound and the ground floor made of wood, or,
if of brick or stone, there should be wood placed upon it
at the parts where it is used. No dampness of the
floor or walls should be permitted.
A moderately dry, clear, bright, and cool atmosphere
is the most fitted for this class of cases, and it must
neither be very dry nor very moist. Westerly, north-
westerly, or south-westerly winds are proper, and if
they should blow strongly they are not to be shunned.
The north and the north-easterly winds are injurious
and to be avoided, but they will be more tolerable when
the temperature is moderately high with a north wind,
and moderately low with an east wind. Kainy weather
is undesirable, and the more so if it be very hot or
very cold ; but in reference both to wind and weather,
a moderately free exposure to them, when not extreme,
is commendable. An extra covering should at all
times be carried, when the patient is exposed to the
weather, and whenever there is a sensation of cold, or
when it varies, this should be employed, and no pains
spared to regain the natural warmth as quickly as
possible. A dry and frosty air is very salubrious, if
the patient be not much troubled with cough, be able
to take brisk exercise, and be sufficiently clad. When
exposed to cool air, as on leaving the bed-room for the
hall, or the house for the open air, the patient should
close the mouth and breathe through the nose, and
336 CATEGORICAL STATEMENT OF MODE OF TREATMENT.
avoid speaking so long as the exposure continues. This
is the effect produced when an artificial respirator is
worn, and the closed mouth is the natural respirator.
The residence of the patient should not be low in
relation to the surrounding country, nor in the imme-
diate neighbourhood of a stream or lake. The ground
should be well drained either by surface or sub-soil
drainage, and in the summer time it may be either clay
or gravel. There should not be any stagnant water in
ditches or in irregularities of the ground, nor any
source of foetid smells from decaying animal or veget-
able matter. The house should be moderately elevated,
but sheltered from the north-east. An open park-like
country is to be preferred to a woodland district, and
in the winter, or at very cold seasons, the town is to be
preferred. The climate in the summer time should be
northerly, and in the autumn the same, if the residence
be near the deep sea or at the south, and in the winter
southerly, or that of the healthy part of a very large
town. There should be an absence of much rain and
fog, or sudden changes of wind to the north.
MEDICINES.
In perhaps every case it is necessary to administer
the mineral tonics : 15 minims of the Tinct. ferri sesqui-
chloridi, with or without an equal quantity of chloric
ether, should be taken thrice a day in a wineglass of
water, wine, beer, or quassia infusion ; or 8 grains of the
citrate of iron and quinine thrice a day. The iodide of
iron, when given, should be frequently intermitted.
Cinchona and the mineral acids may be exchanged at
MEDICINES. ' 337
intervals for the preparations of iron. Two or tliree
drachms of cod-liver oil should be given twice or thrice
a day, when it is tolerated. The condition of the
menstrual function, the digestion and the alvine evacua-
tion, will all need frequent attention. The best internal
remedy for the cough is morphia in doses of 1-16 or
1-13 of a grain, taken every 4 or 6 hours with mucilage
or syrup. Frequent examinations of the state of the
pharynx should be made ; and this, with the state of the
stomach and skin, will determine whether the acid or
the alkaline plan of treatment must be temporarily
pursued.
CHAPTER XXXVIII.
COD-LIVER OIL.
Although we have alluded to the action of cod-liver
oil in other parts of this work, we think it necessary to
discuss the merits of that substance in a yet more
connected and minute manner. It is probable that
no remedy for any disease has ever been more generally
adopted than cod-liver oil in phthisis, not excepting,
perhaps, quinine in ague. It is a remedy which was
used at least so early as the time of Pliny, so far as
regards some forms of disease, as rheumatism, gout,
and scrofula, and its occasional employment was not
forgotten by a few medical men in the 18th century ;
but as a remedy in phthisis, and in consideration of its
universal use, it may be regarded as a new remedy, and
one introduced to English practice so recently as 1841.
It was most ably treated of by Dr. De Jongh in 1843,
and again in his standard work entitled, " L'Huile de
Foie de Morue, &c. Paris, 1853." To Dr. Hughes
Bennett we owe, no doubt, its use in this country,
since he first called attention to the great value which
had already been attached to it on the continent of
Europe.
We have said that within so short a period as twenty
COD-LIVER OIL. 339
years its use has become universal over the whole
civilised world, and we may well inquire as to the
amount of good which it does afford, and the mode by
which that good is effected.
It is quite true that new remedies have arisen from
time to time, and, by that good or bad quality of the
human mind by which so many act upon authority and
are led by a leader, have gained celebrity and have
been extensively used, but notwithstanding have been
neglected and almost forgotten, a few years later ;
such, it may be inferred by the sceptical, may ere long
be the fate of cod-Hver oil. Yet we think that the uni-
versality of its use, both by confiding and sceptical
minds, by the leaders and the led in the profession,
places the merits of cod-liver oil on higher ground
than that occupied by former favourites, and we cannot
think that a remedy so approved can be otherwise than
useful in the present condition of the human system.
Hence we believe that it is a valuable agent, and one
which is likely to remain in use, or lead to the intro-
duction or general use of some other substance of an
analogous nature. In the outset of our inquiry, then,
we confess ourselves an advocate for its general use.
As the subject is one of so great interest and im-
portance, we entered into an inquiry at the Hospital
for Consumption, with a view to determine in what
proportion of cases the use of cod-liver oil was benefi-
cial, the direction of the relief which it afforded, and
the relative advantage of its use when compared with
that of other fats ; and the results which were obtained
are, we believe, substantially true.
z 2
340
COD-LIVER OIL.
In pursuing this inquiry, we sought for testimony in
two directions, viz., both from the patient and the
medical attendant. We questioned the 150 in-patients
already referred to at page 58, as to their own opinion
of the result and the mode of its action; and the fol-
lowing is the result of the inquiry, it being, however,
understood that, in nearly every instance, other medi-
cines were taken at the same time, and the separate
influence of the oil could only be inferred.
85 stated that it benefited them ; 16 stated that it
benefited them at first, and injured them afterwards ;
16 stated that it injured them; and 33 stated that it
had no influence.
Thus those who were, in their own opinion, more or
less benefited by it were 83 against 67, or 55 per cent,
of the whole, or, if we add those on whom it was at
first beneficial and afterwards injurious, 66 per cent, of
the whole.
The mode inwhich they believed that it benefited them
was variously stated. Thus, in their own words : —
Botli stronger and stouter
22
Chest became stronger .
. 2
Stronger . . . .
33
Less pain in the side
. . 2
Stouter
13
Healed lungs
. 2
Appetite improved
8
Less pain in, or soothed,
the
Digestion ,, . . .
5
chest .
. . 6
Breathing ,, .
6
Less hoarse .
. 1
Cougli ,, . . .
Did eyes good .
. . 1
Chest ,, . . .
NouriEhed .
. 2
Voice ,, . . .
Checked expectoration
. . 1
All respects . . . .
Prevented getting thin .
. 1
Bemoved sensation of sinking
Eased stomach
. 1
In some instances the answers included two of the
COD-LIVEE OIL. 341
foregoing heads, and, although they were very dissi-
milar, it will be observed that in the great majority
of the cases the benefit was referred to improved
nutrition.
Of those who stated that they were not improved, or
were injured, by the use of the oil.
36 were made sick.
2 were made weaker.
6 had no appetite.
8 had oily eructations.
2 were made bilious.
1 had headache.
2 found it never to agree.
1 had been better since he
ceased to take it.
Thus, in nearly all this class of cases, the objections
arose from the organs of primary digestion, as distin-
guished from the function of assimilation.
The cases comprehended all stages and conditions of
the disease, and those who had taken the oil for periods
varying from a few weeks to several years.
Such is the information as gathered from the state-
ments of the patients ; we will now question the medi-
cal report.
The medical report of these 136 cases, as furnished
by the clinical clerks who watched the cases daily,
showed that in 64 cases the disease was evidently pro-
gressing more or less quickly, in 43 it was appa-
rently stationary, and in 18 there was an improvement.
So that, in one -half of the cases the disease advanced
in spite of the cod-liver oil and other remedies, and in
one-seventh there was apparent improvement of the
lungs.
We then endeavoured to ascertain how far the
amount of appetite for fat food would correspond with
342 COD-LIVER OIL.
the results from the administration of the oil, and the
returns obtained prove the following : —
1st. In reference to the patients' report of the
effects :
In 80 cases in which benefit was received, three-fifths
had appetite for all the fats, and one -fourth for three
kinds, viz., butter, suet, and milk. In 29 cases in which
the oil caused sickness or oily eructations, only 1 in 3i
had appetite for all fats, and 1 in 3 for butter, suet, and
milk. It is also remarkable that, whilst in those who
received benefit only 2 out of 80 had no appetite for fat
and butter together, in those in whom the oil disagreed
11 in 29 had no appetite for fats.
Hence it follows that, where the oil was assimilated
and was beneficial, there was much greater appetite for
natural fats than where it was rejected in the first acts
of digestion ; but it may not thence be inferred that
wherever there is appetite for all fats in phthisis the oil
would be beneficial, or vice versa, for in 19 cases in
whom no effect was produced, 10 could take all kinds
of fat.
2nd. The medical report showed that, of 43 in
whom the disease was stationary, 28 could take all
kinds of fat, and 8 could eat butter, suet, and milk ;
and of 18 who were reported as improving, 10 could
take all kinds of fat, and 7 could eat butter, suet, and
milk. Hence from this report also we learn, that a
majority of those who were improved during the use of
the oil had appetite for the ordinary fats as food.
The facts elicited in this inquiry seem to be suffi-
ciently definite, but we do not desire to attach too much
COD-LITER OIL. 343
importance to the precise per-centage amounts, since it
is probable that that would vary within certain limits in
other similar inquiries ; but the general expression is
in accordance with impressions derived from a consi-
deration of many thousands of cases, and is, we believe,
an approach to truth. This expression contains the
following particulars : —
1. Cod-liver oil does not remove the disease.
2. The cases of permanent arrest of the disease are
very few when compared with the whole.
3. Commonly the disease ultimately progresses, not-
withstanding the use of the remedy.
4. In a large proportion of cases — about one-half —
the progress is temporarily lessened.
5. The patient may report himself both stouter and
stronger under the use of the oil, and yet the
disease continue to advance.
6. When the oil disagrees with the patient, it is
chiefly from its influence upon the digestive
organs.
7. When its action is beneficial, it is chiefly by im-
proving nutrition. Some remarkable instances
of increase in weight have occurred under
the combined influence of the oil, other reme-
dies, the generous dietary of the hospital, rest
and warmth ; and one of our out-patients gained
27 lbs. in weight. In an appreciable number
of instances the patient is sensible of a local
influence more or less apart from the general
nutrition of the system. This local action is
most important in the pharynx and other parts
SU. COD-Liy^ OIL.
of the mucous tract to which the oil is directly
applied.
8. There is a large class of cases in which it cannot he
taken at all, and another in which, having been
taken, it is not beneficial, and hence the use of it
requires discrimination. As a rule, it is more
commonly beneficial in those cases in which
there is appetite for the ordinary fats in food,
and it is commonly rejected when other fats are
disliked, and hence the substitution of one kind
of fat for another may be commonly effected.
MODE OF ACTION OF COD-LIVER OIL.
Having thus discussed the therapeutic value of this
substance, we will proceed to consider its probable
mode of action.
It has already been proved (page 58) that in a large
X^roportion of phthisical patients there is a diminution
of the quantity of fat which they take, and hence the
natural presumption is that the oil meets this deficiency.
The first point of interest is in reference to the cause
of the lessened supply of fat in those patients who
have the means of obtaining it. This is, we believe,
due to one of two causes, viz., the lessened appetite for
it, and the real or supposed evils which it induces.
The latter is no doubt the rarer condition, since the
ordinary answer to the inquiry is " I dislike it." This
is also supported by the fact that if a patient disHke
cod oil, he likes some other kind of fat ; and by a
judicious selection of fats, and a cautious and yet
unflinching exhibition of them, the quantity taken may
MODE OF ACTIOIT OF COD-LIVER OIL. 345
be greatly increased. It is contended that cod oil has
special properties, which render its assimilation more
easy than that of other fats, and hence among fats it
is the most nutritive ; but however true this may be in
many cases, it is not by any means an universal truth.
The inquiries just related show that in a large number
of cases the oil is rejected by persons who can eat fat
in food, and that even one-third of such persons take
the fat of meat. If they can take fat in food, but not
cod oil, it can scarcely show that the latter is more
assimilable than the former. Moreover, in cases in
which one kind of fat is objected to, the deficiency may
be fully supplied by giving other kinds. Amongst the
poor we find that many prefer pork fat, and affirm that
it agrees better with them than any other fat. It must
not be forgotten that mere dislikes are often very
capricious and temporary, and as they arise, so may
they pass away without reason ; and this may be almost
predicted if the judgment of a rational patient is
appealed to, and that kind of fat be supplied which is
the least distasteful. When the avoidance of fat really
results from some imperfection in the digestive
function, we believe that it always extends to cod-
liver oil also, and it is matter of daily observation that
in cases of disordered digestion cod-liver oil is not
tolerated.
There are others who believe cod-liver oil to exert
especial power by virtue of the amount of the hydro-
carbons which it contains; but we do not see any
ground for it except so far that, in comparing oils of
somewhat different composition, care must be taken to
346 COD-LIVER OIL.
administer as mucli of each kind as will afford the
same elements.
The physical quality of viscidity is also one of great
value, and in this cod oil and neats-foot oil stand pre-
eminent. Where we desire to administer oil in the
form of an emulsion, or to apply it locally to a mucous
surface, and to have it retained upon the surface for as
long a time as possible, as, for example, in throat affec-
tions, there can be no doubt that cod-liver oil has
paramount claims to the attention. In this respect
the dugong-oil is far inferior to cod-liver oil.
The received view of the mode of action of cod-
liver oil is now clearer than was found at the general
introduction of the oil into medical practice. At first,
Dr. De Jongh, Dr. Bennett, and others attached value
to the small quantity of iodine which it contains,
viz., -j-f-o of a grain in each dose, and also to the
phosphorus. Dr. De Jongh also believed that the
various component elements of the oil had an action
in their compound state much more beneficial than
that which has been attributed to them when ad-
ministered separately. In his work already quoted
he writes at page 255 : — " Si nous considerons que
dans les maladies on I'huile de foie de morue se montre
d'une efficacite incontestable la digestion doit etre
relevee, la nutrition amelioree, les secretions excitees,
la fonction du systeme lymphatique vivifiee, et enfin —
indication de la plus haute importance — que le systeme
ganglionnaire doit etre altere ; on se convaincra facile-
ment que ni les principes de la bile, ni les matieres
grasses, ni I'iode, ni tout autre principe ne pourraient
MODE OF ACTION OF COD-LIVER OIL. 347
satisfaire chacun separement k toutes ces indications.
C'estpourquoi nous estimons devoir attribuer I'efficacite
de I'huile de foie de morue, sinon a Taction combinee
de tons ces principes, au moins a celle de la plupart
d'entre eux." But whatever truth may be at the basis
of this speculation, and particularly in reference to
the scrofulous or tuberculous diathesis, we think that
we shall be right in affirming that prolonged inquiry
has led the profession to question these views in refer-
ence to phthisis in general, and to believe that to the
fat must be attributed the good which is undoubtedly
effected by this agent in the latter diseases.
Dr. Bennett affirms, on the theory of Dr. Ascherson,
that the molecules of fat become coated with albumen,
and constitute the molecules found in the chyle ; and in
this manner he asserts that cod-liver oil improves
nutrition. This has been ably answered by Dr. Glover
and Dr. Lawson, and the facts already cited in this
book show that, whilst there may not be so much fat in
the system in phthisis as is met with in health, there is
never such a want as that a tea- spoonful or a table -
spoonful of oil could supply the defect, and it has not
been proved that at all times there is not sufficient fat
for the purpose referred to ; moreover, it is well known
that the increase of weight with the oil and food is
oftentimes far greater than the improvement in nutri-
tion could account for, and also that in numerous in-
stances the tuberculisation proceeds, notwithstanding
the administration of the oil and the increase in the bulk
of the body. Hence we thinlc that whilst this theory
may be a truth, it is far from being the whole truth.
348: COD-LIVER OIL.
In our experiments we have shown that fat always
increases the fulness, and in some instances the
rapidity of the pulse, and thus, in enfeebled conditions,
will sustain capillary vital action. It also tends to
lessen the action of the skin, and thus to prevent per-
spiration and waste of heat ; and we believe ourselves
justified in asserting, that its action is to restrain elimi-
nation by every outlet of the body, and thus to check
loss of, and then to increase, weight. It is to this latter
action principally that must be attributed the rapid and
great increase of weight which is frequently found to
follow the use of the cod-Jiver oil, and which is only
temporary.
We fully agree with Dr. Bennett, Dr. Lawson, and
most of the writers of the day, as already stated, that
the beneficial action of cod-Hver oil is due to its fatty
quality, and we know that, as other fats, it is liked by
some and disliked by others, it is beneficial in some
and useless or even injurious in others ; and often
its place may be advantageously supplied with any
other fat which may be preferred by the patient, pro-
vided it be taken in sufficient quantity and with due
regularity. A prime reason of the good which has
resulted from the use of the cod oil is the regu-
lar supply of fat to persons who otherwise would not
have taken it in due quantity; and a great merit in
the introduction of it to general use is in having led
inquirers to prove the very important part which
fat plays in the animal system, and the real neces-
sity for it which exists in all persons, and particularly
in the young.
MODE OF ACTION OF COD-LIVEK OIL. 349
In concluding our observations we may remark, that
it is of some importance to determine the mode in
which the oil may be the most conveniently adminis-
tered. We have found much variety of taste in the
preference of the brown or pale oils ; and whilst there
are many who prefer the pale, we believe that the mass
of patients offer no objection to the brown oil. More-
over, considering the price, the quality of the oil should
be regarded, and yet it is well known that other oils
are commonly mixed with it. We have been informed
by a manufacturer of cod-liver oil that probably not
one -tenth of the oil which is sold is altogether derived
from the liver of the cod fish. It is, however, impos-
sible in private practice to determine whether the oil
which we prescribe is genuine cod-liver oil or not, and
hence we think it a great advantage that there is one
kind of cod-liver oil which is universally admitted to
be genuine — the light brown oil supplied by Dr. De
Jongh. It has long been our practice, when prescrib-
ing the oil, to recommend this kind, since, amidst so
much variety and uncertainty, we have confidence in
its genuineness. As a rule we prefer that the patient
should take it alone, since, by so doing, the local effect
is produced upon the fauces, and the dislike to it the
sooner passes away. It is also convenient to give it in
a wine-glass full of hot milk, sweetened with loaf sugar,
or with the bitter infusions which are commonly pre-
scribed with it, or in ginger or orange wine, if such
an adjunct be ordered ; but where there is an acid state
of the secretions, or of the mucous membrane of the
throat, the stomach, or the duodenum, it is undoubt-
350 COD-LIVER OIL.
edly the best plan to give it in the form of an emulsion
with liquor potassse, or to administer an alkali with
a bitter infusion a few minutes before the oil is taken.
It is highly probable that an acid state of the intestinal
tract is adverse to the due ingestion of the oil into the
circulation.
CHAPTER XXXIX.
THE INFLUENCE OF CYCLICAL CONDITIONS.
In a work on the cyclical changes in the human
system we have described in detail the variations in
the vital functions which occur in the healthy system
in the cycles of the day and the year, and we purpose
here to apply the results thus obtained to the treatment
of phthisis.
1. THE CYCLE OF THE DAY.
The chief points to be observed in the cycle of the
day are the extreme variation between the day and
night rate of the vital actions, the rapid and great
increase which follows the meals, the equally rapid de-
crease which precedes them, and the lessened degree of
action of food and similar agents in the evening. These
observations particularly apply to the rate of pulsation
and respiration, and the quantity of air inspired and
of carbonic acid expired. In reference to the hourly
elimination of urine, there is the greatest amount
evolved at about mid- day, and this is followed by a
great diminution until about 5 p.m., when, after tea,
there is a second considerable increase until 8 or 9
P.M., and. then the final fall of the night occurs. The
352 THE mFLUENCE OF CYCLICAL COIJ^DITIONS.
hourly elimination of urinary water is the greatest after
hreakfast, and then a rapid decline occurs soon after
mid-day. There is but a small increase in the after-
noon, and at length the quantity in the evening falls to
that of the night, which is the least in the 24 hours.
But in phthisis it was found that all these hourly
changes were exaggerated, so that the difference
between the day and night rate was greater, and the
variations due to food were greater, than in health. The
difference between the day and the night rate was an
extreme of upwards of 40 pulsations per minute. The
rate of respiration was, in numerous cases, greatly
increased in the early hours of the night with sleep ;
and indeed whenever sleep occurred by night or day,
the rate of pulsation decreased, and that of . respiration
increased, during the continuation of the sleep. This
condition of the respiration is opposed to that in health,
and was not universal in phthisical patients. Hence, in
reference to the treatment of phthisis, where the aim is
to supply abundant nutriment and prevent failure of
the vital powers, it is important that food be given
in the night, to prevent too great a fall of the vital
actions and the occurrence of profuse perspirations,
and also in the early morning when the activity of
the functions is great ; and it is desirable that during
the day the food be administered frequently, so as
to avoid the great elevation and the subsequent great
depression which occurs with ordinary meals at dis-
tant periods. Every care should also be taken at
night, by means of warmth, clothing, &c., to prevent
the great loss of temperature and to sustain the vital
THE CYCLE OF THE DAY. "353
powers. Day sleep may be defended upon the same
principle, for although there is at all times a depres-
sion of the vital actions with sleep, there is less with
day sleep. It is also important not to administer
much fluid in the early part of the day, lest the pro-
cess of elimination should be unduly increased. We
must refer for further details to a paper published in
the Medico-Chirurgical Transactions for 1856, which
gives the result of an inquiry made at every hour
during six days and nights without intermission, on
three male and three female consumptives; but the
general expression of the results is the importance
of preventing too great a depression of the vital
powers in the evening, during the night, and before
meals, and too free elimination in the morning hours.
2. THE CYCLE OF THE SEASONS.
It is known that each ser son of the year has its own
evil influences in cases of phthisis, so that with the
heat of summer there is exhaustion, with the cold of
winter inflammation, and at the changes of. the seasons
the liability to take cold, which either develops or in-
creases the rapidity of the progress of the disease. As
each of these conditions is explicable upon the prin-
ciples recently eliminated by us in reference to the
influences of season upon the animal system in health,
and each requires careful consideration in the treatment
of phthisis, we will now refer to the conditions of each
season separately, but must refer to the work already
quoted upon the cyclical changes for a more detailed
statement. '
A A
354 THE INFLUENCE OF CYCLICAL CONDITIONS.
In summer the rate of pulsation increases, whilst
that of respiration declines. This was proved by us
in an inquiry which we conducted on 15 in-patients
during a whole month, in which we determined the rate
of the two functions at 8 a.m. and 4 p.m. daily, and the
results were published in Brit, and For. Med. Chi.
Eeview for April, 1856. The quantity of carbonic acid
and of air inspired decreases from the beginning of the
hot weather in June to the end of August, and at the
latter period the amount is only two-thirds of that at
the former.* The skin is more active and sensitive.
Hence in cases of early phthisis there is a rapid ten-
dency to exhaustion of the vital powers as the summer
advances, and this effect is particularly seen in July
and August, after the long continuance of those condi-
tions, so that there is less appetite for food, lessened
j)owers of assimilation, less innervation, less muscular
power, and both shallower and feebler respiration —
conditions precisely fitted to produce or to rapidly in-
crease the disease. There is also profuse perspiration,
inducing a soft and rapid pulse, with faintness from a
deficient supply of blood to the head, and a tendency
to haemoptysis from the rapid pulsation and increased
tendency to congestion. Usually the cough abates,
and the extremities remain warm, except after the pro-
fuse perspirations which occur in the early morning,
when the skin, and even the breath, often feels cold.
With the muscular relaxation which supervenes, the
pupil dilates, and the power of locomotion is much re-
* Phil. Trans., 1859.
THE CYCLE OF THE SEASONS. 355
duced. In these conditions it is, therefore, highly
important to avoid the sun's rays, to seek a cool and
shaded room, to remain quiet, and even to doze during
the middle hour of the day ; to have food in a plain
form, and often with some form of alcohol added (as
two teaspoonsful of hrandy or rum to milk, or a small
tumbler of hot and weak claret and water) every two
hours, and also often in the night, and to use highly
nitrogenized food ; to vary the clothing carefully, both
night and day, so as to lessen perspiration and prevent
the cold which follows from it ; to lessen the action of
the skin by the external use of salt and water; to
seek the sea-side, or other suitable locality, where the
circulation of the air is free and the temperature
reduced.
On an examination of 177 cases of phthisis, we found
that, when in good health, 51*4 per cent, bore heat badly,
and 48' 6 per cent, bore it well ; so that the two classes
were about equal in numbers. In cases of debility, the
number of the former class was greater, viz., 71 per cent.
This inquiry we deem of vital importance when we
seek to estimate the probable influence of the hot
season, or of change of residence to a warmer climate,
and generally it will be found that as the system
tolerates heat in health, so it wiU in phthisis.
In the winter the conditions of the system become
more sthenic, and therefore in ordinary cases, and where
the health is not materially reduced, and suitable pro-
tection given, this is a favourable season. We consider
that a dry, cool air is the most beneficial in the cases
in question. The evils of the season will, however, be
A A 2
356 THE INFLUENCE OF CYCLICAL CONDITIONS.
the tendency to internal congestion and inflammation,
the increase of cough from the irritation of the pharynx
and air-passages, induced by the inhalation of cold air ;
the tendency to haemoptysis from increased cough, irri-
tability of the mucous membrane, and congestion of the
lungs, and deficiency of temperature from the cold. If
the patient be restricted to an artificially heated atmos-
phere, he will have the evils of dryness, stillness, and
impurity of the air, and will be apt to have night per-
spirations from excess of clothing. Indeed, from what-
ever cause, night perspirations are common in winter.
At this season the chief desideratum is the careful ad-
justment of the clothing, so that whilst the patient
shall never be cold, he shall not be fatigued by the
weight of many clothes ; and the selection of an atmos-
phere so uniform and moderate in temperature, that
he may be able to expose himself, at least under favour-
able circumstances. He should specially protect the
throat, by keeping the mouth closed, and the throat
externally covered, when in the open air. The clothing
should be the best, and therefore the lightest, of woollen
materials. The diet should be abundant, fat, and
solid.
The change from the cold of winter to the warmth
of early summer is attended by depression of the vital
actions, and that in the autumn by the reverse, and the
difficulty to be overcome is the inability of the system
to adapt itself suddenly to the new conditions. Hence,
with the fulness and high activity of spring, there
is apt to be congestion of an active kind when the de-
pressing influences of summer first act ; and at the end
THE CYCLE OF THE SEASONS. 357
of the year the tendency is to exhaustion, from the im-
possibility of the system to increase its vital changes
with due rapidity. Hence disturbance of the circula-
tion is common to both, but haemorrhage is more com-
mon in the spring ; and internal congestions, with drop-
sical effusions, in the autumn. Moreover, it has always
been observed that vascular congestions are found
chiefly in the lungs in the spring, and in the chylopoetic
viscera in the autumn. The indication in the spring
is clearly to hold back the system, as by rest and the
horizontal posture, and to avoid stimulants and excit-
ants ; whilst in the autumn the skin must be well pro-
tected, the vital powers sustained, and the patient alto-
gether sheltered from the adverse conditions of the
weather. It is well known to those who ride much on
public conveyances that the horses get out of condition
at the end of the year, and are unequal to their duties.
Notwithstanding the occurrence of cold weather they
perspire profusely, and need unusual protection and
stimulating food.
It is needful to add a general remark in reference to
the influence of season, that the effects are far more
than the evident qualities of season — temperature, and
weight of the air — can account for, as we have shown in
the Phil. Trans., 1859, and also that an unusual state
of the weather in any season induces conditions
opposed to those ordinarily found at that season.
Thus if, in winter, the temperature should be high, and
the air moist, the patients immediately complain of
all the conditions of body usually met with in the
summer season, as exhaustion, defective appetite,
"^
358 THE INFLUENCE OF CYCLICAL CONDITIONS.
feebleness, and perspirations. A temperature of 56°
in mid-winter produces summer ill-effects, whilst the
same at midsummer would render the season winterly.
It would appear that with the increase of the tempera-
ture from the winter, it is only as the sun increases in
altitude and influence that the increase of heat is
healthful to phthisical patients, and not simply the
warmth which is due to the winds.
CHAPTER XL.
TREATMENT WITHIN HOSPITALS.
This subject is one of difficulty on account of its
mixed character, for whilst the advantages and dis-
advantages offered by hospitals are almost fixed and
determinate, the conditions required for the benefit of
patients are very variable, and hence it would require a
most extensive organization to meet the wants of even
the great mass of cases.
The general hospitals have solved the problem by
cutting, instead of untying the knot, and have rigidly
excluded such cases, chiefly on the ground that they
are irremediable, but also that the arrangements at
such institutions are not favourable to the well-being of
these cases. Hence special hospitals have arisen, into
which the cases are received, but yet having arrange-
ments almost identical with those of general hospitals.
It must be evident from the foregoing observations,
that the class of cases under discussion cannot be
efficiently treated in hospitals, unless those institutions
have regulations and advantages specially adapted to
them. Thus we have urgently recommended abundant
and regulated exercise, a tolerably free exposure to the
atmosphere, due amusement and occupation for the
360 TEEATMENT WITHIN HOSPITALS.
mind, abundance of milk for diet, and frequent and
small meals, and, in addition, certain plans of ablution
and voluntary respiration, which clearly demand the
aid of others and the privacy of a separate bed-room.
But how are these met even by the best arranged
special and general hospitals ? The patients are
restricted to their rooms, or to long uninteresting cor-
ridors which have walls and high windows, or, if allowed
to go outside, may saunter about paved yards or gravel
walks, wet or dry, exposed to the gaze of passers-by,
and with no shelter from the sun, wind, or rain. The
space for out-of-door exercise is very limited, and, from
the nature of things, the exercise must be of such
ordinary kinds as may not attract the attention of
others. There is no gymnasium in which regulated
muscular exertion may be made, and the mind be
pleasantly engaged, nor any system adopted whereby
the power of any special set of muscles may be
increased. There is no plunging bath, warm or cold,
in which the patients may seek tone, strength, and
amusement. There are no games but such sedentary
ones as draughts, and no bodily employment but such
as making small woollen mats, by which a little money
may be realised. There is no culture of the mind,
except such as the clergyman may periodically offer
and a small library afford, nor any such innocent
pleasures as that of singing or instrumental music.
The meals must be, as a rule, limited to three, or
perhaps four, a day, at stated and distant periods, and
it is impossible to supply to each patient the large
quantity of milk which we have affirmed to be a prime
TREATMENT WITHIN HOSPITALS. 361
necessity for the consumptive. Tea, sugar, and butter,
must be found by the patient, and hence be sparingly
,used whilst the action of the two latter is as impor-
tant, probably, as that of cod oil conjoined with other
articles of medicine. The amount of fat supplied in the
dietary must be much less than that which the case
demands, if the milk be limited to a small quantity, the
meat not of the best-fed kind, and puddings contain-
ing fat be not commonly supplied, and hence they lack
fat in food which should (but cannot) be given in oil.
The temperature of the air is kept at an approach to
uniformity, when it has been shown that the hourly
variations occurring in the external air are conducive
to health ; and in the attempt to maintain it by artifi-
cial means, it often occurs that the temperature ap-
proaches 70° in the afternoon, and the degree of dry-
ness of the air is increased to an extent which might
be injurious. The windows and doors are sometimes
doubled, so as to prevent ready access of the external
air, and thus, with whatever care, the atmosphere
within the hospital must be far less fresh and invigo-
rating than that of green country fields. Indeed, the
only conditions which are adopted are such as siipply
a tolerable amount of food, limit bodily and mental
exertion, prevent the influence of low temperature, and
afibrd medical treatment.
We affirm, therefore, unhesitatingly, that in the ordi-
nary conditions met with in the early stage of phthisis,
the arrangements of our hospitals are unsuited to the
treatment of the case, provided the patient have a
tolerable home in the country, with fresh air, green
362 TREATMENT WITHIN HOSPITALS.
fields, and plain simple nutriment. They are, how-
ever, very valuable even at this stage in the exceptional
cases in which there is an irritable cough, an inflam-
matory state of the throat, a tendency to inflammation
of the lungs or to haemoptysis, and in the winter sea-
son, and to all persons who have not a moderate
amount of food and shelter. In practice it should be
advised that such cases as have moderate shelter and
food, and a country residence, should remain at home,
whilst others may do well to gain admission.
Hence it follows that, in reference to this early or
remediable stage of the disease, the necessary attention
to the duties of life, and the greater advantages offered
by the country, limit greatly the usefulness of such
hospitals ; and, indeed, they are chiefly suited to a
more advanced condition, where there is hope of afford-
ing ease and comfort to the patient, and of some-
what prolonging his existence. Such institutions
should, it is said, rather be termed homes or asylums
than hospitals, since the benefit is derived as much from
improved hygienic conditions as from medical treat-
ment. But in order to this, the duration of the cases
in the hospital should be lengthened much beyond the
present narrow limits of two or three months, and thus
avoid that relapse, and oftentimes more rapid progress,
which occurs when the advantages of the hospital have
ended, and the almost helpless patient is returned
again to the privations of life.
Hence, on reflecting upon these questions, we are
led in a degree to sj^mpathise with the objections which
are raised to the admission of such cases into general
TREATMENT WITHIN HOSPITALS. 363
hospitals, where it is presumed that the prime ohject
is the medical treatment, and where, consequently, cases
of an acute nature are most fitly received. We would,
however, very strongly support the effort which has
recently been made to establish cottage hospitals in
country localities, since, with intelligent administra-
tion, they might meet the wants of the mass of cases
which we have been considering. We cannot doubt
that every hospital, whether special or otherwise, re-
ceiving this class of cases, should have some cottage-
buildings, suitably situated, to which the proper class
of cases should be transferred, and thus reserve the
hospital for those which are evidently more fitted for
their present arrangements.
We have not included in these observations the
attendance of out-patients at hospitals ; for whilst we
believe that to be the most interesting and valu-
able part of such institutions for the class of cases
under consideration, the patients do not live within
the walls.
CHAPTER XLI.
CLIMATE.
VOYAGING AND RESIDENCE.
The indication offered by the disease in the selec-
tion of a suitable climate is to find the conditions in
which tone of body ma}^ be improved without increas-
ing the cough, or the tendency to inflammation of any
part of the respiratory organs. This, we think, is a
sufficient indication, and will enable us to point out
those places which will be proper for the greatest
number of patients, but it is evident that in each case
we must estimate the relative importance of the two
conditions according to the special liability to cough
and inflammatory complications. It is also clear that
as the seasons vary in character so must we seek dif-
ferent climates at the different periods of the year.
We will first consider the cases fit for voyaging on
the sea, and then the most suitable climates on land.
VOYAGING.
In the voyages to the East we have conditions which
extend over three to four months in an unbroken chain,
and if the voyage out and home be included a period
of absence of nine to twelve months may be obtained.
VOYAGING. 865
There is of course much diversity in the meteorological
conditions met with in different latitudes, and in that
sense the voyager to India or Australia may be said to
pass through every temperate and torrid climate, but
the mass of water and the motion of the water tend to
maintain much more uniformity in conditions than
occurs with so many climates on land. The air will vary
in the amount of vapour which it contains, but it can
never be a dry air, for an easterly wind passing over a
large surface of water absorbs vapour, and is no longer
dry. There is also every degree of movement of the
air over the water, but commonly the movement is
more uniform and of greater power than on land.
There is also the greatest purity of the atmosphere.
Hence in such a voyage there are the conditions of
atmosphere which are suited to almost every case in
the early stage of phthisis, viz., moderate temperature,
tolerable uniformity in the hourly and daily tempera-
ture, moderate degree of moisture of the atmosphere,
and a full average degree of motion of the air. The
only modifying condition of the atmosphere unfavour-
able to our purpose is, that for a period of some weeks
there will be exposure to the great power of the sun's
rays, less, it is true, than is found in the same latitudes
on land, and pleasantly counteracted by the sea breeze,
but yet of higher temperature than we should desire.
This is however to be obviated, to a great extent, by
shelter and clothing, and is not sufficient to counter-
balance the valuable qualities just mentioned, and
much less so, when to these we add the avoidance of
a multitude of evils inseparable from a residence on
366 CLIMATE.
land, and amongst masses of men. Moreover, the
mode of life on shipboard may be rendered of the
greatest service. Sea-sickness is an evil to which
nearly all persons are liable, but commonly it passes
away within forty-eight hours, and after the lapse of a
few days it is almost or quite forgotten. There is an
utter absence of daily care, and a delightful sense of
freedom is obtained within a few days of this exclusion
from general society. The contemplative who love
retirement, and the merry who rejoice in jollity and
good humour, find in the quiet and regularity of a life
upon the sea, and the companionship of sailors, that
which meets their wants. It is to this, we believe,
that must be attributed the indescribable charm which
the sea offers to the real sailor, and is identical with
the deep sense of security and freedom which takes
possession of the heart of the trapper who, in the
distant solitudes of the far West, will have no com-
panion but his horse and dog, — a state of feeling,
however, toio coelo removed from that of the misan-
thropist. To these we must add the simple, abundant,
and regular meals which are supplied in all well-
regulated ships, and the invitation which is ever
present to spend the hours of the day in the open
air.
There are, however, two circumstances which call
for arrangement, viz., the occupation and the sleeping-
room. It is of great importance that the voyager have
a daily occupation, either in the affairs of the ship, or
one entered into for his own gratification, so that his
attention may be healthfully employed. Hence we re-
VOYAGING. 367
commend such patients as may be able to obtain a
nominal engagement on shipboard, taking care as to
its duties and the food which will be supplied, but as
this is not always attainable, it is better for them to
lend a hand at the ropes, and to practise mounting the
yards, to engage in the games played upon deck, or to
have some scientific investigation in hand. In re-
ference to the sleeping-room, it is certainly of prime
importance that it should be sufficiently large and
ventilated, and be free from the foul odour of bilge
water, or other decomposing matters, and the offensive
smells of the engine-room. A sleeping berth upon the
deck is much better than one below.
Voyaging in the South Pacific Ocean has the further
advantage of offering even greater uniformity of climate,
and of presenting scenes with which the European mind
is not familiar, and is a very valuable agent for the
purpose now under discussion.
The voyage to the Northern States of America is
now reduced to so short a period that it loses much
of its advantages for our purpose ; for if it be made in
a sailing-vessel, it will almost always be performed
within three weeks, and if the object be to remain upon
the sea for a period of many months, there will be the
great disadvantage of perpetual change of climate, and
of frequent delays in port. Moreover, in proceeding to
the New England States or to Canada, there is the
disadvantage of the cold experienced on approaching
Newfoundland, with its fleet of partially dissolved ice-
bergs, unless the course be directed more southerly so
as to reach the Gulf Stream. In a sailing-vessel it
368 VOYAGING.
frequently happens that the proximity to Newfound-
land influences the temperature of the air for a week,
and causes both a sudden and a prolonged effect upon
the system.
In reference to the period of the year when the
voyage may be most suitably undertaken, we may
remark that to America it must be in the summer
season, viz., from May or June to September, but
to the East it matters but little at what period of
the year it is undertaken. It is, however, better to
leave England in the spring, so as to reach Australia
in the winter season, or any period from November to
August.
It is not necessary to enter upon any attempt to
select the fitting cases for voyaging, since, so far as
the disease is concerned, all at the stage in question
are suited, and the selection of this or other plans of
treatment will depend less upon the condition of the
patient than upon other and non-medical considera-
tions. "We think it should be carried out for a period
of not less than one year, and if possible it should
extend over two years. The patient should be suitably
provided with the varieties of clothing required, and
with the exception of some details in diet, as, for
example, the comparative absence of milk, he wdll be
able to pursue the whole plan of treatment.
The voyage to America is less fitted for those who
suffer from irritability of the pharynx and larynx, and
in whom changes of temperature produce cough and
dyspnoea, than for those in whom atony seems to be
the characteristic feature. The former class should
RESIDENCE-ON LAND. 369
certainly proceed to the East or to the Southern Seas,
whilst the latter may take either at pleasure.
RESIDENCE ON LAND.
In reference to the indications already mentioned, we
think that the following conditions should be sought
for in selecting a suitable place of residence.
1. As cool a temperature as is compatible with the
prevention of irritation of the air passages.
2. The least daily variation of temperature.
3. The least hourly variation of temperature.
4. Moderate amount of moisture in the air, and
therefore little or no fog.
5. Moderate movement of the atmosphere.
6. General absence of north-east or easterly winds
in this climate, and hot dry winds abroad.
7. The air free from foul odours and smoke.
8. All the conditions as to society, scenery, and food
which are the most conducive to bodily health and
mental enjoyment.
The year may be practically divided into the winter
"and summer half-years, April or May, and October or
November being the dividing months; for although the
spring and autumn are periods of great anxiety in the
cases now under discussion, it will be safer to add them
to the summer and winter periods respectively.
In discussing the meteorological conditions of the
summer and winter residences, we shall select from the
Eegistrar- General's returns those of the six years which
approach the present period, viz., from 1855 to 1860,
both inclusive. We shall include those of six months,
870 CLIMATE.
July to December, in the summer, and those of three
months, January to March, in the winter resorts.
The subjects of inquiry will be the mean tempera-
ture, the mean daily range, the extremes of temperature,
the degree of saturation of the air, and the prevalent
direction of the winds. It will also be borne in mind
that we shall refer only to those conditions which are
suited to cases of phthisis in the early stage.
CHAPTER XLIL
CLIMATE.
SUMMEB CLIMATES.
We will now consider the climates which are suitable
for the summer and autumnal periods, or for parts of
these periods respectively, but in doing so we must
remark in limine that our object is not to write a
treatise upon climate, but only to point out the leading
advantages of the localities which we recommend in the
treatment of the disease, and the stage of disease, in
question.
As a general expression we state that during the
summer half-year the conditions above mentioned can
be found only in certain positions at the sea-side. In
all inland districts the effect of variations of temperature
is great, and is immediately felt, so that there is much
hourly variation between the day and the night, and
much variation from day to day. Moreover, as the sum-
mer advances the ground absorbs heat, and the effects of
high temperature are thus continued after the highest
temperature of the air has passed over. Hence the
general effect of temperature is considerable, and in-
creases by duration, and it lessens all the vital changes.
At the sea- side, on the contrary, in situations where
B B 2
872 CLIMATE.
there is great depth of water up to the shore, the
temperature is much less than in inland districts, and
is more uniform hoth hourly and daily. The reason of
this is clear, since the temperature of the sea-water in
summer is much lower than that of the air and soil,
and consequently the greater the proportion of sea-
water and the more the air passes over it the lower will
he the temperature of the locality in the summer. We
must, therefore, seek not only for the sea-side, but for
great depth of water up to the coast, and if possible, in
addition, a position where the prevailing wind blows
over the sea. The temperature must, however, remain
so high that the cooler winds shall not so lower it that
the vapours must be precipitated and fogs be produced.
We will now refer to a few localities which appear to
us to meet most of these requirements.
SCAEBOEOUGH.
We take it for granted that, with the conditions
already laid down, we must select some northern sea
coast during the summer half-year, and in doing so our
first choice must be the queen of northern watering
places.
This favourite place is an ancient fishing town, built
on the very margin of a fine bay, at a point where the
bank shelves down somewhat abruptly to the beach,
having on either hand a large range of high and preci-
pitous cliffs. Hence there is a hollow central part,
and two elevated wings, the former constituting the old
town, and the latter the south and north clifi's ; and in
addition there is a remarkable projection of rock ex-
SCARBOEOUGH.
m
tending far out to the sea, at the end of the north cliff,
affording a tolerably large plateau, upon which are the
ruins of the ancient castle. The bay is open to the
north and east, and whilst the north cliff is fully
exposed to both these winds, the central part of the town
is sheltered from the north by the^ large mass of the
castle rock. The south cliff is fuUy exposed to the
east and south-east, but there are parts in an inter-
vening valley where the houses have a southerly
aspect. The elevation of the tide in the harbour is
moderate, and whilst the recess of the tide is suffi-
cient to allow of a handsome promenade at low water,
the high tide reaches the cliff, except at the part of the
coast where the town is built. Hence the depth of
water is very considerable, and it is even at low water
close upon the town.
The mean temperature of the air during each month
of the summer and autumn quarters was as follows in
the six years 1855 to 1860 : —
TABLE No. 11.
Mean Temperature.
1855
1856
1857
1858
1859
1860
July . . .
August . . .
September
56-8
59-3
647
57-3
57-6
52-6
59-6
59-7
57-3
o
56-7
58-3
56-6
o
60-2
60-2
54-2
54-1
54-6
60-8
Means . . .
„ Greenwich
56-9
60-4
48-3
43-9
37-5
55-8
59-9
68-8
63-3
57-2
61-
58-2
62-7
53-2
56-2
October .
November . . .
December
50-8
42-
40-9
52-3
46-8
45-
49-2
42-8
40-2
47-9
41-8
85-9
48-6
42-4
36-7
Means . . .
„ Greenwich .
43-2
42-7
44-6
44-2
48-
47-9
38-9
43-8
41-8
43-2
42-2
42-2
374
CLIMATE.
The average temperature of each of the two quarters
was thus 56*7° and 43 '1°, whilst that of a favourable
inland place, the Royal Observatory at Greenwich, was
60*6° and 44*3°. Hence the average temperature at
Scarborough w^as, as compared with that at Greenwich,
lower in both summer and autumn.
The extremes of temperature, and the range between
the highest and lowest temperature, in each month, were
as follows : —
TABLE No. 12.
Extremes of Temperature.
1855
1856
1857
1858
1859
1860
July . .
. Highest
Lowest
75-5
48-
o
74-5
42-3
66-9
54-9
°
72-
46-2
77-4
53-5
o
69-7
46-
August .
. Highest
Lowest
74-
50-3
75-1
48-3
65-5
57-
71-6
46-3
74-5
49-
64-
46-5
September
. Highest
Lowest
69-5
45-
61-3
41-
61-8
54-5
67-5
46-
66-2
45-
61-
40-
October .
. Highest
Lowest
69-5
36-
63-3
48-4
61-5
39-
62-
38-
64-5
27-
58-
33-
November
. Highest
Lowest
51-5
33-4
44-9
37-8
55-8
31-
51-
29-
50-5
32-5
69-
28-
December
. Highest
Lowest
47-6
22-2
44-
36-8
58-
32-
52-2
30-
50-
14-5
46-
16-
The extremes of temperature in the summer quarter
were 77*4° and 40° ; and in the autumn quarter 64*5°
and 16°. The extreme difference of temperature was
thus 37*4° in the summer, and 48 '5° in the autumn ;
but it is evident that the latter is beyond the ordinary
extremes, since the lowest temperature of that year was
much below the lowest temperature of other years.
SCABBOROUGH.
875
The mean daily range of temperature at the same
periods was as follows : —
TABLE No. 13.
Daily Range op Temperature.
1855
1856
1857
1858
1859
1860
July
August . . .
September
9-4
10-7
9-2
13-3
7-9
7-9
12-
8-5
7-3
10-7
9-6
8-2
o
5-4
10-5
8-8
8-5
8-4
6-9
Means . . .
,, Greenwich
9-8
19-7
9-7
20-
9-2
21-
9-5
21-2
8-3
21-5
7-9
17-4
October . . ;
November . . .
December
6-5
4-6
6-1
4-9
7-1
7-2
6-2
4-9
6-6
6-8
5-
5-7
6-5
6-4
7-3
6-9
4-6
4-
Means . . .
,, Greenwich
5-7
10-8
6-4
11-7
6-9
12-2
10-3
12-4
6-7
12-5
5-1
11-3
The average daily range of temperature was, there-
fore, so small as 9*0° and 6*6°, whilst that at Greenwich
was 20*1° and 11*8, or an amount more than double
of the range at Scarborough.
The amount of moisture in the atmosphere in rela-
tion to the production of fog may be most conveniently
ascertained by determining the degree of approach to
saturation of the air, for when the air is saturated, at
whatever temperature, any further attempt at increase
of vapour, or any diminution of the temperature, must
cause a deposition of vapour. Complete saturation is
represented by 100, and the approach to it will be
indicated by the number below that amount, as in the
following table.
76a
CLIMATE.
TABLE No. 14.
Degree of Saturation of the Air.
1855
1856
1857
1858
1859
1860
July
August . . .
September
91
87
83
82
87
83
84
91
88
87
89
92
80
93
97
92
83
86
87
84
Means . . .
,, Greenwicb
87
79
84
77
87
77
89
73
86
72
October .
November . . .
December
90
90
88
85
85
87
89
92
92
92
94
94
90
98
96
80
91
90
Means . . .
,, Greenwich
89
87
86
89
91
92
91
87
94
88
87
91
The average approach to saturation was thus 86 and
88 as compared with 100, whilst that at Greenwich
was at the same periods 77 and 89. Hence it follows
that whilst the air was not saturated it contained a
considerable amount of moisture in relation to its
temperature — an amount relatively greater than that at
Greenwich in the summer, but not greater than that at
Greenwich in the autumn quarter. It is far removed
from being a dry air, and ig not an extremely moist air
The prevalent direction of the wind in the months
in question preponderates greatly in one quarter, as is
proved by the following figures, which show the rela-
tive frequency of the wind from each quarter of the
compass. In 1855 the general direction is alone given
in the returns : —
SCAKBOEOUGH.
377
TABLE No. 15.
Prevalence of Winds.
1855
1856
July.
August.
September.
N.
E.
S.
W.
N.
E.
S.
W.
N.
E. S.
W.
S.W.
N.W. & S.E.
S.W.&N.E.
8
5
22
27
13
14
18
17
11
14
15
19
1857
4
3
9
15
13
6
'6
9
8
7
9
7
1858
7
6
8
10
9
7
9
6
3
3
12
12
1859
4
3
5
4
2
3
3
4
5
9
14
1860
12
11
4
4
11
7
5
8
9
6
7
8
1855
1856
October.
November.
December.
N.
E.
S.
W.
N.
E.
S.
W.
N.
E.
S.
W.
S.W. & W.
Variable.
N.W. & S.W.
4
10
25
23
19
2
10
29
19
3
6
34
1857
6
8
9
8
7
7
6
10
1
1
10
19
1858
9
5
4
13
6
8
6
10
5
1
11
16
1859
4
3
6
5
5
6
11
8
3
3
12
11
1860
6
3
10
12
5
17
8
5
5
14
12
2
Thus on the average of each quarter the relative
number of east winds was 17*6 and 18*2, and that of
the west was 32*8 and 42, showing a vast preponder-
ance of westerly winds, and when the northern and
easterly, and the south and westerly are respectively
added together, it will be seen that the relative numbers
of the former are 41*5 and 39 against 60*4 and 69*2 of
the latter. The west wind is two and a-half times as
prevalent as the east wind, and the south are one
quarter more prevalent than the north, whilst the
south-west winds are more than one -half more pre-
878 CLIMATE.
valent than the north-east winds. Hence at Scar-
borough there is, during the periods in question, a
manifest prevalence of the west and south-west winds ;
and as the aspect of the sea is north and east, it
follows that the wind is for the most part a land wind,
and does not therefore exert the influence over the
temperature of the place which would occur if it were
a sea wind. The difference of temperature on a bright
summer's day between the air at the top of the cliffs and
that on a level with the water is very considerable, so
that the latter is the most desirable place at that period.
The occurrence of fog is comparatively rare, since
the temperature is never very high in the summer nor
very low in the autumn, and as the former restricts the
capacity for the reception of vapour, and the latter
does not greatly lessen it, it follows that the air does
not readily become saturated with moisture and pre-
cipitate the excess in the form of fog. When fog
occurs it is for the most part due to the injection of a
north-easterly wind, which, whilst traversing a portion
of the bay from north to south, precipitates the vapour
in the lower region of the air, and even in that which
covers the cliffs, but it does not occur at an elevation
at a short distance from Scarborough.
Hence we have shown that there are nearly all the
conditions required in the treatment of early phthisis
found at Scarborough in the summer and autumn
months, viz., low summer and high autumn tempera-
ture, with small daily range and a moderate amount of
moisture, and we may further state that they often
extend into January, and in our judgment it is a
SCAEBOEOUGH. 379
locality well fitted for the reception of this important
class of cases. There is also the great advantage of a
beautiful marine promenade, of a fine hilly surround-
ing neighbourhood, and of numerous excursions, both
by land and water, during the season.
The south cliff is said to be warmer than the north
cliff, and whilst this is true, it may be weU to state
that at present the inhabitants underrate the value of
the north cliff. The south cliff has no doubt the
merit of being gay and fashionable, of being near to
the spa, and of enjoying a beautiful view of the town
and bay, but on the north cliff there are the great
advantages of a cooler and more bracing air in the
summer months, a fine clear sea, proximity to the
castle rock, and above all, so much quietude that, as
the view of Scarborough is shut out from it, it has the
advantage of being itself a small watering place.
The town has for several generations been a watering
place of note, but it has increased most rapidly within
the last fifteen years, so that nearly the whole of the
fine ranges of houses on the north cliff, and a large part
also of the south cliff, have been built within that
period. It is abundantly supplied with accommodation
for visitors, particularly of the middle and higher
classes, and offers some sheltered spots for invalids.
The castle rock is a most picturesque object, and the
crown of it a most elevated and healthful promenade,
and if the inhabitants were somewhat more fond of the
beautiful, they might make walks upon its side over-
looking the town, and by this rock, and a marine pro-
menade to be built from its foot along the shore to the
S80 CLIMATE.
soutli cliff, make this the most magnificent resort in
the kingdom.
There are also other places upon the same coast
which offer similar advantages to the class of patients
under consideration, as for example, Filey, Burlington,
and Whitby. Filey is suited to those who seek quietude,
and Whitby has the advantage of a beautiful neighbour-
hood, with pleasant walks and drives, but whilst they
each have special advantages and are well fitted for the
temporary residence of cases of early phthisis, we
think them by no means equal to Scarborough for the
purpose in hand.
THE ISLE OF MAN.
We have placed the Isle of Man second upon our
list on account of its distance from the greater part of
England, the necessary journey across the channel,
the shorter period during which patients may remain
there, and the comparatively limited accommodation
which it affords, but in truth, in reference to its fitness
in a medical aspect, as a short and temporary residence
for cases of early phthisis, we believe it to be scarcely
rivalled ; and moreover, those who are acquainted with
the stormy periods of its history and its unique social
and political institutions, will find much material foi;
study and amusement, whilst they at the same time
gain the treasure for which they visited its shores.
It is, as is well known, a small island about twelve
miles in breadth and twenty miles in length, and con-
sequently, whatever may be the direction of the wind,
a sea breeze must float over the whole of it. It is
THE ISLE OF MAN. 381
surrounded by deep water on every shore, so that it
has on all sides the means of maintaining an approach
to uniformity of temperature, and in the summer
period as the prevailing winds must come over the sea,
they reduce the temperature of the air in the inland
districts. The shores are precipitous on all sides
except at the northern part of the island, and the water
which washes them is of the clearest blue colour. In
the interior of the island there are ranges of mountains
running north-east and south-west, and in the north -
central part of the island these form a basin of
moderate dimensions. The height of the highest
mountain, Snaefield, is 2200 feet, and that of the range
varies from 900 to 1500 feet. There are also numerous
narrow dells and valleys in which are torrent-like
streams, which afford good sport for the angler. On
the tops of the hills the pure sea breeze is constantly
felt, and in the chain extending in the north-central
direction, it is possible to travel leisurely for several
days without descending into the valleys, except for
the night. Moreover, the cliffs which rise up from the
shores are elevated and well exposed to the breeze,
and particularly on the southern and western sides of
the island, afford unlimited opportunities for the most
healthful exertion. Hence from the surrounding deep
water, the perpetual sea breeze, the high cliffs and the
comparatively large ranges of low mountains, with
rounded summits, the island is particularly adapted to
give tone to those who seek it, whilst the valleys being
numerous, deep and narrow, offer shelter and a warm
and moist air in the hot season.
882 CLIMATE.
The chief towns are five, viz., Douglas, Peel, Castle-
town, Kamsay, and Laxey, the first and two last situate
on the east, and the second on the west shore, whilst
Castletown, the seat of the Government, is on the
south, and away from the sea. There are numerous
farm dwellings and some villages in the inland districts,
but they are not such, for the most part, as could be
occupied by visitors, and it is to be regretted that there
are no habitations built upon the elevated sides of the
mountain ranges. Hence the visitor is compelled to
reside in one of the towns named, and of these un-
doubtedly Douglas, with its magnificent bay, is the
most frequented ; and with Peel, on the western shore,
is the most beautifully situated. But when wandering
for days together over the summits of the hills inhal-
ing the dry, cool, sea-breeze, with its invigorating and
inspiriting influences, and here and there lying
down amongst the heather and gathering the scattered
bilberries, the visitor may probably long to live in tents
for a season, or wish that houses were built, which
would render it unnecessary to descend behind the hills,
which cut oif the sea breeze, and traverse valleys where
the warmth, moisture, and stillness of the air impede
respiration, and relax the system.
In these mountain ranges, once covered with fir
trees, but now quite bare, the island possesses wealth
which it has neither appreciated nor realised ; and as,
owing to the peculiar tenure of the land, and the jea-
lousy of the inhabitants in asserting their rights against
Imperial claims, it is yet impossible that the land can
be used for other purposes than those of the common
THE ISLE OF MAK
383
right. , We venture to predict that when the value of
that locality as a restorer of health shall he acknow-
ledged, and residences be provided, it will become a
summer resort of the greatest value to the middle
classes of England.
We are enabled by the aid of the Quarterly Returns
of the Registrar General to show the meteorological
conditions which belong to the island, and we will ana-
lyse them in the manner already related in reference
to Scarborough, selecting the years 1855 to 1860
inclusive.
The following table shows the mean monthly tem-
perature of the air : —
TABLE No. 16.
Mean Tempeeatorb.
1855
1856
1857
1868
1859
1860
July
August . . .
September
o
58-8
57-1
54-1
o
55-
59-6
53-3
o
571
60-2
56-5
o
66-1
58-
56-5
60-2
67-9
53-7
o
56-2
54-8
Means . . .
,, Greenwich
56-7
60-4
56'
59-9
57-9
63-3
56-9
61-
57-2
62-7
...
October .
November . . .
December
49-
43-2
39-5
52-4
44-7
42-4
52-7
47-
48-9
49-1
43*1
44-7
60-2
44-4
38-
49-5
42-9
38-2
Means . . .
,, Greenwich
43-9
42-7
46-5
44-2
49-5
47-9
45-6
43-8
44-2
43-2
43-5
42-2
The temperature was thus on the average of five
years in the summer and autumn quarters 56*9° and
45*9°, and whilst slightly lower than that of Scarbo-
884
CLIMATE.
rough in the summer, it was higher in the autumn of
the same years.
TABLE No. 17.
Extremes of Tempeeaturb.
1855
1856
1857
1858
1859
1860
July . .
. Highest
Lowest
77-4
427
o
72-
39-
o
73-7
43-5
o
71-7
44-7
o
74-9
45-6
o
75-
43-4
August .
. Highest
Lowest
73-9
42-1
82-1
42-6
81-
46-2
79-1
43-6
74-
45-
69-
40-
September
. Highest
Lowest
69-5
58-
68-8
39-8
73-
41-2
73-4
40-8
68-1
38-
...
October .
. Highest
Lowest
66-9
31-
65-
43-5
64-8
' 36-9
64-4
32-9
66-3
.29-6
63-7
31-9
November
. Highest
Lowest
54-3
28-9
58-1
27-6
57-8
25-9
56-1
27-8
56-1
29-5
56-
29-4
December
. Highest
Lowest
49-9
24-3
67-1
22-
56-5
32-
54-
31-5
52-9
10-3
49-1
12-
The daily range of temperature was as follows : —
TABLE No. 18.
Range op Temperature.
1855
1856
1857
1858
1859
1860
July . .
August , . .
September
o
17-2
14-5
15-3
o
16-3
15-7
13-7
o
16-8
16-7
15-3
16-9
18-3
14-1
16-5
17-4
16-
o
16 -4
14-3
Means . . .
,, Greenwich
15-7
19-7
15-2
20-
16-3
21-
16-4
21-2
20-
21-5
...
October .
November . . ,
December
14-2
10-1
8-8
8-7
9-5
9-4
10-4
10-
7-2
11-8
10-4
7-7
12-5
10-5
11-2
10-4
7-5
8-3
Means . . .
,, Greenwich
11-
10-8
9-2
11-7
9-2
12-2
10-
12-4
11-3
12-5
8-7
11-3
THE ISLE OF MAK
385
The average daily range of temperature during the
two seasons was somewhat considerable in the summer
quarter, and amounted to 16' 6° and 9 '9° at the two
seasons. The average was considerably higher than
that of Scarborough, but nwich lower than that at
Greenwich. It is no doubt due to the influence of the
mountain range over the temperature of the lowland
parts where the observations were made.
The degree of saturation of the air with vapour
is thus represented, the full saturation being regarded
as 100.
TABLE No. 19.
Saturation of the Air.
1855
1856
1857
1858
1859
1860
July
August
September
91
91
86
88
82
84
93
86
91
88
88
91
89
87
84
92
97
Means. . . .
,, Greenwich
89
79
86
77
90
77
89
73
86
72
...
October .
November . . .
December.
85
82
84
87
83
88
90
90
90
87
85
93
90
89
92
88
89
92
Means. . . .
,, Greenwich .
84
87
86
89
90
92
88
87
90
88
89
91
Thus the average degree in the two seasons was 88
and 87 '8, which was a little higher in the summer and
a little lower in the autumn than at Scarborough, and
therefore was higher in the summer and lower in the
autumn than at Greenwich.
c c
386
CLIMATE.
The prevailing direction of the wind in the various
months was as follows : —
TABLE 20.
Prkvalencb of the Winds.
1855
1856
July.
August.
September.
N.
E.
S.
W.
N.
E.
S.
W.
N.
E.
s.
W.
W.
S.W. & N.W.
8
3
9
21
1857
4
9
18
9
7
8
7
5
6
12
7
1858
6
4
7
14
9
3
9
10
3
6
10
11
1859
2
6
7
12
2
2
12
n
11
7
3
9
1860
9
3
5
7
9
4
6
11
1855
1856
October.
November.
December.
N.
E.
S.
W.
N.
E.
S.
w.
N.
E.
S.
W.
w.
N. & N.E.
Variable.
17
5
4
8
19
4
15
23
1857
4
8
9
10
6
13
7
4
3
1
12
15
1858
6
6
6
13
8
14
5
3
3
2
14
12
1859
4
3
6
5
5
6
11
8
3
3
12
11
]860
6
6
5
14
6
6
10
8
12
10
7
2
The observations are unfortunately incomplete, but
by a suitable calculation it may be seen that the rela-
tive number in the two quarters was, east 12 and 18,
west 34 and 29, and when the north-east and the south-
west are respectively considered together, the former
are 31 and 40 against 58 and 55. Hence the westerly
and south-westerly winds greatly prevail over the
easterly and north-easterly, and the larger proportion
of the latter occurs in the autumn quarter.
THE ISLE OF MAK. 387
On a review of these results it will be observed that
there is a substantial agreement between the meteorolo-
gical condition of Scarborough and the Isle of Man,
except that the daily range of temperature and the
variability of the wind are greater at the latter than at
the former.
Our friend, Mr. Oswald, (the oldest medical man in
the Island we believe, and formerly the medical atten-
dant of the recent Lord of the Island, the Duke of
Athol,) has given much attention to this subject, and
with great intelligence has accumulated a mass of facts,
through fifty years .of much interest, in their relation
to disease. It is deeply to be regretted that the scien-
tific world has not hitherto been favoured with the
results of his labours.
But it must be evident that observations made in the
interior and lowlands of the island will vary very much
from any which might be made on the mountain
ranges, and it is to be regretted also, that no precise
information has hitherto been obtained from the latter.
It is well understood that in the winter season the force
of the wind is very considerable, and that the north-
erly winds which then prevail, cause great coldness
on the mountains, and also, that as in all mountainous
districts, drizzling rains are apt to occur in all seasons ;
but for the summer months of June, July, August, and
September, we fearlessly recommend this as one of the
best resorts for the cases under consideration, in whom
there is no marked tendency to inflammatory action.
Until recent years the class orf visitors to the island was
very select, and the numbers were few, but now the
c c 2
388 CLIMATE.
numbers are great — greater indeed than JDouglas is
fitted to accommodate, and consist largely of the
working classes.
There is abundant accommodation for visiting the
various parts of the island, and the pedestrian will
find from the Calf of Man to Kamsay sufficient oppor-
tunities for climbing ; whilst from its high cliifs he may
watch a fleet of from 100 to 200 vessels engaged in
fishing, and beyond it the mountains of Scotland to the
west, and those of Cumberland to the east. There are
also opportunities of proceeding to Whitehaven for the
Lakes and to the Scottish shores. Whilst, therefore,
there is much of the country which looks inhospitable,
the inhabitants poor, and the institutions belong to
an earlier era, the patient will yet find much to interest
him in the natural scenerj^ — something to admire in
the hospitable feeling of the people, and temptation to
seek health and vigour in the remarkably elastic and
bracing atmosphere of the hill ranges.
THE ENGLISH LAKE DISTEICT.
The district of the Cumberland and Westmoreland
lakes is so extensive, and offers so great a variety of
conditions, that it may seem valueless to refer to it as
a whole, and yet for the purposes of this work we
think that minute detail is unnecessary. The general
impression which we entertain is that this district is
not suited to the classes of cases now under considera-
tion as a residence for any considerable period. In
the diversity of scenery Which exists, and which offers
so great charms to the pedestrian, it must be borne in
SCOTLAND. 889
mind tliat the only places in which a patient may-
reside are the valleys, and the neighbourhoods of the
lakes and streams ; and in most of these parts the
summer heat with the moisture renders the atmosphere
oppressive and relaxing. There are none of the
mountains which are adapted for habitations ; so that
whilst the mountain air is most desirable, it can only
be obtained by much exertion, and its good effect is
counteracted by the conditions of the valleys.
In these remarks, however, we have in view the
cases in which the sole object is to give tone to the
system, and where there is not the desire or ability to
spend the whole period in travelling ; but in the cases
in which there is a tendency to inflammatory action, or
to much irritability of the air-passages, there are many
parts of these districts which are well suited to them.
Such are, for example, the higher shores of Winder-
mere, or the head of Grasmere Lake, and, above all,
the charming neighbourhood of Keswick. These cases
are, however, comparatively few, and it would require
great care to prevent the peculiar conditions of the
valleys from lowering the tone of the systein.
Upon the whole we do not regard the English lakes
as well suited for the residence of the class of cases
imder consideration.
SCOTLAND.
The class of cases to which a summer residence in
Scotland is well fitted, is such as are able to make a
considerable amount of exertion, either on foot or
390 CLIMATE.
horseback, and who find special enjoyment in moun-
tain scenery and in sauntering among the heather.
To those of less bodily vigour, and especially to all
such as suffer from irritable cough, much better sum-
mer residences may be found.
The parts of Scotland which are the most suited to
our purposes are : — 1st, The routes usually taken by
tourists, where the desire of the patient is rather to
travel than reside, and of these, none excel that from
Glasgow to Inverness ; or 2nd, the beautiful neighbour-
hoods of Dunkeld and Blair Athol, or those of Bal-
later and Braemar, where every facility is met with
both for residence and travel; and 8rd, an island
situation as that of Skye.
There is one general observation which applies to all
these regions with considerable force, viz., that there
are extremes in the daily range of the thermometer, so
that, with the nights cool or cold, the influence of the
midday sun is very considerable ; also, that the air is
for the most part so near to saturation, and that the
injection of a cooler wind causes a deposition of
vapour, and the well-known Scotch mists are produced.
Hence, as a residence, they can never be well suited
for the class of cases under consideration ; but in fine
seasons, or for such part of the season as the weather
may remain fine, and for travelling and residing alter-
nately for limited periods, they offer many advantages.
Upon the whole, we commend the selection of the Isle
of Skye, or of some other of the northern islands ; but
there, as in other parts of the Highlands of Scotland,
there is difficulty in obtaining a ready supply of fresh
SWITZERLAND AND THE TYROL. 391
meat and other necessary food suited to the invalid
traveller.
The most suitable period of the year is from the
middle of June to the middle or end of August.
NORWAY.
The remarks which we have made in reference to
Scotland apply, in a great degree, to Norway ; but the
latter is more exclusively a place for the traveller than
for the resident. Its deep fiords on the one hand, and
pine-foi-ests on the other, tend much to equalise the
temperature — the former modifying the summer heat,
and the latter the autumn cold. It is, however,
rather to the traveller in the bays and fiords that we
commend it — to one accustomed to the sea, and en-
joying the spout which so much abounds in Norway.
The invalid land traveller meets with many difficulties
which are not encountered in boating besides those
which are more or less common to both, viz., that of pro-
curing a daily supply of fresh meat and other proper
food. The only mode by which Norway may be
advantageously visited by the class of persons under
consideration is by yachting, and the period when it
may be the most advantageously effected is from the
beginning of June to the beginning of August.
SWITZERLAND AND THE TYROL.
The object which influences the visitors to Switzer-
land in the summer season is seldom that of health
primarily, neither has it been common to direct thither
the class of cases now under consideration, or, indeed,
392 CLIMATE.
any class, for the precise object which we have in
view. The variety of its scenery, the grandeur of its
mountains, the beauty of its valleys, and the magnifi-
cence of its lakes, together with the manners of its
inhabitants, must be the chief attractions. There are
also, for many, a simple dietary and an increased
amount of physical exertion, and for all a degree of
lightness and purity of the atmosphere which is highly
conducive to health ; but the tendency of the whole is to
lessen and not to increase the bulk of the body. The
class of persons to be benefited in the ordinary mode
of procedure are the sedentary and the full-fed,
including those whose life is passed in the trouble
and mental turmoil of a great town. But we are of
opinion that, by a different plan, this may be used with
advantage by those whose great desideratum is to
increase the bulk of the body, and at the same time
to increase in tone and vigour.
Every mountainous region may be divided, for the
purposes of health, into two levels. In the lower
there is much moisture, less movement of the air,
greater atmospheric pressure upon the body, and the
sensation of heat is greater. This level varies, in dif-
ferent localities, from an elevation of 1500 to 4000 feet,
but commonly its higher limits may be stated at about
2500 feet. In the higher level the degree of moisture
of the air is much reducedj and at the summits of the
high mountains it is only in the degree observed in dry
air. The pressure upon the body is less, the rate of
pulsation and respiration is increased, as is probably,
also, the depth of inspiration ; the temperature is re-
SWITZERLAND AND THE TYROL. 393
duced, the hourly variations are greater, and the move-
ment of the air is greater. The former condition is
not suited to the class of patients under consideration,
since the climate is mild and relaxing ; hut the latter
is fitted for all such cases, except those in which there
is much irritahility of the air-passages or tendency to
inflammation.
The whole of Switzerland is elevated much ahove
the level of the sea, and, as we seek an elevated region,
it might appear that all parts of it would he equally
suitable, hut this would be an error ; for although even
the lakes are situated at an elevation of much more
than 1000 feet ahove the level of the sea, the tempera-
ture is there too great, at the summer season of the
year, to admit of the advantages which we seek. It is
therefore necessary to obtain a higher region still.
It is impossible for us to point out all the sites in
Switzerland which are suitable for these cases ; but,
from the indications now offered, it will be understood
that any position above 2500 feet will be proper, pro-
vided it be not too much exposed to cold wind, and
offers the facilities for exercise and nutrition to which
we have referred. We would, however, point out a few
which, from our own knowledge, deserve attention; viz.,
Leukerbad, in the Rhone Valley ; the Valley of Zermatt,
near to the foot of Monte Rosa ; the Valley, of Unter-
wald, Lauterbrunnen ; Kanderstag, at the foot of the
Gemmi; Chamouni, Seelisberg, near Griible, on the
Rigi; the baths of Weissenberg, on the Simmerthal;
and to these we may add many positions on the Jura
Mountains.
894 CLIMATE.
We need not remark upon the advantage of choosing
such situations as offer beauty and variety of scenery,
and opportunities for attaining to yet higher elevations,
since those conditions will be found almost universally ;
but it is important that the elevation should not
approach to the limits of perpetual snow, and that
it should be above the level of the lakes and streams.
The mode of life to be pursued is quite different
to that followed by tourists, since it should be the aim
to make only such an amount of exertion as is quite
compatible with comfort, and almost with ease, and to
take as large an amount as possible of the kind of food
already recommended. In nearly all the Swiss vil-
lages there are opportunities of obtaining fresh meat,
and in all, cows' and goats' milk, with cheese, ham, and
honey, are sufficiently abundant. There are, also,
almost everywhere, opportunities of hiring mules or
ponies for the purposes of exercise. Ample clothing
should be at hand, and exposure to the midday sun
avoided; and the aim should be to remain in one
locality, and in a state of comparative rest. The
period for such a visit is from the beginning of June to
the end of August.
CHAPTER XLIIL
WINTER CLIMATES.
IN GREAT BRITAIN.
Heretofore, and particularly some years ago, the
anxiety in reference to change of climate was limited
to the selection of the winter residence. During the
summer the cases were considered to do as well in
any part of England as elsewhere, hut in the winter it
was desired to provide a milder atmosphere. This
arose, no douht, from the greater prevalence of inflam-
mation than at present, and perhaps from attaching an
undue importance to the cough ; hut even now it is
highly desirable that a wdnter residence in a compa-
ratively mild climate should he obtained.
The period when the change from the summer to
the winter climate should be made depends upon —
1st, the condition of the case ; 2nd, the character of
the summer climate ; and, 3rd, the distance of the pro-
posed winter residence : but the general rule to be
adopted is to allow the cases in question to remain as
long as possible in the summer climate. If there be
much irritability of the air-passages, it will be neces-
sary to seek a milder climate in September or the
beginning of October. In ordinary cases, and in ordi-
396 WINTER CLIMATES.
nary seasons, the patients may remain at Scarborough
until November or December ; at the Isle of Man until
September or October ; in Scotland until September ;
in Norway until August; and in Switzerland until
September or October, according to the elevation and
latitude. But in all these instances the period of
change should not be indicated by months, but by the
state of the weather at the time and the healthful
tolerance of the system.
When the winter residence is to be in England, and
the patient is already here, the change may be made
safely at any period of the year, from the rapidity of
travelling and the protection from the weather ; but if
the patient be required to cross the Channel to come
to England, or to go from England to the Continent,
the change must be made not later than the middle
of October. Hence, a winter residence in England
enables those living in this country to remain at the
summer and autumn residences for a longer period
than when they are required to leave our shores ; and,
in accordance with the principles laid down, this must
be considered as an advantage.
We wdll now point out a few of the most suitable
places for winter residence, first in England, and then
on the continent of Europe.
VENTNOE.
We think that for the purpose in hand the first place
must be given to Ventnor, both on account of its
topographical and meteorological characters.
It is well known that Ventnor is placed on the sea
YENTNOR. 397
coast, at a part of the Isle of Wight where there has
been a very large land-slip, extending six miles in
length, and offering sufficient width between the cliffs
from which it has fallen and the sea for the purposes
of residence and travelling. Hence, in front it is
exposed to the open sea, with a south and south-
easterly aspect, and is protected at the back by cliffs,
some having a perpendicular face, and others rounded
summits, 600 to 900 feet in height, from the north and
northerly winds. It is not so low as the level of the
sea, but has an elevation, varying up to nearly 150
feet* The soil consists chiefly of the alluvium and the
detritus of lime and sandstone, and readily carries off
the rain.
Hence, it offers a singular protection against the
most injurious winds prevailing in the early part of the
year ; but it has the further very great advantage of
enabling the resident to obtain a total change of atmo-
sphere, when the weather will permit, by ascending the
overhanging downs, and by travelling to the westerly
side of the island. To this we attach the greatest im-
portance, since the cases to which we refer only need
shelter in a moderate degree ; but they imperatively
require the opportunity for active exertion, and for the
acquisition of tone and vigour. We believe that no
situation offers this combination of circumstances in a
greater degree than Ventnor.
The following are the metereological characters of
Ventnor in the winter quarter, including January,
February, and March, in the six years 1855 to 1860
inclusive, so carefully ascertained by Dr. Martin.
398 WINTER CLIMATES.
The average daily temperature was as follows
TABLE No. 21.
Mean Temperature.
1855
1856
1857
1858
1859
1860
January .
February
March
38-7
38-7
41-1
o
42-6
43-9
43-1
40-
43-1
44-7
o
42-9
40-6
44-1
o
43-5
45-8
47-7
o
43-8
38-8
43-6
Mean . . ,
37-8
43-2
42-6
42-5
45-7
42-
Thus, in the average of six years the temperature of
the quarter was 42 '3°, whilst that at Greenwich was
38-8°.
The extremes of temperature during each month of
the quarter were as follows : —
TABLE No. 22.
Extremes of Temperature.
1855
1856
1857
1858
1859
1860
o
o
o
o
o
January .
. Highest
Lowest
53
25
52
29
53
25
53
26
52
31
53
30
February.
. Highest
Lowest
49
21
54
30
55
29
53
29
55
34
51
26
March .
. Highest
Lowest
53
30
53
33
56
30
64
27
59
33
54
28
• There was singular uniformity in the returns of
the several years, and the extremes were 64° and
21°, yielding extremes of 43° in the course of six
years.
VENTNOR.
399
The daily range of temperature is shown in the
following table : —
TABLE No. 23,
Range of Temperature.
1855
1856
1857
1858
1859
I860
January
February
March .
6-3
8-9
9-8
o
6-6
7-4
10-2
o
7-6
8-8
9-7
o
8-8
8-3
10-9
6-8
8-7
8-9
7-2
10-2
8-7
Mean ....
8-3
8-0
8-7
9-3
8-2
8-7
The daily range on the quarterly average was only
8*3°, as opposed to 12*1° at Greenwich.
The degree of saturation of the air by vapour was
as follows, complete saturation being represented by
100°.
TABLE No. 24.
Saturation op the Air.
1855
1856
1857
1858
1859
1860
January .
February . . .
March
84
83
81
86
90
76
77
86
84
82
81
80
86
82
78
81
77
80
Mean . . .
83
84
82
81
82
79
The mean degree on the average of the quarter was
83°, and that at Greenwich was 85'2°.
The prevailing direction of the wind was E. and
N.E., east and variable in 1855, whilst the relative
proportions of the winds in 1856 to 1860 were as
follows : —
400
WINTER CLIMATES.
TABLE No. 25.
Prevalence of Winds.
1856
1857
1858
1859
1860
N.
E.
S.
"e
2
w
12
8
1
N.
9
4
4
E.
6
5
8
S.
8
7
5
W
11
12
14
N.
6
3
5
14
E.
2^0
38
S.
8
3
3
14
W
10
2
12
N.
4
3
5
11
E.
6
1
1
6
S.
6
6
6
17
W
16
18
19
55
N.
3
10
6
19
E.
7
6
2
15
S.
7
3
8
W
14
10
15
39
January
February
March .
7
6
4
9
10
2S
Mean .
17
42
16
18
20
18
15
37
Thus it is shown that westerly and south-westerly-
winds were more prevalent than easterly and north-
easterly in the proportion of 17 westerly to 12 easterly,
and 25 south-westerly to 20 north-easterly. Hence it
is evident that during the winter season easterly winds
are frequent : but since the residents are protected by
the cliffs and downs from all except the south-easterl}^
their frequency is not of great importance under
ordinary circumstances.
Thus, on a review of the meteorological conditions of
Ventnor, we find that the temperature is upwards of
40°, and, with one exception, higher than the most
favoured parts of the kingdom. The daily range of
temperature is small, but not so small as that at Scar-
borough or the Isle of Man (and, in some 5^ears, one
or two other northern seaports), whilst the air is there
drier than at almost any other place in the kingdom ;
and, in addition to these facts, we must add its almost
perfect shelter from the direct access of the cold winds.
The only doubt which these conditions can raise in
TORQUAY. 401
tlie mind is the eifect of the dryness of the air, since
in cases where there is any marked tendency to in-
flammatory action, that condition would not be quite
favourable. As it respects the vast majority of the
cases in question, there need, however, be no doubt as
to the fitness of the climate for them. Other parts of
the Isle of Wight partake to a considerable degree in
the advantages of Ventnor, but they lack the special
protection which Ventnor claims. The general tem-
perature of the Isle of Wight at this season of the
year is higher than that of other parts of England,
except Devonshire and Cornwall. Newport occupies
an inland position, and Hyde is exposed to easterly
winds.
TORQUAY.
This beautiful sea-side sanatorium has certainly as
great claims to the designation of the Queen of Southern
Watering-places as Scarborough has to the Queendom
of the North; and, in our judgment, no higher praise
could be bestowed.
Torquay is situated upon the shores of a landlocked
sheet of water called Torbay, in the parallel of 50° 28'
N. latitude. It has a fine sea-view, and offers excellent
opportunities for boating on the bay and for excursions
upon the land, and abounds in interesting information
for the geologist. The town itself is small, and situate
upon the shore, and in two ravines, which lead down
to the level of the sea. In the background, and on
either hand, are high cliffs, of which some present a
bold and precipitous aspect to the sea, whilst others
402 WmTEE CLIMATES.
have summits which, gradually rising in height, offer
splendid ranges of terraces, upon which have been built
most commodious villas. The lower town is occupied
for the purposes of trade, whilst in the beautiful pano-
rama which extends itself on every side like an extended
fan above the town, are the residences for invalids and
for the wealthy inhabitants. The position is in the
highest degree picturesque, and it has had the good
fortune to fall into the hands of those who appreciate
the beautiful, and who, with taste, talent, and liberality,
have turned- its natural advantages to the best account.
The sea aspect is south-westerly, and as there are
high cliffs on every other side, the rising concavity in
which the upper town is built is protected from the
north and east. The lower part of the town is indeed
so sheltered, that there is but little movement in the
air, except the wind be from the sea, and, consequently,
in hot weather the atmosphere is exceedingly oppres-
sive ; but as we ascend the beautifully-adorned terraces,
we find a wider expanse for the movement of the air,
and, in the winter season, an expanded basin-like sur-
face, courting the rays of the morning and mid- day sun.
The soil is warm and porous, and, from the rising
nature of the ground, there are great facilities for
drainage. It is also rich and highly cultivated.
The meteorological characters of Torquay are de-
serving of careful study, and manifest in a high degree
its fitness for a winter residence.
The average daily temperature in the th^-ee first
months of the year in the years 1854 to 1860,
excepting 1857 (the returns for 1857 having been
TORQUAY.
403
omitted from the Registrar- General's Tables), was as
follows : —
TABLE No. 26.
" Mean Temperature.
1854
1855
1856
1858
1859
1860
January .
February
March .
42-9
42-6
45-3
38-8
33-5
40-2
43-3
44-7
42-5
42-8
41-4
43-4
45-8
457
47-4
43-1
38-6
43-6
Mean ....
43-6
37-5
43-6
42-5
46-3
41-7
The temperature in the year 1855 differed materially
from that in the preceding and succeeding years ; but
upon the whole period we find that the temperature in
the-quarter was 42*5°. This was precisely the tempera-
ture recorded by us in reference to Ventnor.
The extremes of temperature during each month were
as follows : —
TABLE No. 27.
Extremes op Temperature.
1854
1855
1866
1858
1859
1860
o
o
o
o
o
January .
. Highest
Lowest
54
29
52
28
52
29
53
25
52
33
63
31
February .
. Highest
Lowest
54
30
61
18
64
30
51
29
56
34
49
26
March .
. Highest
Lowest
57
34
52
30
53
33
59
27
68
34
68
28
The extremes of temperature during the quarter, on
the average of five years, was 59° and 18°, giving an
extreme of 40°.
D D 2
404
WINTER CLIMATES.
The daily range of temperature was very small, as
may be seen in the following figures : —
TABLE No. 28.
Daily Range of Tempeeature.
1854
1855
1856
1858
1859
1860
January ,
February
March .
7-3
9-5
10-1
o
6-5
7-3
7-6
o
7-6
5-3
7-8
o
8-8
6-2
9-2
o
6-7
8-4
10-3
o
9-4
9-2
9-1
Mean . . . .
9-0
7-0
6-8
8-0
8-5
9-2
Thus, on the average of the three years, the mean
daily range of temperature in the winter quarter was
8*1°, an amount scarcely less than that at Ventnor.
The degree of humidity compared with 100 repre-
senting saturation of the air was also low.
TABLE No. 29.
Degree of Saturation op the Air.
1854
1855
1856
1858 1859
1860
January .
February . . .
March .
87
78
79
83
95
83
79
75
80
84
86
SO
86
80
75
84
83
70
Mean . . . .
81
87
78
83 80
79
The average degree was 81, which was little less than
that at Ventnor.
Hence, on comparison of the meteorological charac-
ters of these two principal southern Sanatoria, we are
struck with their identity, and arrive at the conclusion
HASTINGS. 405
that either is well adapted for our purpose. Both,
moreover, are places of singular beauty, and replete
with interest for the student of nature.
We do not purpose to continue an analysis of the
characters of the subordinate watering-places of the
Devonshire coast, nor of those of Truro and Penzance
in Cornwall. Th,ey each, however, possess all the
general advantages of the climate, and differ chiefly from
Torquay in the absence of the particular kind of shelter
from the cold and easterly winds which that beautiful
place possesses ; but, speaking generally, they offer
many advantages to the class of cases under considera-
tion.
The mean temperature of the winter months in
Devonshire and Cornwall in the three years 1855, 1856,
and 1857 was 41*4°, whilst the mean daily range was
10'6°, and the mean degree of humidity 85°, condi-
tions which must in this climate be regarded as very
favourable.
HASTINGS.
We now proceed to consider the advantages which
attach to Hastings as a winter residence for the cases
of early phthisis. This fashionable winter resort is
divided into two parts by an artificial line, the one com-
prehending the old town, and known as Hastings, whilst
the other has gradually extended itself along the shore
until it occupies an extent of two miles, and is known
as St. Leonards. Both lie very nearly on the level of
the sea, and have a background of cliffs, but the old
town is built up to the foot of perpendicular cliffs?
406 WINTER CLIMATES.
whilst the extension to St. Leonards has rounded cliffs,
with terraces arranged at various elevations. Hence
the old town is more strictly protected, and on the cliff
offers the fine promenade of the castle grounds ; whilst
the newer neighbourhood is more picturesque, has
handsome buildings for the use of visitors, and possesses
in front a fine sea promenade. It is therefore evident
that the advantages of the locality are offered in various
degrees by the different parts of the town, and that a
warmer and more sheltered or a cooler and more open
position may be selected, according to the nature of the
case and the will of the visitor. In reference to the
class of cases under consideration, the St. Leonards
neighbourhood is to be preferred; but on the occur-
rence of irritable cough or any evidence of inflam-
matory action, the old part of the town should be
resorted to.
We turned to the Registrar-General's returns with
a view to show the meteorological character of Hastings,
but since 1856 there are no records from which we can
make an analysis. The omission in the returns, and
lately the absence of returns, is a most noticeable cir-
cumstance, and would lead the inquirer to form an
unfavourable opinion of the locality.
THE CHANNEL ISLANDS.
There are four islands to which we might direct atten-
tion, viz., Jersey, Guernsey, Sark, and Alderney, each
of which offers certain special advantages, but as only
the two first are frequented by visitors, we shall restrict
our remarks to them.
CHANNEL ISLANDS.
407
The islands are very small, and are situate rather off
the French than the English coast, and as they lie
in latitude 49° N., and are necessarily surrounded by
water, we may expect to find them comparatively warm
winter residences. They are well cultivated, and pro-
duce the most delicious fruits in the richest luxuriance.
The native inhabitants are of I rench origin, and still
retain French habits, so that visitors readily find
pleasant society both amongst themselves and the
residents.
We shall consider the meteorological characters of
Jersey and Guernsey at the same time, since it will be
found that either island is equally adapted for the class
of cases now under consideration.
The average temperature of the air in the months of
the winter quarter in these two islands was as follows ;
but owing to the absence of returns from Jersey for
1857, we have not been able to select the same years in
reference to both places : —
TABLE No. 30.
Mean Temperature.
Jersey.
Guernsey.
1854
1855
1856
1855
1856
1867
January .
February . . .
March .
o
42-2
42-5
44-8
39-
35-2
40-6
43-5
43-7
41-7
40-1
36-5
41-4
o
44-
43-5
41-2
o
42-5
41-7
43-3
Mean . , . .
43-2
38-3
42-9
39-3
42-9
42-5
The average temperature was thus the same in
408
WmTER CLIMATES.
both islands, viz., 41*4° in Jersey, and 41 '5° in
Guernsey, and was nearly the same as that of Ventnor
and Torquay.
The extremes of temperature during the same
months were as follows : —
TABLE No. 81.
Extremes op Temperature.
Jersey.
Gruemsey.
1854
1855
1856
1855
1856
1857
January . Highest
Lowest
February . Highest
Lowest
March . . Highest
Lowest
51-
33-
62-
30-
55-
53-
51-
23-
49-
25-
52-
30-
o
52-
26-
54-
31-
55-
35-
o
51-
27-
49-
27-
63-
33-5
o
51-5
29-5
54-
32-
51-
36-5
°
52-
31-5
49-5
32-5
54-
34-
On looking at this table it is impossible not to notice
the singular uniformity which occurs throughout the
whole period, and the very small variation between the
highest and lowest temperatures. There was no day
in which the temperature in Jersey exceeded 55°, and
in Guernsey 64°, whilst there was no day in which it fell
lower than 25° in the former, and 27° in the latter.
Hence the extreme range between the extremes of tem-
perature during the winter months on the average of
three years was only 30° in Jersey, and 27° in Guern-
sey—a condition much more favourable than occurs in
the most sheltered parts of the shores of a larger
country, as we have shown in reference to Ventnor and
Torquay. This is no doubt due to the insular position
CHAl^NEL ISLANDS.
409
and small size of the island, and the surrounding deep
water.
The mean daily range of temperature in the two
islands was as follows : —
TABLE No. 82.
Daily Eangk of Temperature.
Jersey.
Guernsey.
1854
1855
1856
1855
1856
1857
January .
February . . .
March
o
5-6
7-4
9-6
5-5
5-5
7-6
5-2
6-2
6-5
5-8
7-1
7-1
5-6
3-8
5-7
7-3
7-6
7-7
Mean . . .
7-5
6-2
5-9
6-7
5-0
7-5
Uniformity of temperature is also well exemplified
by this table, for on the average of the whole quarter
the mean daily temperature varied only 6*5° and 6*4°
in the two islands — a degree of uniformity which
cannot be excelled.
It is well known that the influence of the wind is
considerable on these islands, and that every wind
must be a sea-wind to them. The direction is for the
most part north-east or south-west, and during some
part of the period of the year in question the pre-
vailing direction is easterly, both in these islands and
in England.
The degree of humidity is somewhat considerable,
and is represented by the numbers constituting the
following table, it being understood that full saturation
of the air is represented by 100 : —
410
WINTER CLIMATES.
TABLE No. 33.
Degree of Satubation of the Air.
Jersey.
Guernsey.
1854
1855
1856
1855
1856
1857
January .
February
March
94
86
88
80
98
94
90
94
92
86
91
92
84
78
89
80
86
80
Mean
89
91
92
90
86
82
The average degree was thus ninety in Jersey, and
eighty-six in Guernsey, and much exceeded that at
Ventnor and Torquay.
On reviewing these meteorological characters, we
perceive that the Channel Islands offer a warm and
moist atmosphere, and are remarkable for the unifor-
mity of their temperature. It must also be added that
fogs prevail occasionally, as they must do when cool
air is injected into a humid atmosphere. Hence it is a
climate, when the easterly winds are absent, which is
suited to those cases in which there is much irritability
of the air passages, but for the ordinary class of
cases it would be less tonic than the climate of
Ventnor.
CLIFTON.
We purpose to refer only to another home winter
climate, viz., that of Clifton, which in some respects
offers a contrast with that just discussed. Clifton is
situate upon the hills bordering the deep gorge of
CLIFTON.
411
the Avon, leading to the Bristol Channel, and whilst
fully exposed to the south-east wind is sheltered from
the westerly gales of the Atlantic. The surface is very
undulating, so that the lower part is sheltered, whilst
the downs are very exposed, and hence some care is
required in selecting the part of the locality suited to
each case. It is wooded, and offers much variety of
aspect, and is indeed one of the prettiest localities in
the country. It offers every facility for surface drain-
age by its undulations, and also for subsoil drainage
from the nature of the rock upon which it rests.
The meteorological characters are as follows in the
winter months.
The average temperature of the air was lower than
that hitherto recorded by us.
TABLE No. 34.
Mean Tempbeatuee.
1855
1856
1857
1858
1859
1860
January .
February . . .
March .
o
36-2
29-3
37-9
o
40-
41-7
39-6
o
37-3
39-5
41-8
38-5
36-
41-2
o
41-3
42-9
45-5
39-9
36-1
40-8
Mean . . , .
34-5
37-1
39-4
38-6
43-2
38-9
The mean temperature during the three years was
only 38*6°, which was not only much below that
already recorded, but was a little less than that at
Greenwich.
The extremes of temperature were considerable.
412
WINTER CLIMATES.
TABLE No.
35.
Extremes op Temperature.
1855
1856 1857 1858
1859
1860
o
o
o
o
o
o
January .
. Highest
Lowest
51-4
22-2
62-5
21-9
61-3
16-7
53-8.
21-
65-
26-5
56-
26-2
February .
. Highest
Lowest
48-4
11-5
55-5
23-8
51-8
20-3
51-
21-
55-
28-6
48-9
23-1
March .
. Highest
Lowest
55-3
23-1
57-1
24-4
50-1
25-3
66-3
20-9
■68'8
27-3
63-9
21-7
The highest temperature was 66'3° and the lowest
11*5°, so that the range of the extremes during the
period was 5 5 '5°.
The mean daily range of temperature was mode-
rate, viz., 10 '5°, as shown in the following table.
TABLE No. 36.
Daily Range op Temperature.
1855
1856
1857
1858
1859
1860
January .
February . . .
March .
6-5
10-1
12-4
o
8-1
9-6
13-5
o
8-5
11-7
12-9
o
10-4
9-6
14-9
o
8-5
11-3
10-2
9-5
11-4
12-1
Mean .
9-7
10-
il-
11-6
10-
11-
The degree of humidity was not considerable, and
corresponds closely with that observed at Greenwich*
viz., 86° at the former and 85*2° at the latter, but it
was greater than that recorded at Ventnor and Tor-
quay.
FOREIGN CLIMATES.
413
TABLE No. 37.
Deqeeb of Saturation of the Air.
1855
1856
1857
1858
1859
1860
January .
February . . .
March
93
89
88
90
92
82
89
90
85
86
84
82
92
85
87
91
79
90
Mean . . .
90
88
88
84
88
86
Thus the cUmate of Clifton in the winter months
is less warm and of far greater vicissitude than that
of Ventnor, Devonshire, and the Channel Islands.
It is drier than the latter, and less dry than the
two former. Hence its character is rather tonic and
stimulating, and not suited to those early cases of
phthisis where there is much irritability of the air pas-
sages. There are certain cases of that disease for
which it is fitted ; but all such persons should occupy
sheltered houses, and expose themselves to the air of
the downs on fine and warm days.
REVIEW OF BRITISH CLIMATES.
On a review of the characters of the climates to
which we have referred, we consider that Ventnor and
Torquay occupy the first places in reference to the mass
of persons afflicted with early phthisis. The more
robust may winter at Clifton, and the more sensitive
may select the Channel Islands.
FOREIGN CLIMATES.
In selecting a foreign winter and early spring resi-
dence for the class of patients under consideration, we
414 WINTER CLIMATES.
must seek for the conditions which will enable the
patient to spend his time in the open air, and such are
chiefly the temperature, dryness of the air, and the
violence of the winds. Speaking generally, those cli-
mates wiU be the most suitable in which the air is not
moist, the temperature never very high nor low, but
uniformly sustained, and where the easterly winds do
not greatly prevail. In all these respects there is much
diversity in the climates which we shall proceed to
notice ; and we shall much more frequently find that a
particular locality offers both prejudicial and beneficial
characters, rather than the precise conditions which we
need. It is not necessary for our purpose to enter at
length into the characters of foreign climates, nor to
refer to a large number of localities, but we shall con-
tent ourselves with specifying those places which seem
to us to be the best fitted, and with indicating their
leading characters.
THE NILE.
We are, upon the whole, disposed to place the Nile
in the first rank of suitable climates, on account of the
elevation of its temperature and the dryness and elas-
ticity of the air in its upper part.
- The period of the year to proceed from this country
to the Nile is the middle or end of October, and the
best mode is by the Peninsular and Oriental Com-
pany's steamers, although some prefer to travel through
Spain on the way. The voyage to Alexandria is made
in about a month. It is then usual to proceed at once
to Cairo, and engage a dragoman and a boat for the
THE NILE. 415
journey up the Nile ; or, if it is very early, to select a
boat at Alexandria, and proceed on to Cairo. As
it is desirable that the invalid should have as little
trouble as possible, it will be the most convenient to
pay the dragoman a stipulated sum per day, on condi-
tion that he secures the boat which the traveller pre-
fers, and engages the first and second captains and
sailors, and supplies daily provisions according to a
written scale. The journey from Cairo should com-
mence from the middle of November to the beginning
of December ; and as it is usual for two or more per-
sons to join in the expense of the boat, it will avoid
delay if the party could be made up before reaching
Cairo. The journey should be made with a moderate
degree of rapidity until the traveller arrive at Thebes,
and in Nubia he will find the atmosphere in its driest
and most elastic state. In this part of the journey he
will do well to linger, and proceed leisurely to the
second cataract. The return journey should not
commence before the middle or end of February, so as
to terminate at Cairo at the end of March.
The general character of the climate during the
journey will be found to correspond with an ordinary
summer in England, with the sun's rays somewhat
hotter and the nights cooler than in this Northern cli-
mate. The disadvantages, in reference to the climate,
are the hot sun and the cool nights causing a consi-
derable range of temperature ; and if the return journey
be made early, cold winds will be met with below
Thebes. Hence it is necessary that there be a
sufficiency of warm clothing. The journey is also
416 . WINTER CLIMATES.
manifestly more fitted for gentlemen than ladies, since
the former may amuse themselves by sporting, or by
wandering along the banks of the Nile, whilst the sai-
lors drag the boat along ; but the latter are necessarily .
more restricted to the boat. There is not much diffi-
culty in obtaining good provisions ; but the milk, being
obtained from the buffalo, has a rich and peculiar
flavour, and does not agree, unless it be first skimmed,
with certain states of dyspepsia. Whilst, therefore,
extreme dyspeptics, or persons much enfeebled or liable
to diarrhoea, should not undertake this journey, we
think that the mass of persons afflicted with early
phthisis will be benefited by it.
As the termination of the return journey occurs so
early as the beginning of April, it is necessary that the
patient proceed to Italy before he returns to England.
PAU.
Pau is a city containing upwards of twenty thousand
inhabitants, situate in the Pyrenees, at an elevation of
150 feet above the river Gave. It is about twenty
miles distant from the mountains, and 125 miles south
of Bordeaux. It is now within a forty-eight hours'
journey of England, and may be reached by railway,
except the last few miles, for which diligences are pro-
vided from the Aire Station, to carry the passengers
through in four hours. On approaching the city from
the north side, the mountains may be seen extending
over a distance of sixty miles, and as to the general
beauty of the locality we may follow Dr. Taylor's ex-
cellent example, and cite the opinion of Mr. Inglis.
PAU. 417
He says : " It has always enjoyed the reputation of
being one of the most interesting cities of the south of
France, and altogether I think it deserves its reputa-
tion. It lies in one of the most beautiful and most
abundant countries of Europe, in one of the first
climates ; and the city itself is clean, airy, and abounds
in every convenience, and in most luxuries. As for
the environs of Pau, they are certainly beautiful. The
Gave serpentines through the charming undulating
-country that surrounds the town ; grain, meadows, and
vines diversify the scenery, and innumerable country
houses are everywhere scattered around. Nothing can
exceed the beauty of the promenades in the neighbour-
hood of Pau. Some lie along the edge of the Gave,
others along the banks of the smaller river, and
within the town there is a large and shaded platform
which commands a magnificent view over the sur-
rounding country."
The climate of Pau is somewhat cold in the early
winter months ; but in the later ones and the early
spring, it is warm, dry, and fine, and corresponds with
our Devonshire climate. The city is protected from
the north by - the gradual ascent of the Landes of
the Pont Long, and is not very liable to oppressive
southerly winds. It is remarkably free from any
violence of wind, since the neighbouring mountain-
peaks divide the current, and direct it at an elevation
far above the town. The air is clear, and whilst
changes of weather are frequent, they are evanescent
also. The degree of humidity at the season of the
year under consideration is considerable, varying as
E E
418 WINTER CLIMATES.
the east or north wind blows, but it does not pro-
duce fog.
It appears from Dr. Ottley's observations during
eight years, as quoted by Dr. Taylor, that the meteoro-
logical characters of Pau are very favourable.
The mean temperature in the autumn and winter
months was as follows :
Oct.
Nov.
Dec.
Jan.
Feb.
Mar.
B6'5°
46-9°
42-5°
40-5°
43-2°
47-9°
which affords an average temperature of 48"6° and
43*8° in the two quarters.
The difference between means of the extremes of
temperature ivas —
Oct.
Nov.
Dec.
Jan.
Feb.
Mar.
15-3°
13-4°
ll-"
12 •»
13-5°
14-8'
The degree of humidity of the air was as follows,
saturation being represented by 100 :
Oct.
Nov.
Dec.
Jan.
Feb.
Mar.
80
81
83
82
81
79
The general characters of the climate are those of
softness and mildness, allaying nervous and vascular
excitability, which, within moderate limits, are such
as the cases of early phthisis need in the winter
season, but its tendency is to produce a certain degree
of relaxation, and therefore the residence should not
be prolonged to a later period than April or May.
The period to arrive at Pau is the end of October or
the middle of November.
In reference to the cases of early phthisis to which
the climate of Pau is suited, we scarcely see grounds
to make any selection, for there is perhaps no place
MADEIRA, 419
which offers a better chmate in the early spring, and
although during the winter the temperature is below
that of Devonshire, it is perhaps sufficiently warm.
If the patient be moderately robust, he may more
freely expose himself to the cooler temperature of
December and January, and may indeed, if he be fond
of sport, follow the hounds ; whilst those who are less
robust, or who suffer more from irritability of the air
passages, should arrive at Pau later, or, being there,
should limit their period of exercise to the middle
hours of the day. It is not a climate in which tone is
gained, but it is one in which loss of tone and health
in the winter may be avoided.
MADEIRA.
The characters of the climate of Madeira are so well
known that it is not necessary to enter into any detail,
but we may state that generally it is remarkable for
mildness and uniformity of temperature, with a con-
siderable degree of humidity of the air (as determined
by its approach to saturation), clearness, and absence
of fogs. In November and December the climate is
clear, dry, and fine, and until February it is nearly all
that can be desired, but in the spring there is great
liability to easterly winds, and the climate is then in
its least valuable state.
The different degrees of elevation of the island
enable the resident to live in almost any climate, since
by ascending he finds a lower, or descending a higher
temperature, and hence this island is one of the very
few places in which a patient may remain for a
E E 2
420 WINTEE CLIMATES.
lengtliened period. We have not included it in our
list of summer climates, but a i:)atient residing tliere
during the winter may remain during the summer also,
if he can escape the evil influence of the spring season.
The range of temperature throughout the year is un-
usually small.
ALGEEIA.
Whilst Madeira has perhaps lost somewhat of public
favour during the last fifteen years, as other places of
resort have urged their claims, Algeria has been brought
into notice as a winter residence for cases of early
phthisis, and seems likely to attract numerous patients.
The French government have authorised a long series
of inquiries to be made as to the nature of the
climate, and the results speak favourably of it for
persons afflicted with chest diseases. We do not pur-
pose to enter upon the discussion of the whole country,
since the information upon it is as yet very meagre.
The country is very extensive, and portions of it not
very secure, but we shall extract the meteorological
character of Algiers from the interesting work recently
issued by Dr. Scoresby Jackson, of Edinburgh.
(Table No. 38, p. 431.)
Hence it appears that we have in Algiers a climate of
high average winter temperature, of a moderate degree
of daily range of temperature, and of high and steady
barometric indications. The prevailing direction of the
wind is westerly in the months under consideration,
but northerly winds are common, and the north-
westerly wind is a modified mistral. The south-
NICE AND NAPLES.
421
westerly wind is rainy, and there is a large rainfall,
but chiefly in sleet and heavy showers.
TABLE No. 38.
Meteorology op Algiers.
Autumn.
Winter.
Oct.
Nov.
Dec.
Jan.
Feb.
Mar.
Mean temperature ,
Mean daily range
o
73-85
15-84
o
66-40
10-08
o
60-82
12-06
59-18
13-86
o
59-01
12-06
o
60-05
10-08
Barometer (inches) .
30-095
30-005
30-088
30-045
30-039
30-018
Quarter.
Autumn.
Winter.
Mean temperature .
Mean daily range
•
67-02
12-69
o
59-41
12-0
Barometer (inches) .
30-061
30-034
NICE AND NAPLES.
We have classed these two beautiful sea-side resorts
together because there is some similarity in their
climates, and they are only fitted for a limited class
of cases.
The temperature is sufliciently high, viz., 48° at
Nice during the winter months, but in the spring
season cold and easterly winds prevail in both places.
The range of temperature of the day is very small at
Nice, and not considerable at Naples. The degree of
saturation of the air is moderate in Nice, and more
422 WINTER CLIMATES.
considerable at Naples, but the character of the climate
is rather that of dryness. Nice is so surrounded by
mountains that it is much sheltered from westerly and
easterly winds, and from the mistral, whilst Naples
suffers from the sirocco. Hence the conditions of the
mid-winter months are not unfavourable, but from the
end of February they are not such as are well suited to
cases of phthisis.
The class of cases which may winter there are those
in whom there is no pre-disposition to inflammatory
action, and to whom occasional cold winds are not
injurious, and whilst the occurrence of inflammation is
not a leading character in cases of early phthisis, it is
a circumstance so much to be avoided that only a few
cases could with propriety spend the later winter and
early spring months there.
MENTONE.
This little village, situated within a few miles of Nice,
has been known for some years as a locality far better
suited than Nice as a winter residence for persons
affected with diseases of the chest, from the great
shelter which it affords ; but it is only during the last
two or three years that professional attention has been
widely directed to it. The experience of Dr. H. Ben-
nett, and the favourable opinion which Dr. De Pascali
has formed of it, have induced many to avail them-
selves of the advantages ; and whilst some will doubt-
less go there to whom it is not suited, it is probable
that the class of cases now under consideration, in
whom there is no marked inflammatory tendency, may
ROME. 42a
find it beneficial. The immediate neighbourhood and
the line of sea coast are interesting, and offer conveni-
ence for drives and promenades, and suitable accommo-
dation is now prepared for a limited number to pass
the winter with comfort.
The leading character of the climate at the season
under consideration is that of mildness, which includes
a tolerably high temperature with a somewhat consider-
able approach to saturation of the air. It is warm
without being relaxing, and there is no prevalence of
fog. Dr. Bennett states, in his work on Mentone,
that the town is sheltered from the north and northerly-
winds, but southerly winds are often violent. The
sun is hot, and the nights are cool. There is neither
frost nor fog. The sky is clear, and there are but few
rainy days. Yet, whilst the days are commonly warm
and dry, there are sometimes drizzling days, in which
the weather resembles that of a November day in Eng-
land. Dr. Edwin Lee, in a recent work, has pointed
out the advantages and disadvantages of Mentone, and
has shown that in the summer it is relaxing, and in the
winter stimulating.
EOME.
This ancient city, with its unequalled monuments of
art, offers a very good inland winter residence, since its
winter and spring temperature is sufficiently elevated,
and^ the uniformity of temperature is very striking.
The degree of saturation of the air is considerable, so
that its character in the months in question is soft to
a considerable degree. There is no prevalence of wind
424 WINTER CLIMATES.
from any quarter, but occasionally tliere are sufficiently
liigh, dry, and cold northerly winds.
Hence the class of cases to which it is well suited
are those who suffer from irritability of the air pas-
sages, who have much general sensibility of system,
and who have taste to appreciate and study the clief-
d'ceuvres of ancient art. The principal objection to Rome
for persons of only moderate means, is the necessity
for leaving England early, so as to make the long
journey by easy stages; but if this can be readily
effected, the journey will offer the enjoyment of the
climate of southern France and the Mediterranean
before the patient reach his winter residence.
PART ly.
PROGNOSIS.
CHAPTER XLIV.
SPECIFIC CONDITIONS.
It may seem to be superfluous to introduce a
chapter upon ^prognosis in a work which professes to
treat of a curable disease, but as there are many ques-
tions upon which the wished-for issue depends besides
the stage of the disease, we think it will be conve-
nient to discuss tliis subject separately.
The conditions in which we may confidently hope
for a successful result are the following, when they are
all present at the same time : —
1. The disease in the stage preceding any evidence
of the deposition of tubercle, or when the
amount of tubercle deposited is very small and
isolated at the apex of one lung.
2. The progress of the disease has been slow, so
that there have been evidences of slight failure
of the general system during many months, and
with no evidence of a recently accelerated rate.
426 PROGNOSIS.
3. The original state of the constitution was mo-
derately good. •
4. The age from about twenty years to middle life.
5. The existing state of the health still moderately
good, so that, by careful regulation, a due
amount of nitrogenous food and of exertion may
be taken with comfort.
6. The rate of pulsation and respiration not^ mate-
rially varied from that of health.
7. Cheerful willingness to obey the prescribed di-
rections, and such a pecuniary and domestic
position that the whole arrangements necessary
to the treatment of the case may be carried out.
8. Due freedom from anxiety, and removal from
whatever conditions are unfavourable to the
restoration to health.
Such are the most favourable conditions, and it
must further be observed that they are met with in
a large proportion of cases in the middle and upper
classes of society, but they cannot be universal. We
will now enumerate the several circumstances which
are unfavourable, and the degree of importance which
should be attached to them.
THE LUNGS.
When the deposit is increased so that it may he
detected below the clavicle.
The extent of the deposit is important, both from
the interference with the vital functions of the lungs,
and from affording grounds for the occurrence of new
complications; but under these conditions there is
THE LUNGS. 427
ground for hope if the amount of deposit does not
appear to be great, so as to interfere much with the
circulation of the blood in the parts thus occupied, if
the progress have been slow and uniform, and all other
conditions are favourable. We attach far greater im-
portance to the aggregation of a solid mass of tubercle
in a moderate space than to an equal quantity distri-
buted in small masses, and yet not spread over a large
area.
When the deposit is met with in both apices.
We think that it cannot admit of a doubt that the
progress of the case is greater, and the prognosis more
unfavourable, when there is a small amount of deposit
in both lungs, than when only one lung is implicated
in the same, or even in a somewhat greater degree.
This would probably imply that the causes of the
disease exerted a more general influence, or were more
intense, as we should certainly infer that there was
double danger of complications. Yet when the deposit
is very small, and all other conditions satisfactory, the
case is still hopeful.
Whe7i softening has already occurred.
We have limited the curable conditions to those in
which the extent of softening is small, and yet involving
the whole tubercle then deposited. We have seen
cases in which these conditions existed, and every
mark of dis.ease has passed away except a certain
degree of unevenness of the vesicular murmur over the
part. We have, however, the conviction that softening
in any degree very seriously complicates the case, and
it is then only under most favourable circumstances
428 PROGNOSIS.
that we can hope for the removal of the softened
matter, whether with or without the production of a
cavity, which may remain open for a period. In such
cases it is impossible to give a favourable prognosis
except by watching the progress of the case, but when
it is found that the softening is strictly limited, that
the evidences of it gradually pass away, that the vesi-
cular murmur is gradually restored by the increased
degree of expansion of the surrounding cells, and that
no further deposition of tubercle occurs, a favourable
issue may be anticipated.
When the feebleness of respiration is very great, so
that there is general flattening of the chest.
It not unfrequently occurs that the degree of dimi-
nution of respiratory power and action is very great,
without there being any evidences of tubercular depo-
sition, and in such instances there is marked pros-
tration of the whole nervous system. This is much
more common in females than males, but in both
it is particularly found in those who pursue strictly
sedentary occupations, attended by much anxiety
and poor living, as, for example, sempstresses, tailors,
and shoe-makers.
When the patient cannot fully pursue the system of
deep inspiration f tvhetherfrom want of respiratory power
or of appreciation as to the right method of performing it.
We have already intimated that many such cases
are met with in which, with all the training which can
be given, the respiratory action is short, quick, and
gasping, when an attempt is made to adopt the plan of
deep respiration. It is difficult to dissociate these
THE LUXGS. 429
two conditions ; but we have no doubt that in many
persons who have pursued sedentar^^ occupations sedu-
lously for years, and who have lost much courage and
nervous power, they have lost the method of easy and
deep respiration, — in other words, have forgotten how
to breathe. In such instances, the chest falls in
expiration below the normal degree, so that there is a
less amount of residual air remaining in the lungs, and
hence the diminution in the vital processes, and the
difficulty of maintaining a due degree of expansion of
the lung, are proportionally increased. Unless such
patients can be taught to inspire slowly and deeply, so
as to expand the air cells, and also to keep them
expanded from that time, at the end of inspiration we
believe the case to be hopeless.
When hcemoptysis is persistent without any evidence of
progress of the disease, or when the disease progresses
very slowly.
"We have had numerous cases under our constant
care for two or three years in which the disease
appeared to be kept in abeyance, and the general health
improved, but in which there was, from time to time,
attacks of haemoptysis, and ultimately the signs of
progress appeared. The importance of this indication
is no doubt in reference to the want of freedom of
circulation in the lungs as a whole, which attends
deficient expansion, or the state of the blood and
general organism, whereby a healthy condition of
nutrition is not regained. It occurs without any sign
whatever of softening of any tubercle which may have
been deposited.
430 PEOGNOSIS.
THE GENERAL SYSTEM.
When the powers of the general system are greatly
enfeehlecl.
When the capability of reaction is found by experience
to be very small.
When the appetite, digestion, or assimilation is very
defective, and particidarly when milk, fat, and other hinds
of animal food, cannot be sufficiently taken even after
careful training.
When food, clothing, or shelter is deficient in any
Qjiarked degree.
When there is oppressing anxiety.
When the patient cannot be removed from injurious
conditions, such as foul or heated air, exposure to cold,
and sedentary occupations.
When self-abuse in either sex is, or has been, largely
practised, or alcoholic liquors or smoking largely
indulged in.
When the system is highly sensitive, so that the whole
organisation is in a state of perpetual unrest, or when
it is so deficient in nervous sensibility and activity that
it does not respond readily to the ordinary stimidi.
When the patient is younger or older than that
indicated. »
When from any cause the patient will not or cannot
obtain change of climate, and will not or cannot
steadily pursue the prescribed plan of treatment.
We have not thought it necessary to offer separate
comments under these heads, since the whole form a
connected series, and any of them is sufficient to
THE GENEEAL SYSTEM. 431
greatly lessen, or perhaps extinguish, hope in the prog-
nosis of the case. We attach so much importance to
these several questions, that we advise the most careful
consideration of each one of them, and as the opinion
to he formed respecting them is one of degree, it is
often necessary that the case he watched for a time
before a correct judgment can be formed.
The importance of age seems to be less theoretically
than practically. In persons aged twelve to fifteen years,
or thereabouts, in whom the evidences of phthisis exist,
we have found the disease less capable of arrest or cure
than in those at a later age. This may be owing to
the fact that the early attack of the disease may be in
some degree evidence of the deep implication of the
system, and probably it may be in part due to compli-
cations which arise in reference to the appearance of
the menses, and the various rapid changes which occur
in the organism and the passions at the period of
puberty. But however it may be explained, we augur
less favourably of a case in which the disease begins
before set. 16, than of one in whom it is deferred
until twenty years of age or later. The unfavourable
prognosis in advanced age is clearly associated with the
progressing defect of the vital powers, the diminution
in the expansibility of the lung which always proceeds
at that period, and the diminished possibility of
adopting some of the means which are necessary to a
cure.
There is an important relation between the state of
the lungs and the general system, which we must
always consider when forming a prognosis. A small
432 PROGNOSIS.
lampunt of lung disease, with a very enfeebled system,
is far more unfavourable than a somewhat larger
amount of the former, with a moderately robust state
of the latter. "Whilst there are many cases in which
the general health appears to be moderately good when
the lung disease is far advanced, the general rule is to
find the system injured whilst the lung disease is yet
very limited, and hence, after having ascertained that
the latter is restricted within the narrow limits already
indicated as hopeful, the whole question of prognosis
rests upon the state of the general system.
CHAPTER XLV.
PKOGNOSIS.
GENERAL AND NUMERICAL CONDITIONS.
We purpose under this head to introduce a short
summary of facts derived from a very extensive inquiry
into the conditions which may be presumed to have
modified the constitution of phthisical persons ivhen in
health, and to which reference has already been made
in several parts of this work. The .primary aspect of
this inquiry is that of etiology, and had it been our
purpose to have entered specially upon the causation
of phthisis, we should doubtless have referred to the
inquiry under that head, but as it has an important
bearing upon prognosis in reference to the constitution
of the patients, we purpose to insert the results in this
place. We do not, however, intend to enter into much
detail, since the computations were made only when
this work was half through the press, and the subject
has been treated at due length in a paper read before
the Royal Medical ^nd Chirurgical Society on March
20, 1826.
The inquiry embraced 1000 patients, of whom 600
were males and 400 females, and extended over several
years. It was altogether made by ourself, and the
? F
434 PROGNOSIS.
diagnosis of phthisis in a marked stage of consolida-
tion or of destruction was made by our colleagues or
ourself. We will first consider the circumstances
which refer to the parents, and then those belonging
to the patients.
Fifty-four per cent, had lost the father, 46 per cent,
the mother, and 28 per cent, had lost both parents.
In 25 per cent, only were both parents living. Their
average age at death was 50*8 years, with an increased
duration of 4*7 years on the part of the fathers. The
most frequent age at death was 35 to 55 years,
whilst only 11 per cent, died under set. 35, and some
lived to upwards of £et. 95. 18 per cent, had ex-
perienced feeble health before the birth of the patient,
and 34 per cent, throughout life. In 22' 7 per cent,
one or both parents had led unsteady lives, 21*1 per
cent, of the parents had died of consumption, whilst
in 2*8 per cent, the grand parents, in 23' 3 per cent, the
brothers or sisters, and in 9'1 per cent, the uncles or
aunts had died of the same disease. They had suffered
from rheumatism in 22 per cent., from asthma in 9*4
per cent., from liver disease and gout in 9* and 7*2 per
cent., and from fevers, ague, insanity, and diabetes in
between 4 and 5 per cent. Presumed scrofulous affec-
tions were extremely rare. In onl}^ six cases was
there consanguinity of the parents.
The age of the parents at the birth of the patient
was, in half of the cases, from set. 25 tc set. 35, and only
in 2 per cent, was it less than set. 20. The number of
children was very large, viz., an average of 7'5 to a
family, and in some families there were 23 children.
GENERAL AND NUMERICAL CONDITIONS. 435'
The patient was the first child in 20 per cent., and
the first, second, or third child in half of the whole
cases. 40 per cent, of the parents' children had
died.
Hence, in reference to questions involved in the idea
of hereditary predisposition, it has been proved that in
a large proportion of the cases the parents died in the
middle of life, and had had feeble health. Their
children had died in large proportion, and consumption
occurred in one-fifth of the parents. But in all these
matters there was a large proportion in which there
was no evidence of feeble health or direct tendency
to phthisis. The parents did not marry too early
or too late, and the patient was neither the result
of immaturity nor of senile exhaustion, so far as
age may indicate those conditions, yet he was com-
monly amongst the earliest children born to them.
They were unusually prolific.
The question of hereditary taint implies either the
direct transmission of the elements of phthisis to
the child, or a state of system in which phthisis is
pre-eminently liable to occur. Neither of these ideas
are supported by the results now given, as applicable
to this class of cases as a whole, for they support the
previously recorded statement of Dr. Walshe, that the
hereditary transmission of phthisis from the parents,
in hospital patients, is much less frequent than had
previously been asserted. The results show that no
one condition is dominant, but that phthisical patients
are a mixed class of the community.
The average age of the patients at the period of the
F F 2
436 PROGIITOSIS.
inquiry was 28'8 years, and 44 per cent, of the whole
were between twenty and thirty years of age. In only
13 per cent, were they under set. 20, and a few
were set. 60. 24 per cent, had been feeble at birth,
but only 22 per cent, had suffered from feebleness of
the general health, and 17 per cent, from generally
defective appetite. In 12' 6 per cent, the lungs had
always been delicate. Only 2'5 per cent, had been
dry nursed, 25 '4 per cent, had perspired very freely,
and 25 per cent, had never worn flannel next the
skin. 16, 65*4, 60, and 41 per cent, had not had
measles, scarlet fever, smallpox, and hooping-cough
in their order, and the frequency of any long-con-
tinued ill effects from these diseases w^as insignificant.
12*8 per cent, had suffered from enlarged glands,
and 4*5 per cent, from affections of the eyes, but
otherwise the evidences of scrofulous diseases scarcely
existed. 16 '7 per cent, had suffered from inflam-
mation of the lungs, and 14'8 per cent, from rheu-
matism, whilst typhus fever and frequent diarrhoea
had . occurred in 8*0 per cent., ague in 5*6 per
cent., and liver disease in 4*3 per cent, of the
cases.
43*5 per cent, were married, and of these 13 per
dent, were up to the period of the inquiry childless.
Their average age at the birth of their first child was
from set. 20 to set. 25, and in only 9 per cent, were
they under set. 20. The number of children was one
and two in 44 per cent., and one, two, and three in
65 per cent. 38 per cent, of the children had died,
and in 43 per cent, the general state of the health of
GENERAL AND NUMERICAL CONDITIONS. 437
the children was bad. Abortion had occurred in 46"2
per cent, of the child-bearing married women, and some
had suffered eight abortions.
11*6 per cent, had committed sexual abuse, 18*2 per
cent, had masturbated, and 22 per cent, had suffered
from involuntary emissions. 16 per cent, had had
syphilis, and 38*5 per cent, gonorrhoea. 29*6 per
cent, had led a bad life at some period, 24'5 per cent,
had drank to excess, and 48 per cent, had smoked
tobacco. 19*3 per cent, had submitted to late hours,
and 22*2 per cent, had suffered much anxiety. In 70
per cent, there was some complaint as to the injurious
influence of their occupations, and of those causes
exposure, long hours, close and hot rooms, bending
posture, and dust or fumes were complained of in
32*1, 28-6, 24*4, 20 and 15*8 per cent, in their order.
9 per cent, had taken mercury largel}^ and 54*4 per
cent, had been bled at the arm from one to twelve
times.
Thus, a large proportion of the patients had been
born feeble, had had feeble and short-lived children,
had suffered from the effects of injurious occupations,
and had been injured by the anxieties and immoralities
of life. They were thus influenced by original and
acquired causes of disease ; but however important
the former might be, it is impossible not to admit that
the latter was still more so. They had not suffered from
early marriages, and considering their average age,
they had been sufficiently prolific, although no in-
considerable proportion had been sterile.
Hence, again, we cannot but regard phthisical
438 PROGNOSIS,
patients as a very mixed class of persons, and one
vvliicli derives its causes of disease from a great variety
of diverse conditions, many of wliicli are, however,
within their control and preventible. The proportion
of those who had suffered from general feehle health
and insufficient appetite throughout life was very
small, but as they were the judges it may be that
their standard of health was low.
One striking feature to which we must refer was the .
greater liability of the female over the male sex to
many of the ills to w4iich we have referred. Thus,
in reference to the parents, more mothers than fathers
had children earty, had feeble general health, and
had died early. Of the patients, more females
than males had mothers who died early, had most re-
latives who had died of phthisis, had parents with one
child only, had experienced feeble health and defective
appetite through life, had had delicacy of the lungs,
were married when very young, had feeble children,
had lost most children, had suffered from anxiety,
had had measles, scarlet fever, and hooping-cough,
had not worn flannel next the skin, had a very
defective education, were of susceptible tempera-
ment, had brown eyes, florid complexion, and fleshy
habit, and had suffered from coldness of the extre-
mities. This is most striking evidence of the liability
of females to conditions tending to constitutional
disease.
We may now ask, in conclusion, in what way may w^e
regard these inquiries as important in reference to prog-
nosis ? It may be fairly replied that, whatever will so
GENERAL AND NUMEEICAL CONDITIONS. 489
affect ilie constitution as to induce a disease, will, when
the disease exists, be so many reasons against the cure ;
and hence, in estimating the probability of cure of any
disease, it is requisite to weigh well the relative im-
portance of the causes which may have induced it.
The first requisite in forming a prognosis in the early
or curable stage of phthisis, is to ascertain the leading
conditions to which the disease may have been due,
with a view to ascertain the degree of their influence
over the constitution, and the probability of their re-
moval ; and hence, instead of regarding the cases as be-
longing to one class of persons, it will be found that they
are exceedingly multiform and varied. The first place
must doubtless be given to such as originally affected
the system, and to the sex, so that of those patients
whose parents and relatives have exhibited special
marks of disease or of defective constitutions, whether
phthisical or otherwise, and females, the prognosis must
be less favourable. So also we must give a first rank
to a defective state of the system of the patient com-
mencing in early life and long continuing, from what-
ever cause it might have arisen. The importance of
the acquired causes of disease must be estimated by
their intensity and continuance, as well as by the natural
vigour of the constitution and the effect which they
have produced upon it. As a whole, their position must
be secondary to that of those just referred to ; but those
which acted before adult life, and which then injured
the health, — as sexual excess and masturbation, — are of
prime importance. We are, therefore, of opinion that
in every case there should be careful inquiry into the
440 PROGNOSIS.
circumstances now referred to, and that the prohability
of cure will rest as much upon it as upon the more
minute examination of the lungs, and the impression as
to the state of the general system of the patient.
INDEX.
Abortions, 436.
Absorption of tubercle, 213.
Acids disliked, 56.
Addison on tubercle, 199.
Aetius, 14.
Age of occurrence, 18 ; relation
to rate of respiration, 106 ; of
parents at birth of patient,
434 ; of patient, 435 ; at birth
of first child, 436.
Ague in relatives, 434 ; in pa-
tients, 436.
Air inspired under exertion, 100.
Air vesicles in relation to expan-
sion, 165 ; to contraction, 179 ;
spiral arrangement, 169 ; in
1st stage, 186 ; 2nd stage, 190 ;
collapse, 315.
Aire, 416.
Alcohols, 241, 252, 265.
Algeria, 420.
Alimentation, 54.
America, voyage to, 367, 368.
Ancell on early stage, 38 ; on
tubercle, 193.
Ancients, views of, on phthisis, 9.
Andral, 32. '
Animal food, cause of phthisis, 18.
Anxiety, prevalence and evils of,
286, 437.
Apex of lung a seat of tubercles,
202 ; on deep inspiration, 304.
Appetite, 54 ; for various foods,
56 ; with acid perspiration, 57 ;
contrasted with cases of bron-
chitis and debility, 57 ; for fat,
special inquiries on in and out
patients, 58 ; for meat and
milk, 63 ; increase, 257 ; bad
in health, 436.
Aretseus, 10, 21, 22.
Aristotle, 13.
Arrest of tuberculization, 211.
Ascherson, use of fat, 347.
Assimilation, 65 ; relation of food
ingested and assimilated, 66 ;
increase, 266.
Asthma in relatives, 434.
Athol, Duke of, 387.
Atmospheric air, varying com-
position, 275.
Australia, voyage to, 368. ,
Avenbrugger, 26.
Avenzoar, 14, 21.
Avicenna, 14, 18.
Baillie, 15, 23.
Barlow on early stage, 34.
Bartholin, 22.
Bathing in cold water, 222, 332.
Bayle, 22, 24, 25, 32.
Beau's treatment by lead, 234.
Beddoes, 23.
Bending posture, 437.
Bennet, 15.
Bennett, Prof., 27; on early stage,
35 ; on tubercle, 199; cod oH,
338, 346, et seq.
Bennett on the hypo-phosphites,
292.
Bennett on Mentone, 423.
Besoin de respirer, 179.
Blane, 18.
Bleeding, 22, 437.
Blood origin of tubercle, 195.
U2
INDEX.
Boerhaave, 17.
Bontiiis, 19.
Borelli, 18.
Breathing feeble, 173.
Brillouet, 17.
Broncliitis, fat in, 61 ; perspira
tion, 83 ; haemoptysis, 147. }
British climates, winter, 395 ;
summary, 413. \
Bulk of the body, 66 ; restore,
83.
Burlington, 380.
Butter disliked, 61.
Cairo, 414.
Calculi expectorated, 14.
Canada, voyage to, 367.
Capivaccius, 14.
Carbonic acid in cycles, 351.
Carswell, 23, 25 ; on selection of
apices, 202.
Catarrh, dissociated from phthisis,
15 ; cause of, 18.
Categorical statement of whole
plan of treatment, 329.
Causes of consumption, 12, 18.
Cavity, closure of, 312.
Celsus, 13, 21.
Chamouni, 393.
Chemical changes, 282.
Chest movement lessened, 161 ;
measures, 163.
Cheyne, 22.
Childless after marriage, 436.
Children in families of parents, j
434 ; of patients, 436 ; order
amongst, of patient, 435.
Churchill on the hypo-phosphites,
291.
Circulation of blood enfeebled
and quickened, 92 ; conditions
of, 92, 94; rate of, 95.
Civilization and phthisis, 19.
Clark, Sir J., on curability of
phthisis, 4 ; on early stage, 33.
Clark, A., on yellow elastic
tissue, 209.
Clayton, 17.
Clifton, 410.
Climate, 364.
Close and hot rooms, 437.
Clothing, 225, 333.
Cod liver oil, general statement,
339.
Coffee disliked, 56 ; dries the
skin, 231.
Cold countries, phthisis is preva-
lent in, 18 ; cold water to skin,
222.
Coldness of extremities, 79.
Collapse of air-cells, 315.
Complexion in consumptives, 51.
Consanguinity in relatives, 434.
Constitution in phthisis, Sir J.
Clark, 35.
Consumption, both curable and
incurable, 1 ; forms of, as held
by the ancients, 9 ; by moderns,
17; description of, byAretseus,
10 ; connection with hectic,
12 ; contagious, 20 ; its nature,
20 ; treatment, 21 ; in rela-
tives, 434.
Contagious quality of phthisis,
20.
Cottage hospitals, 363.
Cotton on early stage, 36.
Cough, 129; causes vomiting, 150.
Counter irritation, 22.
Cretaceous expectoration, 138.
CroU and Co., author's spirome-
ter, 114.
Cullen, 19.
Cyclical conditions, 351.
Darwix, 20.
Day, cycle of, 351.
Debility, expression of diseased
action in phthisis, 46 ; fat in,
61 ; perspiration, 83.
Deep voluntary inspirations, me-
thod, 303, 308.
De Haen, 19.
De Jongh, cod oil, 338, 346,
349.
Desault, 15, 16, 20.
De Pascali, 422.
De Saussure, 275.
Diabetes in relatives, 434.
Diarrhoea, 436.
Dietary, 247, 249.
Digestion, 64 ; improve, 261.
Dioscorides, 13.
I^'DEX.
443
Dislike foods, 56, ct seq. cod oil,
341, 344.
Drank to excess, 437.
Dry-nursed, 436.
Dulness on percussion, 179.
Dust and fumes, 437.
Dyspnoea, 104, 265.
Early stage, views of writers,
31 ; author's papers upoil, 38 ;
connection of lungs and general
system, 44.
East, voyage to, 364.
Egesta, 77.
Elimination, circumstances affect-
ing, 70, 73 ; treatment, 215.
Emissions, 437.
Employment, 331.
Epithelial origin of tubercle,
199.
Excitability, 52.
Exercises, 269, 331.
Exertion, eftect of, over respira-
tion, 100 ; increase assimila-
tion, 267 ; increase expansion,
299. ^
Expansion of lungs, 164 ; lessened
as a cause of tubercle, 202 ; in-
crease, 269.
Expectoration, 135 ; of tubercle,
210.
Exposure, 229 ; evils of, 437.
Eyes, color of, 50.
Fat disliked, 58 ; in bronchitis,
debility, and liver disease, 59 ;
various kinds of fat, 61 ; in
muscle, 71 ; dries the skin,
231.
Eaucial haemorrhage in phthisis,
20.
Feeble health of parents, 434 ;
of patient, 436 ; of patient's
children, 436.
Females special liability to dis-
ease, 438,
Fernet on chloride of sodium in
blood, 283.
Fevers in relatives, 434.
File3-, 380.
Fish, 253.
Flannel shirts, 226, 436.
Flint on besoin de respirer, 189. •
Follicular disease of throat, 126.
Foods disliked, 56 ; amount eaten,
65 ; influence over elimination,
70, 231 ; special kinds, 261 ;
to increase assimilation, 271 ;
selection, 329.
Foreign winter climates, 413.
Forestus, 14.
FothergUl, 22.
Fourcroy, 23.
Frankland, 275.
Fruits disliked, 56.
FuUer, 22.
Galen, 12, 20, 22.
Gave, 417.
Gelatin as food, 251.
General system, consideration of,
neglected, 7.
Gilchrist, 16, 20, 21, 22.
Glands enlarged, 436.
Glover, action of fat, 347.
Gonorrhoea (See Syphilis).
Gout and phthisis, 19.
Guernsey, 406.
Habit of body, 51.
Hair, color, of, 50.
Hall on epithelium in the sputum,
208.
Hastings, 405.
Harvey, Gideon, 21, 22.
Hereditary predisposition, 435.
Heat influenced by the skin, 76 ;
eff'ect, 280 ; how borne, in
phthisis and debility, 355.
Hectic and phthisis, 14.
Hildebrand,,234.
Hippocrates, 9, 21, 24, 26.
Historical sketch of views on
phthisis, 8 ; on early stage of
phthisis, 31.
Haemoptysis, historical sketch, 14 ;
a cause of phthisis, 15, 19,
144 ; not a cause, 16 ; fre-
quency of, 142 ; success of,
145 ; significance of, 147 ; fre-
quency in bronchitis, 147 ;
Ui
INDEX.
cause of frequency in phthisis,
148 ; treatment, 321.
Hofmann, 18, 20, 21.
Holland, Sir H., on expansion of
the lungs, 296.
Hooping cough, 436.
Horse exercise, 22.
Horses out of condition in autumn,
357.
Hospitals, defects of, 360.
Hot climates, phthisis less pre-
valent in, 18.
Humidity of air, Scarborough,
376 ; Isle of Man, 385 ; Vent-
nor, 399 ; Torquay, 404 ; Chan-
nel Islands, 410 ; Clifton, 413;
Pau, 418.
Hutchinson's spirometer, 111.
Huxham, 18.
Hypersesthesia of throat, 125.
Hypo-phosphites, 291.
Inactivity, cause of phthisis, 18.
Inflammation of lungs, 436.
Inglis on Pau, 416.
Innervation, 114.
Inunction, 216 ; physical action,
218 ; method, 221 ; increase,
289, 299.
Insanity in relatives, 434.
Iodide of iron, 310.
Iodine in cod oil, 346.
Isle of Man, 380,
Isolation of tubercle, 311 ; and
closure of cavitv, 212.
Jackson on meteorology of Al-
giers, 420.
Jerking respiration, 178.
Jersey, 406.
Jura mountains, 393.
Kandeestag, 393.
Labouk, mental and bodily, 284.
Laennec, 4, 23, 24, 25, 32.
Lakes, English, 388 ; Swiss, 393.
Lard in inunction, 220»
Late hours, 437.
Lauterbrunnen, 393.
Lawes and Gilbert's experiments
on nitrogen in crops, 272.
Lawson on early stage, 37 ; action
of fat, 347, 348.
Lead, 234.
Lebert on softening of tubercle,
192.
Lee on Mentone, 423.
Leucorrhoea, 120.
Leukerbad, 393.
Lewis's Spirometer, 112.
liiebig on alkali in blood, 282.
Liver disease, with phthisis, 16 ;
in relatives, 434; in patients,
436.
Louis, 25, 26, 32.
Lungs, relation to general system,
44, 153 ; expansibility, 164 ;
structure, 165 ; delicate, 436.
Macbride, 19.
Madeira, 419.
Markham on early stage, 39.
Martin, Dr., 397.
Married, 436.
Masturbation and muscular pains,
122, 157.
Mead, 21, 22.
Measles, 436.
Meat disliked, 63.
Medicines, 233, 310, 336.
Menses, age at occurrence, 118 ;
irregularity, 119.
Mental labour, 284.
Mentone, 423.
Mercury taken largely, 437.
Middle ages, views on phthisis, 13.
Milk, 14, 22; disliked, 56, 63;
in treatment, 232.
Mistral, 422.
Moderns, views in phthisis, 14.
Morgagni, 20.
Mortality of parents, 434 ; of pa-
tients' children, 436.
Morton, 15, 22,
Movement of chest lessened, 160.
Mudge, 16, 20, 23.
Muscular power lessened, 90, 121 ;
treatment, 325.
Musgrave, 19.
IKDEX.
445
Naples, 421.
Nature of phthisis, 20.
Nervous organization, 53.
Nice, 421.
Nile, 410.
Nitrogen in dietary, 247 ; excites
assimilation, 272.
Nitrogenous foods in adoles-
cence, 244.
Nitrogenous tissues in relation to
weight, 72.
Norway, 391.
Nubia, 415.
Obsolescence of tuhercle, 211.
Olive oil, 14, 220.
Onanism and muscular pains, 122.
Oribasius, 14.
Oswald, 387.
Ottley on meteorology of Pau,
418.
Oxygen, 23.
Paeacelstjs, 14.
Parents' age at death, 434.
Pathology of phthisis and tubercle,
185.
Pau, 416.
Paulus iEgineta, 14.
Pearson, 16.
Penzance, 405.
Perspiration, sour, 57, et seq. 85 ;
quantity of fluid lost, 177 ; re-
lation to heat, 79 ; in excess,
83 ; constitutionally, 83 ; con-
ditions inducing, 84 ; acrid, 85 ;
treatment, 232, 233 ; in health,
436.
Pharynx, diseased states of, 124;
relation to cough, 129, et seq.
to expectoration, 137.
Piorry, 26 ; on absorption of de-
posits, 212, 213, 302, 310.
Portal, 16, 20.
Precursory stage of Lawson, 37.
Pregnancy arrests phthisis, 19.
Preliminary stage of Cotton, 36.
Pringle, 22.
Prognosis, 425 ; relation of eti-
ology, 438.
Prolonged respiration, 176.
Puckerings of lungs, 315.
Pulsation, 92 ; treatment, 277 ;
in cycles, 352, et seq.
QuAiN on early stage, 37 ; chest
measures, 163 ; on the hypo-
phosphites, 292.
Eadclifle, 17.
Kainey on softening of tubercle,
193, 139.
Eeid, 17.
Remediable conditions, limits,
307.
Removal of tubercle, 208, 309.
Residence, 335, 369 ; conditions
required, 369.
Respiration, 99 ; relation of feeble
and shallow, 102 ; rate of, 105 ;
increase, 274; in cycle, 351.
Reynaud on feeble breathing, 173.
Rheumatism, 436.
Roe on early stage, 35.
Rokitansky on tubercle, 157.
Rome, 423.
Rush, 17, 19, 20.
Sanctorius, 22.
Scarborough, 373.
Scarlet fever, 436.
Schnepf's spirometer. 111.
Scotland, 389.
Scrofula, in relatives, 434 ; in pa-
tients, 436, relation to phthisis,
17, 18.
Season, cycle of, 353.
Summer (See Season), climates,
371.
Seat of tubercle, 193.
Seelisberg, 393.
Seminal emissions, 437.
Sennertus, 18.
Sexual abuse, 437.
Sibson's chest measure, 163,
Signs of preliminary and precur-
sory stage, 36, 37.
Sims, 18.
Simmons, 18.
Sirocco, 422.
Skin elimination by, 74 ; action
increased, 74 ; not vicarious for
446
IXDEX.
the lungs, 74 ; relation of ac-
tion to heat of body, 75 ; loss
of liuid, 77 ; relation to cold
exhaustion, 79 ; treatment, 215.
Small-pox, 436.
Smoke a cause of phthisis, 18.
Smoking tobacco, 437.
Smyth, Carmichael, 21, 22.
Softening of tubercle, 191, 209.
Sour perspiration in relation to
food, 57, 58.
South Pacific Ocean, voyage to,
367.
Speaking, 22.
Spigelius, 18.
Spiral arrangement of air .cells,
169.
Spirometers, 110.
Stables useful in phthisis, 19.
Stages of phthisis, 42 ; must in-
clude state of general system,
43.
Stahl, 18.
Stark, 16, 20.
Statistical inquiry on 1000 phthisi-
cal patients, 433, et scq.
Stokes on feeble breathing, 173.
Structure of lung in relation to
expansion, 165.
Styptics, 323.
Sugar disliked, 5Q.
Sulphuric acid, 14, 22.
Summaiy of knowledge on phthisis,
28 ; of evidence of phthisis, 183.
Swinging, 22.
Switzerland, 391.
Sydenham, 17, 22.
Sylvius, 16, 20.
Syphilis and gonorrhoea, causes
of phthisis, 18 ; prevalence,
437.
Taylor on the hypo-phosphites,
290.
Taylor on Pau, 416.
Tea disliked, 56.
Temperament, type of, in this
country, 48 ; no sole type in
phthisis 49 ; evidences of hair,
eyes, 50 ; complexion, habit of
body, 51 ; excitability, 52.
Temperature of body in defect, 87.
Temperature at Scarborough, S73 ;
Isle of Man, 383 ; Ventnor, 398 ;
Torquay, 403 ; Channel Islands,
407 ; Clifton, 410 ; Pau, 418 ;
Algiers, 421 ; Nice, 421.
Throat, 124 ; treatment, 317.
Timms on tubercle, 158.
Tissues with tubercle, 205.
Tonsils relation to expectoration,
137.
Torquay, 401.
Training and tread wheel, influence
of over weight, 71.
Tralles, 15, 16.
Trallian, Alexander, 13.
I Tread wheel, 71.
I Treatment, 21, 215.
Truro, 405.
Tubercle, not the cause, but a
consequence of phthisis, 5-7 ;
on free surfaces, 6 ; not extend
by infiltration, 6 ; historical
views of, 16 ; Bayle's and
Laennec's division, 24, 190 ;
relation to phthisis, 156 ; 2nd.
stage, 190 ; microscopic cha-
racter, 192 ; origin, 195 ; pro-
gress, 204, 207 ; removal, 208.
Type of disease varies as type of
health, 47.
Typhus, 436.
Tyrol, 391.
Unsteady lives, 434, 437.
Unterwald, 393.
Urea in Cycles, 351.
Urine, natural variations in quan-
tity, 69 ; quantity and specific
gravity, 80 ; lessen quantity,
240.
Yan dee, Kolk on tubercle, 199 ;.
on yellow elastic tissue, 269.
Valsalva, 20.
Van Swieten, 18, 20, 23.
Ventnor, 397.
Vesicular murmur feeble, 174;
relation to debility, 176.
Virchow on tubercular disease,
157 ; on tubercle, 199.
Viscidity of oils, 346.
Vital actions increase, 255.
liSTDEX.
447
Vital capacity lessened before
tubercle, 38, 107 ; temporary,
109.
Voluntary respiration, deep, 302.
Vomiting, 150.
Voyaging, 364.
Walker, 19.
"VValslie on tubercle, 199 ; on
hereditary transmission, 435.
"Waterproof clothing, 228.
Wavy respiration, 178.
Weight and bulk of body, lessened,
66 ; natural causes of variation,
67 ; period of inquiry, 67.
Weissenberg, 393.
Welsh on composition of air, 275.
Whitby, 380.
Williams, duration of phthisis,
29 ; on tubercle, 195.
Willis, 17.
Winds, prevalence of, Scar-
borough, 377 ; Isle of Man, 386 ;
Ventnor, 400.
Winter (see season) climates, 395.
Withering, 19.
Young, analysis of works on Con-
sumption, 8.
Zermatt, 393.
THE END.
BRADBURY AND EVANS, PRINIEilS, WHITEFE1AR8.
BY THE SAME AUTHOR.
CYCLICAL CHANGES IN THE HUMAN SYSTEM.
Small 8vo, with 10 Diagrams, 10s. 6c?. cloth,
HEALTH AND DISEASE,
AS INFLUENCED BY THE DAILY, SEASONAL, AND OTHER CYCLICAL
CHANGES IN THE HUMAN SYSTEM.
By EDWARD SMITH, M.D., F.R.S.,
Assistant Physician to the Hospital for Consumption, Brompton, and
Physician to the Royal Dramatic CpUege.
The BritisJi arid Foreign Medico-Chirurgical Revieic, April, 1862.
"After reading the preface to this work we turned to its pages with more than
ordinary interest, inasmuch as the author states in limine, that he has undertaken
to supply a deficiency ' which exists in medical literature, and to offer the results
of a series of inquiries in aid of our knowledge of the two functions of the medical
practitioner — ^the preservation of health and the treatment of disease.' And we
are glad to be able to say that in the perusal, from the beginning to the end, we
have not been disappointed, — the performance, we think, as a whole, answering '
the promise."
"From the very nature of the work, both its method and matter, it is difl&cult
to review, its method being aphoristical — a series of propositions — its matter cycle
within cycle of human existence, passing in order from the daily to the weekly,
and seasonal, and from thence to the changes in the ages of man, first giving the
results of scientific researches, next their appUcation to health and disease, includ-
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omitting those epidemic visitations which from time to time, as far back as
history reaches, have been the scourges of mankind."
"One and the chief . peculiarity of the work is its scaffolding or frame, this
being the original researches of the author on certain physiological points of
the first importance in their bearing on the vital economy — such as the rate of
pulsation and respiration at different ages and under different circumstances, the
quantity of atmospheric air inspired, the quantity of carbonic acid expired, the
quantity of urea evolved, and of urinary water excreted ; comprising researches
carried on for several years, and in part daily, with little interruption, and not
neglecting those of other inquirers, chiefly contemporary, and most deserving of
credit. Whilst such is the framework, the larger portion of the whole may be con-
sidered as deductive ; inferences from the scientific premises used in explanation
of the registered results, and the accredited cyclical changes and events." ■
"The second chapter on the apphcation of the scientific results to health and
disease, is that portion of the work which is likely to be most studied, as laying
down rules for the preservation of the one and the correction of the other, en-
forced by explanatory remarks founded on the results of experiments, using them
as principles. The propositions expressing these rules will for the most part be
wiUingly assented to — more readily we fear than adopted and acted on, many of
them being in opposition to the ordinary habits of society."
"On the cure of disease Dr. Smith has some admirable remarks, which are
especially deserving of the attention of the practitioners of homoeopathy and their
patients, as regards delusions, and of the sound physician and the sensible portion
of the public, as regards the probable influences of seasons in restoring health."
"The eighth chapter on the cycle of the ages of man, in its ascending and
descending series, and intermediate stage in middle life, will well repay perusal.
The phenomena of each are weU described, traced through the more important
functions, and in connection with each series the subject of diet is specially con-
sidered."
' ' His remarks applicable to health and disease which follow this summary, and
complete the ninth chapter, are excellent, such as we can adopt almost entirely in
an unqualified manner, and with the firm persuasion that were the rules they
inculcate followed out in practice, the minimum of sickness and mortality; the
maximum of health and longevity, would be the lot and the reward of social man."
"The three last chapters, on the cycle of the generations of man, are of the
highest interest, both from the nature of the subject and the manner of its
treatment."
ADVERTISEMENT.
British and Foreign Medico-Chirurgical Revieic (continued).
*' So thoughtful a work needs to be read with thought, and no work that we are
acquainted with, at least of recent times, deserves more and wiU better repay
attention in its perusal."
Athenceum, Jan. 11, 1862.
" This is a remarkable book. It contains the result of a vast amount of original
observation of facts, and a thoughtful application of the observed facts to practical
purposes. . . . The work thus becomes a sort of practical physiology with
regard to the hours and the days, and the seasons of life. . . . But, however
much we may differ from Dr. Smith in some of his conclusions, we strongly re-
commend his book to the attention of the student and practitioner of medicine."
Lancet, Nov. 2, 1861.
""With all this, however, it must be admitted that Dr. Smith teaches us much
that we are ready to accept, both as new and true in the history of the func-
tional activities of the human frame. Whilst his book has on the one hand the
aspect of severe science, it has on the other the capacity of forming pleasant read-
ing, from the easy and i^ractical way the conclusions arrived at are brought to
bear upon many popular departments and questions in medical science."
Banking's Abstract, Bee. 1861.
"Xor have they been wanting in important results. On the contrary, every one
who is acquainted with them, will acknowledge that they necessitate the recon-
sideration of many of the doctrines which are now applied to the preservation of
health and the treatment of disease. The remarks upon urea, as a mixed product
of the destruction of tiss\ie and the conversion of food, appear to us particularly
interesting and important."
British Medical Journal, Bee. 14, 1861.
"To supply this deficiency — to formiilate the unwritten laws of the cyclical
changes, and to make up by modem scientific research the complement of ancient
and popular observation — is the task in which the author has been engaged during
six years, and the results of which, in part already known, he has embodied in
the present work. ... He is not only a laborious but a careful experi-
menter. . . . To all our readers we heartily commend the book. "
Medical Critic and PsT/chologicalJournal, Jan. 1861.
" These researches differ from and surpass all previous experimental observations
on the subject in comprehensiveness, completeness, and extent. . . . It is
difficult to exaggerate the importance of these researches both in their scientific
and their practical results. In the former respects they throw a flood of light
upon the diurnal and seasonal phenomena of disease ; in the latter they furnish
rules of incalculable importance for ovir guidance in the preservation of health
and the treatment of disease. These points are treated with admirable perspi-
cacity by Dr. Smith, and his work as a consequence should become simply a
necessity to the scientific physician. "
Bublin Quarterly Journal, Nov. 1861.
" There are few subjects of more importance than those ti-eated of in the volume
before vis, nor are there many whose investigation is attended with more difficul-
ties, or on which the physician is more frequently appealed to by society. . . .
This reproach can no longer, however, be cast on the present age, for Dr. Smith
has devoted himself, with a perseverance and an energy of purpose that must
excite not only admiration but wonderment, to the investigation of all the pro-
cesses of life, and the effects produced on them by the various external influences
to which man is subjected. For this purpose he bas neither spared him-
self nor his household ; all have been subjected to experiments of fasting and
of feasting, of sleeping and of watching ; the ingesta and the egesta have been
weighed and analysed, the influence of postui-e, of season, of day and of night, of
youth and of age, of rest and of exercise, — all have been sought- out and their
history recorded here, forming one of the most remarkable, valuable, and useful
books we have ever met with."
" We said at the beginning of our review that we regarded this as a most re-
markable, valuable, and useful work ; and we now appeal with confidence to the
outline we have given of its contents, imperfect and meagre as it is, in confirma-
tion of our judgment. . . . We most earnestly reconmiend the book to all
oiu- readers."
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Camera Obscura. The Microscope. The White Ants ; their Manners and Habits.
The Surface of the Earth ; or, First Notions of Geography. Science and Poetry.
The Bee. Steam Navigation. Electro-Motive Power. Thunder, Lightiiing, and
the Aurora Borealis. The Printing-Press. The Crust of the Earth. Comets.
The Stereoscope. The Pre-Adamite Earth. Eclipses. Sound.
WALTON AND MABERLY,
UPPER GOWER STREET, AND IVY LANE, PATERNOSTER ROW.
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