CORNELL UNIVERSITY THE — Flower Beterinary Library FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. STATE VETERINARY COLLEGE 1897 This Volume ts the Gift of pee Dr ie OO ETE I nc concsranmmintvon 5 CORNELL UNIVERSITY LIBRARY wii PRACTICAL TREATISE ON PHTHISIS PULMONALIS; EMBRACING ITS PATHOLOGY, CAUSES, SYMPTOMS, AND TREATMENT. BY L. M. LAWSON, M.D., PEOFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF LOUISIANA; VISITING PHYSICIAN TO THE NEW ORLEANS CHARITY HOSPITAL ; FORMERLY PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE MEDICAL COLLEGE OF OHIO, ETO. CINCINNATI: RICKEY, MALLORY & CO., 73 WEST FOURTH STREET. NEW YORK :—S. 8S. & W. WOOD. 1861. I Entered, according to Act of Congress, in the year 1860, by L. M. LAWSON, M. D. in the Clerk’s Office of the District Court of the United States for the Southern District of Ohio. TO WARREN STONE, M.D., AND JAMES JONES, M.D., PROFESSORS IN THE UNIVERSITY OF LOUISIANA, THIS VOLUME IS RESPECTFULLY INSCRIBED, BY THEIB FRIEND AND COLLEAGUE, THE AUTHOR. TO - WALTER HAYLE WALSHE, M. D., Professor of the Principles and Practice of Medicine, and of Clinical Medicine, in University College, London, PRE-EMINENTLY DISTINGUISHED AMONG THOSE WHO HAVE BESTOWED ATTENTION ON THE DISEASES OF THE LUNGS, THIS TREATISE IS INSCRIBED, as A TESTIMONIAL OF PERSONAL RESPECT AND PROFESSIONAL ADMIRATION, BY HIS OBLIGED FRIEND, THE AUTHOR. PREFACE. In offering to the profession of the United States this Treatise on Phthisis Pulmonalis, I desire to state briefly that I was im- pelled to the task from a belief that a work on the subject was needed. There has been no American work on phthisis since the publication of Dr. Morton’s Illustrations, in 1838, which is now out of print; and although many excellent foreign monographs on this subject have been republished in the United States, they can not supply the want of an indigenous treatise. It is not presumed that consumption is different in this country from the same disease elsewhere; but at the same time it is evident that the influences of climate, domestic habits, races, and other modifying conditions, render a systematic account of the disease as met with here highly important. Hitherto, the facts in relation to the prevalence of phthisis in the United States have not been collected in a system- atic form, and hence the most opposite opinions prevail on the subject. Some believe phthisis to be most prevalent in the North- ern states, while the highest authorities (Forry, Drake) teach that the disease is more common in the South. I have endeavored by. the collection of the most accurate statistics to settle this important question, and thus to enable the practitioner to direct his patient to those localities which offer the greatest chances of relief. But while particular attention has been given to the prevalence -- (¥) xi PREFACE. of phthisis in the United States, an account of the Geography of the disease, in a general sense, has been introduced; and the sub- ject of a change of climate has been carefully considered in its relations to the different stages of the constitutional and local mor- bid conditions. It has been attempted, also, to furnish an outline of the whole subject of Tuberculosis, embracing the principal facts which have been clearly established by the concurrent observations of the profession. The most prominent theories of the pathology of phthisis have been noticed, with remarks on their intrinsic merits, to which is added my own opinions. I have made an attempt to systematize the therapeutics of phthi- sis, according to the different stages of the disease, thus placing the whole treatment, as far as practicable, on a scientific basis. Particular reference has been made to the forming or precursory stage, which, it appears to me, has been too much neglected by systematic writers. Having for a number of years past been thrown somewhat largely into the treatment of phthisis, in all its aspects, in public institu- tions and private practice, I have been enabled to form opinions for myself in reference to the treatment of the disease, and these opinions have been candidly stated in the succeeding pages. And while due respect has been paid to the views of others, I have not hesitated to indicate my own preference for particular modes of treatment, based on personal observation and experience. Finally, whatever defects may be observed in the literary exe- cution of this work, I must plead in extenuation, at least in part, constant and extensive professional engagements, which have pre- vented that careful revision of manuscript which might otherwise t L. M. Lawson. have been made. Cincinnati, November, 1860. ERRATA. Page 229, line 22, for increases read decreases. Page 545, insert a dash (—) between Prognosis and Conclusion. CONTENTS. PAGE DR DICATIONS rsieucciectsaasjaceaswas dssas ce cedaeswechsn acausanacd os enead vances sneaisewanales ili-iv IPRER AGH, csiicgsdesesuawldehicseouawataaspasnees sGhreess als a Stechetenccisates se ana nena oreR ae v PART I. PATHOLOGY OF PHTHISIS. DIATHETIC ORGANISM. CHAPTER I. Tre TUBERCULOUS CONSTITUTION .......cscscsscesccececestcccerstsccersveuscseceecneccees 15 Secrion I. The Physical Conformation 16 “TE. Changes in Primary Digestion.........ccccccsssecssessssecesetsoeeasenees 19 “ TIL. Condition of the Respiratory Function..........ccccecccsceeseesesseeees 22 TV. State of the: Cirewlationcicsssscsasas ovixvenevacvenieinyeavsteseciestaeas ie 24 fh OV, Staterof ther Glands. ccsccscesasnosnwensicsicees vee ses sin alsintcoiieniswieirdaleninaieis 25 “ VI. Condition of the Nervous Function..............cscceeeeee sesewssy 26 te WED: Anima) HiGati.; «cs ciesa sein shies cnasdneencsamansarvenicaeaereetaueans sncsoes 27 PRIMARY MORBID CHANGES. CHAPTER II. THE Preoursory Stace or Puruisis OR TUBERCULOID CONDITION........0006 28 SECONDARY PATHOLOGICAL ANATOMY. CHAPTER III. TUBERCULAR DEPOSITS.......eceseesseers ail ba tralia eats Woda ves ne ducecanes one iol Section I. Physical Characters of Tubercle........ssccsssseeesceceseeeeseceeeerens 81 “ JI. Varieties of Tubercle.........ccsseceeseesesenceeesnseeeneeees ete t neni Saree 33 ( TEL. Forms of Tubercle: ccesscwsenoeasnacsveessnsasnasaoe sek uusceriwecesenaeunas 34 & TV. Histology of Tubercle......cccccssceseesssensseeseesessseeeeseseeennaeennes 35 « —V. Chemistry of Tubercle..........006 s aaisiaale ale adidas Suse vaacgevets sekueee” 42 viii CONTENTS. CHAPTER IV. : PAGE CONDITION OF THE BLOOD.s...csssesccesecseeecccenseneesenneeenceseeperssceeessesenssnees 53 Section I. Physical Properties of the Blood..........sseceserseseeceeseeeeaceee sense 54 “ IL. Microscopic Appearances of the Blood........c.seeeseserseseeeeeeeeene 55 “TH. Chemical Composition of the Blood........:ssccsescsessseeesecesereaees 56 “IV. State of the Chyle and Lymph..........ccccccsccsersctserseesersceeerecnes 64 CHAPTER V. STATH OF THE: SEORETIONS .scasenisiesnasdinenedossnoaieddaegenssiens ve dbaeveccadenssaboes 66 Billary Secre ton smoccewssaswosc sy speavet since cctiwseaseeaecawine ese os nadoeqegessaudsaensens 66 UPinary BeGreti OW ie sacexeen ida iteiicnecires at sisiein he seuvanniedie du vlanau sie gsbieulsabaratenice 68 Cutaneous and Mucous Secretions. ...........c.cesscecsesseceeessceseeseeseenneeeeeaees 71 ADIPOSE SCHOO sass sceav cera sinbieriewncisaeiniga vial uisdnwisl ddvslesodealiavesausicatnan sides 72 Menstrual Secretion snsesssssacccersenevoreoasneessnvioneecenuenees sesstansrcburenvees 72 CHAPTER VI. DEPOSTR ORT OBEROT Ms cotsiad. shale (sc dasa saa ou caucasian swanel ova sateeensnmbeagvteusbeaysies 73 Section I, Tissues in which the Primary Deposit takes place.......::.0000000 73 (IL. Mode of Deposit of Tubercle.........ceeeccesececececsseneeeseeesseeeeneas 75 “ TIL. Relation of the Blood-vessels to Tubercular Deposits............0++8 78 “ IV. Mode of Enlargement of Tubercles...........ccsseccccccseeseesseeeeeees 81 “'V. Relationship of Gray and Yellow Tubercle..........sssecssesseescaees 84 CHAPTER VII. CHANGES WHICH occuR IN TusercuLar Deposirs.......... eiiieetiseeuntenesazens 88 Szction I, Absorption prior to Consolidation.........cs:cccseessssceccssenseeseeees 88 “ IL. Absorption after Softening........cssssssssscessscecusssceosesecerseees 90 “ TIL. Contraction, or Stationary Condition.........c..cccscsssssesseeceees 92 “ IV. Softening and Elimination. ...........cccssssseccsosssseacscecessessceeeses 93 “ .V. Cretaceous Transformation.........c:cccssscceessesssssecessncseeseaces we 96 CHAPTER VIII. CHANGES CONSEQUENT Upon Sorrenine AND Exruination or TUBERCLES...... 98 Section J. Changes in the Pulmonary Tissuc......s..csescessssscereceeesenscesecece 98 ‘IL Condition of the Bronchiv.s....csesccccssessssssssecescesessrecsseseeees 102 “ III. Condition of the Pleura............:ccccscssessssesssavecsanececccecesceeeee 103 DIstRIBUTION OF TUBERCLE........ccsscssssssesssessscsescssssscessesssevsesesessecsecese 105 CHAPTER X. SECONDARY AND INTEROURRENT LESIONS...cccccssesseceeseresseces sivas sasnmee wen LOT CONTENTS. ix PAGE Seorion I. Pneumonia in its Relations to Phthisig..........ccccesseeeesrersnees 107 OO Te Rlewrisysesicssscennecssponeeesereaoteasvericens ecbaeeeleseWewes levee sie tans ll4 Oe HID, | BROUCHULISHica ss ceeesastsod Goendos peo easadeeadadoneeie nat nrmnatgdsvauielanuneumatinn 115 WAV, Bmphysemaesvc:sssswnssasa carves ses seseas deusreyaresteesoteseemseciimeeneees 116 OV. Pulmonary (sd emis se ussecsssscccusascetsccvabeastdssied saevacd seenenss 118 & VIL Pulmonary Hemorrhage...........ccoccecsessssserenssonssrevsesceeensireces 119 “ ‘VII. Pulmonary Gangrene.............066 WadineiiivadaeueneabbesesvereceNT GATE 120 TERTIARY LESIONS. CHAPTER XI. TERTIARY LusIons........... dpeseawensnewaasy ssiaparneeancaeateereenas edseieguinessgernaes 121 Seotion I. Tertiary Lesions of the Organs of Circulation.........cccceseseeeeeees 121 “IL. Tertiary Deposits in the Liver........cccccsssssccecceccesesecereveeeeeens 124 JIL Tertiary Effects on the Fluids.........csscesccssssscesssseveeseerseseeves 125 CHAPTER XII. FoRMS OR VARIETIES OF PHTHISIS......cccccseeeeesseeseeees daathaenucheneeeteamecas .. 128 CHAPTER XIII, NATURE OF PHTBISIS...iccccccsnesesnsrecstnatsscnerepocessceneccorsnscoieesenstessinnenee 131 Section I. Impaired Primary Digestion............cccccceuserceneseeesseceeseeseaues 132 “II. Imperfect Development of Chyle.esssecseeceseesetesnseneteeeeeseree 135 “& TIT Morbid Condition of Lymphu......ccccecsccsescceneeeseneeesenneseseneeees 136 “ IV. Defective Respiration............ atueecagestnie’ L waveneantvisensacimenervene 137 & 'V. Morbid States of the Blood ........cccccsecossseresseaseeeeesenesarseneoens 139 VIL A Specific Poison...........ccesccostssssscceneceeneesenteeesaasneneeeneeeeoes 140 “ VIL Changes in the Condition of Albumen and Fibrin...............66 142 “VIII. Retrograde Morphology......csccccssccssresssessesceeessteeeeererersreeees 144 “TX. Derangement of the Organic Nervous Powet.......sssessseesoreeeee 144 6 XK, Unflammation.......sccusecseccscseesscenseeeessseveesensceeesseeseesenseseaes . 145 PART II. ETIOLOGY OF PHTHISIS. GENERAL REMARKS.....ccsccccssecceeceessscceececsneeseseesenseensussavausoens scenic ee CHAPTER I. CoNGENITAL PREDISPOSITION TO PHYTHISIS.......ssecccnecerseeseseeeeseneeterseueeees 185 Suction I. Hereditary Predisposition transmitted by Phthisical Parents... 185 « JI. Hereditary Predisposition transmitted by Non-Phthisical Pa- LON ESccesevonsicnaavmnweudainder vaasoeyesrsarves seeadeseene onde sod slesiee 194 x CONTENTS. CHAPTER IT, PAGE CAUSES WHICH MAY INDUCE PHTHISIS, INDEPENDENT OF AN HEREDITARY PREDISPOSITION sco esennnccaairacsvanvexdamndcamentenenaessedsocsevarcarenmies 198 Section I. The Influences of Climate in the Production of Tuberculosis..... 199 “II. Temperature in Relation to Phthisis..........scssccssessesseeeerevevens 232 “ TII. Humidity in Relation to Phthisis............0:.cccsseceeseesenenseenes 238 “IV. Altitude in Relation to Phthisis...............:ccceseseceeseeceseseeenene 242 “« V. Atmospheric Impurities as Causes of Phthisig............ccseseesees 243 “VI Temperaments in Relation to Phthisis.........:.cc:csseesscrssesseeses 245 “ VII. Age in Relation to Phthisis “ VIII. Sex in Relation to Phthisis..............::::sseceesesseseeeseceeeeeeensens ‘IX. Occupation in Relation to Phthisis..........c::cccesssceseceseseeeees 252 « X. Ingesta in Relation to Phthisis.............ccsscccssessseeeeeeereeeteets . 262 CHAPTER IIT. PatHOLoGIcAL INDUCING CAUSES OF PHTHISIS...........cecccccereeseseeseeceeeeerees 275 Section I. Relationship of Pulmonary Inflammation, Congestion, and Hem- orrhage to. Phthisisisicsessassvssontesssiss seveevuededeeeveeosiven 275 “II. Relationship of Influenza, Pertussis, and Asthma to Phthisis.... 284 “ III. The Relationship of essential and eruptive Fevers to Phthisis.... 286 “IV. Relation of various Constitutional Conditions to Phthisis...... 300 “ V. Influences of Diseases of the Heart.....cccsscccessscssesseeceesseees 308 PART IIil. SEMETOLOGY OF PHTHISIS. CHAPTER I. SyMPTOMS OF CHRONIO PHTHISIS..........csssssccccssssssssssesocecssseeeeeeecrseeceses 313 Section I. Symptoms and Signs of the Precursory Stage of Phthisis...... 315 ‘‘ IL. Phenomena of the Stage of Tubercular Deposits...........0...066 328 “ III. Phenomena of the Stage of Softening.........cccscsccceseesccseceee 362 “IV. Symptoms and Signs of the Stage of Cavities. .......cccssssceees 366 V. Diagnosis of Chronic Phthisis..........ccccccsscsccssecsecceeseseeeenses 379 “VIL Duration of Chronic Phthisis........s.c.csccsssscsscsssssseseeceesecene 389 CHAPTER II. Symptoms or INFLAMMATORY PATHISIS.......cecceceee de vandaeisauennnnievassite sonar 393 CONTENTS. xi PART IV. THERAPEUTICS OF PHTHISIS. CHAPTER I. PAGE TREATMENT OF CHRONIC PHTHISIS.....ccssscssssscesesscsssssecsssscsssacessaaeessnees 407 Secrion I. Treatment of the Precursory Stage of Phthisis...... (canine maseas 408 “Il. Treatment of the Stage of Tubercular Deposits..........ccccc00 seve 480 “ TIL. Treatment of the Stage of Softening...........cceseeeseeeeeneees .. 462 “IV. Treatment of the Stage of Cavities.........ss:ecccsessessrecenereaees 476 “ V. Treatment of Incidental Symptoms.......cssseecceseeecescseeeecenseeee 490 “ VI. Treatment of Complications.........cccsscccccsseccsscssteceeenseseeeees 1» 502 CHAPTER IT. TREATMENT OF INFLAMMATORY AND ACUTE PHTHISIS.......scsccesessercscreensees 509 CHAPTER III. SpectaL Questions IN THE TREATMENT oF PHTHisiS....... i seni uatiad dynes vedas seas BIT Change of Climateiscssscansesnessesesemseanimsaveecpaavaiwiassivesesasersiewey weaeeoats 517 ICA VOVAPOSS cove cussne aa sada uhssie gel rosdeaay sos daeded ened csdedasiadesoseanans ea tenbiee 520 Gestationivvsiavssevsvesvcnsrivssasisaciaswvacesasanses guenusaanieananrceaieasieaederieas erie 525 Topical Medication.......sccesveres deacbanatias Wasa cies cae ad Ravana ste atnenamet eee » 531 ConcLust0N—PROGNOSIS...4.0006 sian wanewnwesiy aseaeneacenevess imasen cre auesin daocrene 545 PART FIRST. PATHOLOGY OF PHTHISIS. PATHOLOGY OF PHTHISIS. Tue pathology of Phthisis Pulmonalis embraces every element of disease, connate and acquired, from the mere diathesis, or hereditary tendency, to the lesions resulting from the local deposits. It includes, therefore, that well-known, but ill-de- fined condition, denominated the tuberculous constitution, or diathesis, no less than the fully developed stage of tubercular deposits, together with all the ulterior changes which take place in the various organs and tissues of the body. These different stages of disease will be examined under the following heads: . I. Tue Diatuetic ORGANISM. II. Tur Primary Morprp CHANGES. IIL. Tur Seconpary PatnontoeicaL ANATOMY. IV. Tue Tertiary Lesions. (14) i, THE DIATHETIC ORGANISM. CHAPTER I. THE TUBERCULOUS CONSTITUTION. Tue most extended and accurate observations conclusively establish the fact, that certain organizations are naturally pre- disposed to the ultimate development of tubercular disease. In what this constitutional predisposition essentially consists must, of necessity, like all ultimate facts, remain largely conjectural; but that it is of a character capable of transmission from one generation to another, and of ultimately merging into active disease, numerous facts abundantly attest. The term diathesis, applied to this particular organization, is employed to designate a mere tendency to disease, but not itself a morbid condition. It appears to me, however, that this application of the ‘term diathesis is palpably unphilosophical, and contrary to the well- known laws of the human organism. If the term does not indicate disease, it must, of necessity, represent a state of health; and if a normal state of structure and function exist, there can not be at the same time a predisposition which leads spontaneously to a particular form of disease. On the contrary, when the organization and vital actions are perfectly normal, the tendency is to the maintenance of that condition, and the development of disease requires the intervention of an exciting cause. A state of the organism, therefore, which spontaneously (15) 16 PATHOLOGY OF PHTHISIS. leads to a particular disease is of itself an abnormal condition, and consequently is something more than a mere predisposition to morbid action. Hence, instead of employing the term dia- thesis in its conventional sense, I shall substitute the phrase tuberculous constitution to designate a state of the organism which is a departure from the true physiological type, and which, under varied influences, may remain stationary, recede, or spontaneously advance to the completion of the tubercular process. The tangible changes which constitute this tubercu- lous constitution, are observed in the modifications of certain structures and functions, which indicate a departure from the physiological type, instead of a simple predisposition to disease. SECTION I. ~ THE PHYSICAL CONFORMATION. The physical conformation indicative of the constitutional predisposition to phthisis, is believed by many to be sufficiently marked to admit of ready recognition. But it must be ob- served that most writers include under this head those external signs connected with the scrofulous diathesis, which impairs the accuracy of their general statements; for whatever may be the relationship of scrofula and tuberculosis, I have no doubt that, in general, the same external manifestations do not exist. Sir James Clark, speaking of the tubercular cachexia, makes the following statement: “When of hereditary origin, it is manifested by a peculiar modification of the whole organiza- tion,—in structure and form, in action and in function.”* And he proceeds to state that the countenance, in early childhood, has a pale, pasty appearance, the cheeks full, and the upper lip and nose tumid. If the complexion is dark, the skin is sallow; if fair, it is white or blanched, with prominent veins. The external signs become more marked with advance of age. * Treatise on Pulmonary Consumption. THE PHYSICAL CONFORMATION. 17 The eyes and pupils are large, with long eye-lashes. When the complexion is fair, there is great beauty, with a placid expression of countenance; while in the dark complexion, the skin is coarse and sallow, and the features less regular. The body, in early infancy, is large, but is not firm, and there is a want of proportional development as age advances. The head is large, trunk small, abdomen tumid, large, and clumsy, or slender, with large joints, The development of the body is irregular, being slow and imperfect, or preternaturally rapid. Such is the description given, by one of the most distin- guished writers on the subject, of the physical evidences of the tubercular cachexia, and it will be readily recognized as that which is usually applied to scrofula. Dr. Glover* has con- densed the statements of Le Pelletier and Deygalliéres, Fisher, Disse, and Bredow, (who, in turn, copied their descriptions from Hufeland,) in relation to scrofula, and it will be observed, from the following abstract, that they agree sufficiently with that of Sir James Clark, as applied to the tubercular conformation. 1. A want of bodily symmetry, by a tendency to disunion at the mesial line; a gibbous chest; weak and often crooked limbs; broad jaws, low, angular forehead, and short neck. 2. A pe- culiar expression of countenance, due to the form of the jaw and forehead, and a large head, puffed visage; eyes and pupil large, and eyelids edematous; meibomian secretion in excess ; eyelashes long, ete. In these statements we perceive precisely what has been re- marked by almost every writer, from Hufeland to the present day, as indicative of the scrofulous constitution; and, as sug- gested by Dr. Glover, the descriptions are evidently copied, one from another, and each one with but little inquiry as to the truth or fallacy of the general statements. Much has been said, too, of the particular conformation of the chest in those predisposed to tubercular consumption. The gibbous, conical, narrow chest, are the terms applied to indicate a malformation, or a deficient development of the pulmonary structures. JFournet, Woillez, and Hertz have attempted to * Pathology and Treatment of Scrofula. 18 PATHOLOGY OF PHTHISIS. establish some general laws on this subject, especially that, in the tuberculous constitution, the transverse diameter at the superior part of the chest is diminished, which gives the thorax a cylindrical form, and diminishes its general capacity. In opposition to these views, however, we may quote the opinions of Hasse and Rokitansky. The former declares that “a frame of body certainly indicative of future phthisis does not exist;” while the latter states that “the well-known and so-called ohitttanl conformation of the chest is not always present; and what peculiar relation it bears to tubercular dis-. ease is still unknown. The assumption that it depends on smallness of the lungs is unwarranted and hypothetical.” In the midst of these contradictory statements, each observer must be left to decide in accordance with what passes under his own immediate observation ; and guided by this rule, I have long since reached the conclusion, that there are no certain and infallible external indications of the tuberculous constitution. It is true, certain inferences may be drawn from incomplete, irregular, or preternatural development of the organization ; it may become a fair conclusion that in such systems, premature decay, or the development of disease, acute or chronic, will more often supervene than in well-developed bodies; but, at the same time, it is impossible to know that such persons will become scrofulous or tubercular, or whether they may not fall victims to other forms of chronic disease. If we meet with a person exhibiting the conformations of the chest described by Fournet, and we know that he comes of a tuberculous family, we might safely predict the occurrence of the same form of disease; but if we observe a similar condition of the thorax independent of a known hereditary taint, we would not be authorized, in the present state of knowledge, to declare such a person to possess a tuberculous constitution. There can be no doubt, however, that when the tuberculous taint is very strong, (for example, when both parents have been affected,) the development of the body is more or less incom- plete, and often presents some of the peculiarities named; but these signs are not always present, even in extreme cases, and are more frequently manifested in the functions than in the CHANGES IN PRIMARY DIGESTION. 19 external structures. Governed, therefore, by my own observa- tions, I have no hesitation in reaching the conclusion, that the external marks of a phthisical tendency are too inconstant and variable to admit of ready recognition, or to be relied on in diagnosis. Being daily in the habit of examining the chest, I have failed to recognize in its contour any constant or even frequent deviation, until after the deposition of tubercles takes place. And I can not avoid suspecting that many of the de- scriptions of prominent shoulders, contracted chests, and pro- jecting clavicles, have been taken from the actual disease, instead of the mere predisposition. It is probably true that tall persons are more prone to phthisis than short ones; but certainly we could predicate but little on such a fact, for we would scarcely be safe in affirming that every tall person was predisposed to consumption. Nor do I doubt that scrofula has more evident external signs than phthisis; indeed, this form of disease is more prone to affect the exterior, and hence is more distinctly impressed on the external structures. But there is sufficient reason to believe that the phthisical constitution is more distinctly foreshadowed in the functions than in the structures of the body; and these deviations will be briefly enumerated. SECTION II. CHANGES IN PRIMARY DIGESTION. The condition of the digestive function, as presented in the well-marked tuberculous constitution, has been carefully studied by many competent observers; but the conclusions do not ex- hibit that degree of uniformity, and that definiteness of result, so desirable in scientific investigations. The facts, however, which have been disclosed, are sufficient to arrest attention, and are capable of becoming the basis of a safe generalization. The state of the digestive function has been carefully inves- tigated by many of the German pathologists, and they indicate acidity as the characteristic condition; and still more recently 20 PATHOLOGY OF PHTHISIS. Dr. Bennett, of Edinburgh, has drawn attention to some special views on the subjegt. This author mentions particularly the occurrence of acidity in the prime vie as a constant accom- paniment of the tuberculous constitution; and he expresses the opinion that this acid neutralizes the salivary and pancreatic fluids, in consequence of which carbonaceous and fatty food is not properly transformed; and, furthermore, the same condi- tion renders the albuminous element preternaturally soluble, and hence it is introduced into the system in too large quan- tities, which leads to local disease. In this state of the digestive function, it is presumed the fatty substances enter the circula- tion in diminished quantities, and hence the want of properly elaborated chyle.* The opinions of Dr. Bennett, although plausible and ingeni- ous, appear to be largely hypothetical; the observations, indeed, on which they rest are evidently based on limited views or speculative notions. At the same time, I do not presume to deny the modified condition of primary digestion in this state of the system; but it is rather a predisposition to disorder than a well-defined state of indigestion, as the remarks of Dr. Ben- nett would indicate. The delicate character of the structures appertaining to the true tuberculous constitution imparts to the function of digestion a condition of irregularity rather than positive disease; hence, such persons exhibit variable, and, at times, vitiated appetites, frequently consuming large quantities of food, with perfect primary digestion. Indeed, a majority of young persons who inherit this constitution manifest a strong desire for food, which is eaten with avidity, and digested with facility ; and the only marked deviation from a state of health is the condition of irregularity, more or less constantly observed in such persons. It is proper to remark, however, that the large quantities of food which some persons take, exceed the powers of digestion, and, as a necessary consequence, acidity and other disorders of the function arise. But this condition is altogether secondary, and therefore not to be regarded as the type of the tuberculous * Pathology and Treatment of Pulmonary Tuberculosis. CHANGES IN PRIMARY DIGESTION. 21 constitution. It would be erroneous, however, to characterize this condition as dyspepsia, or any form of primary gastric disorder; on the contrary, the acidity, nausea, vomiting, diar- rhea, and so on, met with in persons of this class, are but the results of over-eating, to gratify a craving appetite. These paroxysms of gastric disorder at once produce the impression of primary dyspepsia; and the constipated or relaxed bowels, vitiated bile, or light-colored stools, together with occasional pain in the stomach and bowels, confirm the first impression. But a careful analysis of the facts shows that the morbid con- dition is often secondary, being dependent on improprieties in diet, either in regard to quantity or quality. The dyspeptic phthisis of Dr. Wilson Philip, and the stru- mous dyspepsia of Dr. T. J. Todd, are widely different from that legitimate tuberculous indigestion to which I have referred. Dr. Philip’s indigestion is a primary disorder of the stomach and liver, acting either as a predisposing or exciting cause of phthisis, and is, therefore, no measure of the intensity, or index to the existence of a tuberculous constitution, acquired or hered- itary. On the contrary, it is merely an inveterate dyspepsia, which may ultimately lead to the deposit of tubercles. And the strumous dyspepsia of Dr. Todd is the result of primary disease, and not a necessary element of the tuberculous consti- tution. The conclusion, therefore, which appears most in accordance with the facts is this: the derangements of primary digestion incident to the tuberculous constitution can not, as a rule, be regarded as a cause of the tuberculous constitution, but that the digestive defect, whatever it may be, is a part of the con- stitutional infirmity, and therefore is an accompaniment, and not a cause, of whatever derangements ensue. 22 PATHOLOGY OF PHTHISIS. ° SECTION III. CONDITION OF THE RESPIRATORY FUNCTION. It has been previously stated that, according to some ob- servers, the chest frequently affords evidences of diminished capacity, most marked at its superior part, and affecting chiefly the lateral diameter. There is not suflicient evidence, however, that the contour or dimensions of the chest are so constantly and uniformly affected, as to establish a rule in the tuberculous constitution. On the contrary, it has appeared to me, from my own observations, that even when the hereditary predisposition was distinctly marked, the chest was often well-formed and fully developed. Dr. J. S. Campbell* has attempted to prove, that -the capillaries of the lungs are imperfectly developed, which is shown by the incomplete passage of injections through them. That such want of development may exist, it would be unwise to deny; but, at the same time, additional experiments are required to determine the question. I do not believe, therefore, that any degree of deformity of the chest, however frequently it may be observed, is at all essential to even the rapid and fatal development of tubercle. But while this is admitted, it is quite as apparent that the respiratory function becomes more or less impaired, either habitually, or at the near approach of phthisis. There is, evidently, a period when these variations are so slight that no physical or rational exploration can detect them; but when the diathesis is more marked, or the precipitation of active disease nearer, the signs of respiratory derangement are too evident to admit of doubt or misapprehension. The special and evident change which occurs, consists in impaired power of expansion. At a more or less early period, the muscles concerned in the active expansion of the chest seem to lose a portion of their power, and the chest expands imperfectly and irregularly. In consequence of this, the ordi- * Observations on Tuberculous Consumption. London, 1841. CONDITION OF THE RESPIRATORY FUNCTION. 23 nary breathing capacity is diminished, the respiratory murmur becomes more or less weakened, and, at the same time, wavy and even jerking. These changes in the respiratory murmur are readily perceived by auscultation, and the diminished capac- ity may not only be inferred from the condition of respiration, but positively demonstrated by the movements of the chest. I have long been in the habit of observing these modifications of the respiratory function, and regard them as decidedly the most characteristic of all the signs supposed to indicate the existence of this state of the constitution. It should be re- marked, however, that these signs are more readily recognized in what will hereafter be described as the precursory stage of phthisis; but it is equally true that they exist, in a minor degree, in the fully developed tuberculous constitution. Dr. Theophilus Thompson* has pointed out the existence of wavy inspiration prior to the development of tubercles; and it is the. more satisfactory to myself, from the fact that I had often ob- served it before being aware of this author’s researches. I can not, however, with Dr. Thompson, ascribe it to an exudation about the terminal bronchial tubes and areolar tissue, but am inclined to believe that it arises, at least in many instances, from weakened respiratory action, depending on impaired energy of the muscular and nervous systems, and is, therefore, purely func- tional. That the deposits mentioned may take place is not de- nied, and it is quite possible they may cause the sign in ques- tion; but it appears to me equally evident that the imperfect expansion and interrupted respiration depend, in a certain class of cases, on functional derangements. The pulmonary system, embracing the areolar tissue and capillaries, partakes of the same defects that belong to these structures in the tuberculous constitution generally ; hence, it may be assumed that the capillaries of the lungs are com- paratively weak and attenuated, and the areolar tissue coarse and inelastic. To this we may add a weak right heart and probably deteriorated blood; all of which tend to a disordered circulation, but especially so when the deficient expansion, * Clinical Lectures on Pulmonary Consumption. 24 PATHOLOGY OF PHTHISIS. previously described, becomes one of the elements of disorder. When, therefore, the respiratory action becomes weak and . incomplete, congestion of the pulmonary capillaries, or even inflammation, is liable to occur under the influence of ex- citing causes. And the occurrence of congestion, simple or inflammatory, speedily induces tubercular exudations, and thus ushers in active disease. We thus see how the combination of circumstances made up of structural and functional defects, tend to develop local disease, and to convert a constitutional affection into a fatal pulmonary lesion. SECTION IV. STATE OF THE CIRCULATION. The vascular system in the tuberculous constitution is more or less defective in organization and functions. Mr. Ancell* observes that there is a visible tenuity in the coats of the arterial and capillary systems, and hence these vessels are defi- cient in contractility, while the veins are weak and inelastic. To this may be added, that the fibers of the heart are propor- tionably weak and deficient in contractility, giving rise to a slow and sluggish circulation. It has been affirmed by Dr. J. 8. Campbell,} as the result of direct experiment, that the capillaries of the lungs are smaller in the tuberculous constitution than in others. This opinion is based on certain experiments, in which he injected a colured material through the pulmonary artery, and it was found that in those evincing a tuberculous tendency the coloring matter did not pass, while the finer material went freely to the left side of the heart. The author believes these experiments war- rant the conclusion that the pulmonic capillaries are of smaller dimensions in the tuberculous constitution, and therefore can * Treatise on Tuberculosis. London, 1852. T Observations on Tuberculous Consumption. London, 1841. STATE OF THE GLANDS. 95 not transmit particles of the same diameter that would readily pass those of ordinary size. The structural modifications of the vascular system, espe- cially the capillaries and heart, are doubtless sufficient to im- press the system in a very important manner; and if we add to this the weak and defective condition of the areolar tissue, which serves as the matrix for the distribution of the capillary vessels, it will be manifest that important modifications of the vascular system and of the circulation will readily occur. There can be no doubt that the tenuity of the vessels, and the inefficient support which they receive from the investing tissues, greatly favor the mechanical processes of endos- and exos- mosis, thus giving rise to the ready deposition and absorption witnessed in this constitution. The natural tendencies, there- fore, of the circulatory function, is to congestive action, ready exudation, and rapid absorption. SECTION V. STATE OF THE GLANDS. The glandular structures are generally of normal size, and in some instances manifest more than natural activity. I have already referred to the facility with which deposit and absorp- tion take place, and this same activity pervades the glandular actions generally. Where the serofulous element predominates, the lymphatic glands seem to possess undue development, and to take on excitement with great facility; and in the pure tuber- culous constitution there is evidently the same crude structure and function connected with the chyliferous system and its appendages. It is probable, however, that the modifications met with in connection with the glandular system are ex- plained, at least in part, by the peculiarities of the capillary and areolar tissues already mentioned. Hypertrophy of the thyroid body has no evident connection with the diathesis under consideration. The alleged hypertrophy of the liver 26 “PATHOLOGY OF PHTHISIS. (Rostan, Parola) has been generally admitted; and there is some reason to believe that this gland is crudely enlarged,*independ- ent of the fatty deposit which often occurs in advanced stages. SECTION VI. CONDITION OF THE NERVOUS FUNCTION. The nervous system in the tuberculous constitution possesses an average degree of tonicity below the healthy standard; that is to say, its powers of endurance are evidently inferior to those of a different conformation. This remark, however, applies mainly to the organic forces; indeed, the defects, if any exist, in the cerebro-spinal system, especially with reference to the intellectual faculties, are much less obvious than in the organic system. There is reason to believe that the original structure of the nervous system is not specially defective; indeed, the large amount of albuminous material (probably) existing in the blood, would be quite sufficient to furnish materials in abundance for the formation of nervous structures. But if the various con- stitutional defects previously noticed exist, especially changes in the nutritive system, functional disorder of the nervous sys- tem will necessarily ensue. Irregular action, consisting of alternate excitement and depression, is very constantly observed, which is more evident in the organic than intellectual acts. Thus the occasional copious watery and otherwise altered secretions, irregular distribution of blood, and above all, the rapid changes in deposit and'absorption, point to the condition of innervation; for notwithstanding other functions and con- ditions are concerned in these acts, (especially the state of the blood,) yet the sudden transitions under the influence of ordi- nary stimuli, indicate that the nervous system is materially involved. Indeed, the large influence exercised by the nervous system over the nutritive function, may serve as a basis for, at least, a plausible conjecture that the organic nervous force ig materially at fault in the tuberculous constitution. ANIMAL HEAT—CONCLUSION. 27 SECTION VII. - ANIMAL HEAT, If we admit the physiological law that the development of animal heat bears a relation to the red corpuscles, (which are probably deficient in this constitution,) the conclusion will be irresistible that the calorific power is necessarily reduced. And this inference is fully sustained by observation. I have con- stantly observed, in the tuberculous constitution, manifestations of an inordinate sensibility to a reduced temperature; and so prominent and constant is this condition, that it becomes, as we shall see hereafter, an important feature in the history of phthisis. A sluggish circulation, altered blood properties, and weak innervation, will invariably fail to produce the normal amount of animal heat, except when febrile or inflammatory action supervenes. Hence, the characteristic of the tuberculous constitution in this relation is imperfect development of animal heat. CONCLUSION, The various modifications of structure and function which have been mentioned in the preceding remarks, as characteristic of the tuberculous constitution, are not invariably present; on the contrary, where the hereditary taint is comparatively slight, requiring the intervention of some exciting cause to develop the disease, the evidences of an imperfect or peculiar organism may be either entirely wanting, or but partially manifested. Hence, we must not always expect to find the full development of the external signs said to characterize this peculiar constitu- tion; nor, in their absence, are we authorized to conclude that a predisposition to disease does not exist. But these vices of constitution may be safely regarded as an accurate measure of the intensity of the predisposition ; and hence they afford an element of prognosis, possessing great intrinsic importance. ee PRIMARY MORBID CHANGES. CHAPTER II. THE PRECURSORY STAGE OF PHTHISIS, OR TUBERCULOID CONDITION. We come now to consider a stage of morbid action inter- mediate to the tubercular constitution, on the one hand, and the local deposit of tubercle, on the other. The mere constitu- tional condition, embracing certain structural and functional deviations from the ordinary physiological type, and, therefore, not a stage of perfect health, is, nevertheless, short of positive morbid action, as that term is generally received. It consists, in fact, of certain irregular actions, exhibiting deficiencies and excesses, but not a clear and evident establishment of a well- defined disease, tending to progressive increment, and therefore, not giving to the patient the sense of morbid action. But there is another condition, which I have denominated the pre- cursory stage of phthisis, which is characterized by decided morbid action, and yet is anterior to the deposit of tubercles. In the precursory stage of phthisis, we observe a more marked departure from the physiological state than belongs to the mere constitutional predisposition; thus, the system loses weight, the strength diminishes, the secretions become still more variable, and calorification and innervation sink below the natural standard. In addition to these evidences of morbid action, there is, in a large proportion of examples, more or less (28) THE PRECURSORY STAGE OF PHTHISIS. 29 disease of the fauces, occasional chills, with slight febrile move- ments, and often variable digestion. This state of the system becomes permanent, and is not, like the mere constitutional predisposition, variable in its manifestations; nay, more, it is progressive, and if not arrested by appropriate treatment, surely and steadily advances to tubercular deposits. The pathology of this precursory stage, doubtless, consists in those preliminary acts which accompany the formation, and precede the local development of tubercles; and the evident derangement embraces changes in the nutritive function, vary- ing in intensity, according to the natural force of the disease, and the accidental circumstances which surround the patient. Dr. Cotton makes the interesting observation, that we are too much inclined to regard phthisis and tubercle as the same thing, whereas the former represents a morbid state of the general system, and the latter merely the local manifestation of that general disorder. Doubtless, this remark is strictly true; in- deed, the precursory stage of phthisis represents this morbid condition preceding the deposit of tubercle; and this state is, in fact, veritable phthisis; but it is not associated with the deposit of tubercles. It is evidently of the highest importance that this stage should be recognized, for it is, in fact, the most curable period of the disease; and the reader is referred to that part of this’ treatise in which the signs and symptoms represent- ing this stage of phthisis are fully detailed. CONCLUSION. T think there can be no reasonable doubt that there exists a condition of the system, anterior to the development of tubercle, which is a well-defined state of disease, constituting, indeed, the first stage of phthisis. It is characterized by cer- tain conditions, the natural course of which is to progressive increase, and it is, therefore, truly a morbid state. The mere constitutional predisposition, although not representing the 380 PATHOLOGY OF PHTHISIS. true physiological type, is, nevertheless, not open disease ; and hence the obvious difference between the conditions which have been described. One constitutes a tendency to disease, while the other is already a morbid state. We are not prepared, at this point, to enter into a full con- sideration of the intimate nature of this precursory stage, for that would involve the main question as to the essential nature of phthisis. Nevertheless, it may be remarked, that there is evidently a disturbance of the nutritive functions; a diminution of the vital powers of the system, including a certain degree of disturbance of innervation, circulation, and respiration. These disturbances may exist for a considerable length of time without the occurrence of tubercular deposits; or, in favorable cases, this precursory morbid state may be relieved, and thus the local affection may be entirely avoided. The recognition of the precursory stage of phthisis coincides with the general opinion of pathologists, that phthisis, taken in its broadest sense, is a constitutional disease. But, in addition to this mere accordance with the received doctrine of the profession, the full recognition of this stage of the disease will serve more forcibly to arrest the attention of practitioners, and to induce patients thus early to submit to systematic treatment. In a future chapter the symptomatology of precursory phthisis will be fully discussed, while its essential character will be con- sidered in connection with the general nature of tuberculosis. Lit. SECONDARY PATHOLOGICAL ANATOMY. CHAPTER III. TUBERCULAR DEPOSITS. SECTION I. PHYSICAL CHARACTERS OF TUBERCLE. Tux physical characters of Tubercle vary in form, color, and consistence, with the different varieties of the deposit. At the moment of exudation, tuberculous matter is probably fluid; but at this early period it is difficult, if not impossible, to make ac- curate and reliable observations. Tuberculous matter is clearly an exudation from the capillary vessels; but whether it occurs in the form of a simple fluid, or whether there is a liquid blas- tema containing nuclei which become developed into more or less perfect cells, may reasonably admit of doubt. The earliest stage of the deposit has been described by some observers as exhibiting a clouded aspect, with stellated points, which ulti- mately coalesce and form the solid deposit. Dr. Baillie* was the first to describe, in the following language, the infiltration which occurs in connection with the formation of tubercle: “In cutting into the lungs, a considerable portion of their structure sometimes appears to be changed into a whitish, soft * Morbid Anatomy. London, (31) 82 PATHOLOGY OF PHTHISIS. matter, somewhat intermediate between a solid and a fluid, like a scrofulous gland just beginning to suppurate. This appear- ance is, I believe, produced by scrofulous matter being deposited in the cellular substance of a certain portion of the lungs, and advancing toward suppuration. It seems to be the same matter with that of tubercle, but only diffused uniformly over a con- siderable portion of the lungs, while tubercle is circumscribed.” Doubtless, what Dr. Baillie thus describes as fluid tubercle, is the exudation of the tuberculoid material, from which the solid substance is ultimately formed, and not, as he supposed, an in- cipient state of suppuration. It corresponds, therefore, to the “juice of cancer,” and may be justly termed the juice of tubercle. It is probable, however, that the amount as well as character of this fluid is different in the two principal forms of tubercle, namely, the gray and the yellow, and that in the former it par- takes more nearly of the character of inflammatory exudation. If, however, the formation of tuberculous matter bears any relationship to other exudations, we may safely assume that its primary form is a liquid blastema, perhaps containing nuclei, from which the tubercle-cells are ultimately developed. When first recognized, however, as solid bodies, tubercles may be described as small, rounded masses, not larger than a pin’s head, of a yellowish ‘or grayish color, and varying in consist- ence from complete softness to almost cartilaginous hardness; usually, however, somewhat friable, and presenting a granular surface when cut. In form, it may be spherical or somewhat angular; but Rokitansky describes it as being more or less branched at its circumference. It exists in disseminated par- ticles, or in aggregated masses. The form, color, and consist- ence vary with the different varieties, to which I refer for a further account of these peculiarities. VARIETIES OF TUBERCLE. 33 SECTION II. VARIETIES OF TUBERCLE. Two principal varieties of tubercles have been so constantly recognized and described by pathological anatomists, that they must be made the basis of our classifications, although, without precautions, it will lead to erroneous conclusions. These two varieties embrace the gray and the yellow. 1. Gray or Semi-transparent Variety.—Andral describes these bodies as being grayish or at times reddish, and varying in consistence from a soft structure to almost cartilaginous hard- ness. It is remarked by Rokitansky, that smaller, softer, and more transparent bodies are often found interspersed among the larger; which may, I think, fairly be regarded as merely an earlier stage of the same substance. In size, the gray tubercles are variable, depending, no doubt, on the stage of development. The minutest form (as shown by Rokitansky’s observation) is a mere transparent granule, which may be microscopic, and this enlarges, according to the laws of cell-growth, until several of these aggregated consti- tute the gray granulation or semi-transparent tubercle. The ordinary size is that of a millet-seed ; but occasionally it appears in aggregated masses as large as a pea. It is usually somewhat tough, and, as the term indicates, more or less transparent, and when cut, its surface exhibits a comparatively smooth aspect. It exists mainly in the form of miliary tubercles, or dissemin- ated deposits, scarcely, if at all, in aggregated masses of any considerable size. | 2. Yellow or Crude Tubercle-—The yellow or crude variety . (which might properly be styled true tubercle) is of a yellowish hue, opaque, of rounded or angular form, varying in size from hemp seed to that of the common pea, with a tendency to coalesce in larger masses. It is somewhat friable or cheese- like in consistence, readily breaking up on pressure, and its cut surface presenting a granular aspect. These are the varieties of tubercle as described by systematic 3 34. PATHOLOGY OF PHTHISIS. writers, and which, in very general terms, may be called the gray and the yellow, or the semi-transparent and the opaque. It may be fairly questioned, however, whether these products in fact belong to the same class, or whether they are not radi- cally distinct in origin, essential characters, and ultimate ten- dency. This question will be more fully discussed hereatter ; but it may be remarked here, that the ultimate tendencies of these two varieties of morbid products seem so widely different that they can scarcely be assumed to represent the same species of exudation. Thus, while the yellow variety naturally tends to softening and elimination, the gray as constantly undergoes a retrogressive action, and never softens, except as a result of its possible transformation into the former species, or by its becoming involved in the general process of disintegration, when the two classes co-exist. Hence, according to this view, there is but one species of true tubercle, which is the opaque or yellow form. SECTION III. FORMS OF TUBERCLE. 1. Miliary Tubercles—This form occurs as disseminated or isolated tubercles, about the size of a pin’s head, or millet-seed, and may be either the gray or yellow variety—the gray being the most common. They have been called “ gray granulations;” and, as already stated, it is a question whether that term is not made to include morbid products not essentially tubercular. These bodies constitute the miliary tubercles of Laennec and Bayle; the disseminated tubercles of Gendrin; the simple tuber- cles of Lombard and Home. 2. Aggregated Tubercles.—Tubercles often become aggregated so as to form large masses, which are made up of a simple aggregation of the elementary deposit. These masses are mostly of the yellow variety, and denote an aggravated form of con- stitutional disease. Softening readily occurs where these masses exist, and large cavities are thus speedily formed. HISTOLOGY OF TUBERCLE. 35 3. Tubercular Infiltration —There are some examples in which the whole texture seems so completely occupied with the deposit, that it has received the name of infiltration. In the lungs it doubtless occupies the areolar tissue, conjointly with the air- cells, and thus, by copious.and uniform deposition, renders the part a mass of tuberculous matter, which might be properly designated tuberculous hepatization. In consequence of a deposit of black pulmonary matter, the indurated portion exhibits a ° mottled aspect, or assumes a gray or greenish hue; and, like ordinary hepatization, the torn surface is quite granular. This | condition occurs in what is known as acute or rapid phthisis. , The infiltration may be either gray or yellow. It is probable, ‘however, that what has been by some termed gray infiltration, is, in fact, an inflammatory deposit, and therefore not tubercular. Laennec describes a gelatiniform or albuminous deposit, which he thought was ultimately transformed into the crude or yellow, but which Rokitansky regards as an indication of a tendency to resolution. 4. Tubercular Dust.—This is a still more minutely comminuted deposit than the preceding, and is, indeed, so exceedingly atten- uated that it has been denominated dust. So exceedingly mi- nute and delicate are these particles, that their pressure, even when congregated in masses, does not always obliterate the -vessels; and hence Rilliet and Barthez have discovered drops of blood forced from the mass by pressure. Tubercular dust is, indeed, merely a form in which the particles deposited are exceedingly minute. SECTION IV. HISTOLOGY OF TUBERCLE. The minute anatomy of tubercle presents points of great interest, as illustrating its character and tendencies; and al- though some of these points are not definitely and conclusively determined, (as is shown by the discrepancies which exist 86 PATHOLOGY OF PHTHISIS. among microscopists,) yet enough is known to enable us to state with precision the essential elements which enter into the anatomical composition of these bodies. ‘True or essential tubercle embraces three anatomical elements: 1. An amorphous hyaline stroma; 2. Granules; and 3. Tubercle-cells. 1. The Amorphous Stroma.—This substance, which is the matrix in which the essential elements of tubercle are deposited, is described by Vogel* as perfectly resembling fibrin, and ex- hibits the same chemical reactions. This statement, however, evidently conveys an erroneous impression, for, if it perfectly resembles coagulated fibrin, it must necessarily reveal the ele- ments which characterize fibrin, and which would render it no longer amorphous. The fact is, this stroma or matrix is an albuminous pabulum, or cytoblastema, in which the granules and cells are formed, and doubtless affords nutriment for those structures. In the earliest stage of appreciable tubercle this stroma is present, and may, indeed, be regarded as the initial step in the morbid process. Acetic acid and alkalies produce a marked effect on the stroma, gradually rendering it less dis- tinct, until it finally disappears. 2. The Granules.—All observers agree that tuberculous matter contains numerous minute granules. These molecular bodies are exceedingly minute; they vary in size, according to Lebert, from yepth to zsooth of a line in diameter, and. are often too small to admit of admeasurement. They consist of three different classes: 1. A protein compound, insoluble in acids, alkalies, or ether. 2. Fatty granules, soluble in boiling ether. 38. Calcareous salts, carbonate and phosphate of lime, soluble in acids. These, molecules are round, occur in clusters or masses, and exhibit a slight shade of color—grayish or brown. They often surround the tubercle-cell, as well ag pervade it internally. They greatly increase when softening occurs. 3. Tubercle-cells—Microscopic observers are not agreed as to the exact appearances of the cells found in connection with tubercles. Some describe them as containing nuclei, while * Pathological Anatomy, etc. HISTOLOGY OF TUBERCLE. 387 others have not been able to verify the existence of such bodies. Lebert describes a tubercle-cell which he regards as peculiar, and as being characteristic of that product. According to his observations, these tubercle-cells present an irregular form, without nuclei, but contain molecular granules. These cells he - believes to be peculiar to tubercle, and therefore distinguishes it from all other morbid products. Gerber proceeds a step further, and describes four classes, varying in vitality: granu- lar tubercle, cytoblast tubercle, cell tubercle, and the filament tubercle. Gruby describes the tubercle-cells as of large size, being much larger than the pus-cell. On the contrary, Mr. Simon has denied the presence of cells as essential to the ex- istence of tubercles. Wedl describes tubercles as consisting of molecules, flocculent masses, nuclei, irregular granular corpuscles, and nucleated cells. ; These discrepancies doubtless arise from examinations having been made of different varieties of deposits, or different stages of development; and, again, while the substance was being acted on by different chemical reagents. This latter condition is capable of varying the results of microscopic examinations in a very remarkable manner. But when the true yellow tubercle is examined with an instrument of good defining power, the results will exhibit a remarkable degree of uni- formity. ; Tubercle-cells vary somewhat in size, but as a general rule they range from the géoth to gioth of a line in diameter. When the deposit is quite mature, or softening has commenced, the cells present a larger size. Their outline is mostly irregu- lar, being angular or fragmentary, but in some instances ex- hibiting a spherical form. The cell consists of a distinct cell- wall, containing from three to twelve, or even more, spherical granules; and apparently the same class of granular bodies exist around the cells, imbedded in the cytoblastema. Chemical reagents modify these appearances in a very re- markable manner. Thus, weak acetic acid renders the cell more transparent, and some of the granules disappear; ammo- nia dissolves the corpuscles, more or less, according to its con- 388 PATHOLOGY OF PHTHISIS. centration; while caustic potash completely holds them in solution. In the calcareous granules the particles are irregular in outline and dimensions, often intermixed with crystals of cholesterine. It may be added, also, that black pigmentary matter is sometimes intermixed with the tubercular deposit. In regard to the presence of nuclei, or true cytoblasts, in the tubercle-cell, as already intimated, observers are not agreed. While a majority of the most reliable histologists concur in the opinion that the intra-cellular bodies are granules, and not cytoblasts, a few, of equal reputation, including Rokitansky, Vogel, Gulliver, and Wedl, describe well-defined nuclei as occa- sionally, though not constantly, present. Among these may be particularly mentioned Vogel, who describes and figures tubercle-cells as containing, under some circumstances, distinct and unequivocal nuclei, and nucleoli. It is not a little remark- able that so distinguished an observer as Vogel should differ so widely from others equally accurate in histological investi- gations. But, notwithstanding the authority of his opinion, it would be illogical to admit it in opposition to such conclusive testimony as exists on the subject. I have examined tubercle- cells in every stage and variety, aided by the best instruments, and have never been able to verify, in a single instance, the presence of a nucleus. I can but agree, therefore, with Lebert, Bennett, and the majority of microscopists, who deny the exist- ence of nuclei, and regard the cell as containing only granules. In addition to these demonstrative evidences, it will be appar- ent, when we consider the nature of tubercle, that, a priori, it must necessarily consist of bodies widely different from nucle- ated cells. Indeed, no two classes of structures could be more dissimilar than the heterologous formations which contain nu- cleated cells, and those which we regard as tubercular deposits. It is quite possible that the occasional presence of organic cells, depending altogether on accidental circumstances, or existing in products not actually tubercular, and constituting no part of true tubercle, has given rise to the opinion entertained by Vogel, Gulliver, and a few others. In addition to these characteristic elements of tubercle, others quite constant, but not essential, are observed, among which CONCLUSION. 39 are epithelial-cells, pus-cells, blood, oil globules, cholesterine, and other less constant substances. It will be observed, how- ever, that some of these (as the pus-cells) belong to the stage of softening, and no doubt discrepancies have arisen from de- scriptions applied indifferently to the solid and softened states. Variations of Structure in the different Forms.—The elements which have been described as characteristic of tubercle, vary somewhat in the different varieties, as well as the stages of the deposits. The first deposit is probably the amorphous cyto- blastema, and immediately succeeding this, or simultaneously with it, the granules also appear; while the cells are of more gradual growth, conforming, in that respect, to the general development of organic tissues. The histological elements differ, however, in the two principal varieties. Thus, in the yellow variety, the protein compounds, granules, and fat, predominate, which render it soft and friable, while in the gray formations, the granular element is much less abundant, which places the cells in more immediate juxtaposi- tion, giving the structure its hardness and transparency. It is abundantly evident that the predominance of granules in the yellow, and of cells in the gray, explains the characteristic ten- dency of the former to softening, and the latter to remain sta- tionary, or even undergo a retrogressive action. CONCLUSION. The essential pathological character of tubercle, as well as its relation to the tissues in which it is deposited, have been variously explained by different observers. One party contend that it is an essential or heterologous morbid product, being wholly unlike the tissues in which it is deposited; while another class believe that it is strictly homologous, and is merely a retro- grade metamorphosis of the elementary structures of the part. Several distinguished pathologists have regarded the forma- tion as a process analogous to inflammation, among whom stand pre-eminent Reinhardt and Schroeder Van der Kolk. 40 PATHOLOGY OF PHTHISIS. The latter, however, believes that the deposit takes place in the epithelia of the air-vesicles, which become detached and converted into tubercle. Lebert considers that the tubercle- corpuscle is specific, and the local disease, therefore, is unlike all other morbid products. The opinion of Virchow is inter- mediate, in relation to the two parties; or rather, it embraces both views, in the explanation of the constitutional and local disease. He recognizes a general or constitutional disease, which he terms scrofulosis, and this leads to the local deposit, which is styled tuberculosis. And although the local changes consist in a retrograde metamorphosis of the tissues of the part, it is induced by the constitutional affection. -It is difficult to decide many of the ultimate questions started by pathologists in relation to the formation of tubercle; but, at the same time, thanks to the indefatigable researches of numer- ous observers, we are able to offer a reasonable explanation of the process. If tubercle is simply a retrograde metamorphosis of pre-existing tissues, without a specific exudation, it is essen- tially a local disease independent of a constitutional dyscrasia ; but, as already stated, Virchow admits both conditions, although he regards the local change as an altered state of the structures of the part. The histology of tubercle reveals peculiar cells, destitute of nuclei, and wholly unlike the corpuscles of any other product, healthy or morbid, and there is no direct evidence that they constitute a degraded state of any pre-existing tissue. The tubercular deposit may, indeed, take place in the air-cells, as believed by Schroeder Van der Kolk, Sieveking, and many other pathologists; but this fact, if true, does not establish the addi- tional opinion, that tubercle-corpuscles are merely changed epithelia. The fact, that they are unlike all other cells, affords a reasonable ground for the opinion that they are swi generis, and hence not a changed structure. It is a question whether tubercle admits of a microscopic diagnosis. Wedl* remarks that if a pathological new-forma- tion contains the elements of tubercle, and nothing else, it is * Pathological Histology. CONCLUSION. 41 purely tubercular new-formation. And this, it appears to me, is the key to the microscopic diagnosis of tubercle. If the substance consists of the elements described as constituting the characteristics of tubercle, and is destitute of blood-vessels and a fibrous tissue, the substance can be nothing else than tubercle. Morbid anatomists, from the days of Baillie to the present period, have described a fluid deposit as the primary state of tubercle; and this has been called, by recent writers, the amor- phous hyaline stroma in which tubercle is formed. It would appear, indeed, that this amorphous fluid is the true pabulum of tubercle—in other words, it is the morbid exudation in which the peculiar corpuscles constituting tubercle arise. The char- acter of this exudation determines the nature of the subsequent growth or development of the morbid substance; and, indeed, we observe that the same laws of development obtain here as elsewhere. Thus, during ordinary inflammatory action, the exudation consists of fibrin, and the result is a growth corre- sponding with that element. In the cancerous cachexia, the exudation is of a peculiar character, which gives rise to can- cer-cells. Indeed, the blastema or cancer-juice performs the same office in the development of malignant growths that the amorphous hyaline stroma does in the tubercular condition; the same laws of exudation and development of morbid growth pertain evidently to the two conditions, the special difference consisting in the elementary character of the exudation. According to this view, tubercle is an essentially morbid and specific exudation, appearing first in a fluid condition, in which the tubercle-cell is developed, and is entirely independent in its formation of the surrounding tissues. And it is immaterial whether this tuberculous exudation takes place in the epithelia, as supposed by some, in the simple areolar tissue, or on free surfaces ; for if the epithelial cells be the seat of exudation, they are completely destroyed, no vestige of their structure remain- ing. I would not deny that the nuclei of epithelia, as believed by Van der Kolk, might be nourished by the tuberculous fluid into tubercular cells; nor would this fact change the bearings of the main question. The pabulum must determine the char- acter of the growth, independent of surrounding tissues ; hence, 42 PATHOLOGY OF PHTHISIS. inflammatory exudation gives rise to false membrane; the can- cerous exudation to cancer-cells; the tuberculous exudation to tubercle-cells; and so on, with all morbid exudations. SECTION V. CHEMISTRY OF TUBERCLE. The importance of a correct chemical analysis of tubercular matter is too obvious to admit of doubt; but we are obliged to confess, in the beginning of our investigations, that the numerous discrepancies which exist leave the subject incom- plete, and present results in many respects unsatisfactory. These discrepancies arise in part from the inherent difficulties of the subject, and in part from the varying character of the materials analyzed. Some analyses have been made from hard, others from softened tubercles; some from what is known as scrofulous deposits, others from gray granulations. These facts are sufficient to account for some of the discrepancies arising from chemical investigations, and for which due allowances must be made. I shall endeavor to reduce these differences as nearly as possible to general results, and thus to exhibit what is actually known on the subject. It is quite apparent that the different microscopic elements which enter into the composition of tubercle will yield differ- ent chemical results; thus, the amorphous stroma, the granules, and the tubercle-cells exhibit different chemical reactions under the microscope. The amorphous stroma is rendered pale, and finally disappears, under the influence of acetic acid and caustic alkalies; the protein granules are not soluble in acids, ether, or alkalies; while those of a fatty nature are soluble in ether. Cells containing nuclei are more or less soluble in acetic acid, and completely so in caustic alkalies* It will thus be seen that the several organic constituents, when examined sepa- * Vogel. CHEMISTRY OF TUBERCLE. 43 rately, must, necessarily yield different results; but as this deli- cacy of chemical manipulation is difficult, if not impossible, we look only to the analysis of all the constituents, in the aggre- gate, which are found in tubercle. As a first and general proposition it may be affirmed, that tubercle, in its ordinary forms, consists largely of animal matter. Thus Thénard found solid tubercle to consist of 98.05 animal matter; chloride of sodium, phosphate of lime, carbonate of lime, 1.85; and some traces of oxide of iron. Hecht found in six grammes of tuberculous matter: albumen, 1 gramme, 4 decigr.; fibrin, 2 grammes, 8 decigr.; gluten, 1 gramme, 2 decigr. Preuss found 19.5 per cent. of solid matter, 80.5 water; the solid portion consisted of an animal matter which gave the reactions of casein, a fatty substance containing cholesterine, and a small quantity of salts.* The nature of the animal matter is a subject of dispute. ANALYSIS OF SOLID TUBERCLE. Let us turn first to the ultimate or elementary analysis. The following result was obtained by Scherer, in an analysis of crude tubercle :+ Cav bon sessenciesasesnsnmactess carte enriects 53.888 Hydrogen ....secccsseneseenseeeeeneeareees 7.112 Bites acicsanecapasand esis is 17.237 | =i OXY QOD. sceeeccecseeneterseceeecesen scares 21.767 100.004 The formula for this analysis is thus expressed: Cys, Hy;, No, 0,3. The analysis of tubercle obtained from different parts of the body, according to Scherer, exhibits a remarkable uniform- ity of composition, as will be seen by the following table.t Tubercle from the lung.......scssseeeeseerens C, HH; Ne Ors Tubercle from the liver......ccccsceeneseeen C,; Hs Ne Or Tubercle from the peritoneum............+. Cy Ha Ne Ors Tubercle from the brain.......cceeceeseerees Cy Hy Ne Ors Tubercle from the mesentery....seceeeeee Cy Hs Ne Os * Glover on Scrofula. { Simon’s Chemistry. $ Ancell. 44 PATHOLOGY OF PHTHISIS. The following results were obtained by Dr. Glover, in a series of analyses :* Cc. H. N. oO. 1. Crude granular mesenteric tubercle,.....54.97 6.63 12.31 26,09 2. Crude granular mesenteric tubercle......56.40 ..... 15.56 wa. 3. Crude tubercle from lung.......seseceeee 53.43 6.64 14.02 25.91 | It will be observed that these analyses furnish a close resem- blance to the composition of the so-called protein compounds, and, therefore, that tubercle bears a relation to protein. Taking Liebig’s formula as the basis of the hypothetical substance denominated protein, we have the following: Cx H,, Nz Ou Albumen, however, being the basis of those substances known as “protein compounds,” constitutes the proper physiological product with which we may compare the pathological substance known as tubercle. The following is the composition of albu- men, as given by Scherer and Mulder: Scherer. Mulder, CREDO... acaieivtsen tyreacengteincnee os 54.9 53.5 Hydro getsssciscceesacretsigecsavien 7.0 7.0 NIPO BCH... cas cenevancinsinsinasiisi'iees 15.7 15.5 Oxygen...... 22.0 Sa] PHU 5c. Pek cvenesveenteaees wee 22.4 1.6 Phosphorus } 0.4 100.0 100.0 It will be observed that, taking Scherer’s analyses for com- parison, there are marked differences between the elementary composition of tubercle and albumen, which will be the more evident when brought into juxtaposition, thus: Albumen, Tubercle. CarbO travers oes ct sasondestvaits 54.9 53.888 Fydrogen.....ccssesssssscsssesees . 7.0 7.112 Nitrogen sucaearvevssswiviesiens oer 15.7 17.237 Oxygen (Mulder)..............06 22.0 21.767 Sulphur (Mulder)....... mie LO = avaas . Phosphorus (Mulder)............ C4 ——vriaine ‘ * Pathology, etc., Scrofula. = CHEMISTRY OF TUBERCLE. 45 There are differences between the physiological and patho- logical products in their proportions of carbon, hydrogen, nitrogen, and oxygen, but these constituents are doubtless liable to variations in the different forms and stages of the tubercu- lous deposits, so that the results are less significant than might at first view appear. It will be remarked, however, that the morbid substance contains neither phosphorus nor sulphur, both of which enter into the composition of physiological albumen. Tubercle, however, contrary to our @ priori conclusions, con- tains a larger proportion of nitrogen than albumen, a fact which may ultimately assume a greater degree of importance than is at present attached to it. Proximate Analysis.—As previously stated, Thénard, at an early period, analyzed crude tubercles, with the following re- sults: Animal matter......cccsccscscsscssscersoees 98.15 Muriate of soda Phosphate of ne sdaaiisansinuhissiesivne 1.85 Carbonate of lime Oxide Of irOM...ccccsseccerersenceceersecene traces 100.00 According to Hecht, of Strasburg, six grammes yielded the following results: Gramme. Decigrammes, ATDUM Clivewewessncavevencdevesainacceseiie see 1 4 GOLA... nas dine acacssencrdnmareeneseas 1 PUD Eves ve aleagacanaasinevarincsicesann tanceaeee 1 8 Water (or 10ss)....cccseccccrereceeaseeeee 1 6 6 0 These analyses, however, are far from conveying a definite idea of the proximate constituents of tubercle. The more re- cent and complete observations are those of Scherer, Glover, and Preuss. SCHERER’S ANALYSIS. 1000 parts of solid tubercular masses, found in the abdomen, yielded : 46 PATHOLOGY OF PHTHISIS. Ha Ey pemreeereteroa von ui sap aca age sass Sie ew es be ana wieage dan seeeeee 25.40 Casein and alcoholic extract.......ccccesssececeesaseceseeee 12.39 Pyin and watery Cxtract.....sscccssccsseseeserseeeserseeee 6.19 GATES conyenne oventarisisletieewien eoeredieriasts sebuisig natant eandoecnanal 7.43 Crude tubercular matter........cccececceseseccesseeeeeeserses 54.55 SIMON’S ANALYSIS. 100 parts contained : Waite Riccsqsesnnesscccnwenteempblantenucisiisies ne sfetastialdlgadeisisinceslugiguiys 84.27 Fat containing cholesterine...........scecssesseseesscenrecoes 1.40 Spirit extract with salts.........:-...seee. je digpasinseeiciean teat 1,52 Caseous matter with water extract. ......scsccsscssseeseees 1.14 Water extract and Salts.......c:ccccsscssescscesensceeesseresees 3.80 Insoluble constituents.........csscecesceeeers iesuauveroreimetes 4.44 PREUSS’S ANALYSIS. + In 1000 parts were found: Wialererssccsesscsene sist seunad saeels niaasesapeeamerewaneacouans aeeienes +. 199,50 Residue of the pulmonary tissue, composed of— Gelatin obtained by boiling...........ceseseeees 13.497 Substances furnishing no more gelatin....... 49.106 Fatty matter.........scsecsssssseeseessseeresenans 2.697 65.30 Tubercular matter, containing: A. Substance soluble in boiling aleohol— 1, Cholestering...........ccccccccssscaseceecssrecenes 6.685 B. Substances soluble in cold alcohol and water— 2: OAC OL SOM Gi vc cand sans eoonundoons he sisanstesaes 18.269 8. Chloride of sodium ............. 4, Lactate of soda.......ssceceeees 5. Sulphate of soda... FO ky LAG 6. An intermediate substance... C. Substances soluble in water and not in aleohol— iy. Casein: covsssuseevensreackesreeee 8. Chloride of sodium.............. 9. Sulphate of soda......ceeeeeeee PO seen 10. Phosphate of soda............06 D, Substances insoluble in alcohol and water— 11. Casein altered by heat......... -12. Oxide of iron............c..cceee 13. Phosphate of lime............... 14, Carbonate of lime............00. 15. Magnesia.......ccecseccssccesseees pe 16. Soda........... desleaicet eseanananoween 1000.00 CHEMISTRY OF TUBERCLE. LEGENDRE’S ANALYSIS. In 100 parts WHER, .oyissa cae ueraencapspann eran morewariccaienearadaesnvenesTeieet 66.67 Albumen soluble in water........ccccccccssesseesseceesssnanecs 5.08 ChOleSte rine, cons uiienesshassscueismacdsanesaarseenieieyeusts 14.38 Gelatinis. cioscunsqneccasuwerdisuwxuvanapoaraaemnes scueieeneeaiios dees 25 Subphosphate of lime...........sssseesssseeeesreeecerereseteees 7 Batty Matter ec. saved ces sonmciicee vest sinereianelean cureciece vitesreae 1.70 Membrane and coagulated albumen.............:scceeceeeee 11.07 LOB SE cans steninenesiuasls ps snecoudaaen onstavweneceounindesaneneeies , 1 100.00 LASSAIGNES’ ANALYSIS. In 100 parts of tubercle from lungs of a horse: ANIMAL WHALE Bx,.. saccccsssasaseatesincor madsiineae snpisavadlaeudyededaseains Subphosphate of lime Car borate Of Lime: vcuaccdsoncuonastseas acenebecseorwasoss dees Salts soluble in water,...........ssccssessscessescecescecscstsscensse 100 WRIGHT’S ANALYSIS.* Fatty matter with oil globules........sssssseeseeresetseereeees 15.9 Geel atith: avaiieeronemsamanuvnterreewemanexaxeneaeapigsaeenesinabian . 64 Phosphates.. Likue cine. a | eee pid diaatsnaanannniaiassnccaans 11.2 : soda Muriates..... Carbonate of lime....cc.cccceccecessesceceseccnerseesaeseneeee a trace. Albuminous matter with fibrin.........:.cccsseeesesseeeeereees 65.2 98.7 Fatty matter with oi] globules.....s.sssscessecseseeeseseeeeeees 7.4 ROT AVELT ss copcccsase dsdetsctscraloriaieteinstre wegen alaieetl din spiopila aivabiomimaiawag 11.8 Phosphates.. lime Sulphates.... sighs. PRR eae sinorene ON 2.5 Muriates. .... Albuminous matter..c...ccsscsccscecerserscscnssessseceeenseseneee 76.9 98.6 * Med. Times, vol. xi. 47 The two following analyses give the mean result of numer- ous examinations of matured (cheesy) tubercle: 48 PATHOLOGY OF PHTHISIS. ANALYSIS OF SOFTENED TUBERCLE. But few analyses of softened tubercle have been made. The authority of Lehmann is quoted to establish the fact that the protein-elements gradually lose their phosphorus and sulphur. It is generally affirmed that in proportion to the advance of the process of softening is the increase of fatty matter. L’Hertier observed the presence of albumen, fatty matter, fibrin, and car- bonate of lime; while, according to Boudet, the tuberculous matter becomes alkaline.* The development of fat is evidently the most notable change which takes place during the process of softening, and the change has been compared to fatty degen- eration. ANALYSIS OF CRETACEOUS TUBERCLE. According to the analysis made by Boudet, calcareous tuber- cles contain 70 per cent. of soluble salts, viz.: chloride of sodium, phosphate and sulphate of soda. He found but a small amount of carbonate of lime. This result, however, is not in accordance with the observations of others, and is prob- ably incorrect in reference to the existence of so‘ large a pro- portion of soluble salts. The following are the most reliable analyses: ANALYSIS BY SCHERER. Organic matter sssccsevsisacccccacssosseeenvenncersevetecsvacne 20.10 Phosphate Of Tiit@icc. sass seutsnass svcsneanitvnesscveeenceovense 69.92 Carbonate of lime........ idee aces rdacsaabcaaits 9.09 Chlorate of sodium, phosphate and sulph. soda........... 0.89 \ 100.00 ANALYSIS BY L’HERTIER, Animal matter... sccsccccsessssecessssssseees 5 to 9 parts, Phosphate of caer Carbonate of lime fret ttretteettteteeeretenenes 98 to 91 parts. Many additional analyses might be given, but these are suf- ficient to indicate the true constitution of cretaceous tubercles. * Ancell, log. cit. CONCLUSION. 49 It may be remarked, however, that some observers have found, at times, a preponderance of the carbonate of lime, and again, of both the carbonate and phosphate, with ammonio- magnesian phosphate. It is stated, on the authority of Leh- mann, that these concretions frequently contain cholesterine. It appears, however, to be well established that the phosphate of lime predominates, with generally a large proportion of the carbonate. An analysis made by Simon gave the following results in 100 parts: Earthy phosphates..........cc:ccccccssssscsssssssrsceseecavsnees 87.2 Carbonate of lime.........c.cccccsceeseessececesseseassceneceeees 11.5 SOlAPIS: Ba 108 scsi sence ented anatintnaneabaaasateesvcoaccteenaus tetas 0.65 The organic remains are variable, but always exceedingly small. 1 CONCLUSION. + It will be remarked that the preceding analyses are far from being uniform, and hence the subject can not be considered definitely settled. Nevertheless, the most accurate organic chemists have succeeded in determining the existence of cer- tain constituents, the presence of which can not be doubted, and may, therefore, be regarded as composing a part of tuber- cles. Nor is it surprising that an absolute want of uniformity should exist; for it is obvious that the composition of these albuminous or protein bodies are liable to considerable vari- ations even in the same essential product, and, therefore, while the general characters remain nearly identical, the individual constituents will be found to vary in their proportions. This will be more apparent when we bring into a compact form the substances which have certainly been found, as will be seen in the following arrangement: Thénard found: muriate of soda, phosphate of lime, car- bonate of lime, a trace of iron. Hecht found: albumen, gelatin, fibrin. 4 50 PATHOLOGY OF PHTHISIS. Scherer found: fat, casein, pyin. Simon found: fat, containing cholesterin, caseous matter. Preuss found: carbonate of lime, phosphate of lime, oleate of soda, chloride of sodium, lactate of soda, sulphate of soda, casein, oxide of iron, magnesia, soda. Legendre found: cholesterin, gelatin, fatty matter. ¥. Boudet found: casein, gelatin, cholesterin, oleic acid, mar- garic. acid, lactic acid, saponified fat, cerebric acid. Giiterboch found: a@ peculiar substance, (not observed by other chemists,) pyin, phymatine, fat, albumen. Glover found: pyin, muco-extractive, a peculiar extract, fats. Chevallier and Lassaigne found: xanthocystine. So far as reliance can be placed on the results of chemical analysis, we may regard the following substances as entering more or less constantly into solid tubercular deposits: 1. Albumen. 2. Casein. 38. Fibrin? 4. Pyin. 5. Fatty matter. 6. Salts of soda and lime. 17. A peculiar substance, (Tuberculin ?) é It is abundantly evident that the organic basis of solid tuber- cle is a protein compound, bearing a relationship to albumen and casein, but it is probable that true fibrin does not exist in this morbid product. The intimate relationship existing be- tween fibrin and albumen might readily induce a mere chemist to give the former title to the latter. It is not, however, by chemical tests alone that we can recognize the presence of true fibrin; on the contrary, it is the vital actions, including spon- taneous coagulation and ultimate organization, which can de- cide the question. It is probable, therefore, that fibrin does not exist in tubercle, while its congeners, albumen and casein, constitute the true basis. Casein, which is so nearly allied to albumen, has been recognized by Scherer, Simon, Preuss, and Boudet. Giiterboch and Glover have detected pyin. All these, it will be remarked, belong to the so-called protein series, and bear a relationship to each other and to organic lymph. It is abundantly established, also, that fatty matters, in various but demonstrable forms, are always present; these consist of simple fat, saponified faf, and cholesterin. Gelatin has been detected by Hecht, Legendre, and Boudet. CONCLUSION. 51 It appears that several protein compounds have been detected by chemists; but they have not fully decided which of these con- stitutes the true basis of tubercle. It is believed by many that albumen is the essential organic element, while others regard it as being either true or modified casein. Mr. Ancell* is of opinion, that it bears a close analogy to casein, if it is not iden- tical with that substance. In support of this view is the im- portant fact, that tubercle contains neither phosphorus nor sulphur, and the same is true of casein, except that a small proportion of sulphur is present; while albumen is rich in both these elements. It seems probable, therefore, that the organic substance met with in tubercle is more nearly allied to casein than to albumen. It is proper to add, however, that the action of reagents (such as heat) show also the presence of albumen; but it is probably in a changed or degraded form, exhibiting merely coagulation by heat. The fatty substances are quite abundant in tubercle, and in- crease with. the process of maturity and degeneration. The following table will show the relative proportion of fatty matter as detected by different chemists: Scherer.........4..25 parts fat in 1000. Simon..........068 140 “ “ containing cholesterin in 100, Legendre......... 14.38 cholesterin ) , 1.70 fatty matter i mal, The relation of tubercular deposits to fat are further shown by the observations of Guillot, that the substance of the lung which had been consolidated by tubercles, yielded, when dried, from forty to fifty-two per cent. of fat. The same condition has been observed in other forms of consolidation, such as pneumonia, and in the foetal lung. These facts have suggested the idea that the tubercular deposits bear a relation to fatty degeneration; and this view is further strengthened by the researches of physiologists, which prove that albumen may be converted into fat. * Tuberculosis, etc. i 52 PATHOLOGY OF PHTHISIS. The occasional presence of gelatin is not a very significant fact; it merely shows a degeneration of the tissues. Finally, it is evident, that the chemical analysis of tubercle expresses but a secondary result, and throws no light whatever on the primary change. The fluid exudation, which constitutes the pabulum of tubercle, has not and can not be analyzed; and it is only the solid substance, which has grown into textural form, that comes within the range of chemical reagents. And while, therefore, the nature of these ultimate .growths possess great intrinsic importance, they not only fail to elucidate the essential nature of the process by which they are formed, but they are equally remote from revealing the laws by which the morbid growth is regulated. The fact, that tubercle is a protein compound, does not establish its essential nature; for the same result, in a general sense, would apply to almost every morbid growth of the body. CONDITION OF THE BLOOD. 53 CHAPTER IV. CONDITION OF THE BLOOD. Tux condition of the blood, whether viewed as a primary or secondary disease, is of great importance in tuberculous affec- tions. This fluid furnishes the blastema for all tissues and organic products, healthy and morbid; and any departure from a state of health, whether the cause or sequence of the original disease, can not fail to influence both the constitutional and local affections. In an examination of the state of the blood in phthisis pulmonalis, we are, unfortunately, without sufficient data to determine its condition in the precursory stage of the disease; indeed, the observations which have been made on this subject have reference exclusively to the condition of the circulating fluid after the development of tubercles. This obvious defi- ciency, however, may be, to some extent at least, overlooked ; for what is observed in the stage of tubercular deposits, is probably merely an advanced state of what existed prior to the formation of tubercles; and we have only to consider, there- fore, that the elementary changes found after the supervention of local disease, is but a further development of the early condition. Hence, although we have to regret this want of knowledge in regard to the precursory stage, it is probably less important than might at first appear, and indications for treatment may be safely drawn from the more advanced condition. It is proper further to remark, that many of the analyses have been made from cases in which external scrofulous disease existed; and it becomes a question how far this condition is to (53) 54 PATHOLOGY OF PHTHISIS. be received as a fair representative of the true tuberculous state of the system. But a more serious defect is found in the fact, that venous blood alone has been subject to analysis and examination ; and although it may be assumed that this portion of the san- guineous fluid can be taken as a fair type of the whole, yet there is reason to apprehend that differences. exist. And although it can not be affirmed that an analysis of arterial blood, even that of the aorta, would throw any additional light on the nature of tuberculous disease; yet, when we reflect that it is the arterial blood which furnishes the nutriment for the different organs and tissues, and that this nutrition is evidently disturbed in tuberculosis, we can not but regret that the fluid more immediately producing these important changes should not have been the subject of examination. SECTION I. PHYSICAL PROPERTIES OF THE BLOOD. The observations which have been made in reference to the physical properties of the blood in scrofula and incipient phthisis, are comparatively few and unimportant, but they are sufficient to demonstrate that its general constitution is im- poverished. This is evinced by its imperfect coagulation and excess of water-qualities, which clearly demonstrate its impaired vitality. Coagulation is usually sufficiently prompt, but the clot is small, and, at times, loose in its texture, while the serum is decidedly in excess. The most evident physical change, therefore, is an excess of the watery portion; the size of the clot and its firmness of contraction present considerable varia- tions, and, therefore, are not constant. According to Dubois, (dV Amiens,) the blood coagulates slowly, and the clot is small and diffluent, the serum thin, and, at times, of a red color; and Mr. Phillips states that the clot was usually small and soft, and the serum large. Some of the older writers affirm that the MICROSCOPIC APPEARANCES OF THE BLOOD. 55 blood assumes a brighter hue than natural; and although we have not the data to determine that question with certainty, yet it has appeared to me, that when the deposits exist, a lighter hue is observed. No attempt to form a buffy coat is ever witnessed except when local inflammation is present; but I have observed a gelatinous appearance of the surface which was probably. albuminous. It is worthy of remark that so few patients are now bled in these affections, that we have seldom ‘good opportunities to judge of the physical changes in the blood. SECTION II. MICROSCOPIC APPEARANCES OF THE BLOOD. At an early period of my investigations into diseases of a tuberculoid character, I sought to satisfy myself in regard to the alleged deviations of the corpuscles from a healthy condi- tion; but now, after some years of investigation, J must con- fess that the results have not been conclusive qr satisfactory. The only deviation which seemed to occur, consisted in the occasional increase of the white corpuscles, and a correspond- ing diminution of the red. It is proper to state, however, the observations which have been made by others. Dr. Balman found the colorless cor- puscles notably increased, sometimes amounting to seventy and eighty in the field of a quarter of an inch object-glass. These corpuscles varied greatly in dimensions, some being less than half the size of the red corpuscles, while a majority exceeded the diameter of the latter. Nasse and Popp have made observa- tions nearly similar. M. Dubois observed both classes of cor- puscles. He describes the red as appearing irregular and notched, and so nearly transparent in the center as to give the appearance of wheels. The coloring matter also appeared as if separated, or loosely adherent to the corpuscles, and the serum sometimes being of a rose color. Lebert represents the red corpuscles as lighter than natural, with some degree of 56 PATHOLOGY OF PHTHISIS. irregularity in the outline; and Mr. Nicholson confirms the same observation. Dr. Glover found the red corpuscles irregular in the outline, star-shaped, and sometimes studded with granules; but he does not regard this appearance as necessarily abnormal. Mr. Ancell remarks that his own observations on the blood corpuscles of tuberculous subjects, before the development of local disease, have led to the conclusion that they are paler, of more irregular outline, and more speedily undergo anomal- ous changes than healthy blood. A careful examination of this subject has induced me to believe that the microscopic observations of tuberculous blood possess but little interest, and have established no special point, except the increased quantity of the white corpuscles and dim- inution of the red. This is an interesting fact, which the pa- thologist will not fail to remember. The other changes are merely incidental, and therefore possess no special significance. SECTION III. CHEMICAL COMPOSITION OF THE BLOOD. ‘We now enter upon a wider, and, perhaps, more tangible field; at least it ay be affirmed that the results of chemical analyses of the blood in the tuberculous condition now occupy a large share of the attention of pathologists, and may ultimately lead to highly important results. These analyses have been made during either incipient or confirmed phthisis, or open scrofulous disease; and the blood used has been invariably venous. It may be stated in advance, that the principal changes in the blood in this disease, as made out by the most competent chemists, are the following: increase of water, increase of albu- men, and diminution of red corpuscles. Other changes doubt- less occur, as will be seen hereafter, but they are not so well defined as the preceding. Dr. Frick,* of Baltimore, has analyzed the blood during the * American Journal of Medical Science. CHEMICAL COMPOSITION OF THE BLOOD. 57 existence of crude tubercles, and the following are the results of four cases, together with what he regards as the standard of health. 8 4 a 2 2 +.3. Se |s3 $ #3 a3 E s ges $3 |Sa. Pe & & § 5 ag | S64, . (5s, les¢8 s | #8 | 28 | 2 | eg | Se | 2822] 2 | & ose [842 % as ES & a3 aa |A8ee| & | 4 [S88 fsa 1 | 212.631 | 789.369 | 3.395 | 125.645 | 86.546] 87.23 | .564| .272 | 2.530 | .336 2 | 199.666 | 800.334 | 2.688 | 111.453 | 86.525] 90.30 | .487 | .257 | 5.632 | .197 3 | 200.602 | 799.398 | 2.862 | 117.480 | 80.260] 84.31] 512 | .276 | 4.822 | .203 4 | 207.007 | 802.993 | 2.159 | 104.600 | 100.248} 101.46 | .416 | .283 | 2.910 | .351 Mean | 204.976 | 798.021 | 2.776 | 114.794 | 88.144} 90.82 | .494 | .277 | 3.973 | .271 Health| 208,622 | 791.378 | 2.952 | 127.426 | 78.244 582 | .183 | 4.882 | 874 It will be remarked that, in the above analysis, the principal changes consist of a notable increase of the solids of the serum, increase of water, and diminution of red corpuscles; also, a decrease of the chlorides and phosphates of soda and potassa. Dr. Frick has obtained one result, however, which has not been demonstrated by others, namely, an increase of lime. The following results were obtained by Andral and Gavarret, in the analysis of twenty-two cases: Solid residue Water. Solid Residue. Fibrin. Corpuscles. Geer Maxima........060. 845.8 225.0 5.9 122.1 105.4 Minima...... raaketi 775.0 154.2 2.1 76.7 65.1 Mean..... dvsapwnsns BOOT 190.3 4.4 100.5 85.3 Health..........006. 890.0 (?) 210.0 3.0 127.0 80.0 These analyses lose much of their value from the fact that neither the condition of the patients nor stage and complica- tions of the disease are mentioned; but, notwithstanding these defects, they show such a remarkable uniformity in the dimi- nution of the corpuscles and moderate increase of albumen, that they may be regarded as furnishing a fair view of what occurs in phthisis. They indicate, however, an increase of fibrin, which probably represents a pathological state separate from simple tuberculosis. 58 PATHOLOGY OF PHTHISIS. The following tables are from Becquerel and Rodier: EXAMINATION OF FIVE MEN, CONTRASTED WITH HEALTH. In phthisis. In health. W albert cncaesbssiw acne ssveanienreiveunesiern 794.8 779.0 Solid constituents... ....ccscceseeeeeee 205.2 PADYticsiiivaivas ainiscderieananyee adowien sss, “458 2.2 Pal cwcsspancae ese seewsarenesiaban nesenanels 1.554 1.60 ATDUMCH: 05: devccmiceanacvensavieece wee 66.2 69.4 Corpuscles,c.c. ss ncerussasennensnsee 125.0 141.1 Extractive matter and salts....... ve WCE 6.8 RESULTS IN FOUR WOMEN : In phthisis, In health, "Water siccsscsisrcrevwesawarsvervasiwavs 796.8 791.1 Solid constituents........ en segucnew ae 203.2 HiPTID 495 seanisacounavesvesvone meanest 4.0 2.2 Wal titan eisetrnc dara ves aeuadaa uaa caste usec 1.729 1,62 Albumen........ eGisteswaluisaiudet elite Costoor . 70.5 70.5 Corpuscles:.v.cesssssesveczssunisesenys 119.4 127.2 Extractive matter and salts....... » 7.6 7.4 In these analyses the results are slightly different from some others, arising, in part, from the authors adopting different stand- ards of health. ‘Thus the fibrin shows a greater increase than properly belongs to incipient phthisis, while the albumen is but slightly augmented in males, and not at all in females. The following table exhibits the analyses by Dr. Karl Popp :* Amount of water Sex. Age. in 1000 parts. Fibrin. Blood corpuscles, Residue of serum,. 1. Male...... 22 806.628 4.068 123.816 65.517 2. Male...... 22 801.933 5.400 107.038 85.629 3. Male...... 22 818.005 5.161 94.791 81.543 4. Male...... 22 786,926 1.864 125.526 85.684 5. Male...... 23 801.087 5.434 107.489 85.990 6. Male...... 24 802.299 6-101 80.996 110.604 I. 841.573 2.620 84.678 71.129 7. Male......26 a 827.282 10.736 91.045 70.937 8. Female...26 791.569 2.306 125.615 80.508 9. Male...... 27 800,174 38.475 108.162 87.189 10. Male...... 27 771.136 2.129 151.663 75.072 11. Male.....:28 812.203 4.862 96.282 86.653 12. Male...... 28 810.848 8.305 95.183 85.664 * Ranking’s Abstract. Am, ed.; p. 267. CHEMICAL COMPOSITION OF THE BLOOD. 59 Sex. Age. econ oe Fibrin. Blood corpuscles, Residue of serum. 13, Male......36 819.094 3.294 76.695 100.917 14, Male......38 810.923 6.228 ==> 117.863 64.986 15. Male......39 845.872 5,302 68.584 80.242 16. Male......40 806.000 7.438 ~=—=—-103.858 82.704 17. Male......46 821.729 6.124 85.011 87.136 18, Malo......46 825.429 «5,498 83.528 85.615 19. Male......48 828.252 3,334 94.660 73.754 1. 784,582 5.782 ‘125,290 84.346 Bi Aer a 802.100 5.098 ~—>—-116.530 76.272 21, Male......51 835.641 2,750 22, Male......53 790.442 4803 114.389 90.366 23, Male......54 801.723 3.790 ~—=-126.289 68.198 1.813413 3845 104.618 78.124 oe Seem ie 854.290 4,009 78.002 63.699 The preceding table exhibits a remarkable increase in the proportion of fibrin, reaching, in one instance, as high as ten parts to the thousand. The following is Elsner’s analysis in incipient phthisis.* Waterss. ccasine spabis ieaay enmaap nialdamececcorsomemmaibeneauee 803.404 Lib titecsecyewtesnepwressiaben os ciehdedveasesyererar ataaneaantven 3.443 Fait, LROUE ADE wicce cindy caicee sic evauainaeeudaacledeaisiaeeleaaiievas 0.153 Fat, from other constituents..........s::cceseeeceseeeseeee 0.643 Album Ciivaces sitscveeretan caarniieasaeeens ceieetnaacaet 102.100 STOUT icc ciapsiesinaas sale gous lectincnedevnonlarsed suueumeds 74.948 Fie mahitives:coscsedeumamsonencaivareecesaeaemamescaneresnces 2.466 Extractive matter, salts, and sugar...... sioapewinnonises 11.258 Analysis of two fatal cases by J. F. Simon; one in the second stage, the other in the third stage, with night-sweats and fever, to which is appended the standard of health. 2d stage. 3d stage. Health. WEEE Ties seeaiecsinsisleasinioinaie sina 807.500 825.200 791.900 Solid residue............... 192.500 174.800 208.100 THGRI Ra. csscveiaeaesessede 4.600 6.500 2.011 Raitvapcceswossmanatis 2.350 4,200 1.978 Albumen 98.360 90.350 75.590 GODWIN scence casiecaie seus 71.230 61.110 105.165 Heematinivcecsseccesasoceces 3.110 2.690 7.181 Extractives and salts... 9.850 8.000 14.174 * Ranking’s Abstract. Am. ed., p. 268. 60 PATHOLOGY OF PHTHISIS. In these analyses, the notable increase of fibrin, albumen, and fats, with a diminution of globulin, hematin, solid residue, extractives and salts, will not fail to arrest attention. The analysis of scrofulous blood deserves to be mentioned in this connection. Dr. Glover* obtained the following mean results in eleven males and six females: Males. Females. Solidssiosecesuswssanee bsidtor scwassiletsuiiveicues 208.5 203.845 PibP iti cagesvecneatesunrcemuaveresmucesneceetey 8.132 3.585 Solids of SeruM........ccsccssceeseveeceses 87.60 85.28 Globulesiicsswsvessen orsasansreaeaensaeensesiess 117.32 114.87 In the examinations made by Mr. Nicholson, the following results, the mean of twelve cases, were obtained from scrofula in its various stages: Corpuscles NAgslecn ea diieaarnusinnedes Dees neaW eRe deReNe ee wE ris oes 82.12 Bibi Vics cas cs siete ndings Soceceene Geteinnda died abade lig etes cane lasses sacs E22) Dissolved substances in SCTUM............scseecsseesereees . 79.06 Water........ ycawecavuecsentas Beuiasinian ged keud ea seakcwanen seins 836.6 Summary of analyses by different observers, embracing the principal constituents: eis Red Fibrin. corpuscles, Albumen, Fat. ae ee SIMON. ess .cesseereeerveee 4 to 6.500 63 to 74.340 90 to 98.360 2to4.200 8 to 9.354 BT accessors disonsace? 2 to 3.395 104 to 125.645 80 to 100.248 _— — Andral & Gavarret...2 to 5.9 76 to 122.1 65 to 105.4 —- —- Becquerel & Rodier.. 4.8 125.0 66.2 1.554 UT Popp... 78 to 151.663 63 to 110.604 — —. Elsner. 77.414 102.100 0.796 11.258 The above summary exhibits a wide range between the min- ima and maxima results; but, instead of casting doubts on the accuracy of the observations, it only serves to show that the different stages and varying conditions of patients give rise to corresponding variations in the constitution of the blood. The examinations made by Mr. Phillips showed the corpus- cles diminished, and, in a majority of cases, the fibrin was below the healthy standard, while the albumen was generally in excess. Becquerel and Rodier, and Mr. Phillips found the * Pathology and Treatment of Scrofula, ete. CONCLUSION, 61 salts increased. In sixty-seven cases examined by Mr. Phillips, the proportion of salts was generally in excess, in some instances nearly double the healthy standard. According to Schultz, the blood was found to be less alkaline than natural, which was thus determined: in a healthy state the blood requires two\ drops of acetous acid to neutralize one drachm, whereas in one scrofulous subject one drop of the acid neutralized four drachms | of blood; and in another case of scrofula the serum was quite - neutral. CONCLUSION. A. careful examination of the preceding analyses will be suf- ficient to indicate some of the most obvious changes of the blood which take place in tuberculous disease. It will be re- marked, that in reference to some points, chemists are nearly uniformly agreed, while, in other respects, discrepancies exist. These doubts and difficulties arise, at least in part, from the inherent difficulties of the subject; nor is it probable that any future researches, however faithful and minute they may be, will arrive at uniformity in every particular. All observers agree, however, that the red corpuscles are uniformly and con- siderably diminished in quantity; and, if we may trust the microscopic observations of Dubois, Lebert, Glover, and Ancell, they are also more or less changed in configuration, and, there- fore, in their vital properties. But our views in regard to their vital changes must be rather analogical and inferential, than positive and demonstrative. In addition to this, it is to be remarked that the observations of Balman, Nasse, and Popp show a decided increase of the white corpuscles; and this state- ment corresponds with my own observations. The proportion of fibrin, as reported in some of the analyses, must be received with a certain degree of reservation. Some represent the cipher as being above the natural standard, while others believe it to fall below. Thus Simon represents the proportion in two cases respectively as 4.600 and 6.500, while 62 PATHOLOGY OF PHTHISIS. he regards 2.104 ag the normal standard. Andral and Gavarret, in their twenty-two cases, give the mean of 4.4, the healthy standard being 8.0. Becquerel and Rodier give the proportion as 4.8 in males, and 4.0 in females, the healthy standard being 2.2 in both sexes. Popp found it as low as 1.864, and as high as 10.7386. These statements have induced the belief that fibrin is actu- ally in excess in phthisis. But we have additional testimony which clearly contradicts the statement contained in the pre- ceding examples. In Dr. Frick’s analysis of incipient phthisis, the mean of the fibrin is stated at 2.776, the healthy standard being 2.952. The examinations by Mr. Nicholson and Mr. Phillips indicate a diminution of fibrin, and Popp found it as low as 1.864. To these may be added others whose authority goes to confirm the opinion that, at an early period, the fibrin is slightly diminished. The probable cause of the discrepancy will doubtless be. found in the stage of the disease when the examinations were instituted. Thus, when local inflammation supervenes, (which is so common as the disease advances,) the proportion of fibrin must necessarily increase; and there can be no reasonable doubt that such was the case in at least some of the examples furnished by Andral and Gavarret, and Bec- querel and Rodier. In the examples given by Becquerel and Rodier, the blood was drawn to relieve hemorrhages, fibrile action, and even inflammation. The two analyses by Simon, in which such a noted increase of fibrin existed, were equally fallacious, the first being in the second stage, and the other in the third, the patient suffering with fever and night-sweats. These examples, and such analyses, can not be regarded as analogous to what occurs in simple and uncomplicated cases of phthisis; and we feel fully warranted, from all the facts before us, to express the conviction, that they clearly indicate a reduced quantity of fibrin as the characteristic state in incip- ient phthisis, prior to the supervention of inflammation. I do not wish to intimate that this reduction is very large; on the contrary, it seems quite evident that the change is generally small, though probably nearly, if not quite, constant. It should be remarked, also, that there is not only a diminu- CONCLUSION. 63 tion, but probably likewise a depraved state of fibrin, as shown by its frequent imperfect coagulation. In regard to the albumen, it is conceded by nearly all ob- servers that its proportion is increased. Some estimate it as high as 100 parts in the 1000; and it has been seldom found as low as the natural standard. No positive deduction can be made in reference to its quality; but it is a fair inference that, like fibrin, the albumen sinks below the normal vitality. The watery portion of the blood is sensibly augmented, for, notwithstanding the increase of albumen, the red corpuscles and whole solid constituents are so far diminished as to give a pre- ponderance to the watery element. It remains a question as to the increase or diminution of fat. According to the analyses of Simon, the fat is increased. He adopted, as the healthy standard, 2.346; while he found, in two cases of phthisis respectively, 2.850 and 4.200. These, ‘however, as previously stated, were advanced cases, and, there- fore, can not be received as indications of what occurs at an earlier period; nevertheless, they do show the ultimate increase of fat in an advanced stage of the disease. According to Becquerel and Rodier, there was a mere fractional decrease of fats; thus, in males, the fat in health being 1.60, in phthisis it was 1.554; and in females the healthy standard was 1.62, while in disease it was 1.729—shades of differences too minute to be of any practical value. It is probable, however, judging from the best data in our possession, that the fatty matters are some- what increased, and especially in an advanced stage; and, as we shall see hereafter, there is also a tendency to the accumu- lation of fat in particular organs. According to Dr. Frick, iron, the chlorides and phosphates of soda and potassa, were diminished, but lime was increased. The testimony of chemists on these points is not uniform. Phillips, Rodier and Becquerel, and others, found the salts increased, while L’Hertier states that the earthy salts are diminished, and Schultz mentions that the blood was either neutral or less alkaline than natural; while, in the observations of Glover and Nicholson, these constituents were nearly nor- mal. These facts show that the question in relation to the i 64 PATHOLOGY OF PHTHISIS. alkaline constitution of the blood in tuberculous disease is still unsettled; and, perhaps, much of the contrariety of opinion arises from the constantly varying state of the salts, as the result of medicine, food, and disease. We are now prepared to make a general summary of the results which have been obtained by chemical analysis of the blood in tuberculous disease. The following statement may be regarded as the sum of our knowledge on the subject: 1. Red corpuscles deficient in number, and probably altered in properties. 2. Albumen increased, and apparently depraved in quality. 8. Fibrin slightly deficient, and probably depraved in quality, in incipient phthisis; increased when local inflammation super- venes. 4. White corpuscles increased. 5. Fats increased. 6. Water considerably increased. 7. The condition of the saline elements, and all other con- stituents, not positively known. It will at once be perceived that blood of the above quality represents a depraved circulating fluid, which necessarily pos- sesses a low state of vitality. SECTION Iv. STATE OF THE CHYLE AND LYMPH. ‘We possess no positive and definite knowledge of the con- dition of chyle and lymph in tuberculous disease. The few observations which have been made, have reference to the state of these fluids after the disease has proved fatal. Schultz has represented the chyle as deficient in granules, these bodies being imperfectly formed, and the fluid itself having lost some of its plasticity. These are changes which we would readily surmise to have occurred both in chyle and lymph; but we are not authorized, from the few and imperfect experiments which STATH OF THE CHYLM AND LYMPH. 65 have been made, to say it has been demonstrated. If we ad- mit the agency of the mesenteric and lymphatic glands in the elaboration of chyle and lymph, the disease of these structures must necessarily imply an imperfectly formed vital fluid; and that such imperfection exists, all the phenomena of the disease indicate, but the nature of the change has not been demon- strated. 5 66 PATHOLOGY OF PHTHISIS. CHAPTER V. STATE OF THE SECRETIONS. Our knowledge of the chemical constitution of the secretions, as they habitually occur in tuberculous diseases, is necessarily limited. We can, indeed, perceive the alienations from a nor- mal condition, and, to a certain extent, the chemical changes are known; but still our information on these intricate subjects is far from, being definite or satisfactory. Many of the most accurate observations have been made on scrofulous subjects, and each one must be his own judge how far this state repre- sents tuberculous disease. The condition of the biliary secretion varies with the pecu- liarities of individuals, as well as the stage of the disease. In some examples, no appreciable derangement exists, especially during the earlier stages of the disease, and it is only when the vital powers generally fail, that manifest disorder of this secre- tion occurs. But in other cases, especially in the bilious temper- ament, the hepatic secretion becomes early and almost constantly . deranged throughout all the stages of the disease, which, no doubt, exercises an important influence over the general course of thie constitutional and local affection. When phthisis is fully established, the secretion of bile evi- dently partakes of the general disorder. In addition to this general influence, there is evidently a reciprocal relationship existing between the pulmonary and hepatic secretions; and as the local affection of the lungs increases, the liver will neces- sarily take on increased or modified action; and hence, at this advanced period, when the blood is anemic, almost constant derangement, more or less marked, may be anticipated. The STATE OF THE SECRETIONS. 67 investigations, however, which throw light on this subject, have been comparatively few, and amount to little more than vague generalities. In one example Chevallier found the bile of a brownish yellow color, containing 2§ of dried residue, of which 0.83 was biliary sugar. Chevallier believed the bilé in cases of phthisis to contain but little fat.* Le Pelletier, Bordeau, and Garrod found the bile deficient in consistence, and to contain small proportions of resin and coloring matter. Lehmann considers the bile generally, but not invariably, poor in solid constituents in phthisis. Gorup-Besanez found the bile of ordinary consistence; while Frerichs always found it attenu- ated, except when fatty liver was complicated with the tuber- culosis. Both these observers found the bile dense when fatty liver existed.t+ The analysis by Frerichs furnishes the following results in phthisis and scrofula: BILE IN SCROFULA. 1 2 3 WiateD vis cedsiea ssansneusevensuanacietpuguectones . 96.94 96.00 96.95 Solid constituents........cssesscscssescneeeees . 38.06 4.00 3.05 Bilate Gf SOd as. csnccsabescscscacsaeeeseawensstes 2.18 2.81 1.78 Ea brecieatiaia aeldeiostas ang tatananeebaagencbueldecsnte’ 0.09 0.20 1.21 Mucus, protein-compounds and salts..... 0,71 0.99 1.06 BILE IN TUBERCULOSIS WITH FATTY LIVER, WITH THE HEALTHY PROPORTIONS OF THE SAME ELEMENTS. 1 2 Wate cs acicccsaneecesevenasssesises ssivebaiga evened odes oagietane 84.77 91.00 Solid constituents........cccccscsessereseeseeceeeseeeaees » 15.03 9.00 Bilate of soda........sccsccseereeceresesseeeteresneceevones 8.32 9.94 © Bat...csccssssessccesssseccaersensceaetsessoseaeecesosonsorver 0,25 0.09 Mucus, protein-compounds and salts.......ssseerers 6.46 2.97 * Simon’s Animal Chemistry. t Lehmann. 68 PATHOLOGY OF PHTHISIS. HEALTHY BILE, (FRERICHS.) 1 2 Woatter ...sccsccrseccecscccsccssccsssecesssccscvsssenesseneneees 86.00 85.92 Solid constituents........secescecscersrecceerensereene seeee 14.00 14.08 Bilate of soda.....csccsscesereecsscevceetetsessesscerscecsas 10.22 9.14 Cholegterin.....ccccscsseccsesceccersccsceescnescesersesesees 0.16 0.26 Margarin and olein.....ccscceseeesrseesseserteteeecenseees 0.92 Mucus... ..scscscccsscscccecccsceccccssccucnaccearsesrerescesens 2.98 Chloride of sodium 0.20 Tribasic phosphate of 80da......ssccceeeeeeee ssedbuiine . 0.20 0.25 Baie PpRp Ste De NTE nse } ouiesan auaialiaaniecanies . 0.18 0.28 te magnesia en Of Lime.......ssesseeceescenccssereasonseeeesseees . 0.02 0.04 Peroxide of ir00........sesecseeeee diabepisamecdyessalisdsanns traces. traces. Tt will be observed from these analyses that nothing definite has been established in relation to the secretion of bile in tuberculosis. There appears, however, to be a slight diminution of fat; and, in advanced cases, free from fatty liver, the solid constituents are diminished. The secretion of bile from anzemic blood, and in general debility of the system, must, of necessity, exhibit a thin or watery condition; but, beyond these general results, nothing has been discovered in this secretion which elucidates the nature of the tuberculous process. The urinary secretion admits of more ready and accurate analysis than the other secretions, and hence its more frequent examination. It has been stated that the special character of urine in phthisis is an excess of water, and consequently a low specific gravity, a small proportion of urea, and frequently a ‘predominance of the phosphates and lithates, in the form of white sediment.* The examination by Becquerel in scrofulous cases, showed that the constituents varied with the stage of the disease. When much debility was present, the urine was of low specific gravity—1010—pale, and in a few instances c@n- tained a small proportion of albumen. But in another class, in which there was little debility, he found the secretion dimin- ished in quantity, of higher color, greater specific gravity, acid reaction, and deposition of uric acid.t * Ancell, Tuberculosis, etc. T Séméotique des Urines, STATE OF THE SECRETIONS. 69 ' Dr. Glover* examined the urine in nine cases of scrofula. The results which he obtained I have arranged in tabular form, for the purpose of exhibiting at one view the proportion of the different constituents. Water. Solids. Uricacid. Urea. Incin, Residual salts. solids. Spe. gr. Quan. Acid, Case 1. 954.40 45.60 00.70 10.50 1035 2405 1022 44 « “2. 981.15 1885 00.70 4.50 8.00 5.65 1012 63 “ “ 3. 945.80 54.20 0050 1240 15.15 26.15 1025 273 * “4, 950.50 49.50 00.70 17.00 10.70 2110 1023 27 * “ 5. 955.40 4460 00.22 1800 1140 1498 10245 19, “ “ 6. 968.00 82.00 00.55 6.90 8.00 16.55 1016 59% “ 7, 962.00 37.70 00.15 11.90 750 1815 1019 380 « “ 8, 981.91 18.10 00.50 3.50 2.10 1200 1010 55 “ « 9. 956.05 43.50 00.30 11.50 6.60 25.10 1020 17% “ Mean 961.69 36.22 00.48 10.68 8.85 18.19 1019 38 It will be remarked that the results, so far as they appear in the above table, do not exhibit any special modification, except a smaller proportion of uric acid than natural. We may safely assume, however, that Dr. Glover’s analyses do not show any obvious departure from the normal state. It is true he does not give an analysis of the separate salts, which leaves a doubt as to the relative proportion of each. Dr. J. F. Simon} remarks, that in a majority of cases of phthisis after febrile symptoms become continuous, the urine assumes the inflammatory type, has an acid reaction, the usual specific gravity, and at times rises higher. But in the early stages, he found all the constituents nearly normal. In the second stage, when considerable hemoptysis occurred, he found, the urine anemic. Ancell observes that the state of the urine, as observed by himself, corresponds with, and is the measure of the low vital- ity of the blood and tissues. It is evident from these various statements that the secretion of urine is influenced more di- rectly by the presence or absence of fever, and the degree of debility, than any specific condition arising from the state of tuberculosis. * Pathology and Treatment of Scrofula. f Animal Chemistry, 70 PATHOLOGY OF PHTHISIS. The following analyses, given by Simon, were both in an advanced stage: (1) Water ...cccsseccernessneeceteneaesstenersreeees 975.95 grains, Solid constituents.......csssecceseeseeresseees 24.05 UL ea. secesececssscrserersseeseesecsensarepecnseses 9.00 Uric acid.....ccssesesseeeeersreenscerseseeseeeees 1.25 Specific Gravity....cssccceesseeeeseeesenssecersnseeeenes 1014.7 Quantity....ccccccccseeesseesceesesesoersenerseaeeneeeees 16.2 oz, (2) Water...ccccccscsssesssscesesecsreceseaenscsoees 935.92 grains, Solid constituents.......secccesesssrrreseeeors 64.08 UPGR «0. ccness cine sadveaad estuasamerrnneainny 23,90 ULiC BCI dsscsasspvasaeseonsansres sivtinseena ss cones 2.40 Fixed Salts. cesses sasnteonwteasienareesves 10.85 Specific Qravity....cscccssscceceesccssseeeseseeeseseeseens 1026.6 Of the 10.85 parts of salts, 1.3 were earthy phosphates, while the sulphates formed but a small part. Dr. Golding Bird made the following analysis in the case of q man aged twenty-four, in the early stage of phthisis, before softening : Waited. .sscsesisasastasssteaviasesneeaemins 19,125 grains. Solids casisvasasssaesonssistiansaavieaserenen aie se 936 OCR: seiesasas sesvicensessuaesvnndteewaaeevuenees 328.5 API CHA CIC ws sw ascisainseue sehensuaniansislcnieseebaee 4.5 Bpecific Pravi ty tececassewsqsencnaeseawans teres seemsweses 1020 QU aT EE aiescaes aac anasebeewenes aWdenye sieaiandeasiens abeiivadeinm 45 oz. Dr. Balman* examined the urine in thirty-two cases of scrof- _ ula. In these cases it presented a pale color, generally deposit- ing a “very light, filmy sediment,” the acid reaction was slightly weaker than natural, and in two instances it was neutral. Its specific gravity was 1012. In nineteen of the cases he found crystals of the oxalate of lime, in ten of which they were very abundant. The specific gravity of that which contained crys- tals was 1020; in one instance as low as 1005. In the thirteen cases without oxalates, he found four with excess of phosphates. It appears, from the observations of Dr. Balman, that oxalate * Researches and Observations on Scrofulous Diseases, STATE OF THE SECRETIONS. 71 of lime existed in the proportion of 38 per cent. in various affections; whereas, in the scrofulous gland cases that deposit was detected in the proportion of 74 per cent., and in phthisis 40 per cent. The next most frequent appearance of the oxalic deposits was in affections of the skin, amounting, in those dis- eases, to 66 per cent. F It was found, also, that the oxalate of lime and excess of phosphates rarely co-existed ; and Dr. Balman is of opinion that these substances do not frequently alternate. Finally, the only notable result from these analyses is the apparent increase of uric acid, as given by Simon, Becquerel, and Schénlein, and the large proportion of oxalate of lime, as observed by Dr. Balman. Dr. Glover’s analysis, however, gives a different result in relation to uric acid. It will be remarked that these analyses, for the most part, have been made either in an advanced stage of the disease or in scrofulous subjects, neither of which will probably represent what occurs in the earlier stages of phthisis. The observations of Becquerel, although numerous and interesting, relate to the advanced stage. He found, however, that after the disease passed the first stage, the urine often had a high specific gravity, was reduced in quantity, and of high color; all of which indi- cated a febrile state, and that the local disease was extending. As debility advanced, the urine became aneemic. But little has been determined in relation to the actual state of the cutaneous and mucous secretions in the tuberculous con- dition. It is certainly true, however, that these secretions are often performed with undue activity, and again sink below the normal standard; indeed, the irregularity of action, which per- tains to the functions so generally in this diathesis, is especially evident in the state of the skin. The watery state of the blood, and the modified condition of the capillaries, necessarily favor free cutaneous transpiration under particular circumstances, and again as readily recede to the opposite extreme. It is in this condition, also, that we witness partial perspiration, partaking, at times, of the condition known as clammy. The mucous se- cretions are equally variable, but our knowledge of their changes is very incomplete. It must be admitted, however, that we have 72 PATHOLOGY OF PHTHISIS. no positive knowledge of any special changes which occur in the composition of the fluids during the existence of the tuber- culous diathesis. The condition of the adipose secretions evidently undergoes important changes, the most obvious of which relate to the rapid fluctuations which often occur, especially in the diathetic and precursory conditions. It will often be observed that young subjects predisposed to scrofulous and tuberculous affections, rapidly lose and gain their adipose material, showing the ready absorption and deposition which take place in such constitu- tions. These functional changes, however, probably simply indicate a state of the system in which depression is readily induced; for, notwithstanding the belief that the fatty sub- stances belonging to the tuberculous constitution are different from those found in healthy systems, there is, in fact, no evi- dence to sustain that opinion. There can be no doubt, indeed, that fat and the fatty acids sustain an intimate relationship to nutrition, in a general sense; but we are unable to determine any special fact in the relation of this substance to the tuber- culous process, and hence it is merely the physiological changes to which, in this connection, our attention is directed. The menstrual secretion is liable to important changes. In the advanced stages of tuberculosis it becomes suppressed, and in the earlier periods it is often irregular. And in the mere tuberculous constitution, or the incipient stages of the disease, this secretion is liable to become suppressed, and to act as an inducing cause of tubercular deposits. There can be no doubt that the menstrual secretion bears an important and intimate relationship to tuberculosis; and a knowledge of this fact is of great value to the practitioner in the treatment of the dis- ease, and also in preventing its access. In all persons, especially young females, in the slightest degree predisposed to tubercu- losis, the menstrual function should be carefully observed, and all its irregularities as speedily as possible removed. DEPOSIT OF TUBERCLE. 73 CHAPTER VI. DEPOSIT OF TUBERCLE. SECTION I. TISSUES IN WHICH THE PRIMARY DEPOSIT TAKES PLACE. It was announced by Magendie, in 1821, and Schroeder Van der Kolk, in 1826, that the primary seat of tubercle of the lungs was the terminal portion of the air passages; and the latter, in 1852, published additional observations confirmatory of the first opinion. Magendie describes the earliest tubercular deposits as consisting of yellowish material located in the air-cells; at times it appeared limited to a few of the cells, but usually occupied an entire lobule. This tubercular matter appeared to be secreted by the pulmonary capillaries, and was generally ad- herent to the vessels, but was sometimes movable. He never observed the gray granules preceding the true yellow tuber- cle.* It is the opinion of Schroeder Van der Kolk, that the tuber- cular matter is imbibed by the epithelial cells, which enlarge, are finally cast off, and rupture, and thus give rise to the smaller or true tubercle-cell. This process Van der Kolk regards as an- alogous to hepatization of the lungs; but as he considers tubercle to be of inflammatory origin, the analogy which he seeks to establish must be considered purely hypothetical. Henlé, Vir- chow, Addison, Sieveking, Radclyffe Hall, and others, entertain views essentially similar to those of Shroeder Van der Kolk, at least so far’as relates to the location of tubercle in the epithe- / * Journal de Physiologie, 1821. 74 PATHOLOGY OF PHTHISIS. lial cells. It is well known, also, that Dr. Carswell held the opinion, that the mucous tissue was the seat of tubercle, which he demonstrated with great care and ability. Mr. Gulliver observed tubercular matter occupying the interior of the air vesicles, but at the same time also the inter-vesicular areolar tissue. According to Mr. Rainy’s observations, tuberculous matter is secreted into the air-cells and inter-cellular passages ; and in either case the deposits compress the adjacent vessels, the parietes of which disappear. Rokitansky divides tubercles into two classes—interstitial tubercular granulations, and tubercular infiltration. The inter- stitial granulations are seated in the “ interstitial cellular tissue, between the lobules and air-cells, and on the walls of the air- cells themselves ;” and may form a prominence on the internal surface of the air-vesicle by pushing the membrane before it. These granulations, therefore, do not occupy the interior of the vesicles. The infiltrated tubercle, on the contrary, is deposited within the air-vesicles, as a result of “croupous pneumonia,” the deposit being changed, under the influence of the tubercu- lar dyscrasia, into yellow tubercle. Like Van der Kolk, he regards the process as analogous to hepatization. According to Andral,* the primary deposit of tubercle may be observed in the form of whitish points on the surface of lobules, or within their substance, which sometimes multiply and become united, occupying entire lobes in the form of large masses. In other examples, the inter-lobular cellular tissue becomes the seat of a reddish infiltration, in which tubercles appear in the form of isolated white points. Hence Andral concludes that tubercu- lous matter is secreted indifferently in the terminal bronchial tubes, the air-cells, and the inter-vesicular and inter-lobular areolar tissue—being equally seated in the mucous and areolar tissues. In addition to this, Andral has clearly described the existence of tubercles in the lymphatic vessels of the lungs, the groin, and in the thoracic duct. Lebert is of opinion that tu- bercle is most commonly deposited in the areolar tissue, but that it is also observed in the air-vesicles and capillary bronchial tubes. * Medical Clinic. MODE OF DEPOSIT OF TUBERCLE. 45 The most obvious conclusion which can be drawn from the numerous experiments and observations on this subject, is, that tubercular exudation, like that process in general, tends to a free surface ; and hence the morbid deposit will appear in the air-cells, and on the surface of serous membranes surrounding viscera. There is but little tendency, however, to tuberculization of the skin, although it has been observed. But it is equally true that parenchymatous structures of viscera, such as the liver and brain, become the seat of tubercles; and there is no sufficient reason why the same result may not occur in the lungs. Indeed, all vascular tissues may become the seat of tubercular deposits, although they manifest a preference for particular organs and structures. The change observed in the epithelial cells is probably due to an altered nutrition of the part following the exudation; and hence no specific agency is exercised by those bodies in the formation of tubercle. It is true, the tuberculous material may be attracted by and deposited in the epithelia; but it is not an act of elaboration in that structure, but is rather an accidental deposit. SECTION II. MODE OF DEPOSIT OF TUBERCLE. The deposit of tubercle being essentially an exudation from the capillary vessels, the only important question relates to the degree of action with which it is associated ; whether, in other words, the process is analogous to simple secretion, or whether it is associated with congestion or inflammation. ; Vogel describes the tissues surrounding tubercular deposits as being in a natural condition ; they are neither altered nor displaced, but the deposits seem merely to fill the interstices, without modifying the adjacent textures. A still more minute description has been given by Mr. Rainy, who states that the capillaries are comparatively healthy, which is strongly con- trasted with the irregular condition, dilated and tortuous course, 76 PATHOLOGY OF PHTHISIS. pursued by the same vessels when proceeding to fibrinous or inflammatory deposits. According to this view, there is no evident increase of action (inflammatory or congestive) in the capillaries, giving rise to tubercular effusion; nor does obstruc- tion in the vessels occur until the accumulation increases so as to produce mechanical compression. Schroeder Van der Kolk is of opinion that a plastic material is exuded into the air-vesicles, and that it is absorbed by the epithelial cells, which enlarge and are cast off from the mem- brane, and thus constitute the tubercular substance. The pro- cess by which epithelial cells are transformed into tubercles is regarded as analogous to glandular secretion, which, however, he considers similar to the process of hepatization. It is evident, from the whole tenor of Schroeder Van der Kolk’s description, that he regards the process of tuberculization as analogous to inflammation. When the tubercular masses enlarge, they com- press the vessels of the air-vesicles, the local exudation ceases, and, in consequence of the loss of fluids, the mass acquires additional firmness, which renders it stationary until softening supervenes. Nearly similar views have been expressed by Virchow. Ac- cording to this observer, the epithelial cells enlarge by endo- genous formation, and finally break up into a granular detritus, in which shriveled and irregular tubercle-cells, as described by Lebert, are formed. This process, according to Virchow, is effected through a disturbance of the nutrition of the part, constituting an altered exudation, either inflammatory or an analogous affection. It will be remarked that both Virchow and Schroeder Van der Kolk regard the formation of tubercle as a process of exudation, in some sense analogous to inflam- mation, although they do not give it that name, but rather refer it to the class of secretions. But the idea embraces a morbid exudation, through the agency of which the epithelial cells undergo tuberculization. Dr. Sieveking goes a step beyond Virchow and Scroeder Van der Kolk. He asserts, as the result of his own observations, that the local and molecular changes in the vascular system, connected with the formation of tubercle, are characteristic MODE OF DEPOSIT OF TUBERCLE. "7 of inflammatory action, as shown by the enlargement of vessels and the presence of exudation-cells. It is declared by Dr. Sieveking, that he has observed, in all stages of the local de- posit, the air-vesicles filled with tubercle, surrounded or invested with exudation-corpuscles. He distinguishes, however, between this inflammatory process and the true tubercular exudation; one is merely the accompanying phenomenon and incidental change, while the other is the essential morbid product. He does not regard tubercle as a growth, nor is it identical with the effusions of blood-constituents resulting from exalted action; and, on the other hand, the epithelial cells form no part of the new product.* Andral, at one period, expressed the opinion that an active sanguineous congestion preceded tubercular deposits; but in a subsequent note he adds, that he no longer regards hyperemia as a necessary part of the morbid action. On the contrary, he considers the whole process a mere perversion of secretion, which may be connected with local irritation or it may be in- dependent of any such change in the vessels. In reviewing all the facts which have been developed in this connection, it seems to me sufficiently evident that the process of tubercular exudation, or formation, bears no direct relation- ship to inflammation. Nor is the evidence sufficient to prove, notwithstanding the high authority of Virchow and Schroeder Van der Kolk, that the process consists of a transformation of the epithelial cells into tubercle, or that they are in any sense connected with the formation of that substance. In relation to the analogy existing between inflammation and the tuberculiz- ing process, the microscopic and chemical constitution of tuber- cle afford abundant evidence that it is not the product of a high grade of action, or, in other words, that it is not of inflam- matory origin. For, notwithstanding the declaration of Dr. Sieveking, that he observed exudation-corpuscles to be present, they do not enter into the composition of tubercles, and, there- fore, must be regarded as purely accidental. Indeed, making * British and Foreign Med. Ch. Rev., April, 1853. + Med. Clinic. 78 PATHOLOGY OF PHTHISIS. all due allowances for the constitutional influence, it must still be admitted that if inflammation were truly present, as the basis of the process, there would necessarily occur more definite signs of the existence of that morbid state than the presence of a few bodies bearing the form of exudation-corpuscles. The only conclusion, it seems to me, which can be deduced from the known facts is, that the exudation is a specific act, and the product a compound sui generis; and hence, that it is neither the legitimate result of inflammation nor congestion, and that it is not necessarily accompanied by either of these element- ary lesions of circulation. The mode of deposit, therefore, in its elementary character, bears a closer relationship to glandular secretion than to any other known action; but the whole pro- cess, as well as the resulting deposit, I regard as essentially specific, and, therefore, unlike all other actions and products. SECTION III. RELATION OF THE BLOOD-VESSELS TO TUBERCULAR DEPOSITS. It appears to be a fair inference that the tubercular material 1s secreted from the capillaries of the pulmonary artery. The relation of these vessels to the air-cells, and the chief deposits occurring in those structures, favors the belief that the pulmo- nary vessels furnish the morbid material ; and if this supposition be true, it disproves the opinion that tubercle is simply a lesion of nutrition, for the nutritive function belongs essentially to the bronchial arteries. The function of the pulmonary artery is to convey venous blood to the air-vesicles; and as this variety of blood is not destined to perform nutritive acts, it becomes im- possible to connect the physiological textural changes with the capillaries belonging to this system of vessels. And hence, the deposits of tubercular matter must be regarded as a new act, and not a perversion of an ordinary function. We are not, authorized to conclude, however, that the capillary vessels of the bronchial arteries are incapable of depositing tubercular RELATION OF BLOOD-VESSELS TO TUBERCLE. 79 material; for the fact, that the morbid deposits are met with in the bronchial glands, which are supplied with blood by these vessels, is conclusive that these arteries may furnish the mate- rial. It seems sufficiently evident, however, that the great mass of the morbid material is received through the medium of the venous blood, and is thus eliminated by the pulmonic capillaries. The ultimate relation, however, of the blood-vessels of the lungs, pulmonary and bronchial, to the different stages of tuber- cular deposit and transformations, has not been clearly demon- strated, although certain facts have been made known which throw some light on the subject. It has been demonstrated by Dr. Stark, Schroeder Van der Kolk, and others, that blood- vessels, in the vicinity of tubercular masses, become obliterated, not only by compression, but also by coagulated substances internally, and that this occurs not alone in capillaries, but likewise in vessels of considerable size. And it is remarked by Hasse, that when the pulmonary vessels become obliterated they are replaced by others from the general or aortic system, which is effected by enlargement and new connections of the bronchial arteries. In this manner the intercostal and mam- mary arteries, by the formation of new branches, establish connections with the obstructed lung. When this communica- tion is formed, the injections thrown into the pulmonary artery pass into the intercostals, and the pulmonary artery can be injected from the aorta, so that blood may be returned to the heart by the intercostal and pulmonary veins. These views are based largely on the observations of Schroeder Van der Kolk; but Hasse expresses the opinion that these anastomoses are not constant, and the systems of vessels generally remain distinct. According to the observations of M. Guillot, the new vessels are at first independent, but finally anastomose with the systemic circulation, and contain bright or arterialized blood. According to this observer, the adventitious vessels are arranged as a network around the tubercular deposits, which are primarily independ- ent, (like the formation of vessels in the embryo,) but finally anastomose with branches of the bronchial arteries. When, how- 80 PATHOLOGY OF PHTHISIS. ever, adhesions have taken place or cavities formed, the newly- developed vessels communicate with the mammary and intercos- tal arteries. According to this view, the adventitious vessels can not supply the place of the obstructed pulmonary capillaries, and, therefore, do not contribute to the decarbonization of the blood. The same observer believes, also, that tubercles soften more rapidly when the new vessels are numerous; and as these vessels multiply proportionally to the extent of softening and obstruction, they ultimately supply the principal circulation of a considerable portion of the pulmonary organ. Hence, M. Guillot observes, the arterial circulation becomes increased as the deposits are more extensive and the obstacle greater. The capacity: for arterial blood increases, while the venous propor- tionally diminishes. These considerations (if they ultimately prove correct) present an important view of the process of tuberculization. It would be out of place here to anticipate a discussion of the nature of tuberculosis, (which belongs to a future chapter;) but it is desirable barely to allude to the curious fact just mentioned. If the observations of Guillot are not erroneous, the arterial system of vessels ultimately largely predominates, which would. harmonize with the destructive deposits progressively increasing, and the inflammatory action which so constantly takes place. But the question at once arises, how can the adventitious arte- rial capillaries supply the place, or perform the function of the true pulmonic vessels? It is difficult to conceive how the newly-formed vessels can be so arranged as to supply the function of those obliterated capillaries which belonged to the pulmonary artery. Still it does appear that, by some process, arterialization of the blood goes on perfectly, even in the most extreme cases; which is evinced by the florid countenance of the patient, even when the lungs have become extensively solidified. There is something very peculiar in these cases. Patients, even far advanced in phthisis, with extensive cavities in both lungs, and large consolidations, with a pulse of one hundred and twenty, and forty respirations to the minute, with constant dyspnea and exceedingly deficient expansion of the chest, will, nevertheless, exhibit florid cheeks and lips, and the MODE OF ENLARGEMENT OF TUBERCLES. 81 whole aspect will indicate perfect (even hyper) arterialization of the blood. It will not be a sufficient explanation to say, that the frequency of respiratory movements or the diminished quantity of blood compensate for the degree of obstruction; for the increase is only one-fourth in favor of respiration, (thirty respirations being the physiological ratio of a pulse of one hun- dred and twenty,) while the pulmonary obstruction and the defective expansion would certainly reduce the capacity of the lungs much more than this one-fourth excess of respirations would supply. Hence it appears, that the arterialization is even more perfect than in health, notwithstanding the large obstruction and obliteration of the pulmonary capillaries. Let me suggest, then, without attempting more, does not this con- dition indicate an increased capacity of the lungs for oxygen? It appears to me a fair induction, that a largely-augmented affinity exists between the lungs and the oxygen of the air, by which the latter produces an unusual and even morbid effect. It is certainly true that the same amount of obstruction resulting from ordinary pneumonic consolidation is attended by signs of highly carbonized blood. And it may be further remarked, that, independent of the formation of new vessels, the oxygen may, from the morbid condition of the parts, attain an increased affinity for the blood, so that arterialization takes place in a rapid manner. Indeed, this hypothesis seems necessary to account for the phenomena, whether adventitious vessels be formed or not; for in either case there is evident pulmonic obstruction, which, under ordi- nary circumstances, always interferes with the complete oxygen- ization of the blood. SECTION IV. MODE OF ENLARGEMENT OF TUBERCLES. The various views which have been entertained respecting the nature and structure of tubercles, have become the basis of different theories in regard to their growth or increase of 6 82 PATHOLOGY OF PHTHISIS. size. Some consider tubercle as absolutely dead matter, and therefore incapable of growth by intussusception, such as char- acterizes living or organic bodies; while others believe that these morbid products possess a low grade of vitality, and that their increase may be regulated by the laws which govern vital actions. It seems evident, however, that the only mode of growth which can be admitted is one of a modified character, such as belongs to organic bodies whose vital actions have suf- fered a certain degree of degradation. The microscopic consti- tution of tubercle clearly shows that it possesses some degree of vitality; and all the phenomena connected with its natural history tend to confirm this opinion. It necessarily follows, therefore, that the mode of growth of a body having even a low grade of vitality, but a definite cell-organization, must necessarily differ, to some extent, from that which prevails in mere minerals. The cells and granules which make up the microscopic composition of tubercle doubtless possess two prop- erties essential to organic bodies, namely, endosmosis and assim- ilation; and by virtue of these powers, the primary tubercu- lous particle is capable of attracting to itself analogous bodies, and these, in turn, attract others, until the growth is com- pleted. , The size of the largest tubercle-cells are of such dimensions as to forbid the idea that, as such, they pass through the vas- cular parietes; and, as a necessary consequence, their growth must be extra-vascular. In accordance with well-defined his- tological laws, the tubercle-granules are the cytoblasts around which the ultimate cell becomes developed; and it is evident that the granules must constitute the primary condition, and that the cell-formation is the completion of the epigenesis. So far as facts or principles can throw any light on this subject, we have no ground to assume that the formation of tubercle differs, in any essential manner, from the development of other low-grade tissues, except it is in regard to the character of the blastema which becomes its pabulum; nor is there any more reason to doubt that its subsequent enlargement is regulated by the ordinary laws of vitality, and therefore a distinct growth, modified by the character of the materials and the state of the. MODE OF ENLARGEMENT OF TUBERCLES. 83 prevailing diathesis. But, in drawing these conclusions, I wish to observe, that it does not necessarily follow that tubercle is similar to any other product, or that it does not differ from all others in its nature and tendencies. After the exudation of the tuberculous blastema, the produc- tion of granules, or cytoblasts, constitutes the initial step in the formation of tubercles, and the second is the growth of cell- -membrane around the granules; and thus the process goes on, granule upon granule being deposited, and cell after cell formed, until the ultimate development is attained. Thus, although the extension or aggregation of masses is due to external or peripheral deposit, yet the process is by no means similar to that of mere accretion, which belongs to inorganic bodies; for, in tubercle, there is a continuous cell-growth, and not mere aggregation of previously-formed particles, and which, by the usual laws of analogous formations, exhibits indubitable evidences of vital action. Nor is this cell-action limited to mere extension, for it evidently continues to operate, by absorb- ing nutritive material, which sustains the mass for a limited period, until finally, its vitality being exhausted, disintegration results. According to this view, tubercles are, in fact, organic bodies 5 but, in making this statement, it must be connected with the fact that their vitality is of a grade so low that vessels can not form in the new structures. They are, therefore, organic, but non-vascular bodies. This view of the mode of enlargement of tubercle necessarily rejects the theory that they consist of metamorphosed epithelia, or any form of retrograde morphology. These theories, although supported by high authority and numerous experiments, are, nevertheless, isaaly conjectural; and they are so contrary to any well-known pathological epigenesis, that they must fail to receive general sanction. We might, indeed, admit most that has been actually observed on this subject, and still reject the theory as a whole; for the fact that the epithelia are thrown off, and appear mingled with the tubercular formation, proves only that the morbid action has disturbed this part of the structure, and caused the destruction of the cells. And admit- 84 PATHOLOGY OF PHTHISIS. ting, further, that tuberculous matter may be found in the epithelia, it would still be far from proving that it is formed by these cells. SECTION V. RELATIONSHIP OF GRAY AND YELLOW TUBERCLE. Different views are entertained by pathologists in regard to the relationship which exists between the gray and yellow varieties of tubercle. Some regard them as simply different stages of the same deposit, the gray being the nascent phase of the yellow; others believe they constitute entirely distinct species; while a third opinion denies to the gray variety a posi- tion among tubercular deposits. Laennec, it is well known, regarded the gray semi-transparent granules as the first stage of tubercle, and that they were ultimately developed into the yellow or crude variety. Similar opinions are held by Louis, Walshe, and many others. Rokitansky formerly held that these varieties were entirely dissimilar; but he appears to have changed his views, and now regards the gray as being trans- formed into the yellow. Vogel admits the occasional transform- ation of gray into yellow tubercle, but states that the latter may occur independent of the former. Hasse, on the contrary, considers the gray bodies as the result of inflammatory action around tubercular softened masses; but as he declares that they occur only in the advanced stage of tuberculosis, after softening, it is clear he had in view something different from what we are now considering. M. Bayle, who originally described these gray granulations, evidently regarded them as different from ordinary or yellow tubercles. Andral considers these granules as indurated or hypertrophied air-cells, the result of inflammation, and therefore not true tubercles. Dr. Campbell adopts the opinion that gray granulations are different from yellow tubercle, and, among other evidences, adduces the effects of chemical reagents on the two varieties, Thus, yellow tubercles are readily dissolved by pure liquor RELATIONSHIP OF GRAY AND YELLOW TUBERCLE. . 85 potassa, forming a clear, saponaceous solution; but the same agent fails to dissolve granulations, producing only a slight degree of softening and enlargement. Dr. Blakiston has shown, by numerous cases, that granulations arise from inflammation; and Mr. Ancell makes the same admission, presuming, how- ever, that the deposits arise from tuberculous blood; but he adds that they may occur without inflammation. Dr. Williams denominates gray tubercles cacoplastic deposits, and compares them to the effusions which occur in chronic or subacute arach- nitis, peritonitis, and pleuritis; while yellow tubercle he regards as entirely aplastic in its constitution. My own observations, based on the general and local symp- toms, and post-mortem examinations, have resulted in the con- viction that gray semi-transparent granules are inflammatory products, and, therefore, different from yellow tubercle. Thus, I have never witnessed these granules except in asso- ciation with evidences of inflammatory action, more or less intense. A number of examples confirming this opinion have come under my immediate observation, in which the diagnosis was made during life, and the pathology confirmed by examin- ations after death. It would be out of place to enter here fully into the history of these cases; but I may observe that they were associated with decided evidences of inflammatory action during life, such as chills and fever, together with cough, and more or less increase in the respiratory movements. After death, the granules were found scattered throughout the pul- monary tissue, occupying equally the lower portion of the lungs. In addition to this, the general pulmonary structures gave evident marks of increased vascularity, which was further con- firmatory evidence of the inflammatory nature of the deposits. In these examples we have evidences of inflammation fur- nished by the symptoms during life, appearances after death, and the anatomical seat of the deposits. In relation to the last point, it is a well-known law of tubercular deposits, that they begin nearly always at the apex and extend downward ; while in these inflammatory granulations the lower portion of the lungs becomes often more completely studded than the apices. In addition to this, it is well known that exactly similar granules 86. PATHOLOGY OF PHTHISIS. are deposited in other parts, as the effect of unequivocal inflam- mation. This is witnessed in tubercular meningitis of the brain pleura and peritoneum. These examples furnish indubitable evidences that such granules arise from inflammatory action. Even Louis admits that there is a substance greatly resem- bling the gray, but less firm, which is never transformed into yellow tubercle ; and he further says that the gray matter of the upper lobes appears to be the product of chronic inflam- mation. It is freely admitted that the grade of action which produces gray granulations is often very low, but, nevertheless, is made up of vascular irritation; while, in its higher grade of action, a distinct febrile disease is developed, which has been described by some writers under the name of acute phthisis. It is, doubtless, true that all these products bear a certain relationship to each other, in their essential characters, although they may differ in their causes and terminations. Thus, active inflammation occurring in a subject free from diathetic taint, will give rise to organizable lymph; but the same morbid action, either differing in degree (subacute) or occurring in a depraved constitution, will give rise to a lower grade of plastic deposits, such as the semi-transparent granules; while the mere act of secretion, independent of inflammation, is capable of causing yellow tubercular deposits when the diathesis becomes fully developed.. In the examples, then, of granulations, the products are below the degree of vitality which characterizes fully organiza- ble lymph, but above that of common tubercles; the result, therefore, is, that while they are not capable of becoming vascular or fully organized, they possess a sufficient degree of vitality, at least in many examples, to resist decomposition. The tendency of the granules is certainly not to speedy dis- integration. It is true, however, according to my observations, that some examples do advance to softening. I have watched the course of cases in which the early symptoms indicated ordi- nary granular inflammation, but finally signs of softening were superadded. In such cases the post-mortem examinations have revealed tuberculous masses, varying in size from a pea to that RELATIONSHIP OF GRAY AND YELLOW TUBERCLE. 87 of an almond, softened in the center, and sometimes forming small cavities; but they differed from ordinary tubercular de- posits by being scattered throughout the lungs, occupying equally the lower portions. The history and terminations of these cases have induced me to believe, that when the vitality is continuously lowered, and the semi-plastic product increased, it may finally pass into softening, presenting the ordinary characters of crude tubercles. 88 PATHOLOGY OF PHTHISIS. ° * CHAPTER VII. CHANGES WHICH OCCUR IN TUBERCULAR DEPOSITS. Tue natural tendency of crude tubercles is to softening and elimination; while the gray variety may undergo slight con- traction and remain stationary. The possible condition of both varieties, as a primary or secondary action, is absorption. The following divisions, therefore, deserve attention : 1. Absorption prior to consolidation. 2. Absorption after softening. 3. Contraction, or a stationary condition, 4. Softening with elimination. 5. Cretaceous transformation. SECTION I. ABSORPTION PRIOR TO CONSOLIDATION. Tubercle being deposited in a fluid state, absorption must be regarded as a, possible event. It is true we have no demon- strative evidence of that result, nor will it, in the nature of things, admit of such elucidation; but there are certain ana- logical and clinical considerations which favor the supposition that, at least, tubercular blastema may be absorbed instead of becoming consolidated. In the broadest view of the subject, it is a fair inference that a substance which is susceptible of transmission through the walls of one set of capillaries, may return to the circulation through another class. We have no ABSORPTION PRIOR TO CONSOLIDATION. 89 conclusive evidence that tuberculous blastema becomes imme- diately concrete; and if the material remains fluid for even a limited period, it would but obey the ordinary laws of the ani- mal economy to re-enter the circulation by endosmotic action. Nor is it beyond the limits of possibility that such a process may be carried on for a considerable time, and thus delay or entirely prevent the accumulation of the morbid material. When the tuberculous predisposition is not very intense, or if favorable influences are brought to act on the patient, there is no sufficient reason why tuberculous exudation, like the inflam- matory, may not be absorbed. The clinical evidences of absorption deserve special attention. It can not have escaped the observation of those much engaged in the treatment of phthisis, that the precursory stage of the disease may be well marked, embracing emaciation, cough, febricula, hemorrhage, and even certain physical signs, and yet the disease, instead of advancing, may be made to recede, with ultimate suspension of all the morbid phenomena. It is diffi- cult to conceive that all these signs and symptoms can exist without some degree of exudation; and if we advance beyond this, the existence of some form of crackling, will clearly evince the occurrence of local disease. The so-called dry crack- ling, pulmonary crumpling, and cogged-wheel sounds, represent deposits in an early stage; but it is undetermined how far they may indicate a state of fluidity. It will be remembered, how- ever, that these signs are often evamescent; that is, in an early stage of development, they are heard with one inspiration, and disappear the next. It is difficult to conceive how these fluc- tuations could occur if the sign depended entirely on solid tubercles; but if we admit the presence of a liquid, the ex- planation becomes easy and natural. Again, I have often heard a sound precisely like the forcible expansion of air-cells, or pulmonary tissues amid an adhesive fluid—a sound softer than a crepitus and less defined than dry crackling—and which conveyed precisely the idea of expansion occurring amid an adhesive exudation. And while I would not attach undue im- portance to an observation of this character, still, taken in con- nection with the other phenomena, and having observed it very 90 PATHOLOGY OF PHTHISIS. often, I can not avoid regarding it as indicative of tuoerculous exudation. If, then, any of these signs and symptoms warrant the con- clusion that they arise from fluid tuberculous material, the additional fact that they may be made to disappear completely and permanently, is evidence sufficiently conclusive that absorp- tion may take place. It can not be doubted, indeed, that all these evidences of disease, including even dry crackling, disap- pear; and it is far more probable that absorption would take place while the blastema remains fluid, than that, after consoli- dation, liquefaction would be followed by removal of the sub- stance. It is not denied, however, that, under some circum- stances, this latter process may occur; but at the same time, it must be regarded as a much less probable event. SECTION II. ABSORPTION AFTER SOFTENING, A majority of pathologists have denied or doubted the pos- sibility of the absorption of softened tubercular matter; but there is sufficient evidence that such results do, at least occa- sionally, occur. Hasse remarks that cicatrized cavities being free from tubercles in their vicinity, indicate that the deposits have been absorbed and not expectorated. Andral, Walshe, Carswell, and Ancell, regard the absorption of crude tubercles as a possible event. Andral gives examples in which cartilag- inous or fibrous deposits, not unlike those found in obliterated cavities, were met with; but as the bronchial tubes could not be traced to them, he supposed they were not the remains of tubercular cavities, but probably the result of inflammation. It is a fair question, however, whether these masses, at least in some of the cases, were not in fact the remnants of tubercular cavities; and this opinion is rendered the more probable by the presence of tubercles, in some of the examples, in other por- tions of the pulmonary tissue. And if these deposits occupied ! ABSORPTION AFTER SOFTENING. 91 former tubercular caverns, it follows that the softened material had been absorbed and not eliminated, for there were no con- necting tubes through which it could have escaped. There is sufficient evidence, however, that some degree of absorption does take place in those examples in which creta- ceous matter remains. Tere, it is evident, the animal matter constituting the true tubercular material was absorbed, leaving a partial cavity more or less filled with earthy substance. In many of these cases the openings into the bronchial tubes are closed, which forbids the idea that the tubercular matter was entirely eliminated; while in others there is no evidence of bronchial openings ever having taken place, so that absorption was the only mode by which the tubercles disappeared. Hasse is of opinion that in these cases the tubercular mass is sur- rounded by a thin isolating crust of organizable lymph, and when it comes in contact with the newly-formed vessels, absorp- tion of the organic portion takes place.* The same author is of opinion that a majority of these concretions originate in small and closed cavities. Indeed, it seems quite certain that a closed cavity is requisite to produce cretaceous matter; for so long as they remain in free communication with the bron- chial tubes, no accumulation, of any character, can take place. Calcareous masses, therefore, can be deposited only when the tubes have been closed, or when absorption takes place without bronchial communications. A fact which would seem conclu- sive on this subject is, that calcareous transformation of tuber- cle is met with in other organs, so that absorption necessarily took place. Thus, Rokitansky states that tuberculous chalky concretions, invested by a fibrous sac, are met with in the kidneys. It might be further argued that tuberculous matter is ab- sorbed in certain cases of scrofulous swellings. In some of these examples, resolution and complete disappearance of the swelling takes place, especially under the influence of iodine; and, as there is little doubt that some of these swellings contain tuber- culous matter, we have additional evidence of the powers of * Path. Anat., Am. Ed., p. 321. 92 PATHOLOGY OF PHTHISIS. the vessels to absorb such material. It seems scarcely neces- sary, however, to pursue this line of argument further. There is no physiological reason why fluid tubercular matter may not, under favorable circumstances, be absorbed; nor is there any insuperable objection to the idea that liquefaction and absorp- tion may take place, when the mass is in connection with blood-vessels, in precisely the same manner that any other ad- ventitious deposit is removed. In other words, the removal of softened tubercle does not necessarily imply an ulcerative pro- cess, but, on the contrary, simply physiological absorption, without destruction of the surrounding tissues. But while it is admitted that absorption may thus take place, the oceurrence of an ulcerative action, with inflammation and exudation in the surrounding tissues, will often entirely prevent that result. Indeed, the obliteration of the blood-vessels, as shown by Stark, Guillot, and most other observers, prevents direct contact with a vascular tissue, and, therefore, absorption becomes an impossibility. The only method, therefore, by which the adventitious material can escape is by opening into the bronchial tubes, and elimination by expectoration. SECTION III. CONTRACTION, OR STATIONARY CONDITION, Pathological anatomists describe a certain degree of con- traction in some forms of tubercle, which renders the mass stationary in its condition. It is evident, however, that these descriptions apply exclusively to the gray variety, which, by a process of retrogression, is reduced to a semi-cartilaginous con- dition. There is nothing to prove, however, that yellow or crude tubercle undergoes this change; indeed, the only trans- formation known to take place in the latter variety is that of liquefaction; for the histological elements being of a class in- susceptible of any advance in the scale of vitality, the slightest retrograde movement invariably terminates in disintegration. SOFTENING AND ELIMINATION, 93 If, therefore, we exclude the gray variety from the class of true tubercle, there is no form remaining which is capable of contraction or assuming a permanently stationary condition. Doubtless in some forms of even yellow tubercle, where the masses are small and scattered, their integrity may be main- tained, under favorable circumstances, for a considerable period; but this can not be regarded as more than a temporary state, liable to be interrupted by adverse circumstances, or even the lapse of time. SECTION IV. SOFTENING AND ELIMINATION. The destructive tendency of tubercle, in fully developed cases, is shown by the process of softening, and the disorganizing effects on surrounding tissues. The exact nature of the process of softening is still unsettled, though all agree that the mass becomes dead animal matter. Laennec believed the softening commenced in the center of the tubercular mass; and the same view has more recently been maintained by Rokitansky and others. In opposition to this opinion, Lombard, Hope, Andral, Carswell and others teach, that the process of destruction com- mences externally. Those who suppose the act of softening begins in the center of tubercles, ascribe it to a natural ten- dency to disintegration, in consequence of its low grade of vitality ; while others attribute the external change to the influ- ences of pus and serum, which result from inflammation set up around the deposit. Dr. Carswell attributes the apparent cen- tral softening to the opening of bronchial tubes, the deposit having taken place on their inner surface, and leaving a cen- tral canal. Vogel* describes softening as commencing in the amorphous stroma, which liquefies, the elementary granules then separate, the cells and cytoblasts are liberated, break up, and form a sort of emulsion with the fluids. * Path, Anat. 94 PATHOLOGY OF PHTHISIS. ‘A little attention to the histological elements and essential character of tubercle, will enable us to form correct views on this subject. It will be borne in mind that tubercles are made up of more or less imperfect cells, which are capable of exer- cising, for a brief period and to a limited extent, the functions of nutrition and self-preservation; but, inasmuch as this cell action is of an imperfect character, the vitality of the tubercu- lar formation sinks’ still lower, and the cell action becomes mere imbibition, with a destructive rather than nutritive. ten- dency. The consequence is, the cells become distended, the whole mass is rendered more friable, granular, and fatty, until finally the changes cause complete disintegration. Now, it is evident this process pervades, more or less, the whole mass; but in its nascent state will be more prominent at some points than others; perhaps more commonly in the center. In the language of Rokitansky, the softening consists in the solution and disintegration of the solid ground-work of the tubercle; and he might have added, it completes the death or destruction of the deposit. The elements undergo progressive changes; the cells at first enlarge, but finally burst, liquefy, and disappear; the granules contract, and the whole mass is destitute of the slightest remains of vitality. The agency of peripheral inflammation in the production of this softening is exceedingly problematical. During the depo- sition of tubercle the blood-vessels do not necessarily, nor com- monly take on any action beyond that of moderate hyperemia; and there is no evidence that inflammation takes place around the mass, except as a sequence of the softening, or as an occa- sional complication. There may be examples in which the tubercle acts as a foreign body, causing excitement and inflam- mation, especially when the parts are preternaturally sensitive ; but this is not the ordinary course, and it is far more probable that when inflammatory action arises independent of and an- terior to softening, it depends on idiopathic causes, such as exposure, or any of the ordinary conditions capable of increas- ing or originating pulmonic inflammation. When, however, inflammation does arise, it necessarily speedily destroys the vitality of tubercle by cutting off its connection with a healthy SOFTENING AND ELIMINATION. 95 tissue ; and the products of inflammation, pus and serum, tend, as a general rule, to hasten the solution of the tubercular mass. While we admit, therefore, that tubercle occasionally softens externally, as the result of inflammation, we regard that pro- cess as altogether accidental, and consequently its true or legiti- mate disintegration must be ascribed to the action of its own component elements, which, by virtue of their low organization and limited duration, tend to speedy destruction per se. The immediate contact of tubercle-cells with a vascular tissue serves to perpetuate their existence, as well as increase, so long as those tissues remain normal; and, for the same reason, the central por- tions, being farthest removed from the vascular influence, will be the first to feel the effects of age, and hence softening begins in the midst of the mass. The softening of tubercles is a destructive act which, as sug- gested by Mandl, sustains a close relationship to fatty degener- ation. There is an evident increase of oil globules, proportioned to the degree of softening, which clearly suggests the idea of a degenerative process of the fatty nature. Dr. C. Radclyffe Hall has observed the fatty transformation in connection with the epithelial cells and the adjacent blood-vessels. Rokitansky and Virchow have made similar observations bearing on this sub- ject, showing the increase of fat during the process of tuber- cular softening. The same process of softening affects the adjacent pulmonary tissues, by which an excavation is formed, and the bronchial tubes opened. As the tubercular deposits take place within the capillary bronchi, the process of softening extends through the whole structure, and, by ulcerative action, the tubes are opened and the pulmonary substance more or less destroyed. This destructive action is often associated with a low grade of inflammation, and a deposition of degraded lymph; and hence the tubercular matter and imperfectly developed fibrin simul- taneously soften, and each contribute to the destructive process by which cavities are formed. It is, in fact, a process of tuber- culous inflammatory softening. 96 PATHOLOGY OF PHTHISIS. SECTION V. CRETACEOUS TRANSFORMATION. The cretaceous transformation is essentially a curative process ; but examples have frequently come under my observation, in which the disease ultimately proved fatal, notwithstanding the extensive formation of cretaceous substance. I have known patients expectorate cretaceous tubercles without any ameliora- tion of the symptoms, the disease maintaining its inveteracy to a fatal termination. But in a majority of cases in which the evidences of cure are found post mortem, the tubercles have undergone the cretaceous transformation. And the fact that patients die while expectorating earthy masses does not in- validate the general idea that the process is one of cure. Thus certain tubercular masses may be undergoing a curative creta- ceous transformation, while other and more extensive portions of the lungs are subjected to simple softening, and hence the disease ultimately proves fatal. This view explains the fact that patients who die of tubercular disease of the lungs, often exhibit portions healed or rendered inactive by the cretaceous change. The chemical analysis of cretaceous tubercle shows that the animal matter becomes absorbed, while the earthy or inorganic materials remain. The relative proportion of the organic and inorganic substances in the two forms of tubercle becomes ex- actly reversed when the cretaceous change occurs; which is doubtless due to the absorption of the organic, while the ves- sels are incapable of taking up the inorganic. Pathologists speak of this change as absorption of the organic elements while the deposition of the inorganic continues, and thus replaces the former substance. According to this view, the earthy material is an independent secretion, continuing after the deposit of the ordinary tubercular matter has ceased. It is far more probable, however, that the whole mass is deposited in the usual form and composition of tubercle, and that the ulterior changes result from the absorption of the fluid ele- CRETACEOUS TRANSFORMATION, 97 ments, while the earthy substance, being incapable of re-enter- ing the vessels, remains in the cavity. According to Hasse, the calcareous transformation is often preceded by an inflammatory ‘effusion, which takes place in the adjacent pulmonary cells, the texture finally shrivels, and ulti- mately the tubercular mass is surrounded by a thin crust, the vessels of which absorb the fluid portions, and leave the earthy concretion. Rokitansky entertains a somewhat similar view; and he observes that the concretion is seated either in obliter- ated pulmonary tissue or a fibro-cellular capsule. It can hardly be presumed, however, that inflammatory action is essential to this form of tubercular transformation; on the contrary, the surrounding capsule probably results from an effort at repair, consequent upon the improvement in the function of nutrition. The process of absorption takes place very gradually, the mass becoming progressively more dense, and finally reaching even stony hardness. Masses are often ejected during fits of coughing, which possess the hardness and density of the most compact bone. These bodies are frequently as large as a pea, and exhibit various angular projections. It has been denied by Rayer, (and doubtless justly,) that the cretaceous deposits are always the result of softened tubercles, but that they are often the remains of small deposits of pus. The observations apply to both man and animals; but it is probable that when the mass is situated near the apex of the lungs, it generally represents one phase of tubercle. The his- tory of individual cases, when attainable, will often determine the question. It should be remembered, also, that concretions occur in the follicles of the tonsils, which may be mistaken for those of pulmonary origin. 7 93 PATHOLOGY OF PHTHISIS. CHAPTER VIII. CHANGES CONSEQUENT UPON SOFTENING AND ELIMINATION OF TUBERCLES. Tue changes which occur in connection with the softening of tubercles are numerous and important, exhibiting the de- structive tendency of the disease, and the comparatively feeble powers of the vis medicatrix nature. We no longer witness the simple exudation which marked the beginning of the deposit, but a new and destructive action is set up, altogether different from that which existed in the primary stage. SECTION I. CHANGES IN THE PULMONARY TISSUE. When a small tubercular mass softens, the cavity or softened structure is of oval form, (the size corresponding with the mass itself,) and contains merely the debris of the tubercle, without bronchial communication. Very speedily, however, a new and different action occurs in the surrounding tissue; a soft mem- braniform substance lines the cavity, and the pulmonary sub- stance becomes dense, softened, and usually of a grayish color ; while the air-cells, terminal bronchial tubes, and blood-vessels suffer progressive obstruction. The morbid action obliterates, more or less extensively, the small blood-vessels of the part, but their coats are not destroyed. The bronchial tubes, how- ever, become involved in the destructive process, and thus CHANGES IN THE PULMONARY TISSUE. 99 communications between the tubercular cavities and the air- passages, are readily established. The soft membrane which lines the cavities can not, however, arrest the morbid process. Fresh supplies of tuberculous material, and inflammatory exu- dation, speedily take place; the whole structure softens, the membrane is detached, and thus the cavity enlarges. Again, however, a new, soft, and pultaceous membrane forms, as if to oppose its feeble barrier to the progress of the destructive action; but again it is cast off, as new portions of tubercle and exudation matter soften. As the cavities enlarge, the adjacent pulmonary structure usually becomes more and more condensed by the peculiar deposits, until the parts are completely solidi- fied, and no longer crepitate. The tissues, however, adjoining the tubercular cavities exhibit different conditions; they may be nearly or quite healthy, or contain tubercular, melanotic, and inflammatory deposits. The color is usually grayish, but the deposition of melanotic matter may impart a darker hue, and occasionally a reddish mass will be found, not unlike that which belongs to pneumonia. The condition of the pseudo- membrane lining the cavity is quite variable; when the prog- ress is slow, and the disease remains for a time stationary, the membrane assumes a more dense character, approximating the permanent tissues; but when the progress is rapid, it is quite soft, and sometimes scarcely perceptible. As vomice enlarge, the outline becomes more irregular; dif- ferent cavities often communicate, and by burrowing into the pulmonary tissue, anfractuosities are formed, rendering the whole extremely irregular in shape. It happens occasionally, however, that cavities of considerable size maintain the oval form. The size of excavations necessarily varies with the stage of development, ranging from the smallest softened particle to the greater portion of an entire lobe, as a single or several united cavities. The apex of the lungs being the usual seat of tubercles, that portion is the first to soften, and, consequently, becomes the primary seat of cavities; the disease spreading downward, but being less advanced in the lower portions. Thus we often meet with softened tubercles at the apex, solid masses below, and still lower, healthy lung-tissue. The cavities 100 PATHOLOGY OF PHTHISIS. may be single or numerous, according to the original deposits, and the rapidity of softening; but, in fatal cases, they are nearly always necessarily multiplied. The cavities are found at times empty, again they contain pus, softened tubercles, and portions of detached pulmonary tissue; and the whole varying in color and other sensible qualities, according to accidental circum- stances. When pus is recent and tolerably pure, the contents will be yellowish; but if long retained, it becomes greenish. When the walls continue decomposing rapidly, the fluid be- comes less consistent, and is more or less of a grayish aspect; and, not unfrequently, the whole is tinged of a reddish hue by the effusion of blood. The odor is frequently peculiar, but not often offensive; and when the latter condition exists, it sug- gests the idea of partial decomposition of the fluid itself, or a gangrenous condition of the parietes of the cavity. The actual condition of the walls of caverns vary with dif- ferent examples of the disease. As already remarked, there is, in a certain proportion, a false membrane, soft, unorganized, and from time to time cast off by the crumbling walls. Louis met with this membrane in three-fourths of his cases. Laennec witnessed examples in which the pulmonary tissues (smooth, and nearly healthy) constituted the walls, and a single example of the kind occurred in Louis’s cases. As a rule, the surround- ing pulmonary tissue (varying in extent) is indurated, and of grayish color, the condensation arising from a deposit seemingly of the character of gray granulations; crude tubercles and melanotic matter may occupy the same structures. In other examples, a gelatinous infiltration, red or colorless, takes place, intermixed with the other deposits. In still other examples, red hepatization, the result of a higher grade of action, is wit- nessed. These red masses often occupy cells somewhat removed from the tubercular deposits. Hasse calls this deposit gelatin, which, solidifying, becomes reddish, and imparts a firm and sometimes finely-granulated condition to the part. It has seemed to me, however, that these reddened masses, instead of being gelatinous, were, in fact, the fibrinous product of a higher grade of inflammatory action, constituting red hepatization. In certain cases, and especially where a curative tendency CHANGES IN THE PULMONARY TISSUE. 101 exists, the false membrane assumes a higher grade of vitality, may reach a considerable degree of thickness, and is even sus- ceptible of organization. Where, however, the disease is ar- rested only for a time, this membrane becomes more dense, often semi-cartilaginous or fibro-cellular; and when the ten- dency to repair is still greater, the inner surface assumes a smooth, velvety aspect, simulating mucous tissue, continuous with the bronchial membrane, and which may become vascular. The vessels which form in this new structure are, according to some observations, (Guillot,) continuous with the aortic circula- tion, and their minute distribution, in the form of the velvety or villous tufts, brings the blood into contact with the atmos- pherie air. This process, rendered permanent, is necessarily a curative action. Pulmonary cavities are often traversed by bands, which con- gist, in some instances, of altered and condensed lung-tissue, and in others, of compressed and obliterated branches of the pul- monary artery. The condensed lung-tissue is occasionally per- meated by blood-vessels; and the arterial branches at times are not completely closed, and hence destruction of their walls may cause copious and often fatal hemorrhage. The bronchial ves- sels are found in the walls of caverns, obliterated, and pre- senting the appearance of whitish-yellow bands, more or less branched.—(Rokitansky.) Finally, the destructive action which invades the pulmonary tissues, may be properly styled inflammatory softening; for the process clearly involves more or less inflammation, with exuda- tions varying with the state of the tuberculous dyscrasia, and the intensity of the local disease. As a rule, however, the nature of the morbid action does not admit of organization, but manifests almost exclusively a destructive tendency. 102 PATHOLOGY OF PHTHISIS. SECTION II. CONDITION OF THE BRONCHI. When tubercles first soften no communication exists between the cavity and the bronchial tubes; but as the destructive pro- cess advances, the bronchi become involved, and ultimately opened. The morbid action seems to be not unlike that which determines the change in tubercles; but it is evident that some altered state of the tubes must have occurred anterior to the process of softening, which could not take place so long as their vitality remained unimpaired. The capillary or membranous tubes suffer first, and the vitality of these may be impaired by mere pressure, or by the deposition of tubercular matter within the tubes, occupying their parietes or mucous membrane. The tubes may become obstructed by compression, plugging with tubercular or other matter, and liquefy as the process of softening takes place, by which they are abruptly cut off, and form communications with the caverns. Not unfrequently the extremity of the open tube becomes hypertrophied, and the mem- branes exhibit inflammatory redness. Several tubes usually open into a single cavity. At times the bronchi become ob- structed by the accumulation of viscid mucus, tuberculous mat- ter, or other impediments, which prevent, for a limited period, the elimination of the contents of the caverns. Condition of the Nerves.—We have the authority of Schroeder Van der Kolk for the assertion that the nerves which can be traced to the wall of a cavern become swollen, the neurilemma reddened, and as they pass on are lost in the general destruct- ive action, or become converted into condensed bodies not unlike the areolar tissue. Mr. Swan and Schroeder Van der Kolk have witnessed examples in which the pneumogastric nerve was red- dened and thickened; but in many examples no change could be perceived. CONDITION OF THE PLEURA. 103 SECTION IIL. CONDITION OF THE PLEURA. When the tubercular deposits are deep seated, the pleura pul- monalis is in no way affected; but when the morbid action reaches the surface, that membrane becomes the seat of disease. In many instances the inflammatory action extends to the pleura, causing exudation of lymph, more or less extensive, and producing corresponding adhesions. So frequent is this result witnessed, that in one hundred and twelve subjects, Louis found the pleura free from adhesion in a single instance only. The inflammatory action, in its beginning, corresponds pretty ac- curately with the subjacent pulmonary caverns; but when once established, it extends beyond these local changes, and finally may occupy the greater portion of the membrane. The lymph which is thrown out varies in different cases, thus varying the character of the adhesion. This is sometimes firm and com- pact; at others loose and imperfect; while in very old examples the two membranes become almost completely blended, with more or less change of structure, through which the costal ves- sels pass to the lungs. These fibrinous exudations may become the seat of tubercular deposits. These pleuritic exudations and adhesions often constitute the boundary of tubercular cavities, and they take place before an opening can be formed in the membrane, and hence pneumo- thorax is a rare event. In some examples, however, the ulcera- tive action rapidly penetrates the pleura, the contents of the cavern escape into the sac, and almost certainly fatal inflam- mation ensues. And, singularly enough, these perforations are much more frequently connected with small deposits, but which are situated near the surface of the lung. It is asserted by many that the pleura is often the seat of tubercular deposits; and we are not permitted to doubt that the false membrane resulting from inflammation may con- tain tubercles; but, independent of inflammation, I am inclined to regard the deposit of true tubercle as comparatively rare. 104 PATHOLOGY OF PHTHISIS. That rounded granulations, (not unlike the granulations of Bayle,) may occur, is abundantly evident; but it is not equally certain that crude yellow tubercle is often met with on the surface of the pleura. The pleuritis is necessarily modified in its character and products when the tuberculous diathesis exists, but this is very different from the simple secretion of yellow tubercle. I apprehend that the formation of true tubercle on the serous membranes is a much more rare event than many have supposed, and that the products of inflammation (mere granulations) have often been mistaken for true tubercles. The testimony of Rilliet and Barthez is the most decided in favor of the existence of yellow tubercles in the pleura of children, independent of inflammation. These deposits have been seen on the free and attached surfaces, denominated intra and extra- pleural tubercles. According to the observations of Fournet, tubercular depos- its may take place primarily in the pleuritic false membrane, and ultimately extend to the lungs. It seems probable, how- ever, that the term extension conveys an incorrect idea; for it is difficult to conceive on what pathological law the tubercular inflammation of the pleura could be propagated to the adjacent pulmonic structure. Nor is it at all conceivable that the pleura would become the point of primary attack, without a similar or greater predisposition on the part of the lungs. It is far more probable that the examples in which these observations were made, constituted a class of cases in which the tuberculous constitutional predisposition was present, and in which the usual tendency to the lungs existed ; but, in consequence of the devel- opment of intercurrent pleurisy, that morbid action hastened the deposit in the false membrane, thus taking precedence of the affection of the lungs. And, as the diathesis continued, (aug- mented doubtless by the inflammation,) deposits finally occurred in the lungs, not by extension from the pleura, but derived from the primary source. DISTRIBUTION OF TUBERCLE. 105 CHAPTER 4X, DISTRIBUTION OF TUBERCLE. THE question most definitely and concluslvely settled, in re- gard to. the seat of tubercle, is, that the apices of the lungs constitute its common and almost invariable primary location. In nearly all instances, the deposits take place at the apices first ; though, when the disease progresses rapidly, a consider- able portion of the tissue becomes speedily invaded. In the earlier periods the deposits are more frequently deeply seated in the pulmonary tissue, but in other examples they are found immediately under the pleura. True tubercles are found in the lower portion only as the result of extension from above down- ward, or as secondary to pneumonia. In many of the examples in which tubercular deposits are reported to have occurred in the inferior lobes, it is probable the morbid substance was the semi-transparent granules, which, in truth, arise from inflam- mation. So constantly, indeed, is the deposit of true tubercle limited to the apices, that Louis declares he never met with large cavities in the lower lobes. It must be stated, however, that Louis found two cases in one hundred and twenty-three, in which the deposits existed alone in the lower lobes. But this fact, instead of disturbing the general law recognized, serves to establish the belief that deposits in the lower portions of the lungs are infinitely rare. Dr. Hughes found, in two hundred and fifty cases, the upper lobe to be the seat in two hundred and thirty-seven, and in only one instance were the deposits limited to the inferior portion. In regard to the comparative frequency of the deposits in the right and left lungs, professional opinion is i 106 PATHOLOGY OF PHTHISIS. ing to the observations of Laennee, the right lung is the most frequently affected. Louis, on the contrary, inclined to believe the left more liable to the first invasion: thus, of thirty-eight cases in which the superior lobes were disorganized, twenty- eight were on the left side; and of eight cases of perforation, only one was on the right side. The same observer remarks further, that he met with the deposits five times limited to the left, and only twice to the right side. Hasse states, that in thé cases of phthisis which occurred at Leipsic, in 1839, he found the right side the most frequently affected. The cases observed by Dr. Cless gave the result of forty-five right, and thirty left; and Dr. Hughes (Guy’s Hospital Reports) gives one hundred and sixteen cases of left, to eighty-nine of the right side. In a vast majority of examples, however, both lungs are involved; thus, Dr. Green gives the following results in one hundred and twelve cases in children: Both Lun gs:.,, cvsssanssusesecusaesveveseaavnmesweseeeneansursecenwne 101 Right lung only......... beesenecoscessascncverssrscvecencerssoscoete 3 Left: Un O11 yievsssesarsennsnneassajerisdasenden snes oy vssaves seeiewe 8 The following are the results of ninety-eight cases which came under my own observation: Right: lang Only evs ssieseeasesss is veie asinuna ses va cancghaveecnoanworas 28 Defi WATS OY: is as cxsin asi sigoulelenctioansustansan Guadecdomumamoncaiees 20 Both: LUN gsisiessvaccssaeasececncnenssarvaavesawsaedsi vie di sviaconavevede 50 “98 In addition to this, a majority of the fifty cases in which the disease occupied both lungs, were most advanced in the right, which is evidence that it commenced earliest where it had made most progress. It would appear, therefore, from these observa- tions, that tubercular deposits are most frequent in the right lung; but the difference is too inconsiderable to render the ob- servation of any material service either in diagnosis or treat- ment. PNEUMONIA IN ITS RELATIONS TO PHTHISIS. 107 CHAPTER X. SECONDARY AND INTERCURRENT LESIONS. Havine described the primary tubercular deposits, and the changes incident to their different stages and conditions, we are prepared to consider those secondary lesions, and, also, the intercurrent diseases, which exercise such important influences over the course of phthisis. The secondary lesions are those which arise directly from the tubercular deposits, modified by the constitutional derangement, and which involve the adjacent pulmonary tissues. The intercurrent diseases include mainly the inflammatory affections, which arise from general causes, but are of frequent occurrence, and exercise an important in- fluence over the progress of phthisis; and hence, although purely incidental, deserve to be mentioned in this connection. SECTION I." PNEUMONIA IN ITS RELATIONS TO PHTHISIS. The inflammatory affections of the substance of the lungs present different aspects, and exhibit very different etiolog- ical relations, as we consider them intercurrent or secondary, giving rise to three separate forms of disease, which may be thus expressed: 1. Idiopathic, or intercurrent tubercular pneu- monia; 2. Secondary tubercular pneumonia; 38. Hypostatic pneumonia. 108 PATHOLOGY OF PHTHISIS. 1. Idiopathic or Intercurrent Tubercular Pneumonia.—This form of pneumonic inflammation occurs as an intercurrent affection in phthisis, but is the product of general causes, (such as ordi-. dinarily induce pneumonia,) and, therefore, does not arise from, although it is modified by, the tubercular deposit. Idiopathic tubercular pneumonia, therefore, may proceed from any of the common exciting causes which produce the disease in persons otherwise healthy, such as exposure to cold and damp atmo- sphere; and hence the disease is most liable to arise, in our own climate, during the cold and variable weather of winter and spring. The disease, under these circumstances, partakes so far of the common characteristics of pneumonia as to be ushered in with a chill, to produce general fever, and to develop the ordinary physical signs of pulmonary inflammation. It is, however, modified in many examples in regard to location, and frequently occupies the superior or middle lobes. And the same observation may be made in reference to the disease, when it occurs in the diathetic state of the system, for here, also, the inflammation is prone to seize on the apices or middle lobes, in preference to the lower portion. I am inclined to agree with Dr. Walshe, that pneumonia, limited to the anterior portion of the apex, is, in a majority of cases, tuberculous; but, it must be admitted, that exceptional cases occur. It may fairly become a question whether this variety of in- flammation, seizing, as it does, on the apex, is not excited by the local deposits, instead of general causes, and is, therefore, simply a sequence of tubercles. We can not, however, admit such a view, and for two reasons: first, the same location is observed in the mere diathesis, anterior to the development of tubercles; and, secondly, the local inflammation occurring around tubercles produces, in general, different pathological products from those arising from the idiopathic disease. I have already described the gray induration proceeding from inflam- matory deposits around tubercles; and, to establish the dis- tinction, it need only be added now, that the idiopathic form produces red hepatization, such as arises in uncomplicated pneumonia. It seems a fair conclusion, therefore, that tuber- culous pneumonia exhibits a decided preference for the superior PNEUMONIA IN ITS RELATIONS TO PHTHISIS. 109 portion of the lungs, and that, too, whether it occurs in the diathetic state, or when tubercles have been deposited in the lungs. It must not be inferred, however, that idiopathic tuberculous pneumonia is always limited to the superior lobes, for, in a fair but variable proportion of cases, the disease becomes general, and, therefore, occupies the base. The determining cause is, doubtless, the force of the exciting agent, as well as the con- stitutional predisposition ; but, whatever may be the predomin- ating influence, general pneumonia may unquestionably become an intercurrent affection in the course of tubercular disease. There is still another question, however, arising in the same connection, namely, whether, after the deposit of tubercles, inflammation ever occurs in the lower lobes, without, at the same time, affecting the tuberculous portion? It is a fair in- ference that the presence of tubercles will always invite inflam- mation to that part, so that the lower lobes can not become separately or exclusively involved. It is not fully determined in what stage of tubercular deposits intercurrent pneumonia is most liable to occur, that is, whether it is most common before or after softening. My own impres- sion is, (perhaps contrary to the opinion of many,) that it is a much more common event during the crude than softened condition. True tuberculous or secondary inflammation, belongs to the stage of softening, but the idiopathic variety becomes the concomitant of the stage of solid tubercle. It has been observed that tuberculous pneumonia is not commonly fatal; but this unexpected fact must be received with some limitation, for it is abundantly evident that if the disease becomes general, involving the lower lobes, there is a probability of even increased mortality. The low grade of mortality, therefore, applies to the disease when it is absolutely limited to the superior portion, and when the grade of action is comparatively low. But we have the authority of Louis, Andral, Walshe, etc., for the observation that the mortality and mean duration of the disease is even less than in the strictly idiopathic form; and, with the limitations mentioned, Lcan fully coincide with the observation of Louis, that such pneumonia 110 PATHOLOGY OF PHTHISIS. is almost invariably curable; and with Walshe, that the most rapid cases of resolution are of this class. Nor is it difficult to assign a reason for this comparatively mild character of idiopathic tubercular pneumonia. We can easily perceive that the lowered vitality of the lung and the degraded character of the products (being much below .com- mon organizable lymph) would preclude that excessive action which occurs in healthy constitutions, and which is so prone to destructive effects. Indeed, a moderate degree of inflam- matory action, in this state of vitality, would scarcely more than bring the diseased process up to the healthy standard, or, at least, so little exceed the physiological state that the powers of life would not become endangered by over-action. And it may be further remarked, that the pernicious influ- ence of this form of inflammation over the progress of local tuberculization has probably been greatly exaggerated, if not entirely mistaken. It is not very uncommon for inflammatory action to occur, pass through its regular stages, and leave the tubercular deposits without material modification. And, indeed, may it not be true that inflammation is, to a certain extent, incompatible with tuberculous disease, and that the latter is held in abeyance by the former? One is altered action, induc- ing, as its product, plastic fibrin, the other a state of depressed vitality, giving rise to non-organizable deposits. The two con- ditions appear to be incompatible, and one may, to some extent, control the other. The pneumonia which occurs in connection with tubercle is marked by varying degrees of extent as well as intensity. Thus, it is lobar, lobular, and vesicular, and produces red, gray, or whitish consolidation. The red consolidation represents acute action, while the gray or whitish is the result of chronic disease. It is often observed that portions of the lungs become consoli- dated, as in chronic pneumonia, while the central part of the solidified mass may contain softened tubercles. A form of pneumonic inflammation is described by Hasse, under the name of “ Acute Tuberculosis of the Lungs,’ which, it appears to me, has given rise to very great misapprehension. According to this author, the primary form of the disease is PNEUMONIA IN ITS RELATIONS TO PHTHISIS. 111 characterized by the deposit of numerous miliary tubercles, varying in size from the head of a pin to a millet-seed, and uniformly diffused from apex to base. The disease runs its course in from three to six weeks, and more frequently occurs in young persons, especially males, from eighteen to twenty- five years of age. Post-mortem examinations reveal the lungs tumefied, gorged with serum and blood, and slightly softened ; and the so-called tubercles are surrounded to the extent of a line by inflamed or consolidated pulmonary parenchyma. The ex- amples of this character which have come under my observation have been so clearly pneumonie, (pulmonary granulations,) that I do not hesitate to class it with pnewmonia, occurring in a modified or diathetic constitution, whether positively tubercular, or merely one of depressed vitality. A more detailed account of this affection will be found under the head of acute phthisis, It will. be found, also, that the pneumonic granulations may co-exist with true or yellow tubercle. Thus, while the yellow variety occupies the apex, the granular deposits are met with in the lower portions; and, in fact, the two classes of deposits not only occupy different positions, but represent independent constitutional and local lesions. Chronic pneumonia, (as that term is generally understood,) developed as an intercurrent tubercular affection, presents char- acteristics different from the granular form just described. The consolidated portion varies in color from red to gray, (depend- ing on the duration and degree of acuteness,) the latter being the most common; is free from granulations, is tough, solid, has a smooth surface, without exudation of serum on incision; the corresponding bronchial tubes often become plugged with solid matter. Moreover, it is located in the lower portion of the lungs, and spreads from below upward, thus obeying the laws governing, in general, the development of ordinary pneu- monia. These facts leave no room to doubt that such pneu- monia is the product of causes independent of the mechanical irritation of tubercles; but, at the same time, it is inflammation in a tuberculous constitution, and, therefore, modified in its course and results. 2. Secondary Tubercular Pneumonia.—By the term secondary 112 PATHOLOGY OF PHTHISIS. tubercular pneumonia, I mean a form of inflammation which arises from the irritation produced by the tubercular deposits, as they undergo various changes, but wholly independent of general causes. Allusion has already been made to the state of the pulmonary tissue around tubercles, crude or softened, and but little need now be added. It may be remarked, how- ever, that this form of inflammation is nearly always chronic, and rarely becomes acute except when general causes are super- added to those of a local character. In a certain proportion of cases, however, the inflammatory action, secondary to tu- bercular deposits, assumes so much acuteness as to cause red consolidation, and, therefore, constitutes acute secondary pneu- monia. This form is manifested by certain general symptoms, ' consisting mainly of increase of fever, flushing of the face, greatly aggravated cough, at times rusty sputa, or the sputa may be simply glairy or viscid. The occurrence of pure blood is not unfrequently witnessed, where cavities exist; but when the tubercles have not softened, the rusty sputa is more fre- quent. However, there are many cases in which no blood appears in the sputa; so that if we look to that symptom with much confidence, serious errors may result. The ultimate effects of this secondary disease are various. It often degenerates into chronic pneumonia, with induration caused by grayish induration-matter; or it may be resolved without leaving any permanent lesion. It is a question how far it affects tubercular deposits; but it may be affirmed, with much confidence, that inflammatory action has less tendency to increase the deposits than our a priori reasoning would lead us to conclude. We know, indeed, that pneumonia surrounding the deposits, is comparatively easily resolved; and hence the conclusion, that it neither hastens softening, nor promotes de- posits. In all probability its exalted action rather limits or suspends the tubercular exudation, and substitutes one of a higher and more harmless grade. Indeed, if the exudation arising from inflammation can reach the point of organization, the new vessels coming in contact with the tubercular masses would be the surest means of absorption and ultimate cure. It is by no means certain that the exalted action of inflamma- PNEUMONIA IN ITS RELATIONS TO PHTHISIS. 113 tion may not thus aid essentially in closing tubercular cavities, and, therefore, when restrained within proper limits, becomes a curative process, 3. Hypostatie Tubercular Pneumonia.—It appears from the concurrent observations of Louis, Andral, and others, that pneumonia often precedes death from phthisis only a few days. It was observed by Louis in twenty-three cases in the first stage, and eighteen in the second, of his one hundred and twenty-three cases, and preceded death only a short time. The disease was characterized by pain in many of the cases, viscid but not rusty sputa, dullness on percussion, and crepitant rale; and on post-mortem examination true hepatization was found, which left no doubt as to the nature of the disease. It was observed, also, that it occupied almost constantly the lower lobes, more or less extensively. Of the eighteen hepatized cases, nine occupied from a half to three-fourths of the pulmonary structures, while the remaining nine presented merely small, disseminated masses. This form of pneumonia, which precedes death only a few days, is regarded by most writers (following Louis) as intercur- rent disease, bearing a relationship to the tuberculous condition, but still not wholly dependent on that state. The fact that it occurs in the lower lobes indicates its independent character, or that it does not spring directly from the irritating effects of the tubercular deposits. In opposition, however, to the opinion that this is simple pneumonia, modified by the tuberculous constitution, I need mention only a few of the palpable facts connected with its development. Thus, it occurs only a few days prior to death— is generally found in the inferior lobes—and, finally, is precisely similar to what occurs in other diseases of a low grade and long duration. These facts leave no doubt in my mind that the dis- ease is hypostatic in its production, and depends on the gradu- ally failing powers of life, and the ultimate stasis (partly by gravitation) of the pulmonary capillaries. The observation of Louis, (which we have all confirmed,) that other diseases of a low grade manifest the same tendency with equal frequency, is abundant evidence that the morbid change under consideration 8 114 PATHOLOGY OF PHTHISIS. has no special relationship to tubercles, but that it proceeds from debility, and, therefore, is simply hypostatic. ¢ SECTION II. PLEURISY. Tt has been previously stated that tubercular deposits, when situated immediately under the pleura, may excite in that mem- brane localized inflammation; this, however, is often limited in extent, and usually progresses slowly, but finally, under long- continued excitement, may induce extensive adhesions. There is reason to believe, however, that the adhesions so commonly met with in phthisis are due rather to general and independent causes, than the mere mechanical irritation of adjacent tuber- cles. The evil results of intercurrent pleurisy are rather indirect than immediate; for although the co-existing excitement may promote tubercular deposits, yet the greatest evil is to be appre- hhended from the limitation of the thoracic movements growing out of pleuritic adhesions. There is, indeed, abundant reason to conclude that impaired thoracic movements, by diminishing the activity of the pulmonic circulation, will promote the depo- sition of tubercles. It has occurred to me to observe, in many cases, that the extent of tubercular deposits was regulated by the pleuritic adhesions; and by tracing the history of the cases, it became evident that the pleurisy was the primary disease, and tuber- cles the sequence. I can not but conclude that the limitation of respiratory movements, resulting from pleuritic adhesions, exercised a very important influence over the local deposits, and, at least, giving a wider range of diffusion. In such ex- amples I have often found the tubercles extending throughout the pulmonary tissue, and thus encroaching much more than usual on the inferior lobes. But, independently of the effects of intercurrent pleurisy on the tubercular deposits, there are numerous examples in which 4 BRONCHITIS. 115 the inflammatory affection becomes chronic, with tubercular deposits in the membrane, which may be the immediate cause of death. It is not essential, however, that tubercles should be deposited in the pleura, for the intercurrent inflammation of that membrane may be produced by causes altogether independ- ent of the local pulmonary disease, and give rise alone to the products of simple inflammation—lymph, serum, and pus. It is true, that, in a majority of cases, the lymph is of low vitality, and consequently the adhesions slight or absent, with a strong tendency to chronic effusions. It will be remarked, therefore, that intercurrent pleurisy may not only aggravate the primary disease, but become the immediate cause of death; and hence the necessity for early diagnosis and appropriate treatment. We can scarcely assent, however, to the conclusions of Louis, when he asserts that, with one exception, he never knew it entirely cured! According to his observations, the symptoms may be palliated, and yet the patients finally die, and effusions, with false membrane, are found.. There can be no doubt of the evil tendency of intercurrent pleurisy; but surely the view taken by Louis is entirely too grave. SECTION III. BRONCHITIS. The occurrence of bronchitis, as an intercurrent affection in tuberculosis, is far less common than pneumonia or pleurisy. There is reason to believe, however, that it exercises a more pernicious influence over the progress of tubercles, than inflam- mation of the perenchymatous portion of the lungs, and that it is more frequently followed by an increase of deposits than when simple pneumonia occurs. This is probably due to the debilitating effects of bronchitis, and the capillary stasis (with lowered vitality) which necessarily follows. I have at this time under observation a case in which the supervention of bronchi- tis has left the patient with marked increase of dullness, evinc- 116 PATHOLOGY OF PHTHISIS. ing a rapid deposit of tubercular substance. As an inducing cause of tubercle, in the non-tuberculous constitution, bronchi- tis probably sustains a low position; but when the diathesis exists, or deposits have already taken place, the influence of bronchial inflammation is much to be dreaded. How common, indeed, is it to witness cases in which “taking cold” has aggra- vated all the symptoms, or frequently developed the disease with great rapidity. The observations of Andral (Medical Clinic) go far to strengthen the opinion that bronchitis exercises an unfavorable influence in the tubercular constitution; and this view may, perhaps, afford some explanation of the influences of climate in the amelioration, in certain stages and conditions, of tuber- cular disease. In a cold and damp locality, in which bronchi- tis is produced, tubercular disease is peculiarly liable to be developed or aggravated; and that there may be some relation- ship between the bronchial disease and local deposits is, to say the least, extremely probable. SECTION IV. EMPHYSEMA, As a secondary change, emphysema occurs, in a certain pro- portion of cases, seemingly as the result of a supplemental action to compensate for the obstruction resulting from the deposits of tubercles. Mr, Ancell (Treatise on Tuberculosis) is of opinion that emphysema occurs in the early stage of the tubercular deposit, and arises from a mechanical obstruction preventing the free exit of air from the cells. He assumes that, the in- spiratory act.being the strongest, air may be forced in beyond the point of obstruction, but the expiratory effort being less powerful, it is not expelled, becomes rarefied, and so dilates the cells. This theory may be true in certain cases, but it evidently falls short of a full explanation of what occurs. In the first place, EMPHYSEMA. 117 emphysema is not produced alone in the early stage of tubercu- lar deposits, nor is it limited to the cells corresponding with tubes which have been obstructed. On the contrary, it is a physical condition which may occur in an advanced state of the disease, especially when a cure has been effected, and, moreover, is usually found in that part of the lung which is free from tubercular deposits. When a large cavity has formed, involving the destruction of a considerable extent of pulmonary tissue, the vacuum must be supplied either by a sinking in of the thoracic parietes, or an expansion of the cells; and, as Hasse justly observes, the contraction of the walls being slow and difficult, the most ready and natural method of filling the space is by pulmonary expansion. Hence emphysema, in an advanced stage, is the result of an expansive force to fill a vacuum, and therefore serves only to supply what would otherwise be a phys- iological defect. But a still more important condition which gives rise to emphysema, and that which exercises most influence over the tubercular deposit, arises in an early period, and is purely sup- plemental. Rokitansky observes that the superficial parts of the parenchyma, in the vicinity of tubercles, undergo vica- rious emphysema, while the deep-seated portions become hyper- emic and cedematous. When tubercles are deposited in consid- erable masses, it must necessarily happen that bronchial tubes, more or less extensively, become compressed or obliterated, thus causing collapse of those air-vesicles with which they commu- nicate. In addition to this, it is admitted that tubercles are deposited within the tubes, so that this intra-mechanical ob- struction could not fail to become an impediment to the admis- sion of air, and, hence, the whole combined would be quite adequate to obliterate a portion of the cells. Following this condition, the adjacent sound parts take on increased action, dilate, and finally become emphysematous. It is also true that the mechanical effect of coughing tends largely to induce vesic- ular dilatation, and doubtless contributes to the production or increase of emphysema. The most important practical fact bearing on the relationship of emphysema and tubercle is, that the two conditions manifest , 118 PATHOLOGY OF PHTHISIS. an evident antagonism. Thus, in idiopathic emphysema tuber- cles are very rarely developed, and when it occurs in connection with tuberculosis, the dilated portion is free from deposits. These facts suggest an important relationship between dilata- tion of the air-cells and tubercular deposits, and that the former may, to some extent, aid in the cure of the latter. Whether this prophylactic and curative relationship be the result of a degree of compression exercised by the dilated cells on the capillary vessels, or whether it is due to a more general influ- ence, resulting from a modification of heematosis, are unsolved questions. But whatever may be the rational explanation, the fact itself appears undoubted, and should not escape the atten- tion of the practitioner. SECTION V. PULMONARY DEMA. (idema of the pulmonic tissues, during the progress of tuber- culosis, occasionally occurs, and offers considerable embarrass- ment to the respiratory function, by increasing the dyspnea. It is an observation which most careful practitioners have made, that the degree of dyspnea is quite variable in different cases, and does not seem always proportioned to the extent of tuber- culization. We have often remarked, for example, that persons far advanced in phthisis, and, indeed, within a short time of dissolution, manifested but little dyspnea, the respiratory move- ment at times, and when the patient was calm, not exceeding twenty-four to the minute. It is true there are various causes which must modify respiration; but, among the number, edema is not to be overlooked. It occurs around the deposits, and more especially in the inferior and sound portions. This se- rous infiltration is usually associated with an advanced stage, and arises from capillary obstruction, and the changed condi- tion of the blood; the latter state being essential to any con- siderable effusion. An examination of a tuberculous edematous PULMONARY HEMORRHAGE. 119 lung gives the usual appearances: frothy serum follows an in- cision, with pale color, pitting, want of collapse—such as belong to that condition in general. @ SECTION VI. PULMONARY HEMORRHAGE. Tubercular hemorrhage (excluding, of course, mere initial hemoptysis) can scarcely be said to occur as a copious and alarming or fatal symptom, except when it proceeds from ulcer- ation of an arterial vessel. As a rule, blood-vessels, traversing a cavity, become obliterated, so that even large branches cease to convey blood, and remain as solid cords or bands; but, in rare instances, the closure is incomplete, and ulceration causes . fatal hemorrhage. A few cases are on record, also, in which branches of the pulmonary or bronchial arteries were perforated by adjacent tubercles, and fatal hemorrhage ensued. It is true, also, that the ulcerative action of the walls of vomice may reach large vessels, and cause copious hemorrhage. Ulceration of the bronchial tubes is assumed as another cause, but, it seems to me, infinitely rare. In some examples which have come under my own observa- tion, blood appeared to exude from the parietes of the caverns, giving rise daily to the elimination of several ounces of pure blood; but, in such cases, the hemorrhage does not become copious or fatal. Upon the whole, the most common cause of moderate hemorrhage in these examples is, the extension of the ulcerative action to vessels situated in the walls of the caverns; and, at times, an exudative process, arising from venous obstruc- tion. Pulmonary apoplexy, and passage of blood into the air-cells and bronchial tubes, resulting from congestion in the sound por- tion of the lungs, are conditions occasionally witnessed. In these examples there may be rupture of vessels and laceration of the pulmonary tissues, or mere engorgement and extravasa- tion, without appreciable lesion of the structures. 120 PATHOLOGY OF PHTHISIS. SECTION VII. PULMONARY GANGRENE. A limited gangrenous condition occasionally occurs in tuber- cular caverns, or resulting from mechanical compression of blood-vessels. In rare cases, the blood-vessels of a portion of ‘the pulmonary structure may become so completely and extens- ively compressed as to cause the death of the corresponding part, and thus a gangrenous condition, of considerable extent, may be produced. The most common form, however, is a lim- ited extent of gangrene, formed by portions of a cavern be- coming dead and sloughing. In such cases the sputa become offensive, as in ordinary gangrenous lungs. A very slight gan- grenous condition of caverns is not very rare; nor does it always produce any serious results, but, on the contrary, is often of temporary duration, and subsides without great detri- ment to the patient. Se THE TERTIARY LESIONS. CHAPTER XI. Tur primary changes in tuberculosis are connected with, or dependent on, derangements of the metamorphosis of the tissues, or in the broadest sense, secondary assimilation; the secondary pathological ayatomy consists in the deposit of tu- bercles within the pulmonary tissues; while beyond all these, there are certain ¢ertiary lesions, involving the nutritive condi- tions of various organs, and consisting in atrophy of the normal structures, or adventitious deposits, separate and distinct from mere tubercle. These changes are observed in the organs of circulation, digestion, and secretion, involving especially the heart, liver, and alimentary canal. SECTION I. TERTIARY LESION OF THE ORGANS OF CIRCULATION. The most important tertiary changes occurring in the organs of circulation consist in weakened action of the cardiac fibers, and attenuation of the capillary parietes. The atrophy of the heart is much more advanced than is generally supposed. In (121) 122 PATHOLOGY OF PHTHISIS. " cases of long standing the fibers become pale, attenuated, and ,, weakened; hence dilatation of the right side is a very common “yesult. Louis found it flaccid and soft in one-fifth of his cases, and in a large proportion it was from one-third to one-half less than the normal dimensions. In one hundred and twelve cases an enlargement was obvious in three only, which existed in the left ventricles. This statement is singularly at variance with the observations of Dr. Boyd, who found the average weight in one hundred and forty-one cases above the natural standard. Hasse regards hypertrophy and dilatation as of fre- quent occurrence; but Rokitansky very rarely found either of these conditions associated with phthisis. These statements are contradictory, inconclusive, and, there- fore, unsatisfactory. I believe, from my own observations, that the contractile power of the heart is weak, as a rule, even in the diathetic state; and that this condition is increased as the disease advances, modified, however, by the quantity of the circulating fluid. The early weakness of cardiac contraction (either diathetic or tubercular) is shown in the feeble pulse and impaired capillary action. A comparktively feeble pulse (with more or less frequency) is one of the most constant of the early symptoms, which may be, in fact, a result of organization ; but the tertiary debility, to which I now allude, is still more marked, and is usually (if not invariably) dependent on weak- ened, but not generally softened, fiber. The heart is found pale but not flabby; and the absence of this latter condition has served to withdraw the attention of pathologists from the rue state of the organ. The heart is generally small and con- (rst which arises from the diminished quantity of blood; thus, the circulating fluid progressively diminishes, and the organ necessarily contracts, to adapt itself to the change. In this contracted state it is comparatively firm, with small cavities, and parietes of normal thickness. But it is abundantly evident that the thickness is maintained at the expense of general dimensions, and, therefore, there is a positive diminution of volume. If, on the contrary, the quantity of blood remains comparatively large, while the disease is still in progress, the heart necessarily yields to the pressure, and dilatation will TERTIARY LESION OF THE ORGANS OF CIRCULATION. 123 occur. It appears probable that dilatation would always pre- dominate if the blood did not rapidly diminish in volume; but, as the quantity is progressively lessened, expansion of the heart is, necessarily, impossible. There are certain cases of tuber- culosis in which the quantity of blood remains moderately large, although the quality is deteriorated, and it is in such cases that we witness the dilatation mentioned by several pathologists. It must not be assumed, however, that the heart is invariably diminished in volume, or weakened in all its parts; for examples are not wanting in which the right ventricle be- comes somewhat hypertrophied, although the left may not partake of that condition. The capillaries evidently become equally weakened, their walls attenuated, and functions perverted.. This condition per- tains to all the viscera and tissues, but is more conspicuous in the lungs, and membraniform structures. This depraved function, added to altered blood, induces impaired nutrition, attenuated and softened mucous membranes, exudation of serum, ready imbibition of crude materials, and imperfection of all the functions in which this great class of vessels are concerned. The ready imbibition of oxygen and elimination of carbon probably exercises no small influence over the progress 4 emaciation; while, in general terms, the great functions of endos- and exosmosis become so materially deranged, that fluids and gases too speedily find ingress or egress, and the constant disturbance of nutrition is thus maintained. In addition to the ordinary changes of the heart, it is occa- sionally found to become fatty. In a majority of fatal cases of | phthisis, but little fat surrounds the heart, that substance hav- ing been absorbed during the progressive emaciation. I have recently observed a case, however, (tuberculosis being associated with fatal intercurrent pneumonia of the left superior lobe,) in which the heart was surrounded with fat; and, at the same time, the superficial muscular fibers of the right ventricle ex- hibited incipient fatty transformation. Most pathologists have met with examples of fatty heart in chronic phthisis, very often coinciding with adipose deposits in the hepatic cells. In my own autopsies fatty heart has been seldom recognized in 124 PATHOLOGY OF PHTHISIS. tuberculosis, nor does it appear, from general observations, to be a common condition. SECTION II. : TERTIARY DEPOSITS IN THE LIVER, As a tertiary transformation, fatty liver stands quite promi- nent. Andral and Louis met with this condition in one-third of their cases; but Dr. Reid and Dr. Peacock, of England, found it only thirteen times in ninety-eight cases. According to Hasse the liver is, almost always, very fatty; and my own impressions, founded on many observations, have led to the conclusion that fatty deposits (often short of the usually recog- nized fatty liver) are very common, and constitute a peculiar and important lesion in phthisis. In a majority of cases of phthisis, the liver is found somewhat enlarged in volume, al- though not recognized as fatty. Dr. Boyd found it increased above its normal weight five and a half ounces in males, and seven ounces in females. This enlargement is usually ascribed to serofulous deposits, but, it seems to me, that it is more fre- quently fatty than albuminoid. The fatty liver presents the same anatomical and microscop- ical elements which belong to that condition when it occurs independently of tuberculosis; that is, the fat is deposited in the hepatic cells, the organ becomes enlarged, is of a light yellow or fawn color, exsanguineous, and when incised, greases the knife, and emits fluid fat on the application of heat. analysis of Boudet furnished the following results: FATTY LIVER. 1. Oleine and margarine fats, Blightly acid .....sscseceessrecsserstees 30.20 2. Cholesterin .........scsseseseeeees 1.33 3. Dry animal matter............5 13.32 Be OWOUGE ws cavsesuereace veausezaneses DDL! The NORMAL LIVER. 1, Saponifiable fat... cseeeeeees 1.60 2. Cholesterin ....c. “ 173 5 10 12 1 “ 169 12 13 “ 181 5 ll 12 6 “ 174 13 4 “ 186 6 0 12 10 “ 178 13 8 “* 190 It is scarcely possible to make a rule so mechanical as the above applicable to the varying states of the human or ‘ganiza- tion, and especially in the early stages of phthisis, when the changes are often so very slight; but in the absence of more positive data, it may be well to avail ourselves of every means which comes within the range of probability, or which is ca- pable, even with considerable variations, of general application. In summing up the subject, Mr. Hutchinson states a more gen- eral rule, which is of easy application, and may be made ayvail- able when the weight of the patient has not been previously ascertained. In 2976 healthy males he found the average weight to be one hundred and fifty-five pounds; while in seven hun- dred and ten cases of tubercular disease it was reduced to one hundred and eleven pounds in males, and one hundred and four in females. These facts, however, are more important in their general than special application, for while they clearly indicate the progressive diminution of weight in tuberculosis, each case, nevertheless, must rest on its own peculiarities. It is a question how far emaciation is a constant attendant upon early phthisis, or, indeed, whether embonpoint may not be preserved up to a period when the disease has made some progress. According to the observations of Louis, only one- half of the cases exiiiitod emaciation from the beginning. Fournet found ten subjects in one hundred and ninety-two maintaining their fat. Lehmann observes that in some cases emaciation does not occur even when extensive disease is pres- ent; and Walshe has known plumpness maintained with feeble appetite and occasional diarrhea. And to this testimony I may” 3832 SEMEIOLOGY OF PHTHISIS. add my own in favor of such occasional exceptional instances, An instance has occurred to me recently, the patient being destroyed with pneumonia, in which the subcutaneous fat was abundant, and also that around the heart and kidneys. Tuber- cles in the lungs existed to a considerable extent, several masses being softened. Still, all such cases must be regarded as ex- ceptional, for it is clearly established that tuberculosis, as a general rule, is associated with emaciation, beginning at an early period, and steadily progressing as the disease advances. The tissue first invaded by tuberculous emaciation is the adi- pose, which may be almost entirely removed; the areolar tissue, membranes, skin and mucus, vascular tunics, voluntary and involuntary muscles, and even the bones, all suffer as the dis- ease advances, until the emaciation becomes extreme and almost universal. It appears, however, from the observations of Dr. Clendenning that the viscera are comparatively exempt from ‘atrophy; hence the liver, spleen, pancreas, and kidneys main- tain their ordinary size and weight. The heart, however, is an exception to this rule; for, notwithstanding the statement. of Dr. Boyd that this organ is slightly increased, I have so con- ‘stantly found it attenuated, weak, and flabby, as to indicate, beyond doubt, a marked degree of atrophy. I do not mean to express a doubt, however, that even hypertrophy of the right ventricle may occur, for such a state has been observed. But it has not occurred to me to witness this change as frequently as some have seen it. According to Dr. Boyd, the aggregate weight of the viscera was increased above Dr. Clendenning’s physiological standard 25.71 ounces in males, and 14.48 ounces in females.* These statements, however, must be received with great caution, for although the viscera do ‘not emaciate to any obvious extent, still there is but little reason to conclude that there is much if any increase of volume, except in the examples of fatty de- posits in the liver and kidneys. The only method, indeed, by which the weight of the viscera can become suimenited is by adventitious deposits; and as these do not occur constantly, no * Ed. Med. and Surg. Journal, vol. 1xi, p. 288. PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 333 reliance can be placed on the opinion that the organs become, in any degree, hypertrophied. It should be remarked, also, that the progressive diminution of the fluids of the body, no less than the loss of structures, is one of the means by which the weight is diminished. In- deed, in many examples this loss of fluids must be the condi- tion immediately connected with diminished weight, and which, therefore, may be considered the starting point. Finally, emaciation is so nearly a constant attendant upon the early periods of phthisis that it becomes an important and significant symptom, which should always be carefully observed by the practitioner, and its progress duly noted. For this pur- \ pose it becomes necessary to weigh patients, in the most accu- | rate manner, at least once a week, and thus be able to determine / the fluctuations which occur. Chills and Febricula——The occurrence of chills and fever during the stage of tubercular deposits is quite variable, depend- ing much on the constitutional peculiarities of the patient, and the circumstances by which he is surrounded. In most cases chills followed by fever are observed to occur at irregular inter- vals, and in varying degrees of intensity, depending greatly on the delicacy of constitution and exposure to which the patient may be subjected. According to Louis, rigors were absent in one-sixth of the cases; but a degree of coldness, short of rigors, is probably more frequently observed, being in fact nearly uni- versal. Louis’s observations, however, apply to the whole course of phthisis, so that they do not fully represent the different stages, as indicated in this treatise. As a rule, the calorific power is naturally low or becomes greatly reduced, so that even moderate exposure to a cold or damp atmosphere is liable to result in the production of a chill and the consequent fever. The febrile paroxysm, however, is not, in general, very com- pletely marked; the chill is slight, the reaction moderate, and the sweating stage either absent or only slightly developed. But in some cases all the phenomena are distinctly marked, and the paroxysms become complete in each stage, although their recurrence may not be governed by well-defined period- icity. And it may be here remarked, that the occurrence of 834 SEMEIOLOGY OF PHTHISIS. ’ occasional chills, or chilly sensations, with coexisting insidious { emaciation, constitutes a combination of signs too surely indic- ative of beginning tuberculosis. I have but seldom observed strict periodicity in the return of these chills, but, on the con- trary, they seem to result from fortuitous causes, and, therefore, become the more significant. The chills and fever which occur in this stage do not proceed from inflammation; on the con- trary the condition arises from diminished vitality, consequent upon constitutional derangement; and hence the febrile phe- nomena, when uninfluenced by malaria, are altogether irregular, and seldom assume any considerable degree of intensity. Pulse.—The pulse, in the stage of consolidation, becomes quickened, ranging from eighty to one hundred, loses its nat- ural tone, and often presents the condition recognized as irrita- ble. It must be understood, however, that cases frequently. occur in which the pulse is but slightly modified, and, there- fore, presents no characteristic or important change. In rela- tion to the pulse, however, the stage and extent of the disease must necessarily be considered, for as the morbid action ad- vances, and particularly when near the stage of softening, the circulation becomes much more frequent. I have observed, also, that mental excitement or physical exercise hurries the. circulation, even more than in ordinary cases of debility, so that perfect tranquillity of body and mind becomes essential to a proper appreciation of the state of the circulation. The rhythm of the pulse is seldom intermittent or even unequal, its only variation from health consisting in diminished force and in- creased frequency. These changes are usually more marked in females, probably owing to their greater nervous and vascular irritability. II. LOCAL SYMPTOMS. Cough and Sputa.—The character and degree of cough in this stage of tubercular disease are quite variable. Usually in the beginning it is slight, gradually becoming more severe as the disease advances; but, it is doubtless a possible condition that tubercles may exist in the lungs, at least for a time, without exciting more than occasional irritation, and certainly PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 335 without giving rise to a regular or fixed cough. As a means of diagnosis, therefore, cough, independent of other symptoms and signs, can not take a very important position; for in the most incipient stage of the disease, the sign in question is often too trivial and variable to be made the basis of diagnosis, and can scarcely be regarded as more than an incidental symptom. It is important, however, to distinguish between a fixed and an occasional cough ; the former denotes some permanent lesion, while the latter may arise from transient causes. If, therefore, a patient acquires a persistent cough, however mild it may be, it should always be regarded as evidence of some serious lesion, demanding careful examination. The usual course of tubercular cough is to manifest at first a mild character, subject, however, to exacerbations under various influences, and, as the disease advances, to become more constant, severe, and even paroxysmal. Cases occur in which the most violent paroxysms are manifested during this stage of consoli- dation; and others in which a mild cough, upon the application of an irritant, readily passes into one of severity. The degree of cough varies not only with the extent of deposit in the pulmonary tissue, but also with the state of the fauces, larynx, and mucous lining of the air-passages generally. In those examples complicated with early mucous irritation, the cough is proportionally severe, and is, therefore, disproportioned to the extent of pulmonary disease. The implication of the bronchial tubes, the larynx, trachea, or even the fauces, modifies in a very marked manner, the character and violence of the cough, and all these elements must be taken into the account. In addition to this, there is, in some examples, a nervous con- dition greatly aggravating the cough ; it is often associated with spinal irritation, which may be readily detected by pressure on the vertebral column. These cases are highly important in diagnosis. I have often met with examples, especially in young females, in which a hacking, persistent cough was present, with wandering pains about the chest, and increased frequency of the respiratory movements ; and yet, upon the most careful exploration of the chest, tubercles could not be detected. But in other cases, nearly similar nervous symptoms exist, and which 336 SEMEIOLOGY OF PHTHISIS. are associated with tubercles. In these examples, while the cough is largely nervous, it is, at the same time, tubercular. Hence, a due consideration of this nervous cough is of the highest importance in diagnosis. The sputum of this stage is at first inconsiderable, consisting at most of a little transparent mucus; the cough, however, is often dry. When laryngeal irritation exists, the sputum will be more abundant, but not considerable; small grayish masses are at times raised, possessing more or less firmness, or the mucus may present a gelatinous appearance, not unlike a solution of gum arabic. At times the sputum becomes much more copious and frothy, indicating some degree of mucous congestion. All these phenomena are modified by the presence or absence of mucous irritation, such as pertains to the fauces, larynx, or bronchial tubes. Occasionally the sputa become tinged with blood, evincing more or less hemoptysis, or the hemorrhage may be even pro- fuse. It has appeared to me that the discharge of blood was more common at about the third month after tubercular de- posits had taken place; but there must necessarily be much conjecture in such a conclusion. The frequency of hemoptysis in phthisis is variable, but may be stated at from seventy-five to eighty per cent. Dr. Walshe gives the proportion at eighty- one per cent., while in one hundred cases observed by myself, the number reached seventy-four. The serneiological value of hemoptysis is very great. I am fully persuaded that pulmonary hemorrhage, in a vast majority of cases, is the result of tubercular deposits; and when no evident cause can be assigned for the discharge of blood, the symptom should be regarded in a most serious light. Pain.—The deposition of tubercular matter in the pulmonary tissues is, in its incipient stages, a painless process; indeed, even in extreme cases, patients seldom complain of any acute’ sen- sations, so long as the morbid action is limited to the air-cells, or the pulmonary parenchyma. Acute pains, therefore, always indicate either intercurrent pleurisy or neuralgia; but a minor degree of uneasy sensations, increasing at times to actual pain, is almost universal, especially in the advanced stage. The PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 337 more common location, however, of the morbid sensations, is » the shoulders, or extending from the anterior and superior ’ portion of the chest to the scapula. The feeling is usually described as mere uneasiness, seldom amounting to actual pain; but it is evident that patients frequently, mistake a sense of tightness, or difficult expansion, for pain, and it requires some degree of care, in many cases, to elicit the actual, facts. The general character and aspect of the pain or uneasiness, especially about the shoulders, is precisely that of rheumatism of a slight character; and it has appeared to me not improbable that very often the cause of the morbid sensations was nearly allied to the rheumatic diathesis; and many persons, indeed, ascribe these wandering and obscure pains to that condition. But while this may be true in certain cases, there are others in which the pain of the shoulders is a reflected sensation, origin- ating in the pulmonary disease. It is to be remarked, that the true tubercular pain of the chest is not increased by a full in- spiration; nor is tenderness manifested under pressure or per- cussion, except some adventitious action is taking place, such as pleuritic inflammation, or an extension of morbid excitability to the muscles. These conditions, however, belong to a more advanced stage. The practical inferences which we deduce from the character of pain in tubercular affections, is, that any considerable degree of acuteness indicates inflammatory action or neuralgia; and that the morbid sensation characteristic of tubercular deposits, is rather a sense of uneasiness than acute pain. Digestive Function Primary digestion is far less impaired in this stage of tubercular disease than is usually indicated by writers. Most of the systematic writers mention indigestion as one of the early signs indicative of phthisis, and hence has arisen the term “strumous dyspepsia;” but while I admit the occasional or even frequent derangement of primary diges- tion as a symptom of tubercular disease, it is far less common, in ordinary cases, than is generally supposed. The misconcep- tions on this subject arise from blending the different stages of the disease and conditions of patients in the same general description, so that what properly belongs to an advanced stage, 22 338 SEMEIOLOGY OF PHTHISIS. or to the mere diathesis, is made to apply to the whole course and every variety of constitution. There are two special conditions in which the digestive func- tions become more or less modified: 1. In the strongly-marked tuberculous diathesis; 2. In an advanced stage of the disease, after softening has occurred. In the early (precursory) stage the appetite is often variable, but seldom accompanied by positive indigestion, as previously explained; while in the more advanced condition (stage of softening) primary assimilation, in common with other functions, becomes greatly impaired, which will be mentioned under the appropriate head. At an early period of the stage of mere consolidation, I have not found, as a general rule, either greatly-impaired appetite or deranged digestion; and although this function, like most others of the System, can be scarcely ever found in a strictly normal condition, its departure from health is often trivial, never characteristic, and much less constant than is generally believed by our profession. I have often observed patients, throughout the whole of this stage, maintaining a good appetite and digestion, showing evidences of derangement only when adventitious circumstances were brought into action, such as the supervention of chills, and even then no more than would arise from the same amount of chills and fever in persons free from phthisis. There is nothing notable in the condition of the bowels. I have usually found the alvine evacuations regular and natural, ‘becoming deranged only under accidental circumstances, or when indigestion existed. It will be perceived, from the preceding statements, that I attach much less importance to the symptomatology of the di- gestive function than most writers; but, at the same time, it must not be understood that this function is unimportant in reference to tuberculosis, for its derangements possess a much greater degree of interest in their therapeutical than diagnostic relations, and, therefore, demand careful attention. I mean only to be understood as discarding the prevailing opinion that “strumous dyspepsia” is a common antecedent of phthisis, or that it is at all pathognomonic in that relation. In certain exceptional cases, however, digestion becomes early PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 839 and persistently impaired; but the exact pathological condition is exceedingly variable. ‘There is, in fact, no characteristic de- rangement of the digestive organs or function in phthisis, and hence whatever deviation from health occurs must be regarded as accidental. It is true, indeed, that, as the general and local disease advances, there will be observed a gradual lowering of the vital powers, in which all the functions more or less par- ticipate; but the digestive acts are usually maintained equal if not superior to the co-ordinate functions, and hence there is no special derangement. In some examples, however, there is early and persistent gastric derangement. An almost total anorexia will charac- terize some cases, while others will be marked by great irrita- bility of the stomach, and others by deranged biliary and other secretions. When merely anorexia is present, the tongue will exhibit a slight and often broken coat, whitish, and very deli- cate. When irritability is manifested the tongue is more or less red, and often with elevated papille. But when the secre- tions become prominently deranged the tongue is coated more or less heavily, and there is corresponding loss of appetite. The bowels occasionally become torpid, though they are usually regular. The urinary secretion is at times feverish. In a certain proportion of cases, and particularly in the bilious temperament, the hepatic function becomes early and promi- nently deranged. This derangement is manifested by impaired appetite and digestion, coating of the tongue, torpid bowels, and often more or less uneasiness in the right hypochondriac and scapular regions. The skin is generally sallow, and the urinary secretion scanty and highly colored. Emaciation does not progress as rapidly in this as other forms of the disease. Ill. PHYSICAL SIGNS. We now approach the most important considerations in con- nection with the stage of consolidation, namely, the physical signs indicating the presence of tubercles ; and it is essential to a correct diagnosis that this portion of the subject be fully comprehended. The physical signs of tubercular deposits are a 840 SEMEIOLOGY OF PHTHISIS. embraced under the general heads of inspection, percussion, palpation, vocal vibration, and auscultation ; and the application of these means of diagnosis, in a combined form, is indispens- able in all cases; for however pointed the general or vital symptoms may appear to be, the physical signs are required to render the conclusions certain and reliable. Inspection.—My observations accord with those who discard the idea of malformation of the chest, or even a slight devi- ation from the true symmetrical state, as being in any way connected with the deposit of tubercles; and where deviations from what would be regarded as the ideal of a true physical conformation have been observed, they are to be regarded as a result, and not the cause of the pulmonary disease. It has occurred to me so frequently to witness phthisis in those pos- sessing the best formed chests, and who had been placed under the most favorable circumstances, and, conversely, to have ob- served the most contracted and ill-formed to entirely escape, that I have ceased to attach the slightest importance to the natural contour of the thorax. It is important, however, to dis- tinguish between these natural imperfections and those changes which supervene upon morbid action; for while one is simply a physiological state, the other becomes the representative of a pathological condition. It may be stated, as a leading proposition, that the move- ments of the chest become restricted in freedom, and altered in character, in proportion to the quantity and extent of the tubercular deposits; hence, the changes in expansion will vary from an almost inappreciable degree to a state of comparative immobility. In an early stage, and when the matter deposited is small in quantity, it is evident that no appreciable diminu- tion of the expansion-movement exists; in other words, there is a conceivable state in which the local obstruction is so small. that it does not interfere with the expansion of the lungs to an extent appreciable to the eye or instruments. It is a ques- tion, however, to what extent deposits may proceed without notably diminishing the expansion of the chest, and if not diminished, what causes prevent that result. It has been sup- posed, first, that the expansion of the healthy side becomes PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 841 equally impaired, or, secondly, that enlargement of the air-cells adjacent to the deposits compensates for the condensing influ- ence of the tubercles. The compensating action, however, of co-existing emphysema could not account for the result, because that condition itself limits parietal movements; and while it might prevent flattening of the part, or possibly produce even some degree of bulging, it would clearly be impossible that it should favor the expansion-movements. But there can be little doubt that the unaffected side may partake, to some extent, of the limitation of movements, due mainly, if not exclusively, to the general loss of muscular action and breathing force, as previously explained in connection with the precursory stage. There is, in fact, a tendency in all these cases to a restriction of thoracic movements independent of mechanical obstruction, and it is certainly true that the unaffected side partakes, at least to some extent, of the same condition; but it is evident that the presence of any considerable quantity of tubercles must, at an early period, render the difference in the movements of the sound and diseased sides sufficiently obvious. Hence, by comparison, and especially after a full inspiration, the expan- sion-movement of the diseased lung will be fund diminished, and proportionally replaced by elevation-movement. Semeiological Value—The value of diminished expansion during tranquil respiration, as a diagnostic sign, is, per se, insignifi- cant; but when it coexists with dullness on percussion, corre- sponding flattening, and other signs appropriate to this stage, it assumes a higher value, and should always be carefully observed. In applying this sign to the early stage of tubercular deposits, the possible pleuritic adhesions are excluded; but when this condition exists, there will be still greater limitation of move- ments. A modification of contour—depression or bulging—takes place at some period during the existence of tubercular deposits. In the earliest stage, no appreciable change can be detected ; there is neither bulging nor depression, as exhibited to the eye or by the aid of mensuration ; but, as the disease advances, clavicular depression, more or less marked, occurs in a majority of cases. This depression arises from obliteration of air-cells, or the 3842 SEMEIOLOGY OF PHTHISIS. contraction of exudation-matter, either within the pulmonary parenchyma, or in the form of false membrane arising from circumscribed pleurisy. Depression, however, is not so con- stant at an early period as many suppose, but belongs, as a characteristic sign, rather to the stage of softening ; but it often occurs at the middle stage of consolidation, and is occasionally witnessed quite early, although its frequency necessarily in- creases, ceteris paribus, in proportion to the advanced stage of the disease. Its occurrence, however, will be moditied by accidental circumstances, such as the coexistence and contraction of exudation-matter, and the more or less extensive obliteration of bronchial tubes and air-cells. Or, depression may be entirely prevented by coexistent emphysema. Semeiological Value.—Depression, like deficient expansion, taken singly and alone, indicates nothing positive in regard to the cause by which it is produced; but when explained by diminished expansion, dullness on percussion, and other signs, its significance is very marked and important. Thus, previous pleurisy would be capable of producing depression; but when the history shows that the progress of the case has been unat- tended with acuig disease, the conclusion is strongly in favor of its tubercular origin. As to infra-clavicular bulging, there is every ‘probability that it seldom arises from distention caused by the deposits; on the contrary, when such a sign exists, it is to be usually ascribed to coexisting emphysema. I have witnessed, recently, one well-marked case of infra-clavicular bulging. A patient with well-developed tuberculosis, which had reached the stage of softening, exhibited considerable bulging some distance below the clavicle, or at the upper portion of the mammary region. The extent of bulging was ascertained by the callipers, and was found to be half an inch. It did not arise from em- physema, for the part was perfectly dull on percussion. The most careful examination left no room to doubt that the promi- nence was due to extensive tubercular deposits. It is, however, an exceedingly rare condition. Percussion.—The results of percussion in tubercular deposits are not as uniform and definite as we might, @ priori, suppose. PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 843 Theoretically, the deposition of tubercular matter in the sub- stance of the lungs displaces a certain amount of air, and to the same extent reduces the pulmonary tone when percussion is made over the part; but while this is true, in the main, there are many conditions which disturb the general rule, and hence it must not be received in an absolute sense. Under ordinary circumstances, percussion over tubercular deposits yields a sound more or less dull, varying with the quantity and compactness of the morbid substance. The tone necessarily varies from the slightest appreciable reduction below the normal condition, to almost complete flatness. The points where the dullness will usually become first manifest, are the regions corresponding to the apices of the lungs, anterior and posterior; and hence the clavicular and scapular regions are those where dullness will be first detected. As a general rule, the inner part of the clavicular region (including the spaces just above and below the bone) are the points where dullness will be first manifested. It was held by Laennec that the supra- clavicular space did not possess sufficient elasticity to be of value in percussion; but diagnosticians of the present day entertain a different opinion, and, indeed, attach great importance to this region as one of the first where dullness becomes manifest. A single finger, with the palmar aspect applied to the region, may be used as a pleximeter, when, with gentle percussion, consoli- dation of the apex of the lung beneath can be readily detected. In percussing the inner portion of the clavicular region, it is important to remember that the proximity of the trachea may impart an unnatural degree of clearness, unless the force of the blow be directed from instead of to that organ. The supra- scapular region, also, requires to be carefully examined in the early stage of tubercular deposits, for, in a certain proportion of cases, thé disease is manifested first at this point. In making percussion, various methods and precautions de- serve attention, but as these may be readily obtained from systematic writers, I shall mention only a few of the more important. As a general rule, the fingers are preferable as the instruments for percussion, particularly where delicacy of manipulation is desirable. It is not usually necessary to + 344 SEMEIOLOGY OF PHTHISIS. strike with much force; on the contrary, a very gentle blow, with one or two fingers, will be quite sufficient to give an accurate idea of the condition of the part beneath. In some cases, however, where tubercles are deep-seated, a more forcible blow is required; and if the deposits be scattered through a considerable extent of pulmonary tissue, it is requisite to per- cuss on a broad surface, for which purpose several fingers may be employed. The ‘degree of resiliency or elasticity of the parietes of the chest should be duly noted while making percussion, and the ability to do this while the hand is applied, renders this mode of percussion ordinarily preferable. The diminution of elastic- ity is proportioned to the extent of the tubercular deposits, and hence observations on the degrees of resiliency and dullness may be made simultaneously. Instead of the fingers, we some- times employ the hammer for percussion, using, at the same time, an ivory pleximeter, or the finger may still be applied. Where.a forcible blow is required, the hammer is often useful; and also in hospital practice, where many cases have to be examined, it may be used to relieve the fingers from injury. Again, some persons, especially beginners, will use the hammer with greater facility and dexterity than the finger, and hence, to such it becomes a useful instrument. It must be particularly remembered that the results of per- cussion can be made definite and satisfactory only by compari- son; that is, the sound side must be compared with that which is diseased. In a perfectly natural condition, the sounds of the two sides are so nearly similar, that we may, for all practical purposes, consider them identical. Hence, it is the disparity in the resonance of the two sides which becomes instructive to the diagnostician. Another important precaution is to make comparative percussion at the close of a full inspiration, by which it will be shown that the resonance of the diseased side increases much less than the sound portion. The erect position, ceteris paribus, is the best posture for making percussion. But the diagnostician must not overlook certain modifying conditions in reference to percussion; for while it is true, as a general law, that tubercular deposits cause an appreciable dim- PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 345 inution of pulmonary resonance, theré are incidental states of the parts which may render the results nugatory or delusive. In the first place, it must be remembered that, in many ex- amples, the right infra-clavicular region yields a less sonorous sound than the left; and this is especially true of persons who exercise very actively the right hand, by which the pectoralig muscle enlarges. In all such cases, however, the diminution of resonance is very slight, and is not associated with the co-ordi- nate signs of tubercle. This fact, however, renders dullness of the left clavicular region peculiarly significant. Another important modifying condition will be observed, in the muscular contraction of the chest incident to the precursory stage. Thus, if the forming stage of tuberculosis has been protracted, the muscles contract, and, consequently, diminish the pulmonary resonance on percussion. Tence, a compara- tively small tubercular deposit will give rise to a degree of dullness, disproportioned to the extent of consolidation. The additional causes of non-tubercular dullness are old pleu- ritic adhesions, pneumonic exudation, tumors, and pulmonary atalectasis resulting from obliteration of bronchial tubes. But dullness may be entirely prevented by the presence of emphysema, and, also, by tympanitic distention of the stomach. Dr. Flint mentions the latter condition as modifying the results of percussion, especially at the left apex, and I have made similar observations. Certain conditions, also, such as extensive tuber- cular consolidation intervening between bronchial tubes and the costal pleura, or dilatation of tubes, may induce a tubular sound, more or less obscuring the ordinary results of percussion. I am satisfied, also, that well-marked cracked-pot sound may be induced under similar circumstances. We conclude, therefore, that with these precautions and reservations, percussion becomes a valuable aid in the diagnosis of tubercular deposits. Auscultation.—The modifications of respiration indicative of pulmonary tubercles are quite numerous and variable. Thus, the respiratory sound may be weak, exaggerated, harsh, bron- chial, or perverted in rhythm, the latter manifested by jerking and prolonged expiration. In addition to these conditions, cer- 346 SEMEIOLOGY OF PHTHISIS. tain adventitious sounds are heard, such as dry crackling, sibi- lus, crumpling, cogged-wheel ; to which I have ventured to add, tubercular crepitus. These signs may be described under the following heads: 1. Alterations in tone: weak, exaggerated ; 2. Alterations in character: harsh, bronchial, and blowing; 3. Alterations in rhythm: jerking or wavy, prolonged expiration ; 4, Adventitious sounds: dry crackling, sibilus, cogged-wheel, crumpling, tubercular crepitus. These various signs of tubercular deposits are first developed at the infra-clavicular and supra-scapular regions; and when limited to the apices of the lungs, are far more significant of tubercle than when diffused, or located at other points. I. ALTERATIONS IN THE TONE OF THE RESPIRATORY MURMUR. This division embraces feeble and exaggerated respiration; conditions precisely opposite in character, but nevertheless often occurring conjointly. Weak or feeble respiration is met with as one of the very earliest auscultatory signs of phthisis, although it does not belong exclusively to the stage of tuber- cular deposit. The special character of the sound is, in general, that of simple feebleness, (although at times slightly harsh,) occupying a more or less extensive area, and its pathological signification varying almost exactly with its actual extent. It will be remembered that feeble respiration is met with in the precursory stage, in which it depends on diminished expansion of the chest; and as this stage is gradually merged into that of tubercular deposits, feebleness of the respiratory murmur belongs equally to both periods. ' Its relative development, how- ever, in these stages, varies widely in different cases; in some examples the precursory stage is of long duration and marked intensity, while in others it is almost or wholly wanting. Thus, feeble respiration will become fully manifested, and oc- cupy an extensive area, when the precursory stage has been of long standing or full development; while, on the contrary, it will be quite limited in extent, and often but partially developed, when arising alone from the mechanical obstruction offered by the tubercular deposits. PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 847 For these reasons, when the precursory stage has been fully developed, tubercular deposits will be accompanied, even when small, with very marked feebleness of the respiratory murmur, extending beyond the apex, and occupying a very great extent of pulmonary surface. But when the precursory stage has been slight or absent, then the feebleness will be nearly limited to the clavicular and scapular regions, immediately above and below the former bone, and extending to the second interspace. It is, of course, a more important sign when limited to the apex than when more diffused, for the latter may arise independent of tubercular disease. It is important to observe, also, that weak respiration is often found in juxta-position with the op- posite condition, or that of exaggeration; thus, a tubercular mass obstructs respiration, and renders the sound feeble at the point of deposit, but if the stethoscope be removed to the mar- gin of the consolidation, the sound may be even louder than natural. It is necessary, therefore, to observe carefully the varying degrees of intensity as the instrument is changed to different points on the surface. Feebleness of respiration is often more manifest during in- spiration than expiration; indeed, as a rule, the causes which induce a weakness, also, shorten the inspiratory act, and, at the same time, give rise to prolonged and intensified expiratory sound, so that the phenomenon of weak respiration is often associated with prolonged expiration. Diagnostic Value.—The significance of feeble respiration de- pends greatly on its location and extent, as well as the concom- itant signs. When limited to one apex, persistent in duration, and, above all, when associated with dullness on percussion, and accompanied by prolonged expiration, it may be regarded as certainly indicating the presence of tubercles. When existing independent of other signs, and diffuse in extent, no definite conclusions as to the existence of tubercles can be drawn from feeble respiration. Indeed, it is only by a careful analysis of all the existing signs and symptoms, that feebleness of inspira- tion becomes available in the diagnosis of phthisis. Exaggerated Respiratory Sound.—This term 1s designed to represent a morbid sound, heard in connection with tubercular 348 SEMEIOLOGY OF PHTHISIS. deposits, analogous to puerile respiration, and, therefore signi- fies merely intensified normal vesicular murmur. It appears to me, however, that there is a very obvious error in the applica- tion of this term, and that, in fact, the sound designed to be represented, is altogether different from, and something more than simple exaggeration of the normal murmur. The true exaggerated respiratory sound (known, also, by the synonyms puerile, supplementary, hyper-vesicular) is heard in a perfectly healthy lung, the opposite one having become the seat of ob- struction, and the sound is simply intensified normal respiration, preserving its soft and breezy character, together with the rela- tive duration and tone of inspiration and expiration. But systematic writers have designated a murmur exaggerated which occurs in connection with local deposits, being produced by currents of air passing around the point of obstruction; thus, the central part of the obstructed portion may exhibit feeble- ness of sound, while the marginal regions give rise to exagger- ated murmur. A little attention, however, to the phenomena will enable us to perceive that the marginal murmur is some- thing more than simply intensified respiration, and that it partakes of certain special characters, which are better ex- pressed by the term harsh than exaggerated. In addition to this, it will be observed that expiration becomes prolonged and intensified, which is directly opposed to what occurs in true supplementary respiration. In view of these facts, I conclude that exaggerated respira- tion does not arise from the part involved in tubercular deposits,. and that the sound heard is, in fact, harsh respiration; but true exaggerated murmur is met with in the unaffected lung, and may thus be made available in diagnosis, by observing the in- crease in the side which remains free from deposits. Semeiological Value-—Exaggerated or puerile respiration has a comparatively limited signification in diagnosis, and becomes valuable chiefly by enabling the auscultator to contrast the healthy with the diseased side, and thus the more readily to detect feeble respiration. The value of exaggerated respiration, therefore, is rather negative than positive, its existence indicat- ing a healthy lung instead of tubercular deposits, | PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 849 II. ALTERATIONS IN CHARACTER. This division embraces harsh, blowing, and bronchial respira- tion, alterations which arise from the same physical causes, and which insensibly pass into each other. Harsh respiration is regarded as one of the early auscultatory signs of phthisis, but, nevertheless, it requires a considerable amount of deposits before that. quality of respiration will be developed. If it depend, as all must admit, on physical changes, it is evident that scattered tubercles, in small numbers, may exist without producing harsh respiration; but in all cases where tuberculization gradually progresses, this quality of res- piratory sound is ultimately developed. It conveys to the ear a sense of harshness and dryness, of variable intensity, at times barely perceptible, and again merging into actual blowing sound. It occupies the clavicular or scapular regions, gradually diminishing in intensity downward, and may be associated with feeble respiration. Thus, the expansive property of the lung being impaired, respiration becomes, in general, feeble; but simultaneously with this condition the deposit of tubercles occa- sions coexistent harshness; hence the two qualities may be met with in the same lung. But harshness may exist independent of feebleness, the result depending entirely on the degree of expansion; when the deposits are moderately numerous, and the power of dilatation not materially impaired, harshness, without feebleness, will be manifested. As the disease advances, — and consolidation becomes more complete, harsh is ea gradually merges into diffused blowing, and, finally, moderately: developed bronchial respiration. When nearly of the character known as diffused blowing, harshness takes on a peculiar ey ness and roughness of sound of a somewhat. hissing character. Harsh respiration, according to most observers, is character- ized by prolonged expiration, and it is the expiratory sound that partakes first of the alteration, but which finally involves like- wise the inspiratory murmur. This statement, however, requires material modification. -A case at this time is under my charge, in which the rule referred to is not sustained. In this example 350 SEMEIOLOGY OF PHTHISIS. the right lung contains caverns, while in the left there is dry and moist crackling, and harsh respiration, which, on making a full inspiration, is readily merged into distinct blowing; and yet all the harshness and blowing occurs with inspiration, ex- piration maintaining its natural state. There are certain examples, in which feebleness coexists, and in which harshness can be clearly perceptible only by a forced inspiration ; and in such cases the expiratory sound does not become similarly affected, or if so, to a much more limited extent. Semeiological Value.—The value of harsh respiration depends on the care with which all the signs are analyzed, for if such causes as dry bronchitis, thickening of the mucous membrane, or emphysema, can all be excluded, and moreover, if th limitation of the morbid sound is accurately defined by the clavicular region, then it is strongly characteristic of tubercu lar deposits. So constantly, however, are other signs associated with harshness, that we are seldom required to rely on that sound alone, and it is so evidently qualified by other signs that its interpretation can hardly be mistaken. It is necessary to remark, however, that some degree of harsh ness is natural to the right apex, and, therefore, the sign is of ' less value at that point than the opposite; moreover, that in females, in consequence of the active dilatation of the upper portion of the chest, a degree of loudness, often approaching harshness, is usually witnessed. Blowing and tubular sounds are merely exalted degrees of the preceding condition. Diffused blowing, as the term implies, occupies an extent of surface equal to the consolidation, and presents an exalted degree of harshness, partaking of a blowing character, but stopping short of an actual tubular sound. In the tubular form the consolidation is more complete, and the sound exhibits the characters of breathing through a tube, with more or less of the metallic element. This latter condition, however, when well-marked, is indicative of consolidation from coexisting pneumonic exudation. Semeiological Value.—Blowing and tubular respiration indi- cate consolidation of the pulmonary tissue; and when located at the apices, and above all, when associated with the other PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 851 signs belonging to that period, is indicative of the presence and extent of tubercular consolidation. Alterations in Rhythn.—The alterations which occur in the rhythm of the respiratory movements consist in increased fre-. quency, jerking or wavy murmur, and prolonged expiration. \ The intrinsic value of these several conditions depends on so / many qualifying circumstances that it is difficult to assign to either one that pre-eminence which is often claimed for them, and the subject, therefore, requires a cautious analysis in order to avoid serious errors. Frequency.—The frequency of respiration, even in the early stage of consolidation, is often notably increased. Assuming the normal standard to be twenty to the minute, we will), often find, even in an early stage of consolidation, an increase | to twenty-four. It must not be supposed, however, that there is any evident degree of dyspnea; on the contrary, the increase is so slight and gradual that it usually escapes the attention of the patient, and is to be detected only by accurately count- ing the movements. But even with this moderate increase, patients will often observe that upon active exercise, such as rapid walking or ascending a flight of stairs, they become short of breath with evident dyspnea. Much will depend, however, on the degree of consolidation; there is, indeed, a conceivable state of local deposits in which no variation can be detected; while in the more advanced cases the slightest exercise produces very marked symptoms. But even in extreme cases, tranquil resp..ation is often normal in frequency, but becomes hurried and oppressed with physical exertion. Jerking Respiration.—We come now to consider an important modification of the respiratory sound, which consists of inter- rupted inspiration, and, more rarely, expiration, denominated jerking or wavy, and which is regarded as evidence of tubercular deposits. I have fully satisfied myself by careful observations, made under the most favorable circumstances, that jerking inspiration may exist, independent of tubercular disease, or even a tuberculous tendency, and that, unaided by other signs, it can not be relied on as evidence of tubercles. The errors on this subject doubtless arise from a misconception of the causes 852 SEMEIOLOGY OF PHTHIGSIS. capable of producing interrupted or wavy inspiration; and, furthermore, its frequent association with phthisis has induced many to overlook its connection with other abnormal conditions, which largely qualify its diagnostic value. Jerking or wavy inspiration is the result of incomplete parietal and vesicular expansion; and any condition, tubercular or other- wise, capable of impairing pulmonic and thoracic expansion, may occasion the phenomenon in question. Thus, quite oppo- site causes are capable of developing jerking inspiration, such as pleurisy, pleurodynia, asthma, various cardiac affections, nervous conditions, the precursory tubercular stage, and tuber- cular deposits; and any causes inducing loss of nervous and mus- cular power of the chest, and consequent incomplete and unequal expansion. It is, therefore, a condition which may exist wholly independent of tubercular deposits, or even a tuberculous tend- ency, and is not, per se, a sign of phthisis. But the most constant and invariable relation of jerking in- Spiration is its development in connection with tubercles; and when other signs concur, such as dullness on percussion, it may safely be regarded one of the most constant alterations of the respiratory sound. It has occurred to me, however, repeatedly to observe that tubercular deposits, as determined by the most unequivocal signs, may exist without jerking respiration ; that most of the other elements, such as crackling, harsh, and even blowing respiration, with diminished expansion and dullness on percussion, may be present, and yet this sign of jerking or interrupted respiration may be wholly wanting. Still, in a majority of cases of tubercular deposits, it is present. It is not, therefore, the frequent absence of interrupted respira- tion in phthisis which renders it an uncertain sign; but it is the fact that the same modification of sound is of equally fre- quent occurrence in conditions wholly free from tuberculous disease. As ordinarily heard, jerking respiration occurs during inspi- ration, and is revealed by occasionally two, more frequently three, and rarely four, puffs or jerks, involving generally inspi- ration, but frequently conjointly expiration, and rarely expira- tion alone. I have met with a few well-marked examples in PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 38538 which three distinct jerks occurred with expiration, inspiration remaining entirely free from any such phenomenon. There is another important modification which deserves at- tention, namely, jerking respiration may be chiefly developed on the sound side. Thus, in a case at this moment under ex- amination, the signs on the left side are characterized by dull- ness on percussion, feeble respiration, and dry crackling; the right side has no morbid sound except jerking respiration, which is manifested by two jerks during tranquil respiration, and four occurring upon a forced inspiration! Here is an example in which the dullness, feeble respiration, and dry crackling, clearly indicate tubercular disease of the left apex, but without jerking respiration; while the right side is free from dullness and crackling, but has a remarkable development of jerking respi- ration. It is evident, therefore, that jerking respiration does not indicate, in all cases, the location of the disease, but, on the contrary, that sign may be developed on the side least and probably not at all involved. Semeiological Value—Jerking respiration has no character- istic pathological signification, and, therefore, possesses no in- trinsic semeiological value in tubercular disease. It may be developed in any case where incomplete expansion occurs ; and hence, to become of any importance in tubercular disease other signs are required to denote the cause which produces it. In- dependent of dullness, dry crackling, or localized feeble, or harsh respiration, we can not predicate anything absolute and positive on jerking or wavy respiration ; but when it occurs in association with the other signs, it is then one of the evidences of tubercles. It is, to my mind, the least reliable, per se, of any of the reputed physical signs of tuberculosis. It is probably more valuable in the precursory than the stage of actual deposit. Prolonged (Intensified) Expiration.—The opinion that pro- longed expiration becomes a sign of disease is based on the idea (so commonly promulgated by writers) that the movement of the chest in expiration is comparatively short, and that its relationship to inspiration becomes reversed. Thus, it is as- sumed that the duration of inspiration exceeds that of expira- tion in the ratio of three to one, or, according to Fournet, of 23 ’ 354 SEMEIOLOGY OF PHTHISIS. five to one; and, consequently, that a reversal of these states indicates a morbid condition. After very careful and repeated observations, it has appeared to me that the time occupied by expansion and contraction are nearly equal, the difference, if any, being too small to be of material importance; but the sound produced or rendered audible during these acts is much more prolonged and distinct during inspiration, and does not, therefore, bear a direct relationship to the duration of the move- ment. It follows, therefore, that only about one-fourth part of the expiratory act produces a murmur, while the remainder is inaudible; but during inspiration sound is emitted throughout the whole movement, and thus exhibits comparative prolonga~ tion. It is apparent, therefore, that the term “ prolongation” does not represent what actually occurs, for the sound is merely an intensified or exaggerated act, and not one of increased dura- tion of contraction. In a morbid condition, the expiratory sound is heard during the whole movement, (instead of one-third or one-fourth, as in health,) and hence, it is truly an exaggerated © or intensified murmur. The exact import of intensified expiratory murmur, and its importance in the diagnosis of tubercle, is not definitely settled; many observers, however, attach the highest value to it, as an early sign, and regard its presence as strongly indicative of tubercular deposits. According to the observations of Dr. Jack- son, and after him of Fournet, intensified (prolonged) expiration is met with very constantly among the early signs of phthisis. Dr. Walshe thinks its importance somewhat overrated, while: Dr. Theophilus Thompson regards it as one of the most im- portant and reliable of the early signs. There can be no doubt, indeed, that intensified expiratory murmur occurs with a fair degree of frequency in early tubercular deposits, and that it is, therefore, an important sign; but, at the same time, there are so many qualifications necessary to render its significance clear and undoubted, that the sign loses much of its intrinsic value, except in the hands of the most experienced auscultators. It is admitted by all writers that this sign occurs in emphy- sema, bronchitis, pulmonary congestion, pneumonia, pleuritic PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 3855 effusions, pneumothorax, and, indeed, any form of obstructive disease. But it apppears to me there is another condition, independent of local deposit or induration, in which prolonged expiratory murmur becomes evident; namely: when the expans- ive power of the chest is diminished, and its elasticity propor- tionally impaired, as the result of general disease. The condition in which I have observed this state most frequently is in cases of nervous prostration, especially involving the sympathetic system of the chest. In many of the nervous affections, in- volving more or less the heart, (inducing especially weakened cardiac action,) it will be found that the chest loses, in a vary- ing degree, its elasticity, and that the expiratory murmur be- comes proportionally prolonged. Under these circumstances, however, there is neither harshness, blowing, nor other altera- tion of quality, the only change consisting of increased ‘dura- tion, often equal to inspiration. And hence, as pointed out by Professor Flint, the pitch of the sound becomes an important element in determining its pathological signification. When due to tubercular consolidation the pitch is raised, while in most other examples the note is low. It is difficult to determine the frequency with which intens- ified or prolonged expiratory murmur occurs in phthisis, or how far it may be made a means of diagnosis in the stage of consolidation. Dr. Theophilus Thompson* states that in two thousand patients it proved to be the most remarkable physical sign in two hundred and eighty-eight, of whom ninety-one had more or less hemoptysis. In a statement of this character, however, we reach no definite conclusion ; for if two thousand consumptive patients manifest prolonged expiration in only two hundred and eighty-eight cases, it certainly is too infrequent to be regarded as little more than an occasional sign, and, therefore, its absence is comparatively unimportant. In addi- tion to this, it should be remembered that the expiratory mur- mur is naturally intensified on the right side, and especially so in females; hence, existing alone and independent of all other signs of tubercles, its occurrence on the right side is of little * Clinical Lectures on Pulmonary Consumption. 856 SEMEIOLOGY OF PHTHISIS. significance. The more this sign becomes restricted to the cla- vicular region the greater will be the probability of its depend- ence on tubercles; but when largely diffused, it most usually arises from those general causes to which reference has already been made. Examples of clearly-marked phthisis frequently come under my observation in which the expiratory murmur is not pro- longed, probably arising in part from the particular form of the deposits, and in part from the maintenance of the muscular powers of the chest. But whatever may be the explanation, it is, with me, a matter of simple observation that tubercles occur without inducing prolonged expiration. Semeiological Value.—The intrinsic importance of prolonged expiration is greatly diminished by its frequent occurrence in conditions unconnected with tubercles; and, also, from the no less important fact that the deposits may exist, and yet the sign in question will not occur. Hence tubercles may be pres- ent without accompanying intensified expiratory murmur; or the sign may be well developed when no deposits have taken place. It is only, therefore, by the agency of coexisting signs that prolonged expiration becomes really significant. If dull- _ ness, dry crackling, etc., exists, then the presence of intensified expiratory murmur furnishes additional evidence of the pres- ence of tubercle. It is hardly possible for this sign to become fully formed in phthisis without a considerable degree of consolidation being present, as the physical condition on which its development depends; hence intensified expiration of low pitch and without dullness is indicative of some other condi- tion than tubercular deposits. Adventitious Sounds.—In addition to the mere modification of the respiratory murmur, as detailed in the preceding pages, there are certain adventitious sounds superadded to those of a physiological character, and which usually denote some degree of tubercular deposits. These include dry crackling, sibilus, ( cogged-wheel sound, crumpling, and tubercular crepitus. _ Dry crackling is an early and very common sign of tubercles. It is heard most constantly at the pulmonary apex, and usually consists in from one to five or six sharp, dry, explosive, and PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 357 apparently somewhat distant crackling rales. In a large pro- portion of examples it is heard only at the close of inspiration, and usually requires a forcible act for its development. Thus, while the patient is breathing tranquilly the rale is not heard, but on making a forced inspiration it may become distinctly audible. Very frequently this forced inspiration will develop only two or three, and, at times, a single sound; often, indeed, will the observer be almost startled by the explosion of a single dry and almost metallic sound, occurring at the close of a forced inspiration. In a few instances I have met with the sound during expiration, but this is infinitely rare, and probably oc- curs only when the process of softening is about to commence. However, the rule of its development during inspiration is suf- ficiently general for all practical purposes. When dry crackling is once developed, its persistence is con- stant, although it may be more manifest one day than another, or one inspiration than another; but it can hardly be said to cease entirely until it passes into the moist variety, which is its natural tendency. I have often had occasion to observe, in examples where crackling was only feebly developed, that on making a full inspiration the sound might be distinctly heard, but would entirely disappear at the next inspiration, although the act was equally forcible ; and thus, after a few respiratory movements it would again be heard, and so on. This fact is important in ob- scure cases, for without its observance we might readily conclude that the sound was too evanescent to constitute the true tubercu- lar crackling. The more advanced the disease, the more fully does the sign become developed; hence at first it is indistinct and heard only occasionally during forced inspiration ; next it is heard at each full act; and finally becomes audible during ordi- nary respiration. Dr. Walshe admits its occasional disappearance for a day or two; this I have not observed, but it has appeared to me constant when once developed, with the qualifications pre- viously mentioned. Semeiological Value.—I am led to regard dry crackling as an early and common sign in tubercular deposits; but we are not in possession of accurate data to determine the exact period, or the relative frequency of its development. Fournet declared 858 SEMEIOLOGY OF PHTHISIS. that he met with this sign in eight out of ten cases; while Dr, Austin Flint observed it in nine out of twenty-two cases. Still it is evident that tubercles may exist without causing dry crackling; and, on the contrary, it becomes a question whether other pathological conditions than tubercles may not be capable of developing this sign. It is not possible, in the present state of our knowledge, to give positive answers to these questions. For myself, however, I am free to admit, that tu- bercular deposits may take place without inducing dry crack- ling; but that its occurrence in connection with any other pathological state is, to say the least, extremely doubtful. I have occasionally observed cases in which dullness and coex- isting signs clearly indicated tubercles, but without the presence of crackling; still, in all such instances, the crackling may have existed at an earlier period, which, however, would presuppose ‘the possibility of its subsidence anterior to softening—a posi- tion far from being, at this time, demonstrable. Dr. Austin Flint, in a communication to the author, states that alone and unaided by other signs and symptoms, he would not rely on dry crackling as a positive indication of tubercles. What causes, other than the presence of tubercles, are capable of inducing this sign, is an undetermined question. Finally, it is to me abundantly evident that dry crackling is a physical sign of great value in the early periods of tubercular deposits; that when once observed it continues until superseded by passing into the humid variety; and that its absence (al- though rare) is not to be regarded as contra-indicating the pres- ence of tubercles. Certainly with coexisting dullness this sign may safely be regarded as conclusive evidence of tubercular deposits. But that crackling may take precedence of dullness, and nearly, if not quite, all the other physical signs, I am strongly inclined to believe. At this moment I have under treatment a case in which there is neither cough nor emaciation; but the patient complains of wandering pains in the chest, occasional slightly hurried respiration upon exercise; and on examining the left clavicular region there is clearly-developed and well- marked dry crackling. The sign is constant and persistent, PHENOMENA OF THE STAGE OF TUBERCULAR DEPOSITS. 359 having been under my observation for a number of weeks; at each examination precisely the same, and a perfectly charac- teristic crackling is heard at the close of a forced inspiration. This is the only sign indicating tubercular deposits. The spi- rometer shows a full vital capacity of the lungs. Sibilant rhonchi are not enumerated by systematic writers as one of the signs of tubercular consolidation; nevertheless, I have observed cases in which it was evidently present. Thus, I have heard a single fine sibilus (other signs coinciding) at the apex of the lung, especially following a forced inspiration. The mechanism of this sign, as connected with such cases, is doubt- ful; it may arise from mucus temporarily obstructing a small tube, (for it was not persistent,) or, as I am more inclined to _believe, may depend on the compression of a small bronchial tube by a tubercular mass. I have observed it in cases which exhibit signs of scattered masses; and it appeared to me that these were capable of causing the sibilus. Indeed, one is rather surprised that the sign in question is not more frequently de- veloped under such circumstances. Dr. Walshe has described what he terms a “ cogged-wheel” sound, rhonchoid in character, which is presumed to occur in incipient tuberculization. It is characterized as resembling the sound produced by a cogged wheel in rotation, probably caused by glutinous mucus adhering to the bronchial tubes. Certainly a sound somewhat of that character is occasionally heard. Some of the forms of pulmonary erumpling, as described by Fournet, doubtless exist and may occasionally aid in diagnosis. I have frequently heard sounds which belong to this class, but they are variable in character, indeterminate, and, taken alone, insignificant; still, the true crumpling (compared to the sound produced by folding tissue paper) is evidence of obstruction, and, with the concomitant symptoms, may indicate tubercular deposits. Fournet met with it in one-eighth of his cases. In some forms of pulmonary tubercles I have met with a well-marked crepitant rhonchus, wholly independent of inflam- mation, and presumed to represent a particular phase of tuber- 360 SEMEIOLOGY OF PHTHISIS. cular deposit. I have ventured to call this tubercular crepitus, as a distinction between this form and pneumonic crepitus. I have usually heard this sound at the anterior apex, more com- monly near the junction of the third rib and the sternum, or just above that point. I think, also, it has been most frequently manifested on the left side. The rhonchus to which I allude differs but little from the crepitus of pneumonia; but I can not believe that, in the examples which came under my notice, it represented inflammation. I have heard this crepitus in cases where no other physical sign was present, and in cases, too, where no suspicion of pneumonia could possibly be entertained. In other examples it has coexisted with well-marked signs of tubercular deposits; but, under these circumstances, I have usually observed it below the points of consolidation. The crepitant rhonchus to which I allude is never heard during tranquil breathing, but becomes developed at the close of a full and forced inspiration. The sound is very nearly that of the ordinary pneumonic crepitus, but I believe is a little finer, and is, perhaps, a dryer rhonchus. Excluding the possibility of inflammation, (which the clinical history of the cases showed could not exist,) I was led to the conclusion that the crepitus indicated a liquid exudation, tuber- culoid in character, either associated with, or preceding solid tubercles. I have certainly heard it in the precursory stage of phthisis, when no physical sign of solid tubercles was present; and it has also been observed in connection with well-marked tubercular deposits. It does not appear to me that there is anything very remark- able in the development of a crepitant rhonchus in connection with tubercular deposits; indeed, when we remember that solid tubercle is the result of a liquid exudation, the occurrence of a crepitus would rather be anticipated. Probably the reason why this sound ‘does not more frequently occur in connection with tubercle is that the exudation takes-place slowly, and speedily becomes concrete ; but we can readily conceive of a condition in which the fluid would become more abundant and less readily solidified, and hence the sound might be developed. Such, at ° PHENOMENA OF THE STAGE OF TUBERCULAR DEPosits. 361 least, has appeared to me probable, judging from what has come under my observation .in a number of cases. The signs derived from the voice, although not absolutely un- important, are less characteristic than might be supposed. I agree with Dr. Walshe that vocal resonance is too variable in health to admit of any precision of application in disease. An example has come under my notice, in which two gentlemen of ability and experience diagnosticated the presence of cavities, (so intense was the vocal resonance,) but post-mortem examina- tion proved the lungs to have been sound. Still it may be remarked, that exaggerated vocal resonance of the left apex, (the right being naturally loud,) when well marked, must be regarded as important in the diagnosis of tubercles. This is the opinion expressed by Dr. Flint,* and his views are entitled to consideration. The absence, however, of vocal resonance is not sufficient evidence that tubercles do not exist. The devel- opment of vocal fremitus, Dr. Walshe is of opinion, is a much more reliable sign than resonance; but it is evidently only in extensive deposits that its importance becomes manifest, and here other signs should take precedence. While, therefore, both vocal resonance and fremitus are to be duly considered in the physical diagnosis of tubercles, they are chiefly valuable in connection with other signs and symptoms, but, of themselves, possess comparatively little importance. Undue transmission of the sounds of the heart is classed among the signs of tubercular consolidation. It is necessarily more valuable on the right than the left side, and always occurs, more or less marked, in cases of consolidation of the pulmonary tissue. When the first sound of the heart is very distinct in the right clavicular region, other signs coinciding, it becomes a fair indication of the degree of consolidation. But the transmission of the second sound to the right clavicular region, possesses often a different signification. Numerous examples occur in which even a moderate amount of cardiac dilation (without weakened action) diffuses the second sound over a great portion of the chest, and it becomes very audible under the right clavicle. * Physical Exploration, etc., Resp. Org. 862 SEMEIOLOGY OF PHTHISIS. Dr. Latham has pointed out the existence, in occasional cases, of an arterial bellows-murmur, occurring in the clavicular re- gion, or at the left pulmonary cartilage. I have frequently met with this sign in tubercular deposits, but it is so frequently absent that it is comparatively unimportant. The auscultator, however, should neglect no sign which is met with in even occasional cases. SUMMARY OF PHYSICAL SIGNS OF TUBERCULAR DEPOSITS. Inspection: Diminished expansion, contraction, possible bulg- ing. Percussion: Dullness, increased resistance. Auscultation: Weak, harsh, exaggerated, interrupted respira- tion; prolonged expiration, tubular and blowing sound; dry crackling, pulmonary crumpling, cogged-wheel sound, sibilus, tubercular crepitus. SECTION III. PHENOMENA OF THE STAGE OF SOFTENING. I. GENERAL SYMPTOMS. When the period of softening arrives, many of the symptoms belonging to the preceding stage exhibit a manifest increase. ‘The emaciation increases, the febrile symptoms become more marked, the cough and sputa undergo important changes, and the whole case wears the aspect of great and progressive aggra- vation. The muscles of the chest and limbs waste most, while the face often exhibits much less noticeable changes. Chills and consecutive fever become aggravated in a remarkable ‘degree, which contribute greatly to the prostration of the patient. The febrile phenomena are of two classes and grades; one is the result of impaired calorification, while the other is connected with the local changes in the lungs. In the first or PHENOMENA OF THE STAGE OF SOFTENING. 863 common variety, the chills assume something of a periodical type, usually occurring daily during the forenoon, the fever and sweating occupying the afternoon and evening. In many cases the different stages of the paroxysm follow each other with much regularity; nevertheless, they seldom assume all the characters of the intermittent type of fever. Several paroxysms will thus occur for days in succession, when finally a mitigation takes place, and the patient is, for a time, free from fever. In the second form, (that is, fever arising from the extension of local disease,) the periodicity is less distinct, although there may be daily chilliness or sensations of coldness, with consecu- tive fever; yet the actual fever more commonly becomes grad- ually developed toward evening, assuming more distinctly the characteristics of hectic. If much inflammatory action super- venes, the disease may assume a state of constant excitement; but the more usual course is for the feverish symptoms to mani- fest varying degrees of intensity, depending for their aggrava- tion on accidental circumstances. Associated with the febrile condition will be developed the copious, exhausting, acid night-sweats, so characteristic of progressive phthisis. These colliquative sweats are variable in degree, but are usually proportioned to the gravity of the con- stitutional disease. As effete material accumulates in the system, there is evidently an effort on the part of nature to procure relief by elimination through the cutaneous tissue; and hence the irregularity of this particular symptom. Doubtless, the accumulation of effete material in the blood favors the febrile commotion in the system, which is followed by copious sweat- ing; and, after a time, as the morbid material diminishes in quantity, the perspiration measurably ceases, and the patient is temporarily relieved from an unpleasant symptom. As softening takes place, the cough increases manifestly in violence, becomes paroxysmal, and is accompanied by more copious sputa; but these symptoms vary materially in different examples, as well as at different periods of the same case. Cough depends not alone on bronchial irritation, but also on the coexisting laryngeal disease, and hence the latter complication renders the symptom more violent and paroxysmal. The sputa > 364 SEMEIOLOGY OF PHTHISIS. are mixed in character; a portion is glairy and transparent, but the mass finally becomes more or less opaque from the presence of yellowish or grayish material. The quantity of transparent sputa increases proportionately to the bronchial excitement. As the stage of softening advances, the sputa become more constantly yellowish, globular, and non-aérated ; but the char- acteristics vary at different periods, and even different hours of the same day. The yellow sputum is usually most copious in the morning, while not unfrequently the transparent variety predominates through the day. As the purulent element in- creases, opaque strie, of a buff color, appear, giving the sputum a variegated aspect. In more advanced cases the color becomes a darker yellow, and at times greenish. As the sputum comes to be more purely purulent, it is proportionally non-aérated, and sinks in water. The outline of the masses expectorated vary; in some examples the edges are irregular or jagged, while in others they are quite smooth. In a certain proportion of cases, more or less blood appears, commonly as streaks through the purulent mass, or as rusty sputum, not unlike the pneumonic variety. A case came under my observation in which the rusty sputum appeared daily for a period of six months. Phthisical sputum has a peculiar odor, at times becom- ing fetid; the taste is saline or sweet. In the case of rusty sputum referred to, the odor was exceedingly unpleasant, and might be called fetid. The microscopical elements of phthisical sputa will be given under the head of diagnosis. As the disorganizing process advances, respiration becomes somewhat quickened, usually ranging from twenty-four to twen- ty-eight per minute; but the frequency is greatly influenced by the degree of febrile excitement, exercise, and other inci- dental conditions. While the patient is tranquil, and especially when in the recumbent posture, the respiratory movements may be nearly normal; but on exercising, such as walking, or ascending a flight of stairs, the breathing becomes notably quickened, and frequently oppressed. Dyspnea, however, is not an ordinary condition in this stage, and patients are not generally conscious of oppression, except some degree of asthma coexists. PHENOMENA OF THE STAGE OF SOFTENING. 365 The circulation is increased in frequency about in proportion to the respiratory movements; but when chills and consecutive fever occur, the pulse is rendered quick and irritable. The state of the pulse, however, is quite variable; at times, it is nearly normal, or it may become quick, irritable, or feverish. Constitutional peculiarities, as well as the extent of effete ac- cumulations in the blood, regulate the activity of the circulation; hence, the pulse may vary from an almost normal condition to one of great rapidity and feebleness. The degree and character of pain connected with this stage care slight and dull, except pleurisy occurs, when more acute- ness is evinced. The ordinary sensation is that of uneasiness through the chest, extending to the shoulders, or occupying the sternal region. The disorganizing process in the pulmonary tissue does not give rise to acute pain; but the occurrence of circumscribed, dry pleurisy causes considerable acuteness, which often extends to the intercostal muscles. Pleurodynia is, also, an accompaniment of tubercular disorganization; but the in- tercostal pains and tenderness are more commonly due to cir- cumscribed pleurisy. II. PHYSICAL SIGNS OF THE STAGE OF SOFTENING. The physical signs connected with the stage of tubercular softening, are necessarily those belonging to the first, increased. or moditied, to which are added certain characteristic phenom- ena. Parietal depression, in the clavicular and scapular regions, more marked in the former, becomes notably increased; the circumference of the chest is diminished, the expansion greatly reduced, and exhibits more distinctly the elevation-movement. The reduced power of expansion is rendered more evident during a forcible inspiration, and the contrast with the sound or least affected side becomes, in this manner, still more ap- parent. Depression of the clavicle may obscure to some extent flattening of the walls, and hence the use of the calipers may become necessary to detect the extent of the change. Dullness on percussion is increased in extent, and becomes often wooden or tubular. 3866 SEMEIOLOGY OF PHTHISIS. | Humid crackling is the characteristic rhonchus indicative of ‘tubercular softening. Dry crackling appears to become grad- ually merged into the moist variety, which latter, when clearly marked, may be considered conclusive evidence of softening. Some care is required to discriminate between mucous, sub- crepitant, and tubercular moist rales. The special character- istic of the tubercular rhonchus is that, at least in an early (stage, it is circumscribed, limited to the apex, and is heard during, or at the close of, inspiration, often, indeed, requiring a forced inspiration to develop it. It is at times slightly metal- lic, and finally merges into the cavernous variety. Bronchophony and bronchial respiration often become in- creased during this stage, but afford no evidence of softening; and the same remark is applicable to vocal fremitus. In fact, the signs derived from the voice during the stage of softening are in no wise characteristic. Finally, the diagnosis of the stage of tubercular softening depends mainly on the occurrence of humid crackling, and yellow or opaque sputa. In estimating the value of the expec- torated substance the microscope must be resorted to, for mere inspection may prove deceptive. In some examples crackling is absent, while the sputa and other signs and symptoms clearly indicate tubercular softening. SECTION IY. SYMPTOMS AND SIGNS OF THE STAGE OF CAVITIES. The process of tubercular softening produces important changes in the adjacent tissues, and gives rise to new and char- acteristic signs and symptoms. A destructive action is speedily manifested, and the bronchi becoming involved in the process are opened or cut off, and the softened matter thus becomes eliminated. In this manner cavities are formed, the sputa change, and the physical signs undergo important modifica- tions. SYMPTOMS AND SIGNS OF THE STAGE OF CAVITIES. 367 In the mean time the general system suffers severely, and ex- hibits the most striking evidences of decay. The emaciation reaches its greatest extent, patients weighing one hundred and fifty pounds often losing twenty-five or thirty; the strength progressively diminishes, the hectic symptoms increase, diges- tion becomes impaired, the circulation is hurried and feeble, respiration short and difficult, the cough becomes greatly aggravated, the sputa abundant and purulent. In a more systematic detail these changes may be thus stated: 1. The General Symptoms.—In progressive phthisis, with a fatal tendency, the stage of cavities is marked by a great and rapid aggravation of all the symptoms and signs, general and local. Emaciation advances to an extreme degree, the blood is greatly reduced in quantity and changed in properties, the secretions become correspondingly deranged, and the whole organism bears marks of that extensive decay which rapidly leads to dissolution. In some cases the whole organism be- comes nearly equally depressed, while in others particular func- tions suffer in a prominent degree. Thus, some patients sufter from great dyspnea, while others are much less distressed in this respect ; in some cases, febrile symptoms become prominent, and in others, the gastro-intestinal lesions assume the greatest gravity. Primary digestion often suffers in a prominent man- ner, and is characterized by uneasy or painful sensations, gas- eous distention, eructation, and colliquative diarrhea. It must be remarked, however, that the constancy of the gastric de- rangement, as manifested by impaired digestion, has been great- ly overrated by writers. I have observed many cases in which the appetite remained moderately good to within a few days of dissolution ; and, with ordinary care in the selection of suitable food, but little difficulty occurred in digestion. Indeed, few cases occur in which a sufficient amount of nutriment can not be taken to support the system, if that were all that vitality required for sustenance. I have often observed that a good appetite and fair digestion continues throughout the whole course of the disease; and certainly the gastric derangement, in many examples, bears no direct proportion to the gravity of the pulmonary disease. 368 SEMEIOLOGY OF PHTHISIS, The variable character of the gastro-intestinal function de- pends on the extent to which this portion of the system becomes involved in the general tuberculous lesions. Although the stomach and intestinal canal often become affected during the progress of phthisis, yet it must be admitted that these lesions are not unifurm and constant, and hence the variable charac- ter of the symptoms. The lesions which occur embrace, first, a general attenuation of the alimentary mucous tissue, with more or less inflammatory action, deposition of tubercle, and ulceration. Ulcerations are more or less frequently met with in the fauces, esophagus, stomach, and intestinal canal; and tubercular deposits are not infrequent in the small bowels, in- volving the glands and submucous areolar tissue. These lesions are much the most frequent in the small intestines; thus, Louis found ulcers of the pharynx in four cases in one hundred and twenty patients; in the cesophagus six in one hundred and twenty; in the stomach two in ninety-six ; while in the small intestines five-sixths of the cases exhibited ulceration. Tuber- cular deposits were observed in fifty-four of one hundred and twenty cases. It will be observed that the stomach is much less frequently affected than any portion of the alimentary canal, and hence the appetite and digestion often remain good while more or less diarrhoea may be present. It is an important pathological fact, also, that disturbance of the bowels is not always propor- tioned to the extent of the local lesions, for it is well known to practitioners that constipation and ulceration may exist to- gether. Most phthisical patients, however, are more or less subject to diarrhea, either occasional, as occurs throughout the course of the disease, or colliquative, as met with in the latter stages. But patients are sometimes constipated throughout the whole course of the disease. It is by no means certain that all of the ulcerative action met with in the intestinal canal results from a deposit of tubercle; on the contrary, it has appeared to me to result very often from what may be termed tuberculous ulceration, independent of the presence of veritable tubercle. In this sense many of these lesions are more properly tertiary in character, resulting from those ultimate derangements charac- SYMPTOMS AND SIGNS OF THE STAGE OF CAVITIES. 369 teristic of progressive phthisis. In regard to the secretions, it may be remarked, that the changed condition of the blood causes a marked variation from the normal state, the most obvious alterations occurring in the gastric, hepatic, urinary, and cutaneous functions. As already intimated, the gastric \ fluid is evidently deficient in quantity, and probably changed in quality, the hepatic secretion is thin and watery, the urine loaded with lithates, and the cutaneous secretion is frequently extremely acid. In this condition the tongue frequently becomes pointed, red at the tip and edges with elevated papille, and covered with a whitish, or occasionally yellowish coating; pa- tients readily vomit, and are often affected with diarrhea. The chills, febrile action, and consecutive nocturnal sweats, all undergo marked and persistent aggravation. The chills usually occur in the forenoon, the fever continuing often until midnight, when the skin, which was previously hot and dry, becomes bathed in a colliquative acid perspiration, which con- tinues the remainder of the night. In the mean time, the evidences of impaired secondary as- similation become still more manifest; emaciation progressively advances, the tissues become extremely reduced, the adipose matter from the general cellular structure is almost entirely removed, membranes and vessels become greatly attenuated, and vitality sinks to the lowest state. The circulation and res- piration usually become feeble and hurried, though in both these great functions there are frequent and remarkable exceptions. I have seen the circulation scarcely disturbed, and respira- tion remain nearly natural to within a few weeks of death. As the powers of life fail, and the blood undergoes still further changes, dropsical effusion, in the form of anasarca, becomes common, and is usually a symptom preceding death but a few weeks. The mode of death is various, but a majority will fall under one of the following heads: 1. Gradual failure of all the functions. 2. Death by apnea, resulting from extensive consolidation of the lungs, or edema of the glottis, or hypostatic pneumonia. 3. Failure of the powers of the heart. 4. Hemorrhage. 5. Colliquative diarrhea. 24 370 SEMEIOLOGY OF PHTHISIS. 6. Pneumothorax. 1. Intercurrent lesions. Sudden death may result from excessive accumulation of secretions ; syncope; open- ing of a large blood-vessel. The symptoms which have thus been detailed as characteriz- ing the stage of excavations in progressive phthisis, do not, of course, apply to milder and curable forms of the disease. In this latter variety most of the preceding symptoms will be found in a comparatively mild degree; and, if the disease take a favor- able turn, may all gradually recede until final recovery takes place. 2. Physical Signs.—The stage of excavation or elimination presents, in part, the same phenomena which characterize tuber- cular consolidation, to which are added certain new signs indicating the physical changes in the condition of the part. Dullness on percussion may remain nearly unaltered, or become extended in area, and flattened in tone; or, as excavation increases, and caverns of considerable size form, the loss of substance removes a part of the dullness, and may even induce preternatural clearness. The resonance necessarily varies with the extent, position, and form of the caverns. When the cavity is small, situated remotely from the surface, or is surrounded with induration-matter, the sound may be completely flat or tubular; if there be intervening portions of sound tissue, slight percussion fails to elicit dullness, while a more forcible act will reveal the deep-seated solidification ; or, finally, if the excava- tions be large, and situated near the surface, the sound may be clear, tympanitic, amphoriec, or cracked-metal. Moreover, the contents of the cavity exercise a marked influence over the sound; when the cavity is full, the sound is necessarily less resonant. The cracked-pot sound (bruit de pét félé) is heard when the caverns are large, approach the surface, and probably with several openings. To render it appreciable the patient’s mouth should be open. Inspection reveals different states of the parietes and thoracic movement. The flattening generally increases during this stage, not only in degree but extent; thus, at an early period the de- pression is limited to the immediate infra-clavicular region, and then, by contrast, is quite evident; but when softening becomes SYMPTOMS AND SIGNS OF THE STAGE OF CAVITIES. 3871 more extensive, the parietal depression is correspondingly dif- fused, often extending to the mammary region ; and, indeed, flattening of the entire anterior portion of the chest, where both lungs are involved, is the common condition. The parietal movements, as a rule, remain limited, as in the preceding conditions, and the elevation motion takes precedence over normal expansion. However, as pointed out by Dr. Walshe, these conditions may not occur in certain exceptional examples; thus, when the cavity is large and approaches the surface, there may be not only amphoric percussion-sound, but increased respiration, expansion, and even bulging. The cause of these anomalies will be readily perceived. The auscultatory signs of this so-called third stage are more characteristic than the preceding, and are embraced under the following heads: Cavernous rhonchus, respiration and cough; pectoriloquy. Cavernous Rhonchus——(Hollow bubbling rhonchus, gurgling rhonchus.) Cavernous rhonchus is the earliest evidence of the existence of acavern. It is usually described as being associated with cavernous respiration, and this latter is regarded as the true means of establishing a differential diagnosis between cavern- ous, mucous, and suberepitant rhonchi. But at an early period, when the excavation is small, and filled more or less completely with fluid, no sound except the bubbling or gurgling will be heard. In this condition it closely resembles the subcrepitant. Cavernous rhonchus is characterized by liquid bubbles, vari- able in size and number, at times, hollow or metallic, and usually coexisting with inspiration and expiration, though much more distinct with the former. The special character of the sound varies with the size, form, contents, and position of the cavern. When the cavern is small and filled with liquid, the bubbles are of small size, possessing little of the metallic character, and very closely resemble the subcrepitant rhonchus with large bubbles. When the cavities are large, contain fluid, and com- municate freely with bronchial tubes, the rhonchus is fully developed, and partakes of the metallic or even amphoric character, and is usually associated with cavernous respiration. When very small, it has received the name of cavernulous. ‘ 372 SEMEIOLOGY OF PHTHISIS. These varying degrees and special characters of the rhonchus demand particular attention, otherwise the most serious errors may be committed. When fully developed, and especially if associated with cavernous respiration, it is easily recognized; but if the cavernulous form alone exists, it may readily be mis- taken for the subcrepitant rhonchus. Another modification is not unfrequently present, which is a sound approaching the high key of the sibilant rhonchus; indeed, it might fairly enough be regarded as a sibilus, produced by air entering a cavity. The sound is usually loud and shrill, and, no doubt, is developed in connection with narrowing of the tubes by thickening of the mucous membrane, the cavity con- taining but little liquid. It is, however, often mixed with the gurgling. Vailed blowing is sometimes heard, but it is of little practical importance. Semeiological Value.—W hen associated with cavernous respira- tion, this rhonchus positively indicates the presence of a cavern, and if at the apex, nearly certainly of tubercular origin. The finer bubbling (cavernulous) may be distinguished from the sub- crepitant by being circumscribed, few in number, and located at the apex. If the rhonchi be numerous, and diffused generally over the lung, it can not be regarded as cavernulous. The asso- ciated signs and symptoms become the true interpreters of the various grades of gurgling and bubbling rhonchi. Cavernous Respiration—(Cavernous blowing; hollow respira- tion.) This sign is produced by air entering a cavern which contains but little fluid, or the air enters above the liquid con- tents. When completely developed, it is a hollow sound, well imitated by blowing gently into the hands forming a hollow; is heard during both respiratory acts, but is most distinct with inspiration. It usually coincides with cavernous rhonchus, but exists without the latter when the cavities are empty, or the tubes open above the liquid. The tone and special character of cavernous respiration must necessarily vary with the size and situation of the cavern. When small and surrounded with indurated lung, the sound is less hol- low, of a higher key, and closely resembles bronchial or tubular SYMPTOMS AND SIGNS OF THE STAGE OF CAVITIES. 373 respiration. On the contrary, when the cavity is large and approaches the surface, the sound is of low note, hollow, and may readily be distinguished from the tubular variety. It must be confessed, however, that the existence of bronchial respiration and diffused blowing, is capable of so far masking cavernous sound of moderate development, that much care is requisite to make a correct diagnosis. Indeed, both conditions often coexist, and it is only by placing the stethoscope over different portions of the chest that the localized hollow sound of caverns can be detected. In making out a differential diagnosis between tubular breath- ing, resulting from consolidation, (tubercular or pneumonic,) and hollow respiration connected with a cavern, several writers of distinction lay particular stress on the key or pitch of the sound produced. The rule is, that the cavernous variety pre- sents a lower pitch than the tubular. Barth and Roger state that blowing respiration has a “higher key ;” Walshe says of cavernous respiration, “the pitch” is lower than the tubular; and Flint declares the cavernous sound, as compared with the tubular, “low in pitch.” These computations of scale are evi- dently correct, and a careful analysis of the sounds in question will generally enable us to make a correct diagnosis. Thus, cavernous respiration is of low pitch, hollow sound, and is com- paratively slowly developed ; or, at times, when the caverns are large, of amphoric quality. It coincides with both inspiration and expiration, but most marked with the former. On the contrary, the tubular or blowing variety, is of a higher key, more quickly produced, more metallic, and more or less diffused. In addition to these characteristics, cavernous respiration is usually, but not necessarily, associated with cavernous rhonchus. Semeiological Value.—It is abundantly evident that cavernous respiration possesses the highest diagnostic value ; and that its ‘presence, when clearly marked, at the apex of the lungs, is a nearly infallible evidence of tubercular excavation. It is true, other conditions are capable of producing it, such as bronchial dilatations and gangrenous caverns. But the coexisting signs and history of the case will usually enable the auscultator to determine the true condition. Thus, tuberculous caverns are 874 SEMEIOLOGY OF PHTHISIS. nearly uniformly situated at the apex, and are associated with corroborating physical signs; whereas bronchial dilatation is seated lower, and is seldom connected with other signs of tuber- culosis; while gangrenous excavations, besides being infinitely rare, have peculiar and characteristic signs. In certain examples there is such a blending of bronchial or blowing sounds and cavernous or hollow respiration, that it becomes difficult to determine which predominates, or whether caverns exist at all. Several small caverns at the apex, sur- rounded by indurated tissue, may give rise to diffused blowing, which would effectually mask the sounds emitted by the small excavations. But in all such cases of doubt, an observance of the coexisting rhonchi, but more especially the sputa, will gen- erally lead to a correct appreciation of the sounds. Cavernous Cough.—The sound developed in a cavern by cough, is hollow, more or less metallic, at times amphoric, and may be associated with rhonchi. The forcible shock occasioned by the attendant coughing, produces a very distinct, circumscribed, hollow sound, which is justly regarded as one of the surest evidences of the presence of caverns. It has the same physical causes of cavernous respiration, and the two signs usually coexist. Pectoriloquy.—Pectoriloquy indicates distinct sounds produced in a cavity, and issuing apparently from the chest; hence, literally, chest-speaking, or the transmission of articulate sounds directly to the ear of the observer. Under certain conditions this chest-speaking is well developed, and is characterized by a hollow sound, at times ringing, and generally loud. Inasmuch, however, as the articulation must vary with the form, situation, and contents of the cavity, its special character exhibits many varieties ; indeed, its perfect production requires so many con- ditions that it is comparatively rare. A cavity of medium size, smooth interior, superficial, attached to the surface, nearly or quite empty, and with free bronchial communication, will de- velop well-marked pectoriloquy. But if these conditions are not present, cavities even of the largest size may exist without producing chest-speaking. Thus, when the interior is soft, irregular, or traversed by bands; when there are intervening portions of healthy lung; when very small, or, finally, when the SYMPTOMS AND SIGNS OF THE STAGE OF CAVITIES. 375 communications with the bronchial tubes are incomplete, or when very numerous, pectoriloquy will be imperfectly devel- oped, or may be entirely wanting. In addition to these uncertainties, very perfect pectoriloquy may be produced when no cavities exist; thus, when the walls of the chest are thin and attenuated; when a portion of lung becomes condensed, as by tubercles placed between the bronchi and parietes, a sound, more or less articulate, reaches the ear. Walshe regards pectoriloquy as a variety of bronchophony, and there appears to be some reason for this conclusion; but, at the same time, the mechanism and pathological signification are so widely different that clinical accuracy demands they should be separated. Whispering pectoriloquy, according to the same distinguished authority, is more characteristic than loud articulation, and in this opinion I fully concur. When, there- fore, a hollow, circumscribed, and well-defined articulation with whispering, is heard, I have but little hesitation in ascribing it to the presence of a cavern. Many varieties, however, must necessarily exist; at times it is loud and piercing, so much so as to become painful to the auscultator ; in other examples the “sound is amphoric, bearing a relationship to amphoric respira- tion; or, again, indistinct or entirely wanting, although the physical conditions for its production seem to exist. Semeiological Value.—The inexperienced auscultator is apt to place great reliance on the presence or absence of pectoriloquy ; but of all the reputed signs of caverns it is the least reliable, and deserves the least confidence, and especially so to one whose observations have not been extensive. Thus, the ad- mitted fact that it may exist in cases of mere consolidation, and, on the contrary, may be wanting when a cavern is present, furnish conclusive evidence that singly and alone, its presence or absence is by no means conclusive. Nevertheless, the pres- ence of whispering pectoriloquy, circumscribed, hollow, and located at the apex, may be regarded as of cavernous origin. On the contrary, if the sound be somewhat diffused, is found extending toward the middle of the lungs, although whispering produces it distinctly, the sign is to be distrusted, and demands other correctives. Fortunately the same physical conditions 876 SEMEIOLOGY OF PHTHISIS. t which give rise to cavernous pectoriloquy, also produce cavern- ous respiration and rhonchus, and hence these signs become the correctives when doubt exists in regard to the vocal sound. If the resonance arise from a cavity, there will generally be coexisting cavernous respiration and rhonchi; or if from mere consolidation, then tubular or harsh respiration become the true interpreters. Metallic Tinkling—In certain exceptional cases (doubtless large caverns containing liquid and air, with small bronchial communications) metallic tinkling occurs. This sign, however, is but rarely developed in siniple cavities; and, therefore, re- quires no extended notice in this connection. Local Symptoms.—These include cough, sputa, hemoptysis, respiration, pain. Cough.—The cough during the stage of excavation is some- what variable, depending in part on the accumulation of secre- tions in the cavern, and in part on accompanying bronchial and laryngeal irritation. It is, however, in the main, violent and harassing, occurring in paroxysms, and often producing great exhaustion, dyspnea, perspiration, and excitement of the circulation. The most violent paroxysms occur in the evening,* when the irritation is the greatest, and in the morning, when the largest accumulation of secretion takes place. Sputa.—The sputa of the stage of excavation present differ- ent appearances, according to the varying circumstances of the case. The essential physical character of cavernous sputa is their globular or rounded form, opaque and non-aérated, the masses remaining more or less distinct. Clinically we may di- vide purulent sputa into three classes: 1. Small masses, with irregular edges, opaque, yellowish color, a portion of which sinks in water. This form occurs when cavities are small and the expectorated material not abundant. 2. Large masses, smooth outline, varying in tint from a yellowish to a greenish hue, remaining separate even in water, and a considerable por- tion sinking to the bottom. 38. Ash-colored sputa, which lose the globular form and run into one mass, with lines of lighter color, giving it a striated appearance. These varieties represent different conditions, and deserve x SYMPTOMS AND SIGNS OF THE STAGE OF CAVITIES. 3877 careful discrimination. The small, ragged masses, coming from small caverns, consist mostly of softened tubercular matter, but few pus cells being present. When the caverns extend, and the walls secrete pus freely, the masses become larger, with more regular outline, and consist mainly of pus, intermixed with mucus and tubercular matter, and disintegrated tissues. It represents an extension of morbid action by the process of sup- puration which is taking place in the walls of the cavern. The grayish sputa, which run into a common mass, exhibiting usu- ally the striated appearance, are observed when a rapid disin- tegration of the cavernous walls is taking place, and consist almost exclusively of pure pus, together with more or less tissue- matter. They are met with in rapid phthisis, and in advanced stages of the more chronic forms. The appearance of the sputa is frequently modified by the: intermixture of considerable quantities of transparent and some- what glairy mucus. This occurs especially in the first form, when a portion of the small masses sinks more or less com- pletely, presenting the appearance of boiled rice. The quantity of mucus varies with the affection of the bronchial tubes, and doubtless, also, with the peculiar secreting surface of the cavern. Thus, during the progress of a case in which large masses of yellowish sputa have been expectorated, a sudden increase of excitement produces an exudation of tenacious mucus, which again diminishes as the irritation subsides. The quantity expectorated is exceedingly variable; in some cases it is comparatively small, while in others it will reach a pint or even a quart in twenty-four hours. The size of the cavities and the activity of disease are the determining causes which regulate the quantity of sputum. The discharge is often very irregular; in most instances the cavities become filled during the repose of the night, and the greatest expectoration occurs in the morning; in some, a sudden and profuse expec- toration takes place, while the following day there will be but little. In some cases large caverns suddenly open, with pro- fuse discharge, which, in advanced cases, may even threaten suffocation. The sputa are occasionally tinged with blood, and profuse hemorrhage at times occurs. 378 SEMEIOLOGY OF PHTHISIS. Hemoptysis—The occurrence of hemoptysis is variable in this stage. In some examples there is but an occasional effu- sion of blood, in the form of strie; in others, the quantity is larger, and the whole mass of sputa may become grumous; while in another grade the quantity is copious, alarming, or even fatal. I have observed a case recently, in which the sputa during the day presented the ordinary muco-purulent aspect, but at night became bloody, which had continued for weeks in succession. In some cases there will -be continuous exudation of blood for months in succession. In such examples the exudation of blood takes place from the decaying walls of the caverns, and is usually intimately blended with the ordinary secretions, though at times appears in considerable quantities and nearly pure. In a more extreme form of hemorrhage, the gush of blood is copious and may prove immediately fatal. Such events arise from the rupture of imperfectly-closed blood-vessels, traversing, or occupying the walls of caverns. These copious hemorrhages Dr. Walshe has witnessed most frequently in males, and such has been my own observation; this fact, however, if it really exist, is probably due to the more active exercises of this class rather than any special tendency to that result. The hemor- rhage may prove suddenly fatal by asphyxia or exhaustion, or more remotely by the exhaustion alone. Respiration.—The respiratory movements vary greatly in dif- ferent examples; but it is a curious fact that the frequency often bears no relationship to the extent or gravity of disease. The usual range, even in the worst cases, during tranquil breath- ing, may be stated at from twenty-four to thirty-two. It is _ equally remarkable that the ratio of the pulse and respiration is often destroyed. In a case of acute phthisis at this time under observation, the pulse is habitually from one hundred and twenty to one hundred and forty, while the respiratory movements do not exceed twenty-four per minute. It must be remarked, however, that in most cases the respiration becomes hurried and oppressed when the patient exercises, such as walk- ing, or ascending a flight of stairs. Pain.—The pain which attends this stage is of three forms: DIAGNOSIS OF CHRONIC PHTUISIS. 3879 pleuritic, muscular, and neuralgic. Nearly always we find dull muscular pain, simulating rheumatism, most intense on the affected side. And when the pleura becomes involved con- siderable acuteness is observed; but frequently a lancinating neuralgic pain will be momentarily developed, or at times mani- festing some persistence. In many cases, however, but little pain of any kind is experienced. SECTION V. DIAGNOSIS OF CHRONIC PHTHISIS. Summary of Symptoms and Signs——Having passed in review the main points bearing on the symptomatology of chronic phthisis, it may be useful, before proceeding to the diagnosis, to present a brief resumé of the subject, restricting the state- ment to the most prominent features, in the order of their relative importance. 1. Paecursory Stace.—Symptoms.—Diminution of strength and weight, (often slight;) lowered calorific power; chills and febricula; slightly impaired vascular action; disease of the fauces and tonsils; occasional slight, nearly dry cough; occa- sionally hemorrhage, which may become copious. Physical Signs.—Slight restriction of movement, overcome by forcible inspiration; diminished resonance ; weak and jerking respiration. 9. Srage or ConsoLipation.—Symptoms.—Increase of all the preceding general symptoms, except hemorrhage, which is often more frequent but less copious than in the first. Physical Signs—Diminished and partial expansion ; depres- sion; dullness on percussion ; feeble, harsh, blowing, or bron- chial respiration ; intensified expiratory sound; jerking respira- tion ; dry crackling ; sibilant rhonchus; tubercular crepitus. 3. Stace or Sorrentne.—Symptoms.—The constitutional symp- toms all rapidly increase. Physical Signs Humid crackling ; increase of sputa. 380 SEMEIOLOGY OF PHTHISIS. 4, Srage or Cavitres.—Symptoms.—The constitutional symp- toms become greatly aggravated. Physical Signs.—Cavernous rhonchus; respiration and cough» pectoriloquy; purulent sputa. The facility with which the diagnosis of phthisis may be made depends greatly on the stage; thus, few would mistake the stage of excavation, while a still smaller number would detect the disease in its earliest manifestations. In making a diagnosis no single sign or symptom can be relied on; but we must take into view the whole case, in all its bearings, symp; tomological, etiological, and historical. Thus, if we find an example in which the signs and symptoms are somewhat ob- scure, arising either from complications or incomplete develop- ment, while the history reveals a hereditary taint, the presump- tion is always in favor of tubercular disease. This, however, is but an illustration to meet an extreme case; in a majority of instances the evidences are sufficiently distinct to warrant a positive conclusion. It is evident that the great difficulty in diagnosis pertains to the early stage, and it is to this period that our attention will, in this section, be mainly directed. In the first place, the his- tory of the patient should be carefully investigated: age, hered- itary predisposition, occupation, locality in which he resides, previous diseases, duration and mode of attack of the present indisposition, The diagnostic value of these questions may be thus stated: The presumption is in favor of tuberculosis when the age of the patient is between twenty and thirty-five years; when a clearly-marked hereditary predisposition is present; when his occupation has exposed him to a cool and humid in-door atmosphere, great alternation of heat and cold, or the inhalation of irritating gases or particles of solids; a very low and damp habitation, or moderately elevated table-lands, of limestone formation, where dysentery and typhoid fever prevail, malaria being measurably absent; previous exhausting disease, especially dysentery, typhoid fever, or pneumonia; or, if a fe- male, frequent and protracted lactation, or menstrual irregu- larities; gradual approach of cough, without evident cause, persistent, comparatively dry, and associated with faucial irrita- - DIAGNOSIS OF CHRONIC PHTHISIS. 881 tion; some degree of emaciation, and diminished strength. If hemorrhage has occurred, it is still more significant. But in examining the natural history of the disease, many of the preceding symptoms and conditions may be absent; the patient may not have encountered predisposing causes in regard to hereditary taint, residence, occupation, or previous disease. The only evident signs may be slight emaciation, moderate cough, with or without hemoptysis, and perhaps occasional slight dyspnoea on exercising; in other words, the patient is conscious of “ getting out of breath” more easily than prior to his indisposition. The appetite exhibits no reliable diagnostic condition. Among all these, the most valuable symptoms are emacia- tion, cough, and hemoptysis. But the question arises, are these three signs (emaciation, cough, and hemoptysis) always present? And, moreover, when present, do they afford indubitable evi- dence of tubercular deposits, or may they likewise become the signs of the precursory stage? Let us answer these important questions with care and precision. 1. Emaciation, cough, and hemoptysis are, neither one, always present in tubercular deposits. It is admitted by all that he- moptysis is absent in a certain proportion of cases; and I have beyond all doubt verified the presence of tubercles when there was neither cough nor significant emaciation. The following ex- amples illustrate this statement: Miss M——, aged twenty-eight, eleven months prior to the examination had a tolerably free hemorrhage, (previous health having been good,) followed by occasional streaks of blood in the sputa. The following phys- ical signs were quite perceptible: Slight dullness on percussion, dry crackling and jerking respiration at the right pulmonary apex; left side normal. In this case there was no emaciation, and a scarcely perceptible cough. W. W , aged twenty-four, had slight emaciation, moderate dyspnea on exercising, wan- dering pains through the chest; had seen a little blood. The following physical signs were present: Left apex slightly dull on percussion, inspiratory murmur weak, slightly intensified expi- -yatory sound, dry crackling, jerking respiration. his patient was positively without cough. 382 SEMEIOLOGY OF PHTHISIS. Here are two remarkable cases, one without emaciation, and the other free from cough, and yet the presence of tubercles was clearly demonstrable in both. ,These are fair samples of cases which occasionally occur; and they clearly demonstrate the fact that neither cough, emaciation, nor hemorrhage are essential signs of tubercular deposits. 2. If we observe cough, emaciation, and hemoptysis, are they conclusive evidences of the presence of tubercles? Certainly not. All of these conditions may arise from other causes than tuberculosis; such as chronic laryngitis, bronchitis, or pneumo- nia, to say nothing of other forms of disease. I have witnessed all these symptoms, and yet tubercles were not present. If, therefore, the vital symptoms are not always conclusive, we must bring to our aid those of mere physical origin; and it becomes an important question in diagnosis how far these are positively certain and reliable. Among the most important physical signs may be enumera- ted diminished expansion, partial parietal retraction, dullness on percussion, modified respiratory murmur, (weak, harsh, jerking, intensified expiration,) and the adventitious sound of crackling. When all these signs, or even a few of them, (including dull- ness and the abnormal movements of the chest,) are present, the diagnosis becomes positive and certain; but in the earliest stage the amount of tubercle deposited may be too small to cause perceptible retraction, diminished expansion, or dullness. Nor are the ordinary auscultatory signs more certainly devel- oped at this early period, for there may be neither harsh, weak, interrupted inspiratory sound, nor prolonged expiratory murmur. It has appeared to me, from very careful observations, that dry crackling becomes the earliest, most constant and reliable of the physical signs; and although it is not invariably present when tubercles exist, yet its frequency is so constant as to invest it with the highest diagnostic value. Hence if I find a patient exhibiting even slight emaciation, and some degree of dry cough, which have persisted for some months, and on auscul- tation find clearly-marked dry crackling, I feel fully authorized to make the diagnosis of tubercles. Even a more restricted symptomatology than this may be conclusive. The following DIAGNOSIS OF CHRONIC PHTUHISIS. 383 case is in point. Mr. W. had observed a little diminution of weight, occasional but slight shortness of breath on exercis- ing, some wandering pains of the chest, but was absolutely without cough. Physical exploration yielded a percussion sound 80 nearly natural that it would have been unsafe to affirm the presence of dullness, (although the tone seemed a shade flattened,) but auscultation revealed clearly-marked dry crackling. Here the only positive reliance was the adventitious crackle; and this state of things was observed for three months in succes- sion. Treatment removed the thoracic pains, but dry crackling (the number of sounds varying from two to five or six) con- tinued, and was heard at each examination. This patient passed from my notice, but I learned that he died of phthisis in about two years from the period of the first examination. It is a question, therefore, whether dry crackling, independ- ent of other signs, should be regarded as evidence of tubercular exudation. Certainly it should be, if associated with other well- marked general or local symptoms; but singly and alone, it is regarded by many as of doubtful import. We scarcely know enough of the mechanism of this sign to regard it as positively indicative of tubercular exudation, for it may indeed represent exudations not tubercular. Dr. Austin Flint writes to me that he would not rely on dry crackling in the absence of all other signs and symptoms; and Dr. Walshe, in the late edition of his work, expresses the opinion that this rhonchus may proceed from bronchial irritation, wholly unconnected with tubercle. It must be confessed that the exact pathological signification of dry crackling is undetermined ; but that it represents some form of exudation may be deemed tolerably certain. The most frequent relation of this sound is evidently to tubercle; thus, dry crackling is often observed to pass into moist rhonchi, with all the indications of tubercular softening. Hence it may be deemed positively established, that the deposition of tubercle does give rise to dry crackling, but it remains to be determined whether any other form of exudation will cause the same sound. My own belief is that fully-developed and persistent dry crackling, heard either at the clavicular or scapular apex, is, singly and 884 SEMEIOLOGY OF PHTHISIS. alone, indicative of tubercular deposits. Certainly if any other characteristic symptom or physical sign exist at the same time, the rhonchus in question should be regarded as conclusive. In examinations for life insurance, I have regarded persistent dry crackling as sufficient ground for the rejection of the appli- cant; and who, let me ask, would recommend a person in whom this sign existed, although the general health might be repre- sented as in no way impaired? Finally, I will venture to suggest, that tubercular crepitus is the true sign of tuberculoid fluid exudation, and that dry crack- ling is the positive representative of consolidated tubercle. Microscopie and Physical Characters of Phthisical Sputa—We possess, I think, sufficient knowledge of the microscopic ele- ments characteristic of phthisical sputa, to render the examin- ation of expectorated substances important in diagnosis. The sputa of tuberculous subjects may, for all practical pur- poses, be divided into four classes: 1. The simple frothy mucus, belonging to the earliest condition, possessing no peculiar or characteristic elements, which could distinguish it from that arising from slight irritation or congestion. 2. A gelatinous, semi-transparent fluid, which has been compared to a solution of gum arabic or isinglass. 8. Rounded masses, more or less purulent, yellowish or buff-colored portions, often intermixed with transparent or gelatinous mucus, presenting a striated appearance. This variety represents the stage of softening, and is variously modified, according to accidental conditions. It may be wholly yellowish, or striated with lighter portions, or largely intermingled with transparent mucus. 4. Grayish or ash-colored masses, which run together, and which occur in an advanced stage, representing extensive ulceration with breaking down of the pulmonary tissues. The microscopic characters of the principal varieties of sputa are now very well determined, and afford no inconsiderable aid in diagnosis. In the first variety, or the simple mucus, there is nothing characteristic, and I believe it impossible to distinguish the sputum of this early period from that which occurs in simple mucous irritation, except it may be by the presence of occa- sional blood-corpuscles. The second variety, or the gelatinous DIAGNOSIS OF CHRONIC PHTHISIS. 385 sputum, has been shown by Dr. Andrew Clark, Dr. J. C. Hall, and other observers, to possess certain characteristics distinguish- ing it from catarrhal irritation. The corpuscular composition of this sputum consists of ovoidal and spherical cells, which resist acetic acid ; others are abruptly defined, some compressed and elongated, while others are filled with fat or pigment gran- ules; and finally, corpuscles with irregular outlines, from which nuclei have been eliminated.* The corpuscles with irregular or “jagged” outlines Dr. J. C. Hall regards as indicative of tubercular deposits. These jagged corpuscles may often be detected at an early period, and when the ordinary physical signs may not be sufficiently developed. Dr. C. Radclyffe Hall describes also enveloped blood-corpuscles as met with in the early stage of tubercular deposits. Thus, blood-corpuscles may often be detected when no visible hemoptysis has occurred, and which must certainly be regarded as highly characterisic of tubercular deposits. In a more general sense it may be stated, as remarked by Dr. J. C. Hall, that when the sputum arises from non-tuber- culous irritation, the corpuscles are uniform in their outline, consisting of mucous and epithelial cells; but when tubercular deposits exist, there will be, in addition, cells with irregular outlines, and not infrequently blood-dises. In the third variety of sputa, consisting more or less of yel- lowish material, and representing the stage of softening, two characteristic elements will be observed—the tubercle-corpuscles, and curled elastic tissue. The tubercle-corpuscles I believe, from my own examinations, to be highly characteristic, and may often materially aid in diagnosis. In doubtful cases of bronchial irritation these microscopic elements afford unequiv- ocal means of diagnosis, and in the absence of well-defined physical signs become highly important. The tubercle-corpus- cles are irregular in shape, often fragmentary, and wholly unlike any other substance observed in the sputa; and a microscopist of even ordinary skill will find no difficulty in distinguishing these bodies from mucous, epithelial or pus-corpuscles, with which they are more or less commingled. The elastic tissues * J. C. Hall, Thoracic Consumption, etc. 25 386 SEMEIOLOGY OF PHTHISIS. are derived from the terminal bronchial tubes, in which de- structive action has commenced; and while it may be admitted that any condition in which ulcerative action occurs might pro- duce these fragments of elastic tissue, it is, nevertheless, so sar as known, peculiar to tubercular disorganization. In the fourth variety of sputa, the microscopic elements are ‘pus-corpuscles, epithelia, mucus, at times elastic tissue, and other elements evincing disintegration. Pus-corpuscles, how- ever, predominate, for the condition is one of active suppu- ration. ‘CONCLUSION. Finally, it will be remarked that the diagnosis of phthisis can not be reduced to any single sign or symptom; on the contrary, it is only by a careful and judicious combination of all the means at command—including ‘the history, general and local ‘symptoms, together with the physical signs and microscopic examination of the sputa—that reliable conclusions can be reached. There are some examples in which the general and local symptoms are the most reliable, while in others the phys- ical signs alone can determine the diagnosis; but, in a large majority of cases, a careful combination of signs and symptoms becomes ‘necessary in order to arrive at safe conclusions. The different stages of phthisis present widely different diag- mostic signs. In the precursory stage, the most reliable signs and symptoms are, more.or less loss of weight and strength, slight faucial irritation, irregular and inconsiderable cough, wavy and ‘weak inspiration, slight diminution of sonorousness on percus- ‘sion, and occasionally hemoptysis. If these-signs and symptoms ‘occur in a person whose history reveals an hereditary taint, we should decide the case to be incipient tuberculosis. With or without hemoptysis, this train of symptoms should never be disregarded, for.a misapprehension on the part of the physician would prove:an evil of the greatest magnitude to the patient. Add to the preceding condition any one of the following phys- CONCLUSION. 387 ical signs, and we have the probable, if not positive evidences of tubercular deposits: circumscribed dullness on percussion and diminished expansion, feeble or harsh inspiration, (the latter most significant,) intensified expiratory sound at the left apex, dry crackling or tubercular crepitus. With either one of these conditions sufficiently marked to render the sign unequivocal, it will always be safe to make the diagnosis of solid tubercles. Of course, we presuppose the absence of chronic pneumonia, pleu- risy, and cancer, which must be determined by the history of the case, as well as the present symptoms. The evidences of softening and excavation are those which have been previously detailed, especially the occurrence of moist crackling, cavernous rhonchi, and respiration. The persistence of the physical signs at the pulmonary apices, anterior or posterior, while the lower portions remain free from disease, is a strong indication that they arise from tubercular deposits. For, although the pathological law which determines tubercular deposits to the apices is not invariable, still it is so constant in its influences as to render a decision on its univer- sality almost necessarily true. The sign which I have called tubercular crepitus is, it appears to me, of considerable importance, and particularly so in an early stage, and when other signs are absent or imperfectly developed. Thus, I have observed, during the precursory stage, or at least in an early period of the disease, this sign, while all other physical evidences of tubercle were wanting. And it has appeared to me so conclusive of the existence of tuberculous exudation, but without appreciable solidification, that I could not hesitate in regarding it as indicative of that condition. The frequency of its occurrence I am unable to determine, but probably it exists in a considerable number of cases. But the diagnosis of phthisis is not always so palpable and direct as this brief statement would indicate; for in a certain proportion of cases more or less obscurity will be observed, aris- ing either from the incomplete development of the symptoms and signs, or the modifying influences of coexisting diseases, such as chronic pneumonia, bronchitis, pleurisy, or heart dis- ease. But in the most difficult and obscure cases, a careful 388 SEMEIOLOGY OF PHTHISIS. analysis of the general and local symptoms and the physical signs, will usually enable us to make at least a probably correct diagnosis. If the physical signs are fully developed, the diagnosis can, at once, be safely made; but in the absence of clearly-defined signs, what class of general symptoms afford evidence of tuber- culosis? This is a difficult question to answer; nevertheless, the experienced practitioner, in whom the tactus eruditus is well developed, may often detect the existence of phthisis when the physical signs are indecisive. But this will not avail the inex- perienced physician; and the question recurs, what amount of general and local symptoms, unaided by decisive physical signs, justify the diagnosis of phthisis? I would answer the question thus: if the history reveals an hereditary taint, and the present symptoms show gradual loss of weight, a persistent non-catarrhal cough, sputa, purulent or not, with more or less hemoptysis— the condition having persisted for at least three months—I would not hesitate to diagnosticate phthisis, although the phys- ical signs might be merely negative. It must be remarked, however, that obscure cases will often arise, in which all classes of phenomena are too indefinite to admit of positive and uncon- ditional conclusions. In all such examples, the only practicable course is to give due attention to the history of the case, analyze carefully all the symptoms, present and past, note carefully the results of auscultation and percussion; and then, as a matter of judgment, decide in the most enlightened manner possible, ac- cording to the probabilities of the case, or as the weight of testimony may incline, in favor of or against phthisis. With this kind of cautious and philosophical investigation, the enlight- ened physician will seldom fall into serious error. There are certain forms of disease which so closely simulate phthisis, that the differential diagnosis at times becomes diffi- cult, which is especially the case in chronic bronchitis associated with globular dilatation of the tubes. The distinctive character- istics, however, are usually sufficiently marked to enable us to form a correct diagnosis. In phthisis, the dullness and rhonchal sounds are usually developed in the clavicular or scapular regions; while similar signs, arising from bronchial dilatation, DURATION OF CHRONIC PHTHISIS. 889 are located at a lower point, approaching the mammary region. The constitutional symptoms in phthisis are usually more marked and progressive than in bronchial disease ; hemoptysis is rare in the latter, common in the former. The history of the case, also, will usually show bronchitis to have been the primary disease. But above all, will the sensible and microscopic charac- ter of the sputa be decisive; thus, in bronchial disease, the cells consist mainly of pus, epithelia, and mucus; while in phthisis the characteristic elements previously mentioned will be de- tected. The sputa of bronchial disease often have an offensive odor. Finally, it should be borne in mind that dilated tubes is a disease of comparatively rare occurrence, although it may coexist with phthisis. The spirometer affords very little aid in diagnosis. It is, under all circumstances, too variable in its results to admit of practical application in tubercular disease. When, however, phthisis has been clearly diagnosticated, this instrument is often of use in demonstrating the extent to which the breathing capacity has been reduced. Beyond this, the spirometer pos- sesses little value. SECTION VI. DURATION OF CHRONIC PHTHISIS, In estimating the duration of phthisis, we are obliged to begin with the stage of tubercular deposits; and although this method is not strictly correct, yet such is the variable character and manifestations of the precursory state, that no computation of its length can be more than conjectural. Hence our estimate extends from the time tubercles can be detected in the lungs to a fatal issue. The duration of phthisis must necessarily vary greatly with the accidental circumstances which surround the patient, in- cluding hygienic regulations and medicinal treatment. It is not often, at the present day, that we can trace the natural 390 SEMEIOLOGY OF PHTHISIS. history of the disease uninfluenced by medicines. Medicinal treatment may prove beneficial or injurious, but, in a majority of cases, more or less influence is exercised over the progress and duration of the disease. In examining cases of a medium degree of intensity, we find them ranging mainly from nine months to three years. It is true some will fall below the shortest period, while others greatly exceed it; but these are exceptional cases, either mani- festing an unusual degree of acuteness, or becoming protracted greatly beyond the ordinary duration. The mean duration of three hundred and fourteen cases, observed by Bayle and Louis, was twenty-three months. These cases ranged as follows: twenty-four from one to three months; sixty-one from three to six months; sixty-nine from six to nine months; thirty-two from nine to twelve months; thirty-three from twelve to fifteen months; twelve from fifteen to eighteen months; twenty-eight from eighteen to twenty-four months; twenty-eight from three to five years; ten from five to ten years; nine from ten to twenty years. It will be remarked that more than one-half (one hundred and sixty-two) of the whole terminated within nine months; but as ninety-three of these were fatal between one and six months, it is fair to infer that at least a portion of them belonged to the class of acute cases. But, in addition to this, thirty-five cases ranged from four to twenty years, extending beyond the usual period. Hence, the average duration, excluding the two extremes, is found to be, in this series of cases, eighteen months. Accord- ing to the observations of Andral, at La Charité, the average duration is two years, many, however, terminating at a some- what early period. These observations indicate that a majority of cases range from nine months to two years. In another series of cases observed by Louis, the following results were obtained. Of three hundred and seven cases twen- ty-six died within three months; ninety-eight within six months; one hundred and sixty within nine months; two hundred and sixty-four within twenty-four months. Thus more than one- half (one hundred and sixty to one hundred and forty-seven) died within nine months, and of the whole three hundred and DURATION OF CHRONIC PHTHISIS. 891 seven, only forty-three survived twenty-four months. In the Reports of the Hospital for Consumption, (London,) of two hun- dred and fifteen fatal cases (deducting fourteen doubtful) one hundred and twenty-three terminated in eighteen months. These, however, are the statistics of hospitals, which will not fully apply to private practice. My impression is that the ordinary duration of phthisis, as met with in a good class of private patients, will considerably exceed the estimate of the London hospital, (eighteen months,) or even that of Andral, (two years ;) and we may, with some degree of safety, conclude, with Sir James Clark, that the duration, under favorable cir- cumstances, will not fall much short of three years. However, it is not, perhaps, in a majority of patients that these favorable circumstances can be secured, so that even in private cases, a majority die under three years, generally ranging from nine to thirty months; while in hospitals the duration may be stated at from six to twenty-four months. The influences of age and sex have been noted as exercising some control over these results. Louis expresses the opinion that age exercises but little influence, except that acute phthisis is more common in early life. The following results were obtained at the Brompton Hospital in two hundred and fifteen cases : ; 3 to6 6 to9 9tol2 12to18 18to24 24t030 Agzs. months. months. months. months. months. months. 15 to 25. ..ccceseseeensene Il ll 14 14 8 9° 25 to B5....cceceeceesvens 5 ll 12 9 7 7 35 tO 45.....ccsseereeeeee 2 7 3 10 5 7 It will be remarked that this table shows the most rapid march of phthisis from fifteen to twenty-five years of age. Thus, between fifteen and twenty-five years, fifty deaths oc- curred within eighteen months; while from twenty-five to thirty-five, only thirty-seven deaths took place—a difference of one-third; and the proportion is about the same throughout. These facts indicate that from fifteen to forty-five the duration increases about one-third with each decennial period. The great practical fact taught is, that the younger the subject, ceteris 392 SEMEIOLOGY OF PHTHISIS. paribus, the more rapid the course of the disease, and that, as life advances the duration is greater. The influence of sex over the duration of phthisis is worthy of note. Louis observed that more cases terminated in a year in females than males in the proportion of forty-two to thirty. At the Brompton Hospital the reverse facts were statistically elicited. Thus, it is stated that of the one hundred and twenty- three cases which terminated in eighteen months, eighty-nine, or 60.5 per cent., were males, while only thirty-four, or fifty per cent., were females; but after that period the duration was reversed ; of seventy-eight cases, forty-seven, or 31.9 per cent., were males, while thirty-one, or 45.5 per cent., were females. The two hundred and fifteen cases of the Brompton Hospital are thus tabulated : PER CENT. IN ONE HUNDRED. Male. Female. Male. Female, Less than three months.............se000e «o I 0 = = From three to six months............c0000 17 5 11.5 7.3 six to nine months........s.000006. 28 8 19.0 11.7 «nine to twelve months eves 22 8 14.9 11.7 “twelve to eighteen months......... 21 13 14.2 19.1 “eighteen to twenty-four months... 10 12 6.8 17.6 “twenty-four to thirty months...... 15 8 10.2 1.7 “ thirty to thirty-six months......... 1 5 0.6 7.3 “thirty-six to forty-two months... 7 2 47 2.9 “ ~ forty-two to forty-eight months... 3 1 2.0 14 Above four years.......cccccccesssceneneees 11 3 7.4 4.3 Doubtfil visicissvessowesadeisstsverveoreccn LL 3 7.4 4.3 SYMPTOMS OF INFLAMMATORY PHTHISIS. 3893 CHAPTER II. SYMPTOMS OF INFLAMMATORY PHTHISIS. THE symptoms of inflammatory phthisis vary with the differ- ent forms of disease, the character and extent of the tissues involved, and the peculiarities of each individual case. Pneu- monia, bronchitis, and pleurisy are the particular forms of inflammation which give a special character to this form of phthisis; and among these, pneumonia, including what may be termed the parenchymatous and vesicular forms, is by far the most common and important. It is true, however, that bron- chitis, or broncho-pneumonia, is by no means infrequent; in- deed, the capillary form of bronchial disease, extending to the air-cells, is a variety of morbid action strongly favoring the development of tubercles. In addition to these varieties, there is a lower grade of action, consisting of a congestive condition, with febrile reaction, which may lead to rapid and extensive tubercular infiltration. What has been described as febrile phthisis is little more than chronic pneumonia, or inflammatory engorgement, passing into tuberculization. A low grade of in- flammatory action occurring in a phthisical constitution, with a greatly disordered condition of the system generally, induces a febrile state, in which tubercular deposits speedily take place, giving rise to all the phenomena of phthisis, with constant fever. In ordinary pneumonic cases the early symptoms may exhibit nothing peculiar; but it will finally be observed that, instead of resolution taking place, as in common cases, the disease be- comes chronic with progressive emaciation, hectic fever, and continued cough, with variable sputa. 894 SEMEIOLOGY OF PHTHISIS. 1. Purenchymatous, or Plastic Pnewmonie Phthisis——By this term I wish to designate ordinary pneumonia, with plastic ex- udations ultimately leading to tubercular deposits. It is evi- dent that pulmonary inflammation often becomes the direct inducing cause of phthisis, and imparts to the whole course of the affection an inflammatory grade of action; but, as a general rule, this result takes place only when the taberculons diathesis is present. It constitutes, however, one of the forms of inflam- matory phthisis. The general and local symptoms scarcely differ, in the begin- ning, from ordinary examples of pneumonia; but it will be observed that the grade of morbid action is comparatively mild, both the subjective and objective symptoms indicating less in- tensity than is usually witnessed in idiopathic inflammation. Instead, however, of the disease terminating in due time by resolution, it becomes protracted, the patient wastes, and the symptoms of phthisis replace those of pneumonia. The physical signs of this form of phthisis are more or less obscured by the coexisting pneumonia; but as the disease advances, the dullness extends more toward the apex, the rales are more moist and distinct, and better defined, together with feeble, harsh, or bronchial respiration in the affected part. But the diagnosis will rest mainly on the gradual increase of these principal phenomena; thus the dullness, which was diminish- ing with partial resolution, becomes more marked and circum- scribed, and occupies the apex, the cough increases, and the rales ‘become more characteristic. These events occurring, while the case should be, if simple pneumonia, gradually improving, war- rant the inference that tuberculosis has supervened. ‘When the inflammation occupies the superior portion of the lungs, the diagnosis is more difficult; but even here the pro- gressive symptoms become the principal guides. It will be remembered that pneumonia of the upper lobes is compara- tively passive, often destitute of marked signs or symptoms, except the evidences of consolidation. Thus, it will often hap- pen that the first exploration will reveal tubular respiration, the disease having already progressed to hepatization. Following this, tubercular deposits would be indicated by persistent dull- SYMPTOMS OF INFLAMMATORY PHTHISIS. 395 ness, (but of lessened area,) the addition of moist rales, and increase of sputa. In most cases of this character without tubercles, there is but little sputa, either during the forming or retrogressive stages; hence the occurrence of the signs men- tioned becomes peculiarly significant, and even diagnostic. This form of phthisis is marked by a continued febrile action, which hastens the disease through all its stages; the deposits take place rapidly, softening speedily occurs, and the disorgan- ization of the pulmonary structures is often sudden and ex- tensive. All the functions of the economy are more involved than in the non-inflammatory forms; and hence the continued disturbance of the circulation and nutrition speedily exhausts the system, and, in many cases, the disease proves fatal as much through the general derangement as the disorganizing effects of the local disease. 2. Vesicular Pneumonic Phthisis—This form of tuberculosis has been termed gray tubercles, gray semi-transparent granu- lations, granulations of Bayle, granular phthisis, ete. In a for- mer part of this treatise the characteristics of these granules were referred to, and the opinion expressed that they are of inflammatory origin. According to this view, it is scarcely correct to class granular deposits with phthisis; but inasmuch as these affections appear to a certain extent convertible, it seems best to retain their assumed relationship. These granules, as previously stated, appear to be deposited in the air-cells, as the result of inflammation of those structures, and hence it constitutes vesicular pneumonitis, or cellulitis. These bodies are diffused largely through the pulmonary tissue, coextensive with the inflammation; in many examples they are found principally in the lower and middle portion of the lungs, though at times occupying almost exclusively the superior lobes, or even limited to the apex. I have, within a few days, exam- ined a body in which some degree of textural change had oc- curred in the right apex, interstitial, and imparting an increased firmness, but short of consolidation; and intermixed through this portion were numerous gray granulations, of the usual size and appearance. The lower portion of the right and the entire left lung were free from the deposits. 396 SEMEIOLOGY OF PHTHISIS. In a majority of cases which I have examined post-mortem, there are evidences of general vascularity; thus, the tissues of the lungs exhibit a deeper red than natural, with a degree of engorgement at points approaching consolidation, and at times small portions sink in water. But true hepatization, to any considerable extent, does not occur, the inflammatory action being limited mainly to the air-vesicles, and the exudation in- volving the parenchymatous tissue only to a limited extent. The intermediate cells remain free from disease, and hence the lung, as a whole, does not become hepatized. The tendency of these granules is to remain stationary; but, in cases where the tuberculous diathesis is strongly developed, the deposits enlarge, change color, and finally break down into softened tubercular masses. The duration of this form of phthisis is quite variable. I have known it prove fatal in three or four weeks; but it will, at times, ae beyond this period, espe- cially when the transformation into yellow tubercles is the final result. It may terminate fatally in the febrile stage, or pass on to a more chronic and less phlogistic condition, and thus become stationary or retrogressive. Symptoms.—The general symptoms of this form of phthisis are fever, (characterized by frequency rather than force of the pulse,) heat of the skin, dry cough, dyspnoea, emaciation, loss of appe- tite, and bowels usually constipated. In many cases the access of the disease is sudden, resulting from exposure, inhalation of irritating substances, or other causes capable of developing pulmonary irritation. The respiratory movements become some- what hurried; sputa absent or inconsiderable; when present, merely mucus, at times viscid and even streaked with blood— the latter condition being very rare. The general course of the disease is rapid, the patient dying within a few weeks, appar- ently the result of a slow, wasting fever. In other and less in- tense examples, the febrile symptoms abate, the evidences of pulmonary disease gradually subside, and ultimate recovery may take place. But in less fortunate cases a chronic disease ensues, which either remains as a form of chronic pneumonia, or the deposits take on the true tubercular character, soften, and thus the disease proves fatal, as in ordinary phthisis. SYMPTOMS OF INFLAMMATORY PHTHISIS. 897 Physical Signs.—Inspection reveals a slight restriction of the parietal movement, but this is often inconsiderable; and, in consequence of its being, in many cases, equal on both sides, there is usually great difficulty in determining the question. It will be observed, however, that there is slightly more tendency to the elevation movement, and less uniform expansion. Per- cussion yields nearly similar results. The degree of resonance is slightly diminished ; but this being equal on both sides, where the disease is general, renders it measurably inappreciable. Auscultation is more decisive. The respiration-sound is variable; it may be rough, harsh, puerile, or weak—varieties depending on special but often inappreciable peculiarities. In nearly all cases, however, the respiratory movement is more or less irregular, and jerking inspiration is developed. But the special sign on which most reliance can be placed is, the occur- rence of a crackling, usually intermediate between the dry and moist. This sound has appeared to me so characteristic, that I have not hesitated to base a diagnosis mainly on its presence; and in a number of examples post-mortem examinations have verified the diagnosis. Under such circumstances the crackling becomes diffused over the chest, coextensive with the granular deposits ; and when it occurs over the middle and lower portions, without the concurrent signs of bronchitis, (sonorous, mucous, subcrepitant rales,) may be regarded as pathognomonic. When the disease progresses, and by continued growth the tubercles enlarge and soften, the physical signs indicate the changes. The percussion sound becomes duller ; respiration weak, harsh, bronchial or cavernous; moist bronchial rhonchi ; increase of vocal resonance, may be even bronchophonic; in- creased parietal fremitus. Diagnosis.—It is not always easy to diagnosticate the presence of vesicular phthisis; still the attentive observer will not often fall into serious error. A febrile disease, with marked but not violent thoracic symptoms, dry (or nearly so) cough, with ema- ciation, and the peculiar crackling, will distinguish acute miliary phthisis from bronchitis—almost the only disease with which it is liable to be confounded. In bronchitis the rhonchi are more moist, sputa more abundant—viscid or muco-purulent—skin 898 SEMEIOLOGY OF PHTHISIS. less hot, and surface more inclined to muddy or dusky hue, while in acute granular phthisis it is often florid, as shown in the face. The difficulty of distinguishing acute miliary phthisis from the typhoid form has certainly been greatly overrated. Typhoid fever has more of the essentials of idiopathic fever, with less pulmonary symptoms, and usually the nervous system and ali- mentary canal are much more implicated. In the event of the intestinal glands becoming early involved in tuberculosis, the resemblance to typhoid fever would be greatly increased; but in this vesicular variety, the disease is of purely inflammatory origin, and, therefore, the intestinal glands are not liable to implication. Again, the nearly uniform occurrence of eruptions in typhoid fever serves still further to distinguish these affec- tions. But, above all, the positive pulmonic symptoms, rational and physical, will usually be a sufficient ground of diagnosis. 3. Broncho-pneumonic Phthisis.—There is reason to believe that among the inflammatory affections which lead to tubercu- losis, chronic bronchitis, or broncho-pneumonia, holds an im- portant position. According to the observations of Sir James Clark, bronchitis, in its chronic form, may become an exciting cause of tubercles. This author remarks that the inflammatory. affection, in some instances, begins in the larynx, and extends to the trachea and bronchi. Andral regards the connection between bronchitis and phthisis as frequently very intimate; and although there is some reason to believe that he has at- tached too much importance to the subject, nevertheless, his observations clearly prove that bronchial irritation is often the precursor of phthisis. Dr. Stokes expresses similar views, and remarks that such cases may continue for a long time prior to the development of tubercles, extending from five to fourteen years, or more. The exact relationship, however, of chronic bronchitis and tubercles is an undetermined question; and while the observa- tions of the authors above quoted, with many others, establish the fact that a certain proportion of cases of phthisis are pre- ceded by bronchitis, the percentage of such examples remains to be established. It is believed, by most writers who adopt this SYMPTOMS OF INFLAMMATORY PHTUHISIS. 899 view, that bronchitis induces tubercles in such cases only as have a predisposition to tuberculosis, and it becomes, therefore, an exciting and not inducing cause. But on this subject there probably exists a fallacy. If the tubercular diathesis be present, a very slight exciting cause will frequently develop the disease, or it may even progress to local deposits by its own inherent force; but as bronchitis may exist for a long period, (five to fourteen years, according to Stokes,) before tubercles are pro- duced, we have conclusive evidence that inflammation of the mucous tissue is a very weak exciting cause. The question arises, therefore, whether those examples in which bronchitis existed for many years were not cases of phthisis caused by the local disease, without the pre-existing diathesis. This opinion seems the more probable when it is remembered that, in certain examples, when the diathesis is present, bronchitis may speedily develop the disease. A case is now under my observation in which the disease commenced as laryngitis, with broncho-pneu- monia, associated with persistent aphonia. The case is now of nine months’ duration, with well-marked evidences of softened tubercles and large cavities. The diathesis in this case is unknown. Examples have frequently come under my observation, in which the disease commenced with catarrhal irritation or open bronchitis, with the ultimate development of tubercles; and I have observed that when the diathesis was clearly marked, the local deposits speedily ensued, while in other examples, where no taint existed, they were very slowly developed. It is not at all beyond the limits of probability that long-continued bron- chitis, with copious opaque sputa, may, by exhausting the powers of life, deranging the gastric function, and impeding the circulation of the lungs, ultimately cause the deposit of tubercles; indeed, if phthisis can ever be induced independent of the hereditary diathesis, we assuredly have, in the long-con- tinued influence of chronic bronchitis or broncho-pneumonia, sufficient derangement to cause that morbid state. The induc- ing cause may be limited to the bronchi, or it may extend to the pulmonary substance constituting broncho-pneumonia. Symptoms of Broncho-phthisis—The symptoms which charac- 400 SEMEIOLOGY OF PHTHISIS. terize an approach of broncho-phthisis are those, in the first place, of chronic bronchitis, to which succeed the evidences of a more profound constitutional disturbance. In ordinary ex- amples of bronchitis the constitutional derangements, although often profound and important, remain comparatively stationary; thus, the emaciation usually progresses to a certain point, and then ceases to increase, although the primary disease may con- tinne unabated. But when phthisis becomes ingrafted upon a chronic bronchitis, emaciation becomes progressive, and is often disproportioned to the degree of bronchitic disease. When, therefore, we find a patient laboring under chronic bronchitis, exhibiting progressive emaciation, it constitutes a fair presump- tion that tubercles have been superadded to the primary affection. It will often be observed, also, that the more active manifestations of disease take place; thus, chilliness may occur, with night-sweats, increased dyspneea, and progressive debility. In a certain proportion of cases, when the tubercular disease makes its access, more or less hemorrhage supervenes. I have observed examples in which the affection of the mucous mem- brane would continue for a period of several months, with simply the signs of bronchitis, when, suddenly, hemorrhage would occur, followed by the regular and progressive develop- ment of tubercles. But it must not be assumed that hemoptysis will occur in the proportion observed in phthisis; on the con- trary, many more examples will be met with, in which this sign is absent. The relative frequency of the hemorrhagic and non-hemorrhagic cases remains an undetermined question. Physical Signs ——The physical signs of this form of disease are those which belong to the deposition of tubercle in general. Dullness becomes manifested at the clavicular regions, and the respiratory sounds are modified according to the extent and condition of the deposit. If the ordinary signs of the pre- existing bronchitis are not present at the apices of the lungs, the respiration signs of tubercle will be much more readily’ detected. When, however, sibilant, mucous, or even cavernous rhonchi (the latter from dilated bronchi) are present, much difficulty will frequently be experienced in making a diagnosis. But, even then, the stationary character of the pre-existing SYMPTOMS OF INFLAMMATORY PHTHISIS. 401 signs, the more recent occurrence of apex-dullness, together with more marked prolongation of the expiratory act, will usually serve to indicate the supervention of tubercle. I have met with examples in which bronchitis became complicated with pneumonic inflammation of the apex, so that dullness at that point would arise independent of tubercular deposits. When these cases come under observation during the inflamma- tory attack, no difficulty will be experienced in recognizing the nature of the disease; but if the case is seen for the first time after the subsidence of active signs of inflammation, and often without any accurate history, it becomes extremely difficult to determine the cause of dullness. Usually, however, pneumonic dullness is more extensive than the tubercular, and is associated with more distinctly-marked tubular respiration. But, after all the scrutiny possible, it often becomes necessary to wait for further developments before a positive diagnosis can be made. 4, Pleuritic Phthisis.—But little need be said in reference to tubercles caused by chronic pleurisy. It is abundantly evident that chronic pleurisy occurring in the tuberculous constitution may develop phthisis; but, independently of the diathesis, it can hardly be regarded as a cause of consumption. Certainly pleurisy does not bear the same relation to tubercle that is snstained by bronchitis or pneumonia, and, indeed, its effects must generally be incidental or indirect. It must be admitted, however, that pleuritic adhesions, which limit the expansion of the lungs, may favor tubercular devel- opment, and especially so in the diathetic state. I have wit- nessed a considerable number of examples in which the tuber- cular deposits occurred in a lung limited in movements by pleuritic adhesions, and under such circumstances as to favor the idea that some connection existed between the diseases. Febrile Phthisis, as described by Sir James Clark, is clearly inflammatory in its origin. He observes that the attack is usually sudden, coming on after exposure to cold, in persons apparently healthy, but really of the tuberculous constitution. And he justly observes that the post-mortem appearances, as described by Louis and Carswell, are peculiar, consisting of gray granulations, with serous infiltration, or extensive infil- 26 402 SEMEIOLOGY OF PHTHISIS. tration of cheese-like tubercles, but generally with but small cavities. Indeed, the entire description so clearly shows pneu- monic inflammation, that no doubt can exist on the subject. LARYNGEAL PHTHISIS. This form of phthisis may properly be arranged in the inflam- matory class. As described by Trousseau and Belloc, laryngeal phthisis is chronic inflammation, upon which tubercular deposits may or may not be ingrafted. As known to pathologists at the present time, it is a form of phthisis in which the disease locates largely on the larynx and trachea, with ultimate ex- tension to the lungs, or coexistent pulmonary tubercles. It is generally associated with more or less pharyngeal inflammation, which not unfrequently precedes the laryngeal affection. As this form of phthisis has come under my observation, it has presented evidences of more or less inflammatory action; while the history of the disease clearly revealed that irritation . of the larynx and trachea were, in fact, the earliest symptoms. It may with propriety be assumed, that laryngeal irritation bears the same relation to this variety of phthisis that is sustained by pneumonia to the inflammatory form. When accidental excitement of the laryngeal structures occurs in a tuberculous constitution, such local disease becomes the determining cause, and the essential morbid action is located accordingly. Indeed, various predisposing and exciting causes may be sufficient to locate the disease in the laryngeal and tracheal structures; and hence, the inordinate use of the voice, as in public speaking and singing; the inhalation of irritating substances, gastric derangement, and all those agents capable of inducing chronic laryngitis, may cause laryngeal phthisis. In other words, those agents which, in non-tuberculous constitutions, may induce simple chronic laryngitis, may, in the diathetic state, give rise to laryngeal phthisis. Laryngeal phthisis, as now understood, is essentially a tuber- culous disease; that is, it is either so in its primitive condition, or by continuance becomes connected with tubercular deposits in the larynx, trachea, and lungs. But to constitute what is SYMPTOMS OF INFLAMMATORY PHTHISIS. 4038 properly laryngeal phthisis the disease must begin in these structures, and predominate in them throughout its entire course. When, on the contrary, phthisis is primarily located in the lungs, and the larynx becomes implicated merely in the prog- ress of disease, the affection of the air-passages becomes a mere symptom, and, therefore, does not give to the case an essential character. It is evidently rare that laryngeal phthisis proves fatal with- out the lungs becoming involved in tubercular disease; indeed, all the cases which have come under my observation have been associated with pulmonary tubercles. At the same time we can not deny that true tubercular disease of the larynx and trachea may prove fatal without involving the lungs, or, at least, the pulmonary disease may play a very unimportant part in the morbid action. The symptoms of laryngeal phthisis point more directly to the air-passages than the pulmonary substance. Upon inspec- . tion, the fauces exhibit, more or less, marks of inflammation ; the tonsils are nearly uniformly diseased, varying in extent and special character in different cases; and the larynx, so far as it can be examined, shows evident marks of the disease. By depressing the tongue, the epiglottis can usually be seen, and the larynx can be still further inspected, by means of the laryn- goscope. The epiglottis is usually red, swollen, and eroded or ulcerated ; and the same condition doubtless exists in the larynx, and extends along the trachea and bronchi to the lungs. The extent to which the follicles become involved is variable, but they are usually more or less diseased. The general symptoms of laryngeal phthisis do not differ materially from those of the ordinary variety. The physical signs of laryngeal phthisis are simply those arising from thickening of the mucous membrane, ulceration, and the modifications of secretion. Hence, the laryngeal respi- ratory sounds may be harsh, dry, or whistling; or mucous and sonorous rhonchi may be developed. Finally, as a diagnostic point, it may be stated that laryngeal phthisis differs from ordinary consumption in the fact that the morbid action in the former begins in the throat, while in the 404 SEMEIOLOGY OF PHTHISIS. latter the pulmonary tissues are the first to suffer. There is, therefore, an idiopathic laryngeal phthisis and a secondary laryn- geal affection, the latter a mere sequence or complication of ordinary chronic phthisis. The laryngeal affection, which is strictly idiopathic, begins in the pharynx, and involves, as a general rule, the tonsils, mucous follicles, larynx, and trachea; whereas the secondary form of laryngeal disease is due to the primary pulmonic lesion, and hence does not appear until the latter becomes advanced to the stage of tubercular softening. PART FOURTH. THERAPEUTICS OF PHTHISIS. » THERAPEUTICS OF PHTHISIS. CHAPTER I. TREATMENT OF CHRONIC PHTHISIS. In the treatment of phthisis the physician’s attention must be first directed to the stage of the disease, the constitution of the patient, the character of the exciting causes, and other incidental] circumstances bearing on the nature and progress of the affection. The importance of discriminating between the different stages of phthisis can not be less than in any other affection, and yet it is greatly to be feared that many prescribe for the disease, without much regard to the state of the general system or condition of the local deposits. This indifference has arisen, in part, from the difficulty which many experience in the diagnosis of the early stages of phthisis, and in part, also, from a desire to secure the influence of specifics, or, at least, agents which occupy the position of specifics in the general treatment of the disease. In this manner a single agent is often made to extend through the whole course of the disease, and is employed in every stage and condition. It must be evident, however, to every well-informed pathologist, and to every ac- curate therapeutist, that the same course of treatment can not, upon any sound application of principles, be employed in the precursory stage, the stage of tubercular deposits, of softening, or of excavation; and yet it too often happens that the same (407) 408 THERAPEUTICS OF PHTHISIS. general course of treatment is scarcely varied in these widely’ different conditions. Thus, since the introduction of cod-liver oil, and the establishment of its reputation in the treatment of phthisis, many practitioners conceive they have performed their whole duty, and given the patient the best prospect of recov- ery, when that agent has been prescribed from the beginning to the end. But instead of adopting this indiscriminate course, we should distinguish not only between the different forms of phthisis, but likewise between the stages of each variety. In treating, therefore, chronic phthisis, I shall observe the follow- ing stages: The Precursory Stage. The Stage of Tubercular Deposits. The Stage of Softening. . The Stage of Caverns. . The Complications. or go bo SECTION I. TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. I have already described, at considerable length, the phenom- ena of the precursory stage of phthisis, by which is meant a morbid state anterior to the occurrence of tubereular deposits in the lungs. It might, with propriety, be termed the /irst stage of phthisis, for it does, in fact, constitute the earliest state of the morbid action; but inasmuch as common usage has fixed the period of deposits as the first stage of the disease, it will prevent confusion by denominating this initial condition precursory. The phenomena of the precursory stage, as previously detailed, indicate a state of impaired vitality, mostly hereditary in its origin, and ultimately tending to the formation and deposit of tubercles. The special manifestations of disease are loss of _ weight and strength, variable, though not seriously-impaired \digestion, weak calorific power, diminished respiration, and TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 409 disease of the fauces, extending more or less to the respiratory passages. These symptoms (connected with the physical signs previously detailed) are particularly significant in those heredi- tarily predisposed to consumption, and can not with impunity be neglected. It is true, indeed, that loss of weight and im- paired vitality, in a general sense, may occur in persons in no way predisposed to tuberculosis, and in whom that disease may never be developed; but in all such examples there will be found some obvious cause for the symptoms, independent of inherent constitutional changes, and, therefore, without any direct tendency to tubercular phthisis. Besides, there is a char- acteristic aspect of tuberculous cases, which, although not so well marked as to arrest the attention of the inexperienced, is still sufficient to distinguish it from temporary or accidental debility. In fine, the whole phenomena indicate a state of lowered vitality, which serves as an important indication in treatment. ‘ 1. General Hygienic Course.—In the precursory stage of phthisis, representing a condition independent of local pulmonary dis- ease, and consisting in a derangement of the general system, the remedial course must necessarily be largely hygienic; which consists in the due regulation of the exercise, diet, clothing, change of climate ; and, in certain cases, a general tonic course of medication. The circumstances under which many of these cases originate afford the clearest evidences of the nature of the exciting causes, and the indications for treatment. Thus, persons con- fined to in-door business, such as merchants, bankers, school- teachers, tailors, shoemakers, who breathe an impure and often over-heated atmosphere, with limited physical exercise, are placed under the most favorable conditions for the development of tuberculosis. And in addition to the circumstances named, such persons (at least in the United States) are usually addicted to the use of tea, coffee, and tobacco, agents which operate most unfavorably in such constitutions. The effects of these agents are pernicious in a two-fold manner; they excite the nervous system, ultimately inducing debility, and thereby increase the metamorphosis of the tissues and favor emaciation ; and second- 410 THERAPEUTICS OF PHTHISIS. ly, they impair the functions of the stomach and of primary assimilation in a general sense. The effects of the agents named are widely different. Tea and coffee stimulate, and by long-continued or excessive use, cause irregular action and finally debility of the nervous system, which latter condition favors the metamorphosis of the tissues; while tobacco impairs digestion, depresses and renders irregular the action of the nervous function and the heart, and strongly increases the tendency to emaciation. Some doubt may exist in regard to the effects of tea and coffee; these articles of diet are rich in nitrogen, and acting as nervous stimulants, haye been supposed to impede metamorphosis. The experiments of Bécker and Lehmann favor this conclusion; but, although the observations proved that the excrements were diminished under the influence of tea and coffee, and increased when water alone was used as a beverage, yet they are not conclusive in the premises, and probably stop short of the point which most in- terests practitioners. It may be, indeed, that the moderate use of tea and coffee will sustain nervous action, and thereby im- pede the transformations of the tissues; but beyond this mere initial state, there are effects of these agents the reverse of a stimulating or sustaining influence, which is, in fact, abnormal and debilitating. Those who drink largely of these beverages (especially young persons with little exercise) become “nerv- ous;” that is, the nervous system being over-stimulated, comes to act irregularly, to which debility surely ensues. This state impairs digestion, diminishes the power of resistance, weakens the molecular affinity of the tissues, and thereby favors decom- /position. At the same time, excretion is doubtless diminished, ‘ (as observed by Bicker and Lehmann,) which rapidly impairs . the vital powers. In this manner the free use of tea and coffee, , taking the place of substantial food, impairs primary and sec- ondary assimilation, predisposes to debility, and just to that extent favors the development of tuberculosis. The evil effects of tobacco are more evident and extensive than those of tea and coffee ; and whatever doubts may exist in regard to the action of the fone agents on the metamorphosis of the tissues, there can be none in relation to the latter. It isa TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 411 common observation that the use of tobacco impedes the forma- tion of fat, and is resorted to by many persons for the purpose of preventing obesity. It possesses properties which act with great energy on the nervous system generally, and especially on the heart and stomach, and thus seriously impairs the powers of assimilation, and may permanently affect the nutritive func- tions. In addition to these effects of tobacco, it evidently ex- ercises an unfavorable influence over the glandular structures of the fauces; and where there exists a tendency to follicular or tonsillar disease, or affections of the mucous surface gen- erally, the use of tobacco must prove prejudicial. Finally, whatever opinions, as pathologists, we may entertain in relation to the immediate effects of these agents on the animal economy, we will scarcely fail, as practitioners, to reach the conclusion, that the liberal use of tea, coffee, and tobacco is highly perni- i cious in those constitutions predisposed to tuberculosis, and especially in persons subjected to limited exercise. It must not be inferred, however, that tea and coffee are un- conditionally prejudicial. On the contrary, many persons can use these beverages in tonic quantities, so that they may prove beneficial rather than injurious. A single cup of coffee in the morning, and tea at night, may often be indulged in without injury ; but the personal experience of each patient must determ- ine whether these quantities act injuriously on the nervous function. Large quantities should, I think, always be inter- dicted. Chocolate is an appropriate beverage, and may often be advantageously substituted for tea and coffee. The proper hygienic course, under the circumstances detailed, is to change the habits completely and entirely; the use of tobacco, at least, should be abandoned, the occupation changed to free exercise in the open air, a liberal diet of mixed food used, and every measure taken to invigorate the general system. If the morbid tendency has not proceeded too far, a mere change from a sedentary to an active life, and from in-door to out-door exercise, may be sufficient to avert the impending danger. But if extensive damage has been done to the vital powers, and secondary assimilation, as evinced by emaciation, is seriously 412 THERAPEUTICS OF PHTHISIS. involved, the restoration will require a change of climate, and often a judicious course of tonic medication. 2. Change of Climate—It is not my intention to discuss in this connection the general question of a change of climate in tuberculosis, (that subject being reserved for another place,) but merely its relation to the precursory stage of the disease, Practitioners residing in the interior or middle regions of this country, are divided in opinion as to whether patients laboring under phthisis should be sent north or south; but as these views have referrence mainly to the fully-formed stages of the disease, we are unable to cite authority on the subject of the precursory condition. Nor is it possible to bring statistics to bear on the question; and hence individual observation becomes the principal guide. The influences of a change of climate on persons debilitated with almost any form of chronic disease, are nearly always beneficial, and it is often immaterial whether the climate to which the patient goes possesses any inherent advantages over that whence he came. It is the mere change of atmosphere, diet, and general associations, acting on both body and mind, which modifies the common condition of the system, interrupts the morbid action, and restores the healthful play of the vital powers. Doubtless it is the mind and nerv- ous system which become immediately impressed with the new objects, influences, and associations; and in the absence of decided organic lesions, the activity of the vital powers may be so far improved as to remove functional disorders, and thus avert the tendency of the general derangement to terminate in local disease. Thus far it is almost immaterial what change is made, whether it is to a colder or a warmer climate, provided the general asso- ciations afford the patient the ordinary pleasures and comforts of new scenery and associations. But it can not be doubted that beyond these incidental influences, there are others of a more permanent character, arising from the different elements of climate, such as temperature, moisture, elevation, and so on, which become important in the treatment of tuberculosis. And ‘the principal question which will occupy the mind of the patient TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 413 and physician is, whether a warm or a cold climate shall be sought? whether the mild atmosphere of the South, or the cold of the North, will most certainly change the morbid tendencies of the system, and avert the formation of tubercles? In the United States, the decision will be largely influenced by the geographical position of the parties; if they reside in Northern states, the patient is inevitably sent South; if in the Western, opinion will be divided, some going South, others North. In Europe, I apprehend, most such patients would be directed to the warmer regions. In determining the question of a change of climate in the precursory stage of phthisis, several important considerations are presented for solution, and on which the decision must rest. In the first place, we are to consider the geographical distribu- tion of phthisis, and thereby avoid sending patients to those localities prone to develop the disease. It would assuredly be unwise to send a patient with precursory but unformed phthisis to a country in which the disease was common among the native population; for although a stranger might resist the endemic influences for a limited period, he would ultimately become liable to the natural effects of the climate, particularly if pre- disposed to the disease. The application of this rule to the United States would determine the question in favor of the South, for it has already been shown, by the most extensive researches, and the clearest statistical evidence, that phthisis is three times more common in the Eastern and Northern than in the Southern states, while the Western division holds an intermediate position. Hence, persons residing in the Northern portion will experience favor- able results by removing West, and still greater by a residence in the South; while citizens of the West, instead of going North, should migrate to the South. It must be observed, however, that the preceding remarks have reference exclusively to the winter season, as applied to the South, for it is well known that most of the Southern loca- tions are too insalubrious to permit a Northern or Western man to remain with safety during the summer; besides which, the effects of extreme heat may prove prejudicial in persons 414 THERAPEUTICS OF PHTHISIS. much debilitated by previous disease. In most of the South- ern localities malarial fevers prevail during the summer and autumnal months, and as these diseases would prove seriously detrimental in the precursory stage of phthisis, it becomes im- portant to avoid those localities where they are commonly engendered. The whole South, indeed, is more or less mala- rial; but the extent of its development necessarily varies in different districts, so that comparatively salubrious locations may be found even during the warm season. The main point on which I insist is, that persons threatened with phthisis, residing in the Northern or Western states, should seek a winter residence in the South; and in using this word I mean the southern portion of the United States, the south of Italy, France, or Spain, or even the East Indies. In fact, a ange from a cold to a warm climate, (provided the other ele- ments of climate be favorable,) I hold to be highly important, and often essential as a preventive to the further progress of the morbid action. But it will be readily anticipated that mere elevation of temperature is not the only meteorological condition which exerts an influence over the phthisical constitution; on the contrary, it is equally important that the locality should possess a considerable altitude, and be free from excessive hum- idity. Indeed, nothing is better established by observation, than the injurious effects arising from warm, damp, and low situa- tions, such, for example, as the sea and gulf coasts of the South- ern states. In selecting a proper situation, therefore, in a southern lati- tude of the United States, due reference must be had to the prevailing humidity of the place. It is true, indeed, that the Mississippi Valley becomes more humid as we advance south; but still, great differences will be observed in particular locali- ties. Thus, it can not be doubted that a greater degree of humidity exists along the Gulf coast generally, than in the in- terior and more elevated situations. Thus, the eastern portion of Tennessee, the high pine woods of the Carolinas and Geor- gia, the middle and northern portion of Texas, together with similar positions, afford valuable retreats for those affected with the forming stage of phthisis. There is reason to believe, also, TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 415 that New Mexico, Santa Fé, California, and Oregon possess cli- mates admirably adapted to the precursory stage of phthisis, and are even superior to other regions of the same latitudes. In selecting a Southern latitude with the view of securing the full effects of a change of climate, it is essential that the stay be more than a transient journey, in order that the system may receive the full revolutionizing effect of a warm climate. For this purpose the patient should actually reside South; and with | this view, a location should be selected sufficiently free from the dangers of Southern diseases to enable the patient to remain during the entire year. Or, if this is deemed unsafe, he may retreat North to a convenient and mild point, but should not venture into the cold regions. East Tennessee, in the vicinity of Knoxville, affords an excellent intermediate climate, and will be found valuable for summer or winter. Another important consideration relates to the occupation of the emigrant. The condition of the system demands fresh air, regular out-door exercise, and a generous diet; and it becomes necessary, therefore, that the patient should not be confined to the house, nor should he engage in any pursuit liable to restrict his movements, or expose him to the pernicious influences of night air, humidity, or the intense heat of a midday sun. With these precautions, there can be no doubt that a South- ern residence will prove highly beneficial, and often completely curative, in the precursory stage of phthisis. It is wholly unnecessary to speculate on the modus operandi of a warm atmosphere in these cases; it is sufficient that observation and experience attest the fact that such changes are beneficial, and often arrest the further progress of the disease. Examples have often come under my own observation illustrative of the posi- tion here assumed, and doubtless most practitioners, placed under favorable circumstances for observation, have reached similar conclusions. It is immaterial, therefore, whether we ascribe the beneficial change to the diminished proportion of oxygen contained in the rarefied air; the effects of heat on the surface ; active elimination from the skin; the benefit derived from constant and active out-door exercise; or whether, in still more general terms, we ascribe the beneficial results to the revo- <—7 416 THERAPEUTICS OF PHTHISIS. lutionary influences of a mere change of climote. It may be, indeed, that all these influences are brought to bear on the sys- tem, and each contributes its share to the favorable results; while other unrecognized agencies may aid the curative process, In regulating the sojourn of invalids in the South, we must not disregard their degree of strength, peculiarities of constitu- tion, and other incidental conditions; for it is on these pecul- jarities that the duration of a Southern residence must mainly depend. Thus, if the patients are somewhat debilitated, with a tendency to prostration in warm weather, it would be hazard- ous for such persons to remain during the summer; instead of which they should seek a cooler region as the hot season ap- proaches. This is a point of very great importance to many invalids, and one which can not be disregarded with impunity. If patients laboring under debility attempt to spend the sum- mer south of the southern borders of Kentucky, corresponding ( with the thirty-sixth parallel of north latitade, the relaxing effects of heat will greatly augment the debility, and, not unfre- quently, induce some form of congestive disease, or precipitate the deposition of tubercles. All such invalids should retreat from the South by the middle of April or the first of May, and seek a location in the cool regions of the West and North. Traveling by gradual stages, patients should remain a few weeks in southern Kentucky and Ohio, and finally, early in June, reach a point where the system will be invigorated by a dry and bracing atmosphere. There is probably no portion of the United States which (affords a more congenial summer atmosphere for tuberculous invalids than the great Northwest, embracing especially the ‘Lake Superior region, various portions of Wisconsin and Min- \\. nesota, ranging from the forty-fourth to the forty-eighth degrees \\ of north latitude. The region about St. Paul is probably as salubrious during the summer as any portion of the United States; and as the means of occupation, such as hunting and fishing, offer great attractions to invalids, that locality may con- fidently be recommended as possessing superior advantages. The special characteristics of climate in all this region are, the dry, cool, and bracing atmosphere. It is, also, free from local TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 417 causes of disease, and, therefore, emigrants are in no danger from endemic influences. We can not urge any special objection to the Northern Atlan- tic sea-board during the summer; but I should not feel inclined to recommend it. The want of altitude, the moisture, and variable state of the sea breezes, to say nothing of the endemic prevalence of phthisis, would not indicate it as possessing special advantages. At the same time, a transient visit, rather than pro- tracted sojourn, could not be regarded as particularly objection- able, and might, in some examples, prove eminently serviceable. An invalid, having thus visited the more northern regions during the heat of summer, should again migrate South as the cold season approaches. By adopting this course, the con- stant revolutionizing influence of a change of climate will be secured, and-the patient thereby placed under the most favor- able conditions for ultimate recovery. The comparative duration of a residence in the warm and cool regions must depend on the condition of the patient; if much debilitated, his stay in the invigorating atmosphere should be more protracted, extending, indeed, nearly to the beginning of cold weather; and then, as in the former instance, return to the more genial regions of the South, stopping at intermediate points, as the temperature may indicate. The migratory course here indicated, although introduced especially in relation to debilitated patients, will, in all proba- bility, be found adapted to a majority of cases ; indeed, few Northern or Western persons would bear anything approaching an extreme Southern latitude during the entire summer, while many would find it beneficial to retreat to an intermediate posi- tion, if not to the cool regions of the Northwest. Ina majority of cases, I am inclined to believe, the two extremes will be found preferable; although much must depend on the peculiar conditions, mental and physical, of each individual patient. I desire to qualify, in one other particular, the indications for a change of climate, which is found in the temperament of the patient. There is reason to believe that the bilious temperament will not bear the Southern climate as well as other modifications of constitution ; while, on the contrary, persons of a lymphatic 27 418 THERAPEUTICS OF PHTHISIS. temperament can not endure the effects of cold, but bear well the influences of heat. This latter statement is exemplified in the negro constitution, a race exhibiting the lymphatic consti- tution. It is well known that this race, in the United States, bears the effects of a Southern climate much better than the whites; indeed, the former will remain in good health where the latter perish from the effects of climate. But, on the contrary, the negro is very sensitive to cold, and is, therefore, constitution- ally adapted to a warm climate. It is probable, however, that in the white race, the lymphatic temperament, in consequence of its diminished powers of resistance, is not adapted to either extreme, but that a medium latitude will be most conducive to its healthful action. In relation to the bilious constitution, it has seemed to me very evident that the Southern climate would often promote tuber- cular disease rather than mitigate its progress. In no constitu- tion is the progress of phthisis more certain, and its arrest more difficult, than this; and if such persons be sent to warm regions, the biliary and digestive apparatus become still more impaired, and the constitutional disease advances with even increased rapidity. I regard it as injudicious, therefore, to direct this class of patients to Southern regions, with a view to a protracted , Stay; on the contrary, they should not go beyond the thirty- _ fifth degree of north latitude, embracing portions of Tennessee, \ North Carolina, and Arkansas. And even then, the sojourn should be more brief than in ordinary cases, and the patient should seek the colder regions at a comparatively early period. But there is still another class of patients for whom we must make provision, namely, the residents of the South. The ques- tion arises, Shall those who reside in the South be directed to the tropical regions, with the view of securing a higher degree and more protracted influence of heat? It would be premature and unwise to deny that such a course might not prove judicious and successful. It is, indeed, possible that a native of Louisi- ana or South Carolina might be materially benefited, and even phthisis arrested by a residence at Madras, Senegal, or the Cape of Good Hope; or we may go further, and say that the presump- tion is in favor of the beneficial influence of such a change. TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 419 But, at the same time, it must be remarked that phthisis pre- vails to as small an extent in the Southern portion of the United States as in any of the known tropical regions, and that there is, therefore, less necessity for a change than under the reverse circumstances. Moreover, the patient, already residing in a mild climate, does not experience the evil effects of a rigorous winter. While, therefore, it can not be asserted that the tropics might not prove eminently serviceable, yet it is certain that a more convenient and equally safe course may be adopted. The winters of the Southern states are sufficiently mild to meet the wants of tuberculous patients; and to escape the relaxing effects of summer-heat, and secure the influences of climatic change, such invalids may, with great advantage, seek a Northern resi- dence. Such a change invigorates the system, and induces those common revolutionary effects which legitimately belong to a change of climate. A summer residence in the Northwestern region, already mentioned, will scarcely fail to invigorate the relaxed system, and thereby aid in arresting the progress of phthisis; while the invalid, returning to his native South for the winter, will escape the rigor of the North, which he is so ill-prepared to encounter. 3. Medical Treatment—When the patient can not avail him- self of the advantages arising from a change of climate, or when such an influence seems inadequate to arrest the progress of disease, recourse should be had to a judicious system of medication. The agents which will be found most beneficial in this stage of phthisis are, tonics, (especially the preparations of iron,) cod-liver oil, and alcoholic stimulants. The use of one or all of these articles, or the predominance of either one, must depend on peculiarities of constitution, habits, and idiosyncrasies, But to these must be added the class of alteratives and evacu- ants, in certain constitutions, which will be hereafter named. Tonies.—The agents embraced under the class of tonics are always useful in this as in other stages of phthisis ; and al- though the peculiarities of constitution, and other incidental circumstances, will influence the practitioner in selecting the particular agent, yet, as a rule, the chalybeates are the most important, and, indeed, may be regarded as indispensable. 420 THERAPEUTICS OF PHTHISIS. The preparations of iron which are found most convenient and useful are the phosphate, carbonate, manganate, muriated tincture, citrate, sulphate, and the metallic powder; and among these various preparations there is, in fact, but little choice. For a long-continued use, however, I am inclined to give the preference to the phosphate or carbonate; but it must be con- fessed that the specific influence of iron on the composition of the blood is nearly the same, whatever may be the chemical combination. A very convenient and often useful preparation is what is known in the shops as the compound syrup of the phosphates, the principal constituents being the phosphates of iron, lime, and soda. It contains a large amount of phosphoric acid, which some have regarded as objectionable, if long-con- tinued. A better preparation is what I prescribe under the name of the syrup of iron and lime, which is the compound syrup before alluded to, with which is combined an additional proportion of phosphate of lime, rendered soluble by the use of hydrochloric acid. Six or seven grains of the phosphate of lime may be added to each drachm of the compound syrup, requiring one drop of acid to each grain of lime. Another excellent preparation of iron is the manganate; indeed, there is, in all probability, as strong an indication for the employment of manganese as the iron, and the two combined are, [ think, often more efficacious than either one alone. The preparation which I have generally preferred is the syrup of the manga- hate of iron. The vegetable tonics, especially the preparations of bark, are valuable agents in this condition of the system, and especially so, if there is loss of appetite, or very great debility. They may be given separately, or combined with iron, according to the indications of the case. The bark in substance, the extract, or the compound tincture, are eligible forms for exhibition; or the salts of quinia may be advantageously substituted in certain cases. But, notwithstanding the value of these and other vege- table tonics, they can not, under any circumstances, supersede the chalybeates, although they may be employed at the same time. It is true, indeed, we have not the demonstrative evi- dence of chemical analysis to prove the deterioration of the , TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 421 blood in precursory phthisis; but the general symptoms indi- cate, with the utmost certainty, that the circulating fluid is not in a normal condition, and, therefore, the iron is demanded. And it is immaterial whether the impaired condition of the blood is a primary or secondary change; for, in either event, the chalybeates are equally demanded to restore the blood and prevent further deterioration. The effect of tonics on the system at large is to arrest ema- ciation, and restore vitality to the different functions; and it is by checking this process of decay, (at least in part,) that we can hope to suspend or retard the process of tuberculosis, which is usually associated at an early period with progressive emaciation. The preparations of iron and quinine will be found peculiarly , valuable in retarding the progress of tuberculosis; and, although / it is perhaps useless, if not obtrusive, to speculate on the modus operandi of these agents, yet I may be permitted to say, it is evident that their therapeutical influences are exerted on the blood and the functions of the nervous system. We are igno- rant of the exact agency of the nervous system in the develop- ment of tuberculosis; but some eminent pathologists conceive that the disease originates from derangements of this function, and hence the necessity for employing suitable remedies for its restoration. Indeed, the intimate relationship of the nervous system to secondary assimilation and to the metamorphosis of the tissues, strongly indicates the implication of that function in the initial stage of tuberculosis. But, without basing the indication exclusively on this theoretical view, the more con- vincing proof of clinical observation has taught me that quinine is a valuable agent in the forming stage of phthisis ; it improves the tone of the nervous system, imparts new vigor to the cap- illary circulation, and thus improves the general aspect of the patient. It is important, however, to observe, that quinine should be given in small doses, at least such as exercise merely a sustaining influence, instead of exciting or disturbing the equilibrium of the nervous function; for, if an undue impres- sion is produced, the nervous system will become deranged, and serious injury may ensue. The salt which I prefer is the mu- riate; and I think the observation is correct, that it is better 422 é THERAPEUTICS OF PHTHISIS. borne than the sulphate. One grain I regard as a medium dose, repeated three times a day. It may conveniently be com- bined in the following manner: BR Quin. Mur, Ferri puly. 44 Dj. Sulphur sub. Dij. M. Ft, pil. xx. One pill to be given three times a day. Cod-liver Oil.—The high reputation attained by cod-liver oil in the treatment of tuberculosis, in all its stages, will sufficiently indicate its use in the initial or forming period. If, indeed, this unctuous remedy is capable of exercising any beneficial in- fluence over the progress of phthisis, its curative effects must be more conspicuous at an early than a late period; and, indeed, os the moment that a loss of weight is clearly evident, a nutri- ive agent, such as cod-liver oil is known to be, would, neces- sarily, become a valuable remedy. I shall not speculate, at this time, on the manner in which it operates in the precursory stage of phthisis; but the fact that it is a nutritive article, and that one of the earliest symptoms of tuberculosis is emaciation, affords a solution, at least in part, of its therapeutical action. “Hence, the indication for the employment of the oil consists in the evidences of emaciation; and its beneficial effects will be found pretty nearly proportioned to the loss of weight. And I may here remark, that there is an obvious difference in organ- isms as to the facility with which absorption of the tissues (metamorphosis) takes place; there is, indeed, in some constitu- tions, so to speak, a loose combination of elements, so that the vital affinity is easily impaired, absorption rapidly occurs, and emaciation is the necessary result. In some such constitutions (the phlegmatic, for example) iron and quinine will exercise an important influence in arresting the decay; but, in many ex- amples, a nutritive agent which will supply the carbonaceous element is strongly demanded, and in such cases the cod-liver oil becomes a valuable adjuvant to the tonic remedies. Alone, » and independent of tonics and stimulants, its influence is much \ less than when given in connection with those agents; indeed, TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 423 it supplies but a single indication, which will often fall short of meeting the demands of the case. If the vital powers are greatly depressed, it will be in vain that we attempt to fatten the patient by crowding the stomach with a crude and nauseous oil; for, under these circumstances, the appetite for all other food (the nitrogenized elements) will be superseded by the car- bonaceous substance; and while the adipose deposits are actually increased, the general tissues will continue to waste, and the patient may pass into a tubercular condition while the process of fattening is going forward. There is no evidence, clinical or chemical, to prove that the morbid tendency in the precursory stage is due to the absence of fats; and if this is not a primary condition, saturating the system with oil will not be found adequate to arrest the morbid action. On the contrary, if the ulterior changes are taking place in the solids and fluids of the body generally, and emaciation and loss of fats occur as a secondary lesion, the former condition is that which furnishes the true indication for treatment, while the latter, although im- portant, is incidental and secondary. When the cod-liver oil is resorted to, it should be adminis- tered in about half-ounce portions, from a half to two hours after meals, and may be conveniently exhibited in ale, or any similar vehicle. The period of its administration is not a mat- ter of indifference. It should never be given when the stomach is empty; but the length of time after meals will vary in differ- ent cases. Some will bear it better almost immediately after eating, say half an hour; while, in other cases, it will digest better one or two hours after meals. Something depends on the quantity eaten; if the meal is very light, the oil may be taken within half an hour after eating; when the meal has been of medium amount, an hour will be the most eligible period; but if the person eats a hearty meal, two hours will usually be found the best time to administer oil. In relation to this point, the rapidity of digestion will exercise no small influence; and hence each patient must decide, after repeatedly varying the time, whether half an hour, one, or two hours will be for him the appropriate period. The experience of most - 424 THERAPEUTICS OF PHTHISIS. patients proves that ale is by far the best agent to cover the ' taste of the oil. A table-spoonful of ale, in a wine-glass, on which the oil is poured, completely covers the disagreeable taste, and few patients object to it. It may be given in con- nection with iron, when that tonic is required; or, if there be much chilliness, quinia may be dissolved in the oil, and which will act as a valuable tonic and antiperiodic. The following formula will be found useful when iron is desirable: BR Ol Morrhue Oj. Ferri Phos. 3ij. M. A table-spoonful to be taken three times a day. The oil is contra-indicated when there exist loss of appetite, \. gastric irritation, constipation, headache, and, according to my * observations, in bilious states of the system. If any of these conditions exist, they must be removed before the oil can be advantageously administered. In addition to this, I think the cod-liver oil is comparatively inefficient in the bilious constitu- tion; or it must be associated with the use of evacuants, such (as pil. hydrag., in order to secure any good results. When the oil is ill-borne, or is absolutely offensive to the stomach, there will be little advantage in persevering in its administration ; in- deed, there seems to be often an indication furnished by nature when the article is inappropriate, very much in the same man- ner that the appetite regulates the administration of ordinary articles of diet. Alcoholic Stimulants—The employment of alcoholic’ stimu- lants, in the different stages of phthisis, has gained considerable - favor with many practitioners, and is usually readily assented to by patients. It is somewhat difficult to estimate the value of stimulants in this disease in consequence of the irregular manner of their administration, and the disregard of the stages of the affection in which they are given. As a general rule, they are employed indiscriminately throughout the entire course of the disease, and without regard to the peculiarities of con- stitutions or temperaments; and, what is still more important, without any rules as to quantities or effects. The quantity TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 425 administered, and the frequency of repetition, are often left to the caprice of the patient, and, therefore, subject to the greatest irregularities and the most uncertain results. The observations which I have been able to make on this subject have resulted in the conviction that alcoholic stimu- lants are useful, in certain constitutions, in the forming stage of phthisis; and the presumption is, that their beneficial (cura- tive) effects are nearly, if not quite, limited to this early period of the disease. It is unnecessary in this place to enter largely into the effects of alcoholic stimulants in a general sense, further than to remark that they improve digestion, and thus enable the patient to take a larger quantity of nutriment; and beyond this, they augment capillary circulation, excite the nervous system, and thus improve both primary and secondary assimilation. And there is probably beyond these mere stimulating effects an ulterior action produced on the blood; the carbonaceous element is increased, and the transformations of the tissues (emaciation) diminished, and thus the tuberculous process is more or less arrested. The form in which the alcoholic preparations should be ad- ministered will depend on the constitutional peculiarities, tastes, and habits of the patient. Some will be most benefited by the malt liquors, others by wine, brandy, or whisky. Ale and porter, being a dilute form of alchohol, mixed with nutritious and tonic elements, are peculiarly appropriate, and will gener- — ally promote digestion, increase the deposit of fat, and improve / the general strength. When distilled spirits are employed, whisky, brandy, gin, etc., may be selected; but, as a general rule, I am inclined to give the preference to whisky, although © , the constitutional peculiarities, and, to some extent, the taste of the patient must be consulted. Whisky appears to act more on the secretions than brandy, and on this account is prefer- able; it promotes elimination by the urinary and cutaneous organs while it acts mildly as a general stimulant. In ee purely phlegmatic temperament, the brandy being more heat- producing in its effects, may be preferable; but in the sanguin- eous and nervous constitutions, where less excitation is required, the whisky should be preferred. In some portions of the United / 426 THERAPEUTICS OF PHTHISIS. States a domestic brandy distilled from apples has been used, and patients have often assured me that its effects were better than other liquors. But, independent of the differences in the effects of brandy and whisky, there is a strong reason why the latter should generally be preferred, namely: the difficulty of procuring the former in a state of purity. The “old Bourbon whisky,” and old rye, can certainly be procured in a pure state; but it is exceedingly difficult to obtain brandy which is not entirely factitious. In some cases wines will be found preferable to either malt (or distilled liquors; this will be particularly observed in females or persons of delicate tastes and nervous constitutions. The sharp stimulus of distilled spirits acts with too much intensity, while malt liquors are not only offensive to the taste, but oppress- ive to the stomach. Under these circumstances, Sherry, Port, and Madeira wines will be found preferable. But few persons will bear the acidity of our native Catawba wine, and although I have known it advantageously employed, it is not generally to be recommended. But we must not overlook the important fact that there are certain conditions which contra-indicate the use of stimulants. , Among these may be enumerated gastric irritation, inflamma- i tory condition of the fauces or larynx, derangement of the liver, bilious temperament, and great excitability of the nerv- ‘ous system. Where either of these conditions exist, the stimu- lants will aggravate the morbid action rather than promote the healthy functions. I have often observed that when the ( peculiar irritation of the throat existed, the laryngeal cough -would be aggravated by stimulants, and thus the disease would be made rapidly to advance. In all such examples I have found it expedient to withhold alcoholic stimulants, and depend on unirritating tonics to sustain the system. Again, the bilious . temperament and biliary derangements are conditions inappro- * priate for the administration of stimulants, and demand at least preparatory or corrective treatment. Nor will the nervous sys- tem, when greatly excited, bear the effects of stimulants with impunity, and if administered, they must be in mild forms and small quantities. Finally, it may confidently be stated that _= TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 427 stimulants are most beneficial in the phlegmatic temperament, and least so in the bilious, and that the effects will proportion- ally vary as one or the other of these constitutions predominates. The choice of stimulants as based on temperaments should not be disregarded, for in this respect there are some practical points worthy of attention. Thus, malt liquors will be best: adapted to the sanguineous temperament, ardent spirits to the | w lymphatic, while wines are often the most appropriate for the. nervous constitution. With these limitations and regulations there can be no question as to the beneficial influence of the moderate use of stimulants in the forming stage of phthisis; but the excesses into which persons habitually taking ardent spirits are liable to fall can never prove beneficial, but are always injurious. This is one of the evils attending the stimulating mode of treatment; the habit of taking alcoholic drinks is apt to in- crease until it becomes ungovernable, and thus serious evils arise. But this can not be regarded as a legitimate argument against the employment of stimulants; on the contrary, it is the duty of the enlightened physician to advise such remedies as are best calculated to remove the disease, and the remainder must be committed to the discretion and moral firmness of the patient. The employment of evacuants in the forming stage of phthi- sis is an important, but not well-determined question, in the therapeutics of that stage of the disease. In ordinary cases, patients do not seem to demand the use of cathartics, emetics, or sudorifics; but when the functions become impaired, either accidentally or by the natural progress of the disease, it is im- portant to remove the obstruction as promptly and completely as possible. But the evacuant mode of treatment, either by emetics or cathartics, carried to an extent that would cause general debility, must necessarily prove indirectly prejudicial, and consequently that method is inapplicable to ordinary cases. Tt has been remarked in relation to those cases in which the digestive organs are in good condition, as evinced by a clean tongue, regular bowels, and normal digestion, evacuants are but little required; but there are certain abnormal conditions 428 THERAPEUTICS OF PHTHISIS. in which the assimilative organs become torpid, and the process of elimination through the skin, liver, and kidneys is greatly impaired. There can be no doubt that these conditions demand evacuant treatment, such as cathartics, emetics, diuretics, and sudorifics; and without the preliminary regulation of these im- portant emunctories, neither stimulants nor tonics will produce their usual beneficial effects, but may add to the functional derangements. But it is important to observe that during the admini$tration of evacuants, we must carefully avoid debilita- ting the system, and they should be so regulated as to produce the necessary influence in the mildest manner, and without in- ducing any considerable perturbation in the system. Indeed, tuberculosis is not to be arrested by active or heroic medica- tion; on the contrary, the remedies must act slowly, regularly, and continuously, on the organism. Perseverance becomes, as in many other diseases, a cardinal virtue; while rashness is in- appropriate and always to be deprecated. As a special indication in relation to the evacuant treatment, the function of the cutaneous surface demands particular atten- tion. The diminution of this function is always prejudicial in the forming stage of phthisis, and its due regulation is import- ant in every attempt to arrest the disease. To maintain a due action of the skin, the most appropriate conditions will be found in a warm atmosphere, (as in Southern latitudes,) proper protec- tion by means of clothing, internal diaphoretics, and the warm / bath. The latter is often highly serviceable, and it should be resorted to every evening, with friction until the surface is properly excited. Occasionally the addition of salt will prove valuable by rendering the bath more stimulative; or, the free use of soap will often be sufficient or even preferable. Even active sweating by means of the vapor-bath, (water or alcohol —the latter being preferable,) will produce in some constitutions the most valuable results; and as this method is less debilita- ting than the more active evacuants, it is on that account the more important. During the precursory stage of phthisis, active hemorrhage, as already explained, is liable to occur, and I deem it of the utmost importance to treat such cases in the most prompt and TREATMENT OF THE PRECURSORY STAGE OF PHTHISIS. 429 judicious manner. If any great degree of vascular excitement is present, a moderate amount of blood should be abstracted by means of cups; or if no increased force of the circulation takes place, dry cups will be sufficient. The administration of as- tringents is less important; nevertheless, if the hemorrhage is considerable, common salt, which is one of the safest and best agents, will usually arrest it; or acetate of lead, gallic acid, and similar agents may be used. But the great practical point to which I desire especially to draw attention is to obviate conges- tion, and to prevent the secondary effects of the hemorrhage. And by the secondary effects I mean a morbid excitement in the pulmonary structures which are so liable to induce tuber- culous exudations. Hence, following such hemorrhages, I would, strongly advise continued contra-irritation, by means of dry ) cups, blisters, and pustulation. These agents should be con+ tinued until all evidences of morbid action cease; and, indeed, where the signs of local disease are slight, or even inapprecia- ble, I would still insist on some degree of contra-irritation, for there is nearly always an insidious local action which may be- come the nidus of tubercular deposits. In addition to counter- irritants, expectorants are useful, and among these none will be found better than equal parts of syrup of squills and senega. ~ I believe, also, that the iodide of sodium, dissolved in the fluid extract of sarsaparilla, is beneficial in aiding the removal of sanguineous remains in these cases. But while we are bestowing so much attention on the con- stitutional symptoms, it becomes equally important to address remedies to the local affection developed in the throat. As already intimated, the condition of the throat is often the key to the pathological condition of the system, and it is equally im- portant in a therapeutical point of view. The course of treat- ment should embrace the application of the nitrate of silver, preparations of iodine, and excision of the tonsils. The removal of a portion of the tonsils is particularly insisted on by Dr. Green; and, according to his extensive observations, great benefit is derived from this measure. When these glands are found se- ereting morbid material, and exhibiting diseased action through- out their substance, I am satisfied that great benefit will be G3 ee f 430 THERAPEUTICS OF PHTHISIS. derived from the excision of the diseased portion. Following this operation, the employment of the local applications pre- viously named should be continued, together with the consti- tutional treatment. SECTION II. TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. The stage of tubercular deposits is properly divisible into three periods: solid deposits ; softening ; excavations ; and, although these several conditions are but progressive stages of the same morbid process, yet the extension of the lesion, together with the inci- dental affections which usually arise, render these stages so widely different, both in regard to the local affections and constitu- tional derangements, as to require modified methods of treat- ment. Without this discrimination, all treatment must become - empirical, and every effort at cure will be based on vague analo- gies or deceptive observations. It is true, indeed, that there is a common constitutional disease which runs through all the stages of tuberculosis, and a specific morbid element which is manifested in every period of the affection; but the modifica- tions induced by the occurrence of tubercular deposits in the ' pulmonary structures, of softening, and, finally, of excavations, are too manifest to be disregarded by the enlightened patholo- gist and discriminating therapeutist. The treatment of tuberculosis, after the occurrence of local deposits, and anterior to softening, involves the greatest diffi- culties connected with the whole subject, and requires the most careful attention to the different phases of morbid action, both general and local. Thus, the early period of the stage of solid tubercle still affords hopes that the morbid action may be ar- rested, the exudations absorbed or rendered inactive, and the disease thus arrested in its forming stage. The practitioner should keep in view the pathological laws governing tubercular deposits, and the possibility of retrograde action on the one TREATMENT OF THE STAGE OF TUBERCULAR DEPosits. 431 hand, and on the other, the absolute certainty of softening when it has reached a certain point. It is doubtless true that, in the earliest stage, when the constitutional disease is of mod- erate intensity, or has been mitigated by treatment, and when corresponding to this, the exudations are neither numerous nor extensive, the whole morbid process may be arrested, the tuber- cular matter liquefied and absorbed without elimination, inflam- mation, or ulceration. Or, again, the tubercles may undergo a retrogressive action, and thus remain permanently inert. This is the pathological view, and the therapeutical question arises, What course of treatment affords the greatest probabilities of fulfilling these indications. Advancing beyond this early stage of local disease, and this mild constitutional tuberculosis, we encounter a condition in every sense more profound; the general system becomes more deranged, the exudations ingrease in amount, and softening, with elimination, becomes inevitable. It would be perfectly futile to attempt to render tubercle stationary or inert under these circumstances, and the therapeutical indications, therefore, are to restrict, as far as possible, further deposits, to prevent, during the process of softening, inflammatory exudations into the pulmonary tissues, and thus to secure the elimination with- out extensive local lesions. There is an extent of morbid action in the pulmonary tissues which can not be repaired; and the object of treatment is to limit the local disease, and thus prevent the fatal degree being attained. Hence, the indications in the treatment of tubercular deposits are, first, to suspend the constitutional disease, and render the tubercular deposits inert; or, if the disease has gone too far to admit of the tuber- cles becoming absorbed or rendered inert, the second indication is to limit the morbid action, and keep it within curable bounds. The general indication is to suspend the whole tuberculous pro- cess, and to render the deposits inert. The condition which we are called on to remedy, in fulfilling this indication, consists ina medium degree of general tuberculosis, and of deposits in the pul- monary tissues. So far as pathology has thrown light on this sub- ject, the morbid changes are embraced in a faulty metamorphosis of 432 THERAPEUTICS OF PHTHISIS. the tissue, (secondary assimilation,) inducing deranged blood, innervation, and secretion, with the ultimate exudation of tuber- cular material in the pulmonary structures. The deposit of tubercles in the lungs is not necessarily caused by any appre- ciable degree of vascular or nervous excitement, nor do they, in this stage, act as foreign bodies so as to induce morbid action in the adjacent tissues. And the tubercles themselves are so constituted that, in certain conditions, they may remain station- ary, or even slightly contract, and thus become entirely inert bodies. The two conditions, therefore, which require to be changed, are the constitutional tuberculosis and the exudations im the pulmonary tissues—the first to be entirely suspended, and the other rendered stationary or inert. It is abundantly evident that so long as the tubercular elements are formed in the general system, the pulmonary exudations will continue to augment, and hence no method of local medication, applied immediately _ to the respiratory organs, can be sufficient to remove or arrest the disease. But, while the constitution is being modified and the formation of tuberculous matter arrested, the pulmonary deposits may, at the same time, be fenprested either by the remedies which affect the whole system, or by the additional agents employed for that particular purpose. The advantages of a change of climate in this stage of phthisis, although less marked than in the forming period, are still very great, and every patient should be permitted to enjoy the bene- ficial influences of a new residence. The question as to the temperature and other qualifying conditions, is obviously im- portant; but what has already been stated, in reference to the forming stage, will apply with equal force to this more advanced condition. I am satisfied that, as a general rule, patients will receive more benefit by changing to a warmer than a colder atmosphere ; and if no other reason could be assigned, the simple fact would be sufficient that the powers of resistance in tubercu- lous subjects are materially impaired, and, therefore, they require a milder instead of a more rigorous atmosphere. The general impression that a cold atmosphere is invigorating, and a warm one relaxing, is true as an independent proposition; but, in considering the effects of climate on the tuberculous constitu- TREATMENT OF THE STAGE OF TUBERCULAR DEPOSIts, 433 tion, we must extend our view far beyond this mere elementary influence of heat and cold. The effects of cold under these circumstances may be well compared to the action of a cold bath, the result depending mainly on the duration of the application. Thus, a cold shower bath, or even a plunge, of momentary duration, will be fol- lowed by a healthy reaction, and an improvement of the tone of the general system; but if the application is protracted, the system becomes chilled, the equilibrium of the functions is im- paired, and the person will be proportionally injured. And the same rules will apply, on a more extended and complex scale, to the effects of a rigorous climate on the tuberculous consti- tution. A temporary sojourn in a cold climate might produce’ a favorable reaction in persons whose vital powers have been_- impaired by the tuberculous process; but a protracted residence in Northern latitudes can hardly fail to act unfavorably on a system the vitality of which is already depressed. Under such influences the vital actions are disturbed, pulmonary conges- tions and inflammations supervene, and thus the local disease augments with ‘great rapidity. If a tuberculous patient should, for example, remove from the thirty-eighth to the forty-fourth parallel of north latitude, the rigorous character of the climate would necessarily prevent much out-door exercise, and the con- sequences of being confined to the heated rooms of a dwelling could hardly fail to prove pernicious. On the contrary, the influences of a medium Southern climate would prove in every respect genial, and the constitution would readily undergo those important changes which are necessary | to arrest the tuberculous process. If the climate is moderately | dry, with a medium degree of heat, the capillary circulation i becomes invigorated, the cutaneous function is rendered active, * and, in the absence of extreme perturbations of the atmosphere, the equilibrium is duly maintained. The patient is able to enjoy a large amount of out-door exercise, and thus avoid the evil consequences of confinement'and want of fresh air; while the climatic influences already referred to are producing import- ant changes in the constitution. = But independent of a change of climate, or in addition to 28 8 434 THERAPEUTICS OF PHTHISIS. that influence, patients in the second stage of phthisis impera- tively demand appropriate and well-regulated medical treatment. It is no longer a condition in which the conservative powers of nature are competent to arrest the morbid action, but it - becomes necessary to interpose suitable medicinal agents, the action of which is to suspend the progress of tuberculization. The morbid action which pervades the system in tuberculosis evinces a natural tendency to augment, and hence the impera- tive necessity for the intervention of art. The pathological condition which is to be remedied in this stage consists not alone in the predisposition, but also in the actual formation of tubercular matter; and the indications are to arrest the evolution of the morbid material, and prevent its deposition in the pulmonary tissues. In accordance with the views previously expressed, the morbid action which gives rise to tuberculous matter is connected with the metamorphosis of the tissues of the body; it is not, therefore, a primary lesion of the digestive function, nor of the blood; but is intimately associated with those ulterior changes which take place in the continued evolutions of the organic structures. It may be termed a perverted metamorphosis of the tissues; and the chief object of treatment is to alter this perverted action and restore it to a normal state. There are different degrees of emaciation in the early stage of phthisis which furnish indications for treatment; thus, in some examples, the loss of weight is slight, and the tubercular deposits proportionally limited, while in others these changes are remarkably rapid. It is true these are but degrees of the same morbid condition, but still the variations are too import- ant to be overlooked, and often, in fact, become the basis of treatment. Leaying out of view, however, this particular symp- tom, we may, in a general sense, reduce the indications of treatment to three heads: 1. To arrest the evolution of ele- mentary tuberculous material; 2. To promote its elimination; and, 3. To induce absorption. 1. To arrest the evolution of tuberculous material.—It is not known that we possess any specific agent which is capable of arresting the development of the elementary tuberculous mat- a TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 435 ter, notwithstanding professional and non-professional attention has been so strongly directed toward that object. But it is equally true that many supposed specifics have been discovered, among which may be mentioned cod-liver oil and iodine, to say sate of the numerous vegetable substances which have been elieved to exercise specific effects over the tuberculous condi- tion. It can not have escaped observation that many of these agents are employed precisely as though their specific virtues had been fully established, and that they could be relied on with certainty in every stage, form, and modification of the disease. Such, indeed, is the mode in which cod-liver oil is now employed; it is given in every stage of the disease, re- gardless of the true indications for its administration, or the evil consequences liable to ensue from its indiscriminate use. But if there is any value in pathological knowledge, or any _ scientific basis for therapeutics, we must adapt the remedy to _) the stage of the disease, and select an agent in accordance with its demonstrable effects on particular morbid conditions. Finding, therefore, no specifics in our materia medica, we must endeavor by less direct, but more philosophical, means to attain the desired object; and, as the transformation of the tissues is directly coucerned in the tuberculous process, we will naturally direct our attention first to the morbid metamorphosis which is evinced by the incipient emaciation. The agents which, a fortiori, may be presumed to be capable of arresting ) this process are the stimulants, tonics, nutrients, and, we might_) add, alteratives. But the morbid process being a complex one, some discrimination is necessary in the selection of the agents, for we have not only to remedy the change in the tissues, but must also give attention to the local deposits. Alcoholic stimulants possess the power in this as well as the preceding stage, of modifying materially the metamorphosis of the tissues, and of arresting, more or less completely, the process of emaciation. The hydro-carbon of the alcohol Sea ea modifies, in a most marked manner, the blood, and, through it, the nutrition of the tissues; fatty elements accumulate, the pro- cess of decay is checked, and the weight of the body increased. These are results of the greatest consequence in the tuberculous 436 THERAPEUTICS OF PHTHISIS. condition, and serve essentially to check the formation of the morbid tiaterial, The preparations of iron, cod-liver oil, qui- iF nine, and the tonics generally, aid in producing the same result, “and thus contribute to the arrest of the tuberculous process, Cod-liver oil, as previously stated, possesses fattening properties, and therefora checks emaciation. Iron sustains the richness of { the corpuscular element of the blood, and, through that fluid, \ assists in subduing the morbid state connected with phthisis; or, if it does not directly arrest the tuberculous process, it prevents the blood becoming impoverished, and thus wards off a con- dition which could not fail to prove seriously detrimental while tuberculous matter is being formed. The iron treatment, in- deed, may be regarded as an essential part of the therapeutics of tuberculosis ; it is adapted to nearly every form and condition of the disease, and its omission must always lead to a deteriora- tion of the blood. It is true that so long as primary digestion is well sustained, and nutritious food, together with cod-liver oil and similar agents, can be administered, the blood will be maintained in a condition approximating health; but, at the ‘same time, the agency of the iron is more direct and substantial, and, therefore, should never be omitted. The influence of quinine in this stage of the disease is of the greatest importance. It evidently acts differently from either of the articles previously named, and fulfills an indication not met by either alcohol, iron, or cod-liver oil. Without entering into any speculative views in relation to the effects of quinine, it may be briefly stated that it evidently acts on the nervous ( system, and thereby promotes digestion, circulation, and secre- tion. It is, in fact, a neuro-tonic medicine, and can not fail to exercise a beneficial influence over the deranged state of secondary assimilation, which prevails in tuberculosis. Besides this, the use of quinine will prevent the occurrence of chills, a symptom quite common in all the stages of phthisis, and always productive of serious injury and great inconvenience to the patient. Thus, quinine may be regarded as an important agent in the tuberculous constitution, both on account of its cesential influence in that condition, and also its agency in preventing the occurrence of chills. TREATMENT OF THE STAGE OF TUBERCULAR DEPOSIT’. 437 My own observations have fully convinced me that the nerv- ous system is too much neglected in the treatment of phthisis. The investigations of chemists have drawn attention so forcibly to the condition of the fluids, that the agency of the nervous system is almost wholly neglected, both in regard to patho- logical changes and therapeutical indications. It is true we are not able to locate the evolution of tubercle in any known derangement of the organic system of nerves, and, therefore, can not, like Dr. Copland, adopt the nervous theory of the disease; but, at the same time, it is beyond question that an intimate relationship exists between the capillary circulation, nutrition, and innervation, and that the latter function is always impaired, either as a primary or secondary state, where lesions of the former exist. Hence, it is obvious, that in estimating the ultimate derangements of secondary assimilation, the nerv- ous influence must not be overlooked; and, on the other hand, in adapting our remedies to morbid conditions, we must not depend alone on hamatics, but should likewise employ the nerve-tonics. If the deterioration of the blood is not idio- pathic, but depends on anterior changes in the vitality of the system, it will be in vain that we address remedies exclusively to that fluid; but we must proceed a step further, and endeavor to improve the nerve-power, as the great vital excitant, and through that agency arrest morbid action and restore assimila- tion to its normal condition. There are other nerve-tonics besides quinine which may be advantageously employed in certain constitutions and condi- tions, among which are strychnine, Indian hemp, and perhaps electricity. These agents excite nervous action, and may there- fore prove beneficial in states of depression of this function. I have thought benefit has resulted from a combination of qui- nine and Indian hemp, in the following proportions: KR Quin. Mur. Dj. Ext. Canab. Ind. grs. v. M. Ft. pil. xx. One pill to be taken three times a day. Another formula which has proved serviceable, in the early 438 THERAPEUTICS OF PHTHISIS. stages of deposits, is a combination of the fluid extract of cimi- cifuga and strychnine, according to the following formula: R Fluid ext. Cimicifuga, Syr. Prun. Virgin. 44 3ij. Hall’s Sol. Acet. Strych. Zij. M. Take a tea-spoonful three times a day. The exact effect of the cimicifuga (acteea racemosa) is not cer- tain; but it appears to act on the bronchial mucous membrane, and also decidedly on the nervous system—a combination of powers which may prove valuable in incipient tubercular depos- its. Many years ago, Dr. Hildreth, of Marietta, Ohio, drew attention to this agent in the treatment of the early stage of phthisis; and, although the observations which have been made since that time have not been numerous or accurate, there has been, nevertheless, some additional testimony recorded. My own use of the cimicifuga has been extensive, and my testimony is certainly in its favor. I sometimes combine it with iodine, in the manner to be mentioned hereafter, and as originally pro- posed by Dr. Hildreth. Finally, the medicinal agents which have been found most serviceable in arresting the evolution of tubercle, are cod-liver ( oil, alcoholic drinks, quinine, and iron. The proper combina- tion of these agents must depend on the condition of the patient. The hygienic treatment of this first stage of phthisis is of the utmost importance ; indeed, without a proper regulation of diet, exercise, climatic influences, and other conditions capable of affecting the vital actions, mere medication will usually prove unavailing. The following heads will embrace the subject of hygiene in its relation to this stage of tuberculosis: 1. Diet. 2. Clothing. 8. Exercise. 4. Conditions of the atmosphere. 1. Diet——The importance of a due regulation of the diet,:in a disease which essentially involves the nutritive functions, can admit of no doubt, but there may be differences of opinion in regard to the classes of food best adapted to consumptives. Regarding the subject of diet in its general physiological aspects, we would necessarily conclude that food of a highly nutritious TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 439 quality is demanded in the tuberculous condition, and especially so as the nutritive function appears to become weakened. This proposition may be mainly true, and yet, I am inclined .to believe, it requires to be carefully considered, if not materially modified in this disease. The two great objects of nutrition are to sustain the tissues, and to develop animal heat, which are accomplished by different classes of food. Hence it is requisite, not only in this, but all conditions of the system, to furnish proper proportions of nitrogenous and carbonaceous food; but it can scarcely be doubted that, in pathological conditions, the proportions of these elements of food must be considerably varied from the physiological state. Without entering into the minute doc- trines of the subject, I may remark that the presence of oxygen, carbon, and hydrogen in the system, bear a very direct relation- ship to the metamorphosis of the tissues; when physiologically balanced, the atomic changes will be so regulated that emacia- tion will not occur, but if the oxygen is either positively or \ relatively increased, the carbon must be rapidly echeured transformation becomes active, and emaciation is the result. And it must be borne in mind that the tuberculous material is evolved during the metamorphosis of the tissues, which is, indeed, a perverted act, connected with their ultimate changes. Tn the tuberculous state there is, as I believe, always a perverted metamorphosis, which is evinced by varying degrees of emacia- tion; but it is true that, in the incipient stage, the change is often so slight as to be scarcely appreciable, and hence it is a state of perversion rather than of active reduction. Now, it is generally believed that this emaciation demands nitrogenous food to supply materials for the wasting tissues, and hence ani- mal substances, in large quantities, are forced on tuberculous patients; in other words, they are enjoined to make beefsteak and other meats the basis of their diet. But there is reason to believe there may be a serious error at the very foundation of this doctrine. Our object, in these examples of disease, is to check the perverted transformation, which could hardly be accom- plished by crowding into the system large proportions of nitro- genous elements of food. It would appear, indeed, that there 440 THERAPEUTICS OF PHTHISIS. is diminished resistance and perverted action; and, although I would not attempt to argue the question in detail, yet it appears that, in these examples of diminished resistance, the oxygen, which may be called the liquefying element, gains the ascend- ency, and thus its effects become morbidly active. Hence, instead of crowding the system with nitrogenized food, espe- cially designed to develop tissues, it seems more rational to employ the carbonaceous class, or, at least, those substances which are rich in carbon, and which are calculated to protect the system from the excessive action of oxygen. According to this view, vegetable rather than animal food should be the basis of the diet of tuberculous patients, while at the same time ani- mal food is, to a certain extent, desirable, especially such as contain fats. If the cohesive powers of the tissues be weak- ened, and the molecules tend to separation, it would appear unwise to crowd the nitrogenous substances into the system, the elements of which can scarcely admit of proper assimilation. I do not mean, by these remarks, to interdict animal diet, but merely to indicate, that large quantities of nitrogenized food do not appear best adapted to the tuberculous condition, and that the non-nitrogenized should be made the basis. Hence, “animal food, in which fats predominate, the various vegetables, Gea potatoes, wheat-bread, rice, etc., become more appro- riate than a predominance of lean animal food. The system is thus protected by the carbon, while undue quantities of protein- compounds are not forced into the tissues. But it is equally necessary to observe that the quantity is not less important than the quality. When the powers of as- similation are weakened, it is highly improper to attempt the introduction into the system of a large quantity of nutritive ele- ments; for it is abundantly evident that the nutritive powers having become impaired, the ordinary quantity of food can not be assimilated, and hence the superabundance must be rejected as effete. In this way, in the forcible language of Dr. James Henry Bennett, the system becomes poisoned. But by employ- ing, in a somewhat restricted manner, the nitrogenized class of food, and thus permitting the non-nitrogenized to predominate, and at the same time carefully regulating the quantity, it will TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 441 result, that the tissues will be reduced to a condition in which the metamorphosis will more nearly approach a normal state, and in this way the evolution of tuberculous matter may be suspended. There is some reason to believe that a milk diet, containing farinaceous substances, such as arrow-root, may be highly beneficial in certain cases, especially when the digestive powers are weak. I need scarcely remark, that the diet must be varied with the climate and the season, condition of the patient, and form or character of the disease. Warm climates” and seasons demand less carbon than the cold ones, and hence a variation should be made even during winter and summer. Again, if the patient is able to take active exercise in the open air, his diet may be more liberal; but when his exercise is limited, it is impossible that he can with impunity consume large quantities of food. Other modifications should be made when the digestive system is feeble or irritable. In either con- dition, the food must be of the most digestible character, free from irritating qualities, and mostly liquid. The quantity should never exceed that which can be readily digested ; it is far better, indeed, to submit a small amount of nourishing food to com- plete. gastric solution, than to crowd the stomach with a larger quantity, and suffer the consequences of incomplete digestion. Sir James Clark expresses the opinion that injury is often done by administering too much stimulating food, and there is doubtless truth in the opinion; but the qualifying circumstances will usually be sufficient to guide the practitioner. Thus, as observed by Dr. Copeland, when there is debility, a stimulating regimen may be adopted; but if a plethoric condition is pres- ent, with a tendency to congestion, the diet should be light ) and farinaceous. But in all cases, I repeat, over-feeding is im- proper, and often results in serious injury to the patient. | Most certainly, if an inflammatory condition is present, the diet should) not be full and stimulating, nor will it be proper in such exam- ples to permit the use of alcoholic drinks. I would remark further, that tubercular patients require a change of diet, although the same class of articles may be employed. The system soon becomes accustomed to a given form of diet, and the ap- petite fails under their continuance, so that a modification is 442 THERAPEUTICS OF PHTHISIS. frequently demanded, in order to preserve the nutritive function in a healthy condition. As to the particular articles, much will depend on the peculiarities of individual cases, but the follow- ing may be accepted as embracing, in the several classes, the varieties most appropriate. Animal Food.—Beef, mutton, venison, birds and chickens, fish, oysters. Vegetables.—Potatoes, rice, wheat-bread, (made light with yeast,) corn-bread, tomatoes, turnips, etc. These articles must be regulated according to the idiosyncrasies of patients, the state of the alimentary canal, the stage and con- dition of the local disease, and the state of the general system. Tf the emaciation is rapid, without inflammatory action, animal _ food containing fats becomes necessary; but if there exists i irritability of the alimentary canal, a milk diet with farinaceous ‘ substances will prove most advantageous. While, on the con- trary, if a febrile state of the system is present, a vegetable diet will be preferable to animal, and even the quantity must be restricted to the actual wants of the system. 2. Clothing.—It is highly important to regulate the clothing of tuberculous patients, and especially so during cold or variable seasons. The calorific power in such patients is below the physiological standard, and they are, consequently, peculiarly liable to become affected by sudden changes of temperature. Hence, the system should be guarded by woolen clothing, of sufficient thickness to protect, but not to oppress the system. Extremes are never desirable; and while we are anxious to protect the system from the inflnencds of cold, there is such a thing as oppressing it with ‘too heavy dathing, which may be- come burdensome and injurious. If the body is loaded down with heavy woolen materials, the surface is made to act too freely, and thus debility is induced. It is important, therefore, to regulate the quantity of heavy material with care and judg- ment, so that while we protect the body from the effects of sudden changes of temperature, it does not become oppressed by the measures designed to protect it. One of the most important incidental points relates to the dress of females. The tyranny of fashion induces females to dress in thin and delicate fabrics, with the arms and chest ° TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 443 greatly exposed, and the feet imperfectly protected. In this exposed condition, night visits are often made; and the warmth of crowded rooms, the exercise of dancing, and various excit- ants, cause a free state of perspiration, following which a very slight exposure is sufficient to induce an attack of pneumonia. Many examples of consumption originate in this manner; and it often happens that such cases are neglected or overlooked, the symptoms being regarded a mere cold, until the disease becomes fully established. Such cases are often exceedingly deceptive. A feverish condition, moderate cough, perhaps sputa slightly tinged with blood, are usually the earliest symptoms; and unless the pneumonia becomes fully developed, these symp- toms remain slight for a considerable time, so that even ex- perienced practitioners may be readily deceived. Females, having the slightest hereditary predisposition to phthisis, should be particularly instructed in regard to the importance of proper protection by clothing, both before and after the access of pos- itive disease. 3. Exercise—The greatest importance should be attached to exercise in the first stage of tubercular deposits; but the ques- tion arises as to the character and extent of physical exertions necessary to maintain the system in a state of health. It is abundantly evident that violent or long-continued exercise would be incompatible with the vital powers of the tuberculous con- stitution; and hence those occupations or hygienic regulations which require great or protracted physical exertions should be prohibited. In tuberculous subjects the great constitutional vice consists in a tendency to a rapid metamorphosis of the tissues, and, consequently, wasting of the whole body; and whether the explanation which I have offered in relation to the evolution of tubercle be accepted or not, it must be con- ceded that emaciation is the special condition which accompa- nies the development of the disease. Hence, it is an object of the highest importance to protect the system against this pro- gressive emaciation, and to restore, as far as possible, the equi- librium between supply and waste. But, while we acknowledge the truth of these general views, it is equally evident tleat absolute rest is incompatible with the / 444 THERAPEUTICS OF PHTHISIS. maintenance of health, and hence some form and degree of exercise becomes indispensable. In attempting to regulate this part of the treatment, much will depend on the previous habits, general strength, temperament, and disposition of the patient. Thus, if the habit has been laborious, such as in active mechan- ical or agricultural pursuits, it will be proper to diminish rather that to increase the exercise, so that the system may gain repose, the vital powers recuperate, and the morbid metamorphosis be checked. If, on the contrary, the habit has been sedentary, or confined within doors, the patient should be directed to seek out-door exercise, although not of a violent character. In that class of persons who have been subjected to severe and long-continued exercise, and tubercular deposits occur under such circumstances, it is evident that the habits have not been conducive to health, and, therefore, require to be changed. The exercise may have been too severe for the strength of the patient, and thus the disease is developed by the debilitating influences of over-exertion. A case of this character has come under my observation at the time of writing this section. A gentleman, without the slightest known hereditary predisposi- tion, was subject to great physical exertion in superintending an iron furnace. He was much in the open air, but not neces- sarily exposed to inclement weather; and, moreover, the occu- pation itself is usually regarded as healthy, and the facts seem to show that such is the case. And yet this gentleman became tuberculous, his health gradually failed, and, at this time, has softened tubercles of the right lung. Overexertion, long-con- tinued, was doubtless the cause of the disease in this case. Hence, in all such examples, the exercise should be moderated, and the patient counseled to comparative repose. __ But it is not physical exercise alone which proves pernicious, “put, in addition to this, protracted mental application, espe- cially when associated with anxiety of mind, becomes even a more potent inducing cause than bodily exertion. Many cases “have fallen under my observation clearly traceable to this cause, and there can be no doubt the disease often owes its origin, even in persons but little predisposed to the affection, to the perturbating and depressing effects of nental excitement. Un- TREATMENT OF THE STAGE OF TUBERCULAR DEPosITs. 445 der such circumstances the nutritive powers are impaired, dis- integration of the tissues rapidly takes place, and when the slightest predisposition to tuberculosis exists, that morbid state is readily developed, and local disease speedily ensues. It is evident, therefore, that the regulation of the patient’s exercise requires care and discrimination. As a general rule, it should be regular, but never violent, nor so protracted as to amount to actual fatigue; and it should be a cardinal point to avoid that kind of exertion which will greatly hurry the cireu- lation and increase the frequency of respiration. Hence, run- ning, climbing mountains, or even rapid walking, become inju- rious, not only by inducing debility, but also, by causing too ac- tive a disturbance of the functions of respiration and circulation. Moderate walking and riding on horseback constitute the most appropriate modes of exercise; and especially is the latter of the greatest service, and is that form in which the largest amount of healthful exercise can be obtained at the least ex- pense to the vital powers. Sydenham’s rule was that tubercu- lous patients should live as persons in health; that they should ride throughout the year, averaging thirty miles a day. These rules are, doubtless, too rigorous; nevertheless, the importance of horseback exercise can scarcely be overrated, although it requires the ordinary exercise of judgment. But it is important to observe that, in all cases, the great principle is, to effect a change in the habits of the patient. If he has been accustomed to in-door business, let him be induced at once to exercise in the open air, moderately but persistently. If, on the contrary, he has already been subjected to inordinate out-door exercise, let him at once change, so as to enjoy more repose, and thus prevent the rapid expenditure of the vital powers. 4, Atmospheric Influences—Atmospheric influences, in promot- ing or retarding the development of tubercle, are evidently very great, and the subjects of the disease should always be relieved, as far as possible, from the pernicious effects of an unfavorable atmosphere. As a general remark, a pure atmosphere, with considerable altitude, is that which is most favorable; and the most unfavorable condition is low situations, with cold and de- 446 THERAPEUTICS OF PHTHISIS. cided moisture... Hence, low valleys adjacent to water-courses, not excepting even the sea-coast, are, beyond all doubt, highly injurious to persons having tubercular deposits in the lungs, The effect seems to be to prevent cutaneous and pulmonary exhalations, and thus to favor stagnation in the capillaries of the lungs, and, consequently, exudation of tubercular matter. If persons who occupy low positions be changed to a more elevated and less moist atmosphere, very marked improvement, will usually be observed. This has been abundantly verified in. Peru, by the observations of Dr. Smith. Here, patients removed from the moist localities bordering on the ocean to the mount- ain regions, immediately improved, and often recovered. There can be no question, indeed, of the importance of this opinion; and patients changing climate, especially on going South, should always carefully avoid low antl very damp localities ; and hence no point on or near the sea-coast should be selected, but prefer- ence should be given to the dry and more elevated regions of Texas, Georgia, North and South Carolina, Kast Tennessee, and all regions similarly located. Mere altitude, aside from avoiding excessive moisture, has, doubtless, a favorable influence in the tuberculous condition, and hence mountainous regions are usually preferable to plains or valleys. In making this observation I refer to warm climates, or, at most, temperate regions; for, in the colder latitudes, great elevations prove too exciting, and, therefore, defeat the most important objects we have in view. But mountainous regions are usually dry, and hence the patient may enjoy the advantages of a suitable degree of moisture without being obliged to ascend to a great altitude. But while we inculcate the general principle, that an atmos-. phere charged with moisture is injurious in this stage of phthisis, it is not less important to avoid the opposite extreme. Thus, a very dry and sharply-cool atmosphere is generally not safe, for the liability to establish excitement in the pulmonary tis- sues becomes hazardous, and should, if possible, be avoided. Hence, a medium degree of moisture is preferable to either extreme, and, doubtless, exercises a kinder influence over the morbid state of the lungs than extremes of dryness or moisture. It is doubtful, also, whether a rarefied atmosphere, as in mount- TREATMENT OF THE STAGE OF TUBERCULAR DEPosITs. 447 ains of great altitude, can be safely breathed by tuberculous subjects in the stage of local disease; it is questionable whether such an atmosphere would not increase the pulmonary circula- tion, and thereby predispose to hemorrhage and morbid exuda- tions. But on these points it becomes us to speak with prudent reserve, for the facts are too few to admit a safe generaliza- tion. It does not appear that exhalations from the earth, or breath- ing an atmosphere charged with gases, exercise any beneficial influence over the disease. Laennec, having observed the in- frequency of phthisis on the coast of Brittany, conceived the idea that the exemption was due to the inhalation of iodine, which was given off by kelp; and hence he attempted to create an artificial iodine atmosphere, by placing the plant in the small wards of the hospital. And, at a more remote period, Galen and Celsus sent consumptives to breathe the sulphurous atmos- phere of voleanie regions; while Van Swieten thought the effluvia arising from moistened earth highly beneficial. He refers to the earth-bath employed by Francisco Solano de Luque, in Granada, which he thinks may have done good by the ex- halations. It was employed in the following manner: A pit was dug where no vegetation grew, into which the patients were placed up to their necks, covered with earth, and left until they began to shiver, when they were taken out, and wrapped in linen moistened with rose-water; and, after the lapse of two hours,.were rubbed with the “ unguentum resump- tivum” of Zacutus Lusitanus. He used a new pit each time, and thought the earth safe only from the end of May to Octo- ber. In England, an impression has prevailed that coal-miners were comparatively exempt from phthisis; and in the United States, strong hopes were entertained, at one time, that the great Mammoth Cave, of Kentucky, would prove a most salutary residence for tuberculous invalids. But whatever foundation there may have been for the opinion in relation to the coal- miners of England, the Mammoth Cave proved a sad failure ; indeed, no benefit whatever was derived from its atmosphere, and the experiment was, consequently, abandoned. Dr. Cartwright, of New Orleans, has directed attention to the 448 THERAPEUTICS OF PHTHISIS. atmosphere of sugar-houses, while surcharged with water and saccharine matter. We can well understand the influences which such an atmosphere may exercise over tuberculous pa- tients; but, as this subject will be alluded to in another section, it will not be pursued further here. There is no sufficient evidence to prove that any of these emanations, or modified atmospheres, are capable of exercising a curative influence in cases of phthisis; it is true, indeed, that the iodine, if diffused through the air, would exercise a medi- cinal influence, but its existence in any known locality is too precarious to be depended upon. It is far more philosophical to seek a pure atmosphere, with the qualities previously men- tioned ; and if it becomes desirable to introduce medicinal substances in this manner, let them be diffused through the air in such way that their actions may be properly understood and appreciated. 2. To promote the elimination of tuberculous matter—If the opinion be true that the tuberculous elements possess something of a specific character, and result from a faulty metamorphosis of the tissues of the body, we can readily conceive that such products admit of elimination from the system, and, possibly, local disease may thus be prevented. But whatever opinions may be entertained on this difficult subject, we have, at least, two important facts to guide us in the application of remedies. In the first place, it is admitted by all pathologists that the evolution of tubercle involves the whole organism, and is characterized by emaciation ; and, in the second place, that the emunctories become weakened in their action, proportionally to the progress of disease. And hence it follows, as a legitimate corollary, that emaciation progressing, and the emunctories failing to perform their proper functions, effete matter of some form must accumulate in the system; and that, acting upon this view, we would not be far wrong, in a thera- peutical sense, in attempting to maintain the eliminating organs in a proper state of activity, or even of urging them beyond the physiological degree. Those organs through which we might reasonably hope to promote elimination, are the skin, alimentary canal, liver, kid- TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 449 neys, and the lungs. Speaking of the skin, liver, and kidneys, Dr. Turnbull,* without probably having the full view of the subject before him, remarks: “They are the depurating organs which purify the blood, by removing from it the products of the worn- out tissues, and a healthy activity on their part tends to prevent consumption, and should, therefore, be promoted by appropriate means.” There can be no doubt of the soundness of the views expressed in the above sentence; but the author, not entertain- ing the opinions here expressed, indicates but slight means for accomplishing the important object of sustaining the depurating organs, such as wearing flannel next the skin, cold or tepid bathing, frictions, etc. But these means, however appropriate they may be, will fall far short of the object we have in view. It is true, the physiological state should be maintained by proper clothing, diet, exercise, cleanliness, pure air, etc.; but when the morbid action is decided in its character, and the emunctories come far short of their accustomed duty, the hygienic means referred to will fail to accomplish the objects, and we must resort to more positive medicinal agents. In relation to the functions of the skin, it is important they should be not only maintained in a physiological condition, but, in certain states, it becomes necessary to excite free and full perspiration. Clothing, exercise, and a warm climate are sufii- cient, in cases not too inveterate, to maintain the natural insens- ible perspiration; but in certain constitutions, and when the disease has made considerable impression on the system, it often becomes necessary to resort to medicinal agents and warm bathing. Among these, doubtless, the warm bath may be re- > garded as holding a prominent position ; indeed, the use of external warmth, either in the form of an immersion or vapor- bath, will do much to sustain the activity of the skin. The vapor of water or alcohol will readily excite copious perspira- tion, and if not carried too far, and the skin be thoroughly rubbed with dry cloths, it leaves the function, as well as the general system, in a state of healthy action, without inducing debility. There can be no doubt that the sudoriferous canals * An Inquiry into the Curability of Consumption, etc. 38 450 THERAPEUTICS OF PHTHISIS. become contracted and more or less obstructed during states of cutaneous inaction, and active perspiration, or sweating, is necessary for the restoration of the impaired function. And the importance of the cutaneous system in tuberculous affections, is rendered evident by the acknowledged sympathy which exists between the skin and lungs. Indeed, there is every reason to believe that obstructed cutaneous action will often seriously impair the pulmonary function, and may even largely favor the deposition of tubercles. But more especially is it important to sustain the cutaneous function with the view of eliminating effete material from the system. In the tuberculous condition, as already intimated, effete matter accumulates in considerable quantities, independent of the immediate tuberculous elements; and hence, in a general sense, we should sustain cutaneous action, as one of the great emunctories of the system. In addition to this, however, it is a fair conclusion that the ele- mentary material of tuberculous matter may, with other effete substances, be thrown off by copious perspiration. Thus we have various reasons and many incentives in favor of copious sweating in tuberculous subjects; and it is, doubtless, equally applicable to the precursory stage, and the beginning of local disease. When the latter condition has become far advanced, the sweating process will prove less serviceable, and must be employed to a limited extent, or entirely abandoned; and in all cases it becomes necessary to guard against inducing debility by oversweating. Cold bathing is of questionable propriety; but while there are comparatively few tuberculous subjects who can be benefited by this measure, it would be a hasty conclusion to entirely interdict its use. The sensitive state of the nervous system, and the cutaneous debility, will often prevent the vital powers from properly reacting under the influence of cold, hence, it would defeat the object in view. The cold shower-bath may be em- ployed in the precursory stage with safety and advantage, for here the power to react has not been greatly weakened, and hence, the cold operates indirectly as a tonic. But when tre morbid action is more advanced, and positive disease of the lungs exists, the vapor-bath is infinitely preferable, on every TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 451 account, to the cold shower-bath. The tepid bath (especially by showering) may be employed in those intermediate cases in which debility has commenced, but has not reached an extreme degree. The medicinal agents calculated to promote the action of the skin in this form of disease are not numerous, but still require careful consideration. The alcoholic preparations, by stimula- ting the system, favor cutaneous transpiration, but these require careful regulation in order to avoid the injurious consequences previously mentioned. Moreover, it is only in the incipient stage of local deposits that alcoholic stimulants prove advan- tageous. The preparations of sulphur and antimony are, I have reason to believe, of essential service in some forms of the disease; and especially is the sulphur indicated when a herpetic eruption coexists. The preparations of antimony re» quire great caution in their administration, and, indeed, it is only the milder compounds, as a general rule, which are ad- missible. The pulvis antimonialis is the preparation most re- liable and manageable, when it can be procured pure, and ta this we may add the sulphur, in the following form: R Sulphur. Sub. Jss. Puly. Antimon. 5). Sac. Lac. Dij. M. Ft. Puly. x. One powder to be taken morning and evening. The particular cases in which these compounds become use- ful, are those characterized by dry skin, slight febricula, and inactive bowels. Another method of employing: the sulphur, and which I prefer to the above, is to add the powder to cod- liver oil, when this agent is employed. Two drachms of in ae to the pint of oil, carefully shaken before using, makes an eligible and often very serviceable mixture. Whisky and sul- phur I have known employed, and it agrees very well with some constitutions. Another important emunctory, and one which claims especial attention in this connection, is the liver. Independently of any temporary change of secretion which may occur, it can not be * 452 THERAPEUTICS OF PHTHISIS. doubted that the office of so large an eliminating organ as the liver is highly important in the forming stages of tuberculosis, and should be regularly maintained at a physiological point. We have no direct or tangible evidence that tuberculous ma- terial can be eliminated by the liver; but, at the same time, we know not what morbid elements may be depurated by the hepatic system, and, therefore, should carefully guard against its derangements. Analogy would lead to the belief that in nearly all depurating processes the liver must hold an important place. It is true, however, that.each emunctory has its own peculiar function; the lungs and liver eliminate carbonic acid and com- pounds of hydro-carbon, the kidneys nitrogenous elements, while the skin throws off mixed compounds. But these points are too subtile to admit of practical application, in a positive sense, and, therefore, it becomes the practitioner to view these doubtful questions in a more general manner. And, with this view, it becomes, on general principles, important to maintain the functions of the liver, especially when effete substances are accumulating in the blood. Hence, the employment of altera- tives, mercurial and others, are often appropriate in the treat- ment of tuberculosis. The milder class, such as Pil. hydrarg., or hydrarg. ¢. ereta, alone or combined with rhubarb, or calomel combined with alkalies, may become necessary. The following will be found a very eligible formula: R MHydrarg. chlorid. mit. grs. xv. Pulv. Rhei, Sode Bicarb. 445). / Sacch. alb. 3ss. \ NJ M. Ft. puly. v. One of these powders given at night, and followed, if neces- sary, in the morning, by fluid extract of rhubarb or senna, will usually fulfill the indications. There are, however, two particular conditions in which pur- gatives and alteratives become especially important, namely: in the bilious temperament, and during the employment of cod- liver oil. My own observations have led to the conviction that persons of a bilious temperament often require mercurial altera- TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 453 tives and even active purgatives; and without attention to this condition, the digestive function becomes impaired and the tubercular disease rapidly advances. There is no class of patients in whom tuberculosis is so obstinate and uncontroll-. able as those who have a well-marked’ bilious temperament : and I am inclined to believe that a part of the difficulty arises from the physician’s overlooking the importance of the hepatic function, and thus permitting it to become inactive. The second condition especially demanding the use of altera- tives, is where cod-liver oil has been employed unremittingly for a considerable period. In such cases it will usually be found that patients become bilious, the appetite fails, bowels become torpid, with a coated tongue, and similar signs of hepatic disorder. The introduction of a large amount of car- bonaceous material, in the form of oil, necessarily imposes on the liver increased action; otherwise the refuse portion accumu- lates in the system and induces morbid results. Hence, pur- gatives become necessary under such circumstances. There is another practical consideration important to be remembered in this connection. In the bilious temperament cod-liver oil is often not well borne, nor are its effects so efficacious as in other constitutions. Hence, the two special conditions requiring the use of purgatives are brought together, and consequently that class of remedies must be more freely employed than under any other circumstances. I am fully convinced that, in the bilious temperament, the occasional ex- hibition of purgatives will enable the patient to take the oil more freely, and with greater benefit. But, aside from the action of alteratives on the hepatic func- tion, there is strong reason to conclude that even smart purging is often useful in the initial stages of tuberculosis. Certainly the eliminating powers of the alimentary canal must be regarded as highly important in this form of constitutional disease; but the extent to which purgation should be carried admits of doubt. In all cases constipation should be avoided; and where this tendency exists, my own experience is decidedly in favor of not only maintaining a regular action of the alimentary canal, but also to interpose, at suitable intervals, decided purgation. 454 THERAPEUTICS OF PHTHISIS. I regard it as exceedingly unsafe to permit the alimentary canal to remain, in any considerable degree, locked- up; and while we should carefully avoid undue irritation, and unnecessary exhaustion, by these agents, it is still highly important to resort occasionally to decided purgation. And especially at the mo- ment local deposits are commencing, is it important to maintain a soluble state of the intestines; for, on general principles, I believe the derivative action to be highly important under such circumstances. For this purpose certain mineral waters, in which chloride of sodium predominates, may be safely and . beneficially employed. Among these I would especially men- \ tion the Blue Lick and Louisville Artesian waters. The former “contains considerable sulphur, and is, therefore, especially valu- able, but the proportion of salt is insufficient, and hence that agent should be added at the moment of its use. I would further remark, that the occurrence of spontaneous diarrhea in this stage of the disease should not be too speedily checked, at least so long as it remains within moderate limits, for such an evacuation may, to some extent, prove critical, or at least beneficial. me x The condition of the urinary secretion also demands partic- ular attention, although our knowledge must be regarded as very indefinite on this subject. In tuberculous subjects the urine appears to contain less solid constituents, particularly the nitrogenized elements, while the salts, especially the phosphates, are in excess. In the advanced stages the uric acid is found ( largely in excess. It has a low specific gravity, and readily undergoes decomposition, becoming alkalescent. These condi- tions of the urine represent rather the state of the general system than a disorder of this particular function; but, at the same time, we can draw some legitimate therapeutical indica- tions from its condition. In the first place, as an eliminating organ, it is important that its function be maintained at a physiological point, and there can be no doubt that when it becomes deficient either in quantity or quality, it must exercise more or less influence on the general system. But we observe especially that the nitrogenized animal products are deficient, (while the phosphates are in excess. This condition indicates TREATMENT OF THE STAGE OF TUBERCULAR DEPosITs. 455 that the eliminating action of the kidneys has materially dimin-) ished, for while the metamorphosis of the general system has increased, the amount of nitrogenized products is greatly less- ened. We can evidently base on this fact an indication for treatment; but whether we should resort to diuretics, or depend on the effects of tonics and stimulants, to restore the vitality of the system, may fairly be made a question. It has appeared to me, however, that the employment of diuretics, such as col-_) chicum, exercised a beneficial influence, and, in fact, diminished the tubercular deposits. But it must be admitted that this branch of the therapeutics of tuberculosis is by no means set- tled, and is, therefore, open to further observation. The pre- dominance of uric acid in the advanced stage of phthisis is — clearly due to the rapid disintegration of the tissues and the diminished power of oxygenation, and, therefore, does not admit of relief by agents addressed to the kidneys, but so far as it is within the reach of remedies, they must be directed to the general system. Eimetics constitute an important means of evacuation, and perhaps also of elimination, in the sense here indicated. But, independent of this view, emetics may often be advantageously employed to arouse the action of the chylopoietic viscera, and thus to promote assimilation. I have no doubt, from my own observations, that, under favorable conditions, the occasional interposition of a smart emetic or purgative (one or both, ac- cording to indications) will prove valuable in the treatment of tuberculosis. This course is particularly indicated when other agents, such as cod-liver oil and iron, have been long used ; for, under these circumstances, the system becomes so habituated to their action that the salutary influence seems to be lessened; so that the occasional suspension of this class, and the substi- tution of evacuants, becomes highly important. But to what extent emetics are capable of eliminating tubercle, or tubercu- lous materials, is uncertain. Sir James Clark speaks of tuber- cles being dislodged from the mucous membrane of the air- passages by emetics; but the facts have not been very clearly developed. It is well known, however, that emetics have been extensively employed by medical practitioners, and, as some 456 THERAPEUTICS OF PHTHISIS. have alleged, with great success; but, as this question will be more fully stated under the head of miscellaneous remedies, I forbear further remarks on the subject in this connection. 3. To promote the Absorption of Tubercles.—Pathologists con- sider the absorption of tubercles, or tuberculous matter, as so doubtful, if not impossible, that a discussion of the subject may be considered entirely improper. Still, there is reason to believe that the deposits of tubercular material are not so completely removed from the laws controlling other varieties of exudation, as to require us to reject as absurd the view here indicated. The absorption of tuberculous matter, in some of its phases, has been admitted by Fournet, Carswell, Andral, Boudet, Hasse, and Ancell; but, in most instances, preliminary softening seems to have been indicated. There are two points, however, which merit attention; first, Can tuberculous material, in its most in- cipient state, be absorbed? and, second, After it becomes crude, can it be liquefied and pass into the circulation ? In regard to the first question, it is to be remarked, that in its most incipient state, tuberculous matter is probably fluid, and in that condition there is no reason to doubt that it may admit of absorption. The possibility of such a result can not be denied; but, inasmuch as the deposit usually rapidly in- creases and speedily becomes concrete, the chances of absorption must be regarded as very slight. Still, if the tubercular condi- tion could be suddenly changed, and the exudation thus arrested, it is not improbable that absorption might take place. Under ordinary circumstances this fortunate result could hardly be anticipated; but where the tuberculous constitution is but partially developed, and the tendency to exudation inconsidera- ble, we would not be justified in rejecting the possibility of such arrest and absorption. Cases have come under my observation in which a strong probability existed of the deposit of tuber- culous effusion, and the final cessation of the signs afforded a fair presumption of the arrest of the process. The immediate physical sign which has seemed to me indicative of this condi- tion, is a peculiar, slight, tearing sound, heard with both inspira- tion and expiration, of limited extent, but permanent in its development. The sound is more intense than the crumpling TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 457 of Fournet, and is what I have described under the name of tubercular crepitus. It conveys to the ear exactly the impres- sion of the air-cells expanding in an adhesive liquid, which offers some resistance, but yields with a slight, half-liquid, sticky sound. This sign I have observed in many cases in which a tuberen- lous condition or tendency was supposed to exist, but without any other physical evidence of deposit; and, in due course of time, I have witnessed the disappearance of the sign, and a complete restoration to health. In fact, all the circumstances clearly indicated to my mind, that tuberculous effusion had really occurred, and that it was ultimately absorbed. And, even in the absence of demonstrative evidence, which is an impos- sibility, the position is not so much at variance with the ac- knowledged laws of exudation and absorption as to require. its unconditional rejection, and, therefore, I feel inclined to adopt it. The second condition under which absorption may occur is after softening has taken place. If tubercles are limited in ex- tent, and the deposit ceases, it is probable that the liquefied mass may be absorbed, leaving only a slight contraction, or, at most, cretaceous deposits. Indubitable evidences of absorption of tubercular matter from the bronchial glands has been fur- nished by Hasse and others; and Rilliet and Barthez report a case in which the contents of a gland were completely absorbed, without communication with the bronchia. Hasse dwells espe- cially on the fact, that in some examples, the remains of cavities in the lungs present no tubercles in the adjacent walls, which is contrary to the usual condition, and is, he thinks, evidence of absorption having occurred. Under all the circumstances, therefore, I feel justified in the introduction of this third indication, “to promote the absorption of tubercular matter.” Doubtless, however, the most philosophi- cal mode of viewing the subject, is, to look upon the suspension of the tuberculous process as an essential preliminary step to the absorption of the effused substance. Thus, if we can arrest the evolution of tubercle while the deposits are small in extent, we may hope for absorption, or, at least, that the effusion will not increase; on the contrary, it will be in vain to attempt to 458 THERAPEUTICS OF PHTHISIS. promote absorption unless we can, at the same time, check effusion, for the two processes are antagonistic. We have already seen that stimulants, tonics, nutrients, and, in fact, the hematics generally, are the agents which tend to arrest the evolution of tubercle; but it could not be supposed that the same medicines would directly induce absorption, although, indirectly, by improving the tone of the system, such might be the result. Hence, to promote the absorption of tuberculous material we must leave the hematics, and resort to agents, if not precisely opposite in character, at least such as do not operate exclusively to improve the condition of the blood. In this class of medicines we find mercury, iodine, bromine, and similar agents, while there are still other reme- dies, such as the alkalies, which may promote solution, and thereby favor absorption. It is well known that mercury has often been employed in scrofula, while iodine is acknowledged as a favorite agent in that form of disease; but it must be confessed that these potent medicines have often been administered without any definite idea of their mode of action, and, consequently, too frequently with injurious results. They can not be advantageously em- ployed when the blood is impoverished and the system greatly debilitated ; hence they are inapplicable to the advanced stages of tuberculosis, and should be restricted to the early period of local deposits. If, therefore, these sorbefacients are adminis- tered in the proper form and at the right period, there is reason to hope that they may act favorably on recent deposits. The preparation of mercury best tolerated by the system, and, there- fore, the most appropriate for this disease, is the bichloride or the proto-iodide. The particular advantage of the bichloride is that it may be employed for a long period of time, without generally inducing ptyalism, or causing any form of mercurial- ismus; while, at the same time, it will aid in the resolution of exudations, as far as such medicine can act in that direction. The dose should be small, not exceeding the thirtieth of a grain, and its administration long continued. The preparations of iodine are employed for a similar pur- pose, that is, to promote the liquefaction and absorption of TREATMENT OF THE STAGE OF TUBERCULAR DEPOSITS. 459 exudations. But iodine, in any of its forms, can seldom be employed for a long period without inducing certain morbid results, which require its suspension. The iodides of potassium or sodium can be used for a greater length of time than the article in substance ; but even these preparations are apt, finally, to induce, in most constitutions, morbid results, and, in some examples, can not be tolerated at all. The preparation which I employ, as a general rule, is the iodide of sodium, which is, usually, preferable to the iodide of potassium. I seldom deem it necessary to give more than five grains at a dose, repeated three times a day, dissolved in fluid extract of sarsaparilla, or any other simple vehicle. It is necessary that the effects of iodine be carefully observed; and when any of its morbid in- fluences are detected, it should be at once discontinued, or thé dose greatly reduced. These morbid effects consist in derange- ment of the stomach, loss of appetite, thirst, soreness of the tongue and mouth, and, at times, general febrile excitement. Iodine may also be administered by inhalation ; this is Piorry’s favorite method, and may, doubtless, often prove advantageous. Indeed, we can perceive a pertinent reason for introducing this substance directly into the pulmonary tissues, when we desire to act on deposits at that point. As combining the effect of both mercury and iodine, the proto-iodide of mercury may be substituted for the preceding preparations. Its liability, however, to induce ptyalism is a serious objection to its use, although, in small doses, it may often be given for a considerable period without detriment to the system. The dose should not exceed a quarter of a grain, repeated twice a day. The following formula is employed by Dr. Green: Potass. iod. 3ss. Syr. sarsaparil. Ziv. M. A tea-spoonful to be given three times a day. Tn this formula there is evidently a decomposition, metallic mercury being precipitated ; but it is claimed that the elements recombine, forming the hydrargyro-iodide of potassium. There are some other agents which may be mentioned in this \ Vg ~ 460 THERAPEUTICS OF PHTHISIS. connection, especially the acteea racemosa, or cimicifuga. It was first recommended by Dr. Hildreth, in incipient phthisis ; and although its mode of action is not well defined, yet it seems to me that it may aid in promoting absorption of the element- ary deposits of tubercle. The fluid extract is the most eligible preparation, of which half a drachm is a medium dose. It may be advantageously conjoined with the bichloride of mercury in the following form : K Fluid ext. sarsaparil. 3iij. Fluid ext. cimicifuga, 3). ' Hydrarg. bichlorid. gr. j. M. A drachm to be given three times a day. The great objection to the employment of these agents is, that they deteriorate the blood, and thereby promote, rather than remove, tubercular exudation; and, with this view, they are generally discountenanced. But it is evident, that the error “consists in a reliance upon these agents exclusively, while, in fact, we should give them conjointly with those of a sustaining char- ‘acter. This is the great practical rule—the hematics should be employed jointly with the resolvents. Thus we may admin- ister iron, cod-liver oil, and stimulants at one hour, while, at another period of the day, we employ mercury or iodine. The proper period for the administration of the hematic class is after meals, that is, toward the completion of chymification ; while the absorbents are more appropriately taken into an: empty stomach. In this manner, we may appropriately admin- ister the tonics after, and the absorbents before, meals, without any interference with each other. This I regard as the desideratum in the employment of the absorbents. The system is fully sustained by the tonics, stim- ulants, and nutrients, which are the proper agents to arrest the evolution of tubercular matter; while, at the same time, the absorbents can be given without increasing the debility. Thus, the double object of arresting the evolution, and promot- ing the absorption of tubercle, may be accomplished at the same time, without one action interfering with the other, and without either acting injuriously on any function or tissue. TREATMENT OF THE STAGE OF TUBERCULAR DEPosIts. 461 It is important to remark, in relation to this whole subject, that absorbents, in the sense here referred to, can not be em-. ployed, with any hope of success, except in an early period of the deposits; for, when a certain stage has been reached, it becomes impossible to remove tubercles, except by the process of softening and elimination through the bronchi. Hence, if absorption without softening is to be accomplished, the effort must be made at an early period. When, therefore, the physi- cal signs are barely sufficient to disclose the local disease, and the spirometer shows a vital capacity scarcely reduced below the physiological standard, we are assured that the deposits have but just commenced, and the effort to remove them may be properly made. When, however, the deposits have become extensive, and all hope of absorption has necessarily been ‘abandoned, the atten- tion should be directed to the limitation of the process, and to preserve the pulmonary structures in as healthy a state as pos- sible, so that the process of softening may take place under the most favorable circumstances. In many important particulars, the treatment which is appropriate to the first period must be greatly modified. It is questionable, indeed, whether tonics, stimulants, and nutrients are demanded, or will be borne to the game extent in this as in the earlier stage. The lungs, in this stage, have reached a higher degree of morbid action ; capil- lary circulation becomes obstructed, and there is a tendency to local excitement and general febrile reaction, and a very slight extraneous excitant is capable of developing more or less local inflammation. Hence, the active exercise, stimulants, and full nutrition must, at least, be greatly reduced, and the system maintained in a state of comparative quietude. Great pertur- bation of the functions is now to be avoided ; the circulation and respiration should be maintained in a state of comparative tranquillity ; while the functions of the skin and alimentary canal require to be well sustained. The aliment should be simple and unirritating, and somewhat below the usual quantity. The patient should carefully avoid exposure to a cold or damp atmos- phere, and sudden transitions from heat to cold. These precautions are obviously important, in order to avoid 462 “ PHERAPEUTICS OF PHTHISIS. the occurrence of local excitement, either of a congestive or inflammatory character; for, indeed, the most untoward acci- dent which can occur is the supervention of excitement of the pulmonary tissues at the time softening is commencing. Such excitement, which is very liable to occur, renders the process of disintegration rapid, and the morbid action extends, in an undue degree, to the adjacent pulmonary parenchyma; and, doubtless, also, the increase of irritation serves to promote the exudation of tubercular matter, and thus materially augments the extent of the local disease. SECTION III. TREATMENT OF THE STAGE OF SOFTENING. The stage of softening represents a period when phthisis can no longer remain stationary, nor can it be made to recede or undergo resolution. On the contrary, when the softened tuber- cular matter is in considerable quantity, absorption seldom takes place, and elimination through the bronchial tubes is the only mode by which it can be removed. Admitting the possibility of small, scattered tubercles softening, and ultimate absorption taking place without entering the bronchial tubes, such exam- ples must still be regarded as the exceptional condition, while elimination is the ordinary course. But, unfortunately, the pro- cess is by no means so simple as the terms would indicate; on the contrary, this stage of the disease is very complex, embracing new local pathological changes, and progressive deterioration of the general system. In this stage the new morbid action which is recognized is of an inflammatory character, with fresh exudations of tuber- cular matter and degraded lymph. The whole action, taken together, constitutes an inflammatory condition, although it is of a low grade and specific character, inducing around the softened parts white or grayish consolidation, instead of red hepatization, as in pneumonia, which readily softens and disin- TREATMENT OF THE STAGE OF SOFTENING. 463 tegrates. Hence, an important pathological condition connected with the stage of softening, which we are called on to remedy, is the occurrence of local inflammatory engorgement, with the continued exudation of tubercular matter and degraded lymph. These processes are variable in extent, but always more or less present. The following are the therapeutical indications in this stage : I. To maintain the constitutional vigor. Il. To arrest the further deposit of tubercles. III. To limit the process of inflammatory exudation and softening in the pulmonary tissues. er I. To maintain the Constitutional Vigor—The means by which the constitutional vigor may be maintained, as far as practica- ble, include diet, exercise, and tonic medicines. The regulation of these will depend on many contingencies surrounding each individual case. 1. Diet.—The proper regulation of the diet in this stage is highly important, and requires even more discrimination than the preceding stage. All derangement of the stomach should be carefully guarded against; indeed, the intimate relationship existing between the digestive and pulmonary organs renders it highly important to preserve the function of primary diges- tion in as healthy a condition as possible. Any irregularity of diet, or improper article of food, or undue quantity, can not fail to exercise an unfavorable influence on the pulmonary dis- ease. As a general remark, the diet should be simple and unirritating, but, at the same time, sufficiently nutritious. Over- stimulation of the digestive function can not fail to prove inju- rious to the lungs, and hence the food should possess less of the exciting properties than would be appropriate in an earlier stage of the disease. In regard to quantity, I am convinced that an undue anxiety to sustain the system prompts physicians to permit the intro- duction of too much food, and that the most serious conse- quences often follow this indiscretion. The appetite is far from being a correct guide in this condition of the system; for it 464 THERAPEUTICS OF PHTHISIS. will be remarked that primary digestion is often well sustained, while the system at large continues to waste, and, therefore, the desire for food will prompt the patient to take a larger quantity than can be assimilated in the tissues. Hence the evil effects arising from the introduction of too much food will be witnessed in the stomach, consisting in impaired digestion and the sympathetic irritation of the lungs; and, still more remotely, it will be observed in the contamination of the system with crude materials which can not be assimilated. In the first example, all observation proves that if we con- tinue to task the stomach to its full extent of physiological action, it will ultimately become debilitated, or even suffer from irritation, more or less severe. This occurs when persons are otherwise in perfect health, and it will much more readily take place when the system has been long debilitated by a consti- tutional disease. There is, indeed, as phthisis advances, a gradual lowering of the digestive powers, and this downward tendency is rapidly increased by overindulgence in articles of diet. Hence, the continued indulgence in stimulating food and drinks must necessarily. impair the tone of the stomach, and induce irremediable dyspepsia. But another evil of great magnitude is the introduction into the circulation of more nutritive materials than can be appro- priated to the support of the tissues, and, as a consequence of this condition, the system becomes surcharged with effete sub- stances. Nor will these effete elements obtain ready elimination from the system, for the emunctories are usually impaired, and, therefore, the refuse material is unduly retained. The different classes of food will produce special effects in this secondary relation; thus, if too much nitrogenous material is introduced, the urinary secretion will become involved; while a superabund- ance of carbonaceous food will result in overtasking the biliary organs. In the first instance, lithic acid will predominate in the system, acting most unfavorably on the nervous function; while in the second, the carbon induces congestion of the liver, and impedes the pulmonary circulation. In regulating the diet, therefore, according to these general rules, patients should be restricted to moderate quantities of TREATMENT OF THE STAGE OF SOFTENING. 465 animal and vegetable substances of nutritious qualities, but always in such proportions as will digest with ease and facility. Among the animal substances we may mention beef, lamb, } venison, fowls, milk, eggs, birds, oysters, and fish. Of the vege- tables the most appropriate are potatoes, (Irish and sweet,) . rice, turnips, and beans, including, also, light bread, well baked. . In the use of these and similar articles of diet, much will depend on the taste and peculiarities of patients; but in general, the list will be found sufficiently extended, and requires only the special regulation in regard to quantity. A special remark is required in relation to milk diet. This substance has often been urged as an appropriate diet for con- sumptives, but generally without designating the stage in which it should be employed, or the particular rules governing its use. Hippocrates recommended milk in phthisis, provided the patient was free from fever. Galen mentions its use as being of ancient _ date in his time. ‘Trallian states that persons who used milk — ) early in the disease, and long continued, all recovered. Van ~ Swieten commends the milk diet, and mentions that a young lady used human milk for a year with complete recovery. It is believed by some that the immunity from phthisis observed in the Steppe of Kirghis, is due to the extensive use of a drink consisting of fermented milk. Without attaching much weight to many of the statements which have been made on this subject, I am strongly inclined to the opinion that milk constitutes a valuable variety of food in many cases of phthisis. Its elementary composition affords d priori evidence in favor of its beneficial influence in weak- ened assimilation ; and the presence of the nitrogenous, oleagi- nous, and saccharine substances, furnishes a compound specially adapted to tuberculous conditions. It is evident that this fluid admits of ready assimilation, and that, while it affords all the elements necessary for the repair of the tissue and support of animal heat, it will be less liable to introduce effete or unas- similable substances into the blood, than the more highly- organized animal products. It may be remarked, also, that during infancy, when the change of the tissues is rapid, and the delicacy of the digestive function forbids the use of strong 30 466 THERAPEUTICS OF PHTHISIS. articles of diet, milk furnishes the materials for the rapid and healthy growth of the body; and, although the condition in tuberculosis can not afford a parallel to the formative period of life, yet the lowered state of assimilation, and the tendency to rapid change of the structures, exhibits some degree of anal- ogy to that primary state in which milk proves so beneficial. It is clearly a desideratum in all cases of weak nutritive forces, (particularly secondary,) to furnish the system with those mate- rials which are most readily assimilated to the tissues, and contribute to the sustenance of animal heat, and hence, milk can scarcely fail to prove beneficial in this advanced stage of tuberculosis. The particular kind and preparation of milk must be left largely to the preferences and tastes of the patient. The milk of the cow, ass, and goat have been employed, while, for chil- dren, some would prefer human milk. Probably the most decided effects have been witnessed from the use of goat’s milk, which is known to be very congenial to the systems of debili- tated children. But there is no sufficient reason why the cow’s milk may not be employed with great, if not equal advantage, care being taken to procure it from a healthy animal. Some have manifested a decided preference for new milk just from the cow, and there is a probability of its being more digestible than after cooling; but, above all, the unskimmed article should ‘be used, the cream being secured with the other constituents. This point is important, for milk, deprived of its oleaginous property, loses much of its value to the consumptive. Whey has also been extensively, and often beneficially, em- ployed in the treatment of scrofulous and tubercular patients. The whey of goat’s milk has been highly esteemed, but its superiority over that of the cow is purely conjectural. In Ger- many and Switzerland whey is very extensively employed, and even institutions have been established for carrying into effect this particular treatment. As a general remark, however, it must be admitted that whey containing only the saccharine or carbonaceous element, must, in a majority of cases, prove inferior to the milk containing in addition the oleaginous and nitrogen- ous compounds. TREATMENT OF THE STAGE OF SOFTENING, 467 It remains an undetermined question, how far a pure milk diet is admissible in tuberculosis; that is, whether it would be judicious to limit the diet exclusively to milk, or to compounds of which that article is the basis. Doubtless in children such a course would be proper; and in adults milk might safely be made the principal article of diet, requiring merely modifica- tions in its mode of preparation. Thus, by way of variety, it might, at times, be taken fresh from the cow, at other times boiled, or thickened with flour, rice, tapioca, arrow-root, and similar farinaceous articles. It may be remarked further that fresh cream will often prove highly beneficial, although its prop- erties are different from those of milk, and could not be used as an exclusive diet for any considerable length of time. Another article of diet peculiarly adapted to many cases of tuberculosis is soft eggs. Indeed, these may be advantageously combined with milk in various forms, and would add to the efficacy of that article. Milk and eggs, where the digestive organs are delicate, are greatly preferable to the grosser forms of food, and will often exercise a most favorable influence over the course of a tuberculous affection. 2. Exercise—The limitations of exercise and exposure are much more strictly defined in this than the early stage. There exists, in a general sense, a tendency, during the process of softening, to inflammatory action, and the repetition of such excitement is highly prejudicial, inasmuch as fresh exudations of tubercular matter take place at each increase of vascular excitement. And the vitality of the system being lowered by the morbid state, the powers of resistance are proportionally lessened, and hence patients will not bear exposure to cold or damp air, nor exercise amounting to fatigue. Lither of these conditions prove peculiarly prejudicial and should be carefully avoided. Nevertheless, patients in this stage require sufficient exposure to fresh air to sustain the vital powers, and should, therefore, be required to exercise regularly in suitable weather, and to a moderate degree. The amount of exercise, however, must be determined mainly by the strength of the patient; in some cases, even in an early part of the softening, the debility is very great, while, in others, a good degree of strength is 468 THERAPEUTICS OF PHTHISIS. maintained. These variable conditions necessarily modify each case; but, in all examples, we should never forget the tendency to local excitement, and the evil consequences which follow. Hence, night air, wet weather, and sudden changes should be carefully avoided. The modes of exercise are also important. Walking, in this . Stage, can hardly be recommended. The excitement of the circulation, and the exhausting effects of exercise on foot, more than counteract the advantages of fresh air; while riding on horseback, or in a carriage, seeures all the advantages, without the evil effects. But whatever mode may be adopted, we may safely settle on the conviction that, in this stage, exercise ig not curative, but simply protective; indeed, it is a transition period, which must necessarily advance, and we seek, therefore, merely to preserve the general system in a state of as great vigor as the progress of the disease will permit. 3. Tonic Medication—The lowered condition of the vital powers demands the use of tonic medicines, especially the prep- arations of iron, quinine, and the vegetable bitters. Any of the chalybeates may be beneficially employed, the choice among the various preparations depending, to some extent, on acci- dental peculiarities. Among the most appropriate may be mentioned the phosphates, muriated tincture, and the iron by hydrogen. The combination of quinine with iron is a valuable , compound, and especially so when chills occur, as is often the | case in this stage. The following is a very good formula: & BR Pulv. Ferri, Quin. Sulph. 54 Dj. Sulphur. Sub. 3ss. M. Ft. pil. xxx. One pill to be administered three times a day. The muriated tincture of iron possesses the advantage of improving the appetite, and acting on the urinary secretions, and hence, in particular cases, will be found of great value. It is a question, in my mind undecided, how far alcoholic stimulants and cod-liver oil are appropriate in the stage of softening. My own impression is, that they have a much more TREATMENT OF THE STAGE OF SOFTENING. 469 limited application than in either the early or latter stages, and that, if employed at all, their use must be restricted and care- fully guarded. Whatever opinion we may entertain in relation to the nature of the process by which tubercles are deposited, it must be admitted that the act of softening is connected with a condition more or less allied to inflammation, and that any considerable degree of stimulation will aggravate rather than benefit the local disease. The alcoholic spirits, being absorbed and largely exhaled from the lungs, act very directly on the pulmonary tissues, and can not fail, when taken in large quan- tities, to augment the destructive process. In addition to this, the mucous membrane and secreting structures of the stomach suffer in the same manner, and, finally, a dyspeptic condition results from overstimulation. The liver, also, from a too liberal use of alcoholic stimulants, becomes affected, which completes the series of morbid actions resulting from this cause. Indeed, we can not conceive of a more destructive course of medication in this stage of phthisis than a free use of distilled spirits, for, in all cases, serious injury to the digest- ive function inevitably follows; and the disturbing effects of this derangement will more than counterbalance all the good effects, real or imaginary, which arise from its use. But while I would thus condemn the free use of these agents, it may be admitted that brandy and whisky can be beneficially employed to a very limited extent. When the system is free from fever, and the appetite fails from debility, small portions of these articles may be resorted to; but the quantity should not exceed from one to four drachms, and this should be taken near the time of eating. But, as a general rule, wine will be found far preferable, in this stage of phthisis, to distilled spirits ; it possesses less irritating properties, will be better borne by the stomach, and possesses nutritive qualities; hence, the advant- ages are altogether on the side of wine, and we should give it the decided preference. Malt liquors, also, may be safely and often advantageously employed in this stage. Well-brewed ale and porter often agree with the system, and the union of mild tonic and stimulating properties give these agents peculiar and important advantages. Indeed, as a rule, malt | bad 470 THERAPEUTICS OF PHTHISIS. liquors are preferable to all other beverages for consumptives, while wines rank next, and distilled spirits are least desirable of all. The employment of cod-liver oil in this stage is, also, less effi- cacious than at an earlier or later period. It may be given to a limited extent; but I have a strong conviction, founded on observation, that the very free use of the oil in this stage tends to obstruct the pulmonary capillaries, and thereby to favor the local disease. It has often been suspected of inducing unfavor- able effects on the pulmonary capillaries, causing obstruction, and even inflammation ; and as the process of softening is allied to fatty degeneration, there seems but little propriety in satu- rating the system with oil at the time softening is going on. There are few practitioners, I apprehend, who would give cod- liver oil in the stage of resolution in a hepatized lung; and, although the conditions of the system in the process connected with resolution in pneumonia, and the breaking up of tubercle, are by no means parallel examples of softening, yet the rules which would forbid it in one would be equally applicable in the other. The objection is, that while it does not prevent the deposit of tubercular material, nor arrest inflammatory soften- ing, it does impede absorption, and tends to induce pulmonary obstruction. But besides these objections to cod-liver oil, it will generally be observed that the digestive powers are greatly weakened in this stage, and that the oily preparations are usually ill borne, and strongly tend to derange still further this function. Hence, if the oil is employed at all, it should be given in small doses, not exceeding one or two drachms, and intermitted when un- pleasant effects arise. In this careful manner of exhibition, it may prove useful; while, if pressed to a greater degree, it be- comes offensive and injurious. Finally, the most appropriate means of sustaining the con- stitutional vigor, during the stage of softening, are embraced in the general terms of moderate, nutritious diet ; the prepara- tions of iron, quinine, and the vegetable bitters; the careful employment of stimulating beverages and cod-liver oil, to- gether with well-regulated out-door exercise. Among these TREATMENT OF THE STAGE OF SOFTENING. 471 medicinal agents, none will prove more beneficial than iron and quinine. II. Yo arrest the further Deposit of Tubercles, and to limit the Process of Inflammatory Exudation and Softening in the Pulmonary Tissues.—It must bé admitted that the considerations embraced under this head are of vital importance ; for, unless the deposit of tubercular matter and the inflammatory softening in the pulmonary tissues can be arrested, recovery becomes an impos- sibility. The subject, however, is replete with difficulties, and few practitioners will approach the treatment of this stage of the disease with any great confidence in the results; but, at the same time, the enlightened therapeutist will place a due estimate on the morbid action which is in progress, and apply his agents, as best he can, to the condition which is known to exist. The general indications are embraced under the follow- ing subdivisions : 1. A tonic and sustaining treatment. 2. Change of climate. 3. Counter-irritation. 1. A Tonic and Sustaining Course.—But little can be added to what has already been stated in relation to sustaining the vital powers. The general course adopted to sustain the constitu- tional vigor is equally efficient in fulfilling the present indica- tion. Indeed, the evolution of tubercular matter is to be arrested by such means as maintain the constitutional vigor, and hence tonics, nutrients, and stimulants are the only reliable agents, aside from the possible specifics, in accomplishing this object. The blood and the nervous system should be sustained by the employment of iron and quinine, and such additional treatment as the peculiarities of each case may require. Few agents will exercise a more beneficial influence, in this stage, than a com- bination of iron and quinine, and especially where there exists_ a tendency to chills and sweats. The formula already given, including sulphur, will be proper in the present stage, or any of the preparations of iron will be found beneficial ; the muri- ated tincture, the compound syrup of the phosphates, are excel- ) lent preparations, and will be found well adapted to particular eases. The vegetable bitters are, at times, useful in sustaining the tone of the stomach; the compound tincture of bark, prep- 472 THERAPEUTICS OF PHTHISIS. arations of gentian, quassia, and columbo, are all valuable in certain cases. 2. The Influences of Climate.—The influences of climate in arresting the further deposit of tubercles, although less im- portant than in an earlier period, is, nevertheless, not to be neglected in the stage of softening. The climatic influences on the early stages of the disease, and the rules by which patients should be governed, have already been stated; and although the same principles are, to a certain extent, appli- cable to the stage of softening, yet there are important modi- fications and special rules to be observed in this more advanced condition. The rules heretofore given indicate that, in the early stages, warm climates, such as the southern portion of the United States, are the most beneficial; and that the cool and variable latitudes serve rather to promote and aggravate the disease. When, however, the stage of softening has arrived, patients no longer bear with impunity the warm and humid atmosphere of the South. The effect of such an atmosphere is to increase the debility, and with it, the night-sweats and sputa, and thus to hasten the progress of the disease. Such an atmos- . phere is directly opposed to the maintenance of the constitu- tional vigor, and is, therefore, necessarily prejudicial. But, on the contrary, patients laboring under the influences of softening tubercles, with the vitality of the general system lowered, are not in a condition to encounter a cold or variable atmosphere; for the effect of such vicissitudes must be to mod- ify, in an unfavorable manner, the pulmonary circulation, and often to excite inflammatory action. In all stages of phthisis, out-door exercise is highly important, and the patient should be placed in an atmosphere which will permit him to spend at least a portion of time in the open air; but in cold and variable regions, the morbidly-excitable state of the lungs in these ad- vanced cases forbid that course, and, consequently, such locali- ties should be avoided. If the patient resides in a cold latitude, he must necessarily remain housed during the greater portion of the winter, and he thus loses the advantage of exercise and fresh air. Tn attempting, therefore, to select a suitable climate for the TREATMENT OF THE STAGE OF SOFTENING. 473 stage of softening, the obvious indications are to avoid the two extremes; that is, to protect the patient,on the one hand, against the debilitating influences of a warm and humid atmos- phere, and, on the other, to shield him from the dangers of Northern cold and vicissitudes. Hence a medium latitude, such . as Tennessee, portions of North Carolina, or even Texas and | Northern Mexico, during the winter, would afford sufficient_/ protection from cold, while the temperature would not prove debilitating. But, in all instances, the locality selected should be sufficiently elevated, and free from excessive moisture. But, in some of the regions referred to, the changes of temperature are exceedingly sudden, and, therefore, dangerous. Thus, in Texas, the occurrence of a cold wind known as “ northers,” rapidly reduces the temperature from a genial warmth to a degree of chilliness requiring heavy clothing. These changes are hazardous to consumptives in the stage of softening, for they readily light up inflammatory action, with all its evil con- sequences; and hence, if patients are situated in such localities, it is imperative that they at once seek shelter, and remain ‘housed until the cold wind abates. There can be no doubt that a genial atmosphere, but short of debilitating heat, is that which is best adapted to the stage of softening; and if patients are unable to avail themselves of the advantages of a change of climate, they should be protected by artificial means during cold and inclement weather. It will be far better, indeed, that patients should be subjected to con- finement even to close rooms during unfavorable seasons, than to risk the effects of a harsh atmosphere. In the United States, north of the thirty-eighth parallel, the winters are severe and changeable, and the springs damp and cool. The latter season is peculiarly dangerous; and numerous cases have come under my observation, in which patients have contracted cold, (inflam- matory action,) in the month of March, from which they never recovered. Hence, patients residing in these latitudes should carefully avoid exposure, for the evils of being too closely housed are far less than the dangers of cold. Patients, under these circumstances, should never venture into a cold atmos- phere without being protected by Jeffrey’s or some similar A474 THERAPEUTICS OF PHTHISIS. respirator; but even this is not a sufticient safeguard, for it is not alone through the pulmonary system that cold air acts inju- riously, but it is rather by its influence on the general surface. In general terms, a patient with softened tubercles should seek a mild, equable, and moderately dry air, which will permit almost constant out-door exercise, without the danger of excit- ing inflammatory action. In such an atmosphere the stage of softening will pass more kindly than in any other condition, and, consequently, the possibility of cure will be greatly in- creased. 38. Counter-irritation.—Counter-irritation, in some of its varied forms, has been employed from the earliest period. Hippocra- tes advised cauteries made alternately in the back and breast; Themison ordered external ulcers to be kept open for a long period; Hildanus used a seton in the nape of the neck; and Trallian is said to have successfully cauterized a man on the head for a cough. The importance of counter-irritation, however, in some of its varied forms, can scarcely be overrated in this stage of phthisis. But, in order to secure any decided advantage, the local action . must be long-continued, or frequently repeated. The choice of counter-irritants will depend greatly on constitutional pecul- iarities, as well as the pathological changes taking place. The tendency, in such examples, is to local excitement, and although the process is of a low grade, it is, nevertheless, essentially inflammatory; and the degree of acuteness, as well as the ra- pidity of the morbid changes, will aid in determining the counter-irritant best adapted to the case. Thus, if there is much acuteness of action, or if the process of disintegration of the pulmonary tissues is rapid, blisters will be found preferable to all other modes. But when the disease manifests a low grade, and is slow in its progress, pustulants, such as the croton oil, should be employed. If we apply blisters, they should be from three to four inches square, applied under the clavicles, and permitted to heal with- out protracted discharge. It is far preferable to repeat the application frequently than to set up a chronic discharge, which would weaken and greatly annoy the patient. With this view, TREATMENT OF THE STAGE OF SOFTENING. 475 blisters should be dressed with dry lint or cotton, or, at most, with a little simple cerate. Croton oil may be employed, in most cases, with great advantage; but where the skin is very delicate it should be used at first sparingly, otherwise the irri- tation may induce febrile excitement, and thus react unfavora- bly on the local disease. ‘The tincture of iodine is often a beneficial counter-irritant ; and it is particularly so where much consolidation exists in the pulmonary structure. Doubtless the iodine produces its spe- cific effects, in addition to its action as a counter-irritant, and, in this manner, aids in the removal of obstructions. It can be conveniently applied with a camel’s-hair brush, and should be repeated once a day until sufficient action-is induced. In most cases ythe ordinary tincture will be sufficiently strong; but if a greater degree of excitement is required, we may safely apply a much more concentrated solution. Setons and issues are of doubtful propriety ; they annoy the patient, and are entirely too local in their action to prove very beneficial in a disease occupying a considerable extent of an organ like that of the lungs. Indeed, in all forms of pulmonary diseases requiring counter-irritation, the action should occupy a considerable extent of surface, otherwise the pulmonary cir- culation will not be materially modified. Liniments are comparatively unimportant; but dry friction, ) in all cases, by exciting a healthy glow of the cutaneous ves- sels, will prove beneficial, and, in some examples of limited action, may be chiefly relied on. Generally, however, a higher grade of excitement is required than can be produced by mere friction, and hence blisters and pustulants become our chief reliance. hed : But, whatever may be the mode of counter-irritation, it should be persisted in for a long period ; indeed, its continuance must be proportioned to the duration of the disease itself. There are, however, certain important rules which should be observed in order to procure the full advantages of this method of treatment. In the first place, we should carefully avoid too much excitement, especially when the skin is delicate and the nervous system irritable; for, if this precaution is not observed, 476 THERAPEUTICS OF PHTHISIS. the patient may be seriously injured by the febrile reaction. Again, it is highly important to observe carefully and minutely the progress and degree of the loca] action; thus, if from cold or other cause an increase of acuteness is discovered, the im- mediate application of a blister becomes of the highest import- ance, in order to check, by revulsive action, the morbid exuda- tions which would surely follow the slightest increase of vascular excitement. And, lastly, counter-irritants should be occasion- ally suspended; otherwise, the skin takes on morbid action, becomes thickened and inactive, and the effects of derivative influence is mainly lost. Hence, after their use for a month, , (an intermission of a week or two will prove grateful to the ' patient, and useful in future treatment. ” SECTION IV. TREATMENT OF THE STAGE OF CAVITIES. The stage of excavations, which is generally known as the third stage, may justly be regarded as merely an advanced period of the disease; but as the local changes present condi- tions different from the preceding state, and the constitutional disturbances exhibit certain peculiarities, it becomes proper to consider this period separately from mere softening. When large cavities form, the sputa become copious, with severe and harassing cough, great emaciation, often colliquative sweats and diarrhea, hectic fever, lateritious deposits in the urine, failure of the appetite, and impaired digestion. I believe, how- ever, that the tuberculous matter is less copiously deposited than in the preceding stages, and, indeed, often measurably ceases; but the organic changes of the pulmonary structures, and the impaired state of the whole organism, renders recovery doubtful at best, and often an impossibility. If the morbid action occupies both lungs to a considerable extent, recovery may be considered impossible; but if cavities exist alone in one side, while the other remains free from disease, some TREATMENT OF THE STAGE OF CAVITIES. ATT degree of hope may be entertained. The indications of treat- ment may be arranged under two heads: I. To sustain the vital powers. II. To promote the healing of cavities, I. To sustain the Vital Powers.—Under this head are embraced tonics, stimulants, nutrients, clothing, and climate. 1. Tonics.—The importance of chalybeates and other tonics in this as in the other stages of phthisis, can admit of no doubt, nor can they scarcely be misapplied. But while this is true, the selection of particular agents requires some discrimination. Thus, absorption becomes difficult in this advanced stage, and the chalybeates should be perfectly soluble, and free from ex- citing effects. Hence, pills are always objectionable, and liquids, * especially watery solutions, being more readily absorbed, should / be preferred. The soluble citrate of iron, or the ammonio- : citrate, are among the best preparations, and are comparatively free from exciting properties. It is important, also, that iron should not be administered in very large quantities ; indeed, the irritability of the mucous membrane of the alimeritary canal, and the diminished absorbing powers, would forbid the admin- istration of full doses. With these limitations, iron may justly be esteemed an indispensable agent in this, as in the preceding stages. But, in addition to the preparations of iron, there are other tonics equally important. The vegetables often become exceed- ingly valuable in sustaining the tone of the stomach and in pro- moting digestion. Among these, the infusions of columbo and ) gentian may be esteemed the best; but most of the class may be advantageously employed in a majority of examples. The cold infusion of the prunus virginiana is an agreeable and often beneficial tonic, especially when the stomach is irritable. 2. Stimulanis.—By stimulants I mean the alcoholic prepara- tions, including whisky, brandy, wine, and ale. I have no hesitation in stating that no class of medicines are more bene- ficial in this stage than the different preparations belonging to this class. The general debility demands a decided stimulant; 478 THERAPEUTICS OF PHTHISIS. and while the tonics are being administered, the stimulants should be conjointly employed. Thus, while iron serves to improve the blood, and quassia assists in restoring the tone of the stomach, brandy, whisky, or ale are necessary to arouse the nutritive, circulatory, and nervous functions. The choice of agents will depend largely on the peculiarities of the patient and the condition of the stomach. Of the ardent spirits, I would, as a rule, prefer whisky, but, in some cases, brandy is more agreeable and efficacious. Whisky punch is a prepara- tion which is often of singular value; indeed, patients can partake more freely of whisky combined with milk, than most of the ardent spirits, and being highly nutritious, its good effects are shown in the rapid increase of the nutritive func- tions. Ale is also an agent of great value, and will agree with many patients better than distilled spirits. It possesses the advantage of a valuable tonic, and no inconsiderable nutritive properties in addition to its stimulating effects. ; In the employment of these agents, however, the greatest precautions are necessary, especially in reference to their effects on the stomach. With feeble or impaired digestive powers, and a mucous membrane readily taking on excitement, the stimulants should not be given in concentrated forms, nor in large quantities. If these rules are disregarded, the tone of the stomach is speedily impaired, the appetite lessened or destroyed, and the whole system seriously injured. As a rule, stimulants should be given at or near the time of eating, so that they may aid in promoting the appetite and digestion, while the mucous membrane is protected from overstimulation. 3. Nutrients.—This class embraces diet in a general sense, the administration of cod-liver oil, medicinally considered, and all substances which are susceptible of assimilation, or which sup- ply carbon for the development of animal heat. In relation to diet, it need only be observed that the function of nutrition having been reduced to the lowest point, substantial nutrition is imperatively demanded ; and if we are unable, either from want of appetite or inability to digest, to introduce nutritive substances into the system, the hope of curing the disease with medicines alone will prove utterly futile. TREATMENT OF THE STAGE OF CAVITIES, 479 The condition of primary digestion must determine mainly the articles of food to be employed; and as this function is quite variable in its activity, we must adapt the food to the peculiarities of each case. Thus, in some examples, digestion is performed with tolerable ease even in the last stages of phthisis; while in others the functions of the stomach become depressed to the lowest point, and but little appetite for food exists. In those cases in which digestion is performed in a tolerable degree, the patient should be allowed solid and substantial ani- mal food, such as has been formerly mentioned, but the quantity should be sufficiently restricted to secure easy and complete digestion. Indeed, all disturbance of the digestive function should be carefully avoided, for the sympathetic influences ex- erted on the pulmonary organs will prove highly prejudicial. With this view of the subject, it will be readily conceded that a small quantity of nutritious food, well digested, will prove far more valuable than double the quantity imperfectly chymified. Hence, the physician should carefully adapt the quantity, no less than the quality, to the digestive powers of the stomach. And, in attempting to regulate the quantity of food, we can not always rely on the statement of patients, for I have observed that they often declare their digestion to be good, when further inquiry reveals the fact that they have frequent eructations, distention and uneasiness of the stomach, with more or less acidity. In all such examples the diet should be restricted, and carefully adapted to the powers of the stomach. In another and more unfortunate class of cases the appetite fails, the powers of digestion are reduced to the most feeble condition, and patierits are unable to take solid food. Nor will the ordinary soups or liquid diet prove more successful, for acidity usually takes place, and patients suffer from gaseous dis- tention of the stomach. It is necessary, therefore, to employ concentrated preparations of animal food, such as essence of beef, calf’s-foot jelly, sweet cream, and similar articles, which require but little digestion, are readily absorbed, and afford substantial nourishment. There are some patients with whom new, unskimmed milk, or even cream, will agree, and with such the milk diet is exceedingly valuable. In this condition patients 480 THERAPEUTICS OF PHTHISIS. are reduced to the delicacy of infants, and they should be treated accordingly ; hence, the milk of the goat, ass, or cow may become a second time the natural nutriment for such weak digestive organs. The addition of lime-water to milk will, at times, tae to prevent the formation of acid, while it does not impair the nutritive qualities of the fluid, nor prove unpleasant to the taste. Boiled milk, with or without the addition of tapioca, arrow-root, or other farinaceous articles, will agree with some stomachs better than the raw material; while, in others, milk- whey will be tolerated when the other preparations prove offensive. This careful course of dieting, with mild tonics and stimulants, will often restore the digestive powers so that more substantial food will be tolerated. The administration of cod-liver oil becomes highly important in this stage; and, although it is given as a medicine, it is mainly, if not exclusively, a nutrient. It happens unfortunately, how- ever, in too many cases, that the stomach will not tolerate the oil to any considerable extent, and its disturbing effects coun- terbalance all the benefit arising from the small quantity intro- duced into the system. When patients are unable to take solid food, cod-liver oil will not be well borne; indeed, it is usually rejected in such cases, and no benefit is derived from its use. Under such circumstances the oil must be withdrawn, or ad- ministered in a modified form, such as an emulsion with gum arabic, or, what is better, the yelk of an egg. A preparation is known in market as Querw’s Jellified Oil, which consists of cod-liver oil solidified by the addition of gelatin and sugar. This preparation, although not a true emulsion, will sometimes be borne better than the natural oil. The emulsion with the yelk of eggs, freshly prepared, is a very eligible form; and, when rubbed with mint-water, and taken in wine, constitutes by no means an unpleasant draught. The great point, however, is to introduce the oil, as largely as possible, into the system; for if cavities are ever healed, it must be by the arrest of further decomposition of the body, and thus giving to the tissues a recuperative tendency. At the same time, the phosphates of iron and lime (especially the latter) will materially contribute to the chances of recovery. TREATMENT OF THE STAGE OF CAVITIES. 481 The formula which I prefer is a mixture of the oil and phos- phates, in the manner to be mentioned hereafter. When the oil can not be taken, or even conjointly with it, fresh butter, sugar, and other carbonaceous articles may be used. There can be no doubt that sugar, as a carbonaceous article of diet, is valuable in sustaining animal heat and in ae. the waste of the tissues. The syrup of rock candy (crystallized sugar) or that article in substance, is the best saccharine prep- aration. But it is a curious fact that sugar must be taken in* large quantities in order to be well received by the stomach ; ) ye indeed, small portions often derange digestion, while larger . ones prove eminently nutritious. 4, Clothing.—The calorific power being materially impaired in this stage of the disease, the system requires to be well pro- tected by suitable clothing. Flannel worn next the skin, in cold and variable seasons and climates, is indispensable, while the body is further protected by suitable woolen apparel. But in warm climates and seasons we should be careful not to oppress the patient with too much clothing; otherwise, debili- tating perspiration will ensue, which can not fail to prove prejudicial. Hence, the clothing requires to be regulated with care and judgment, so that the patient may be protected from the influences of cold, on the one hand, and on the other, secured against the debilitating effects of too great warmth of the surface. But, in all cases, the cutaneous circulation should be maintained in a state of some activity; for which purpose we may employ warm baths made stimulating with salt or mustard, or, what is even better, dry friction. The greatest benefit will be derived from stimulating the cutaneous vessels, and should be daily put in requisition. 5. Olimate.—The influences of climate in this, as in other stages of phthisis, are exceedingly important, and should not fail to secure careful attention. In the preceding stages of the dis- ease, I have recommended warm or mild latitudes; but in this advanced condition patients require a more bracing atmosphere, which serves to sustain the failing powers of life. In this stage, the formation and deposit of tubercular matter is comparatively limited, and consequently, neither the arrest of development, al 482 THERAPEUTICS OF PHTHISIS. nor the elimination of its elements, demands particular atten- tion, nor is there the same tendency to local inflammation that is rnet with in the stage of softening; hence, the condition of climate which we particularly seek is that of an invigorating character, without possessing the harshness of extreme North- ern latitudes. Sea-coasts, valleys, and damp localities should be particularly avoided, while the preference should be given to considerable elevations, or mountainous regions. In our own country few situations will be found more valuable for a summer retreat than the mountainous regions of Pennsylvania and Virginia, ranging between the thirty-eighth and forty-first degrees of north latitude. In these situations the atmosphere is pure and bracing, and permits regular out-door exercise. The great Northwestern region of Minnesota, as far north as (_the forty-fifth parallel, is a most favorable atmosphere, possess- ing, indeed, all the advantages required in this stage of the disease. # During the winter season, Arkansas, East Tennessee, and / portions of Georgia and North Carolina afford safe retreats for atients debilitated with phthisis; but in no instance should they seek an extreme Southern atmosphere, particularly the low and damp situations. Mountainous regions, however, even further south, are measurably free from the objections to which I allude, and may often be sought with safety. This is espe- cially true of the elevated and more northern portions of Texas. Probably few régions of country would prove more ‘ propitious than Santa Fé, situated on the thirty-sixth parallel ~ of north latitude. Sea voyages should, also, be classed with the invigorating agents. If the patient retains a fair degree of strength, we may reasonably anticipate beneficial results from sea voyages; but, in order to prove curative, they must be long continued or frequently repeated. Patients, indeed, should live on the ocean, so that the full revolutionary effects of sea air may be obtained. The stage in which sea voyages prove most beneficial are the early and the late, passing by the stage of simple softening. The general principle, however, upon which I insist is, that phthisical patients advanced to the stage of cavities should TREATMENT OF THE STAGE OF CAVITIES. 483 seduously avoid warm, moist, and relaxing climates, for these increase the debility, the expectoration, and colliquative sweats, and thereby hasten dissolution. On the contrary, a cool and dry atmosphere, with considerable altitude, should be selected ; and, indeed, patients should be made to endure as much cold as their enfeebled constitutions will bear. And in determining this question individual peculiarities should always be consulted; there are some patients, apparently in the same stage, who bear cold much better than others, and all such should be sent as far North as their conditions will permit. Hence, I have not sought to furnish a list of localities suitable for this stage of phthisis; but merely to indicate the general qualities of climate best adapted to such patients, leaving the practitioner to make a selection in accordance with the peculiarities and conveniences of patients. The general principle, however, to which I have alluded is one of importance, and should not be overlooked in this last struggle for life. II. To promote the Healing of Cavities—The general course of tonic and invigorating remedies, as detailed in the preceding pages, necessary to sustain the vigor of the constitution, become indispensable in fulfilling the present indication; for every agent, medicinal or hygienic, calculated to improve the tone of the general system, will tend more or less to promote the heal- ing of cavities. But besides these measures, there are certain additional means which appear to promote, in a more direct manner, the healing of cavities, and, therefore, require to be separately considered. It may be here remarked, that for this purpose our forefathers proposed some very extraordinary means, and our cotemporaries have been scarcely less fertile in sug- gestions. De Bligny relates a desperate case of consumption cured by a sword accidentally penetrating the chest 5 and Gil- christ suggested an opening in the affected side, which, by. causing inaction of the lung, might promote the cicatrization of the cavities. More recently, M. Piorry has proposed ex- ternal compression, with the view of approximating the surfaces of cavities, and thus favoring their ultimate closure ; while Dr. Green, of New York, has injected a solution of nitrate of 484 THERAPEUTICS OF PHTHISIS. silver, with the view of changing the action of diseased sur- faces. And a class of practitioners still bolder, have sought to heal cavities by penetrating their walls, and thus applying medicinal agents directly to the diseased part. Among the remedies, however, which are more promising, we may mention the use of the phosphates of iron and lime; the hypophosphites . of lime and soda; sulphur, and various inhalations. In this advanced stage of phthisis, when large caverns have formed in the pulmonary organs, the phosphates of iron and lime seem to possess the double advantage of imparting tone to the system, and supplying the blood with elements which favor the process of healing. It may be difficult to explain the exact modus operandi of these agents; but the cretaceous trans- formation of tubercular masses which frequently occurs, furnishes an indication for the use of the calcareous salts. Speculative opinions, however, are less valuable than practical observations, and guided by my own experience, I have no hesitation in be- lieving that the phosphates contribute to the process by which tuberculous caverns are healed. The preparations which I have ~ usually employed are the phosphates of iron and lime, given alone, or conjointly with cod-liver oil. The particular prepara- tion to which I have given the preference is that known as the compound syrup of the phosphates, consisting of the phosphates of iron, lime, and soda, with a considerable excess of free phos- phorie acid. This compound I have had still further improved by adding a greater quantity of lime, rendered soluble by the addition of a few drops of hydrochloric acid. In this form it is a very elegant and agreeable preparation, and contains a large quantity of soluble phosphate of lime, being in the proportion of seven grains of the salt to a drachm of syrup. Another excellent formula is that already given, consisting of the phos- phates of iron and lime added to cod-liver oil; but in this form the lime is quite insoluble, and, therefore, less efticacious than in the syrup. I frequently employ the following formula: & Ol. Morrhue, 3 vj. Syr. Ferri cum Cale. Vin. Picis, aa Ziij. M. A table-spoonful to be taken two hours after meals, TREATMENT OF THE STAGE OF CAVITIES. 485 Or: BR Ol Morrhue, Oj. Ferri Phos. Cale. Phos. 44 3iij. M. Shake well and take a table-spoonful two hours after meals, With these preparations I endeavor to crowd the system as much as possible with the phosphates, while, at the same time, the other measures in relation to diet, exercise, ete., are strictly enforced. The combination of the phosphates of iron and lime ' with cod-liver oil, is a valuable mode of exhibiting these arti- cles; and it has appeared to me that, in this stage of the dis- ease, they afford almost the only hope of recovery. If the oil can not be taken, the syrup of iron and lime, with or without the wine of tar, may be employed; but intolerance of oil is nearly always a sign of evil import, and should, if possible, be overcome. The hypophosphites of soda and lime have recently been brought to notice by Dr. Churchill, with the view, as he de- clares, of introducing phosphorus, in a low state of oxydation, into the system. But neither the alleged modus operandi of these preparations, nor the practical results, can be received as well-established facts; on the contrary, a great degree of doubt embarrasses the whole subject. Dr. Churchill does not appear to have adduced any fact to show, that the tuberculous condition consists essentially in a diminution of phosphorus in the sys- tem; and, until that theory is established, or rendered probable, we are scarcely justified in relying exclusively on the use of so doubtful an agent. I am, however, inclined to the opinion — that both sulphur and phosphorus are beneficial in phthisis ; ? and, perhaps, some evidence of this may be found in the fact that tubercle contains neither of these elements. But this is far from proving that a diminution of phosphorus is the essential pathological condition in phthisis, or that the supply of that agent is all that the system requires. I have employed the hypophosphites in numerous cases of phthisis, (particularly in this so-called third stage,) but, it must “be confessed, without any definite results. And this opinion appears to have been fully established by Dr. Cotton, of the 486 THERAPEUTICS OF PHTHISIS. Brompton Hospital. After the composition of these com- pounds was made known, Dr. Cotton employed the hypophos- phites in various stages of the disease, according to the sugges- tions of Dr. Churchill, but, unfortunately, without any definite results. And Dr. George B. Wood, of Philadelphia, in a com- munication to the author, observes that he has no confidence in the hypophosphites, and that, after extensive trial, they have been found wanting. We can not, therefore, in the present state of the subject, accept the statements of Dr. Churchill as fully established, but we are left in doubt as to the general results, if, indeed, it is not already certain that a fundamental error vitiates both the premises and conclusions. If, however, any one desires to test still further the hypophosphites, I would advise that they be added to the cod-liver oil mixture, or to the syrup of iron and lime previously mentioned ; for in this man- ner we may secure whatever advantage the articles possess, while, at the same time, we do not abandon the patient to the uncertainties of an agent so doubtful in its character. There is some reason to believe that sulphur, either in sub- stance or in sulphurous waters, possesses some efficacy in this stage of phthisis. Dr. Copland remarks that sulphur, in the treatment of phthisis, has fallen into disuse, but that he has seen much benefit from it in several states of the disease. I have employed it frequently, and, at times, with apparent bene- fit; but, being unwilling to trust alone to so feeble an agent, it has usually been, combined with other articles, especially the eas oil. Three drachms to the pint of oil makes a proper proportion; and if there is much dryness of skin, or evidence of cutaneous disease, it may prove beneficial. The sulphuretted waters have been employed for a similar purpose; but we could scarcely anticipate much benefit from them in this advanced stage, particularly if great debility, accompanied by sweats and diarrhcea, be present. Sulphur, therefore, may, in certain cases, prove beneficial in the stage of caverns, but its range of action, is limited and uncertain. The inhalation of various substances has often been resorted to in phthisis; and if such agents can prove beneficial in the disease, we might reasonably expect to witness their good effects TREATMENT OF THE STAGE OF CAVITIES. 487 in the stage of caverns. From the earliest periods of medical history the treatment of phthisis by inhalations has had its advocates and vaunted cures; but the final judgment of the profession has been against this mode as a curative measure. The inhalation of oxygen, hydrogen, carbonic acid, chlorine, iodine, the vapor of tar, and almost every. conceivable article susceptible of volatilization has been resorted to; and while the regular profession have been experimenting with these agents, quacks have seized the opportunity to impose on the credulous and unsuspecting with the specious but false idea, that medication directly applied to the diseased part was the only proper course. Numerous agents have been recommended for the purpose of inhalation. Galen sent his patients to Tabias, near Vesuvius, to breathe the sulphurous atmosphere; Bennett recommended fumigations, with sulphur and other agents, in closets or cham- bers; Dr. Mead advised frankincense, storax, etc.; Van Swieten employed frankincense, storax, amber, and benjamin; Bonet directed vapors of turpentine and opium; Sir Alexander Crich- ton strongly insisted on the efficacy of tar-vapor, diffused through the room, and breathed for a considerable period; while Sir Charles Scudamore is equally sanguine in the use of a weak preparation of iodine and tincture of conium. M. Gannal commended the inhalation of chlorine; and Piorry, it is well known, employs iodine by inhalation, frequently repeated, and in large quantities. Dr. Turnbull recommended the iodide of ethyle, while ether, chloroform, creosote, and the various balsamic agents, have been employed by others. All these agents, and many more, have been used again and again by the profession, until their virtues have been fully tested; and the result has been, that, in the deliberate judgment of expe- rience and observation, inhalations have an exceedingly limited range of action in the treatment of phthisis. I do not mean to say, however, that this mode of medication is absolutely worthless; but it is evident that, in most instances, inhalations merely palliate the urgent symptoms arising from irritation, or, in some still rarer cases, contribute to the healing process in cavities. It is possible, indeed, that when the deposition. of 488 THERAPEUTICS OF PHTHISIS. tubercular matter has measurably ceased, and the interior of a cavity is merely in a suppurative condition, the inhalation of tar, creosote, naphtha, chlorine, and similar agents, may pro- mote the healing process. The agents which are most beneticial in these cases are those already mentioned, administered by means of inhalers, or diffused through the atmosphere of a room, It is difficult to give definite formule for these preparations, for the degree of concentration must be varied with the condi- tion of the patient; and the only safe rule is the amount of irritation induced at the moment of inhaling, If chlorine is employed, it may be diffused through the atmosphere of the room by pouring hot water on chloride of lime, or the aqua chlorini may be received through an inhaler. In either case, the concentration of the medicine should not be such as to cause irritation, and should never exceed a degree which can be breathed freely by the patient. Creosote, tar-vapor, and naphtha may be inhaled with safety, either separately or in combination. The following formula will meet many cases: R Tinct. conii, Zij. Creosote, 3j. M. One to two tea-spoonfuls may be added to the water in the inhaler, and used for five, ten, or fifteen minutes, according to circumstances. If much irritation is present, hydrocyanic acid may be substituted for the creosote. I have employed, also, carbonic acid, (or, rather, carburetted hydrogen,) as obtained from burning charcoal, with some advantage, especially where profuse suppuration was present. The method is, to ignite ‘charcoal in a portable furnace, such as that employed for do- mestic purposes, and, after all smoke has disappeared, introduce it into the patient’s room, regulating the quantity by opening or closing doors and windows. An atmosphere thus charged may be safely and often advantageously breathed for half an hour, twice a day, the usual effect being to check the profuse suppurative action. Chlorine, which, at one time, seemed to promise so much, has not retained the confidence of the pro- fession, but has measurably fallen into disuse; but there are cases with profuse suppuration, and especially when accompa- TREATMENT OF THE STAGE OF CAVITIES. 489 nied by fcetid expectoration, that receive some benefit from this agent, although we can scarcely estimate its powers above those of a palliative. The inhalation of iodine, in this stage, can promise very little good, if, indeed, it is not generally preju- dicial. As mere palliatives, in examples of severe paroxysmal coughing, a few drops of ether or chloroform, or the two com- bined, will often prove of great comfort to the patient, although they can promise nothing in the way of cure. Upon the whole, therefore, inhalations occupy a subordinate position in the cure of phthisis. In the early stages they are scarcely needed; during the suppurative period, they are often injurious; and in the stage of excavations, no reliance can be placed on their curative powers. Of late, however, unscrupul- ous empirics have deluded a credulous public with the plausible idea of making medicinal applications directly to the diseased part; but no well authenticated case of true phthisis has, according to the best of my knowledge and belief, ever been cured in this manner. The highest position, therefore, which we can assign inhalations, is that of a mere palliative; and, even in this sense, the range of action is quite limited, and, indeed, comparatively unimportant. In addition to the inhalation of vapors, the insufflation of powders has been occasionally resorted to, as well as the intro- duction of liquids. Pulverulent substances, such as the nitrate of silver, mixed or even pure, may be insufflated with safety, and, at times, with advantage. I have used the pure nitrate without inconvenience arising from its strength ; but, generally, from one-tenth to one-half should be the proportion of the silver, the diluting substance being sugar of milk. It is ques- tionable, however, whether these powders penetrate much be- yond the larynx, and hence their agency is most important when laryngeal irritability predominates. The preceding statements in relation to the treatment of the stage of cavities, embraces the principal means which the phy- sician can employ, variously modified to guit individual cases ; and, while a few such advanced cases may ultimately recover under judicious management, a much larger number will fall victims to the intractable nature of the disease. If both lungs 490 THERAPEUTICS OF PHTHISIS. are involved, but little: hope need be entertained; but if one side remains healthy, and the cavities are not too extensive in the affected part, the possibility of recovery should prompt us to the persevering use of appropriate remedies. . SECTION V. TREATMENT OF INCIDENTAL SYMPTOMS. Numerous incidental symptoms and complications arise in the course of phthisis, which demand treatment either to pro- mote the cure, or to contribute to the comfort of the patient. Among the incidental symptoms the most important are— cough, febricula, hemoptysis, dyspnea, hectic fever and night- sweats, indigestion, diarrhea, and thoracic pains. 1. Cough.—As cough is one of the most constant symptoms in phthisis, running, indeed, through all its stages, and often becoming exceedingly distressing, its treatment assumes a high degree of importance. The causes of this symptom are various. The essential tuberculous cough depends on the irritation excited by the morbid deposits in the pulmonary tissues, and the changes which they undergo; or, it may arise from excitement of the mucous membrane of the bronchi and larynx. The true tuberculous cough, arising from the essential local irritation of the disease, admits only of palliation, for its re- moval would imply a cure of the disease itself. The degree of cough is exceedingly variable in different individuals; in some examples, it is so mild as scarcely to demand even palliative treatment; while, in other cases, it becomes so violent as to be exceedingly distressing to the patient. In the early stages of the disease, and prior to the occurrence of softening, the cough is dry, comparatively slight, and is seldom manifested in severe paroxysms. It is, therefore, a cough arising from the deposit of new substances in the tissues of the lungs, independ- ent of mucous disease, and, consequently, is not to be relieved by the ordinary expectorants. Indeed, the only agents capable TREATMENT OF INCIDENTAL SYMPTOMS. 491 of affording relief in this form of cough, are the anodynes; and although these admit of considerable variation, yet the opiates will be found the only reliable preparations. Small doses of morphine, of opium, or of Dover’s powder may be employed; but [ have usually found better results from the salts of morphia than any other opiate. The morphine may be given in the form of syrup, powder, or pill, alone or combined with other agents. The following formula I have found quite valuable : BR Morphie Mur. gr. j. Ext. Conii gy. xxiv. Pulv. Ipecac. gr. ij. M. Ft. pil. viij. Take one or more pills, according to circumstances. If the preparations of opium are found objectionable, coni- um, hyoscyamus, belladonna, etc., may be resorted to in the following or any other convenient combination : R Ext, Belladonn. grs. v. Ext. Conii Dj. Ipecac. grs. ijss. M. Ft. pil. x. The combination of antimony with morphine is often exceed- ingly valuable, especially if any febrile symptoms are present. I usually direct the following mixture: RB Syr. Prun. Virgin. 3ij. Ant. Tart. Morph. Acet. 44 gr. j. M. Dose a tea-spoonful, pro re nata, Tt should always be remembered, however, that ue tend to impair the digestive powers, and hence they shou d be em- ployed as sparingly as the circumstances will permit. Indeed, these preparations should not be given constantly, but merely occasionally, as the symptoms become more severe. In some cases cough is aggravated by vascular fullness of the part, and hence the relief which is at times observed to follow hemoptysis. When this condition is present, counter-irritants, 492 THERAPEUTICS OF PHTHISIS. / such as dry or wet cups, pustulants, etc., become valuable aids in relieving the cough. When the stage of softening arrives, and tuberculous sputa begin to appear, the cough becomes more severe, not infre- quently paroxysmal, and demands, in part, different treatment from the preceding condition. It is true the opiates still re- main the basis of treatment, but their effects may be aided by the stimulating expectorants, antispasmodics, and alkalies. In this stage of phthisis, while the process of softening is going on, there is more or less irritation of the bronchial mucous membrane, which contributes to the aggravation of the cough. The following formule will prove advantageous in many cases: EB Syr. Senege, Syr. Scillee, Vin. Picis, 44 3). Ant. Tart. gr. j. Morph. Acet. grs. ij. M. Tea-spoonful, pro re nata. Or: BR Pulv. Scille, Quin. Mur, 44 grs. viij. Morph. Mur. gr. j. Sulphur, 5j. M. Ft. pil. viij. One pill pro re nata. A saturated tincture of the sanguinaria, to which morphine has been added, proves a grateful anodyne and expectorant. R Tinct. Sanguin. Sat. 3). Morph. Acet. grs. iij-v. Ol. Gaulth. gtt.v. M. “Twenty drops may be taken, on sugar, at night. (Green’s formula.) As the stage of softening advances, and the excavations en- large, opiates become less important in the treatment of cough, while the stimulating expectorants, alteratives, and even decided stimulants, are most valuable. Naphtha, creosote, acetic ether, and similar agents, often prove useful, especially when the cavities are large, and the expectoration profuse. Dr. Turnbull particularly commends the acetic ether, and I have used it with advantage in the following form: TREATMENT OF INCIDENTAL SYMPTOMS. 493 R ther. Acet. 3), Morph. Acet. gr. j. Syrup, 3ss. M. Half a tea-spoonful may be given three times a day. Or the following: EB Acetone, 3ij. Morph. Acet. gr. j. Syr. Prun. Virgin. 3ij. M. Tea-spoonful three times a day. In these formule the morphine may be omitted, at the dis- , cretion of the practitioner. Carbonate and muriate of ammonia often prove useful in promoting expectoration in this stage of the disease, although they can not be classed with the expec- torants. ‘When the mucous membrane of the bronchi becomes extens- ively involved, the antimonial preparations, combined with morphine and the stimulating expectorants, constitute the best course of treatment. The formule already given, embracing these articles, will be found equal to any others; to which we should add counter-irritation, and the inhalation of soothing agents, such as warm vapor, tincture of conium, hydrocyanic acid, chloroform, and ether. In that variety, associated with, or depending upon, ee irritation, local applications of nitrate of silver, iodine, and- counter-irritation become necessary. The local application of the nitrate of silver is highly valuable, and will often do more to relieve the irritation than any other agent. The = should range in strength from ten to forty grains to the ounce of water, and be applied every day or two. Morphine is also exceedingly valuable, alone or combined with squills, ipecac, or conium. The inhalation of weak preparations of iodine, or, if too much irritation exists, of tincture of conium, with hydro- cyanic acid, as previously mentioned, may be used. Sulphur, also, will be found valuable in some cases, either by fumigation or in substance. Counter-irritation with croton oil is decidedly advantageous, especially where much vascularity of the fauces ) is perceptible. 494 THERAPEUTICS OF PHTHISIS. It should always be remembered, however, in relation to this whole subject, that a phthisical cough is not to be cured by the usual expectorant and anodyne cough mixtures; and that these agents should be used as sparingly as possible, merely with the view to palliation; for their extensive employment im- pairs the digestive function, and, in that sense, proves decidedly detrimental. These preparations are designed merely to alle- viate distressing symptoms, and they should not be given con- tinuously, but only occasionally, as circumstances require; thus, an anodyne preparation at night will be found, in a majority of cases, quite sufficient. 2. Treatment of Febricula——The febricula which occurs in phthisis anterior to the supervention of hectic, usually results from chills; and, as the calorific power is low throughout the early stages of the disease, these phenomena are by no means infrequent. As a general rule, the tendency of all febrile affections in the tuberculous conditions is to impair the pulmo- nary functions, and thus to augment the special lesion. Hence, the necessity for treatment in such examples, When chills and febrile movements are observed, we should at once resort fo quinine and anodynes for the purpose of pre- venting a repetition of the paroxysm, while we protect the lungs, as far as practicable, during the febrile excitement. Quinine and Dover’s powder, singly or combined, fulfill the first indication; while mild diaphoretics, such as the spirits of mindererus or acetate of potash, with spirits of nitre, or a little opium, usually meet the second. If there is any marked tend- ency to pulmonary congestion, cups should be applied to the chest, or sinapisms and blisters, according to the peculiarities of the case. At the same time the bowels should be freely opened ; indeed, mild purgatives are highly important in such conditions, and should never be neglected. 3. Treatment of Hemoptysis—Heemoptysis occurs under very different pathological conditions, as well as in variable quan- tities. In the early stages of the disease it is the result of mechanical obstruction or temporary engorgement; while, in the latter period, or that of excavations, a large vessel may be opened by ulceration, and fatal hemorrhage ensue. In other TREATMENT OF INCIDENTAL SYMPTOMS. 495 cases, blood may exude from the walls of cavities, and thus produce a daily discharge even in considerable quantities, I have known a case in which this variety of hemoptysis occurred every night for weeks in succession. In the early stages, if the hemorrhage is copious, it should be very promptly arrested, and for this purpose no agent is more ' efficacious than common salt. It should be taken dry, and» as freely as the stomach will bear; while, at the same time, cups should be applied to the chest, and, if necessary, blood abstracted. If the pulse is full and strong, the abstraction of blood will prove decidedly beneficial; and this may be accom- plished either by venesections or cups, the choice depending on the condition of the patient. In addition to salt, various other agents are employed, such as gallic acid, tannin, opium, sugar of lead, spirits of turpentine, alum, the mineral acids, ice, and eooling beverages generally. Alum and sulphurie acid consti- tute an excellent astringent mixture, and may be employed with advantage in many cases. The gallic acid, however, with opium | and lead, is a very efficacious astringent. But the selection of '” an agent, or a course of treatment, must vary with the condition of the patient; and hence, we bleed and give cooling beverages in one class, while we resort to turpentine, astringents, and tonics in the opposite variety. If the hemorrhage is passive, and small in quantity, it is usu- ally regarded as unimportant; but my impression is that even a small hemoptoe furnishes an indication for treatment which should not be disregarded. If the action is of a low grade, decided counter-irritation should be at once resorted to, together with such astringents as may be required ; and these agents, especially dry cups, sinapisms, blisters, and pustulants, should be unremittingly continued, until the exudation of blood ceases. When, however, there is overaction, bloodletting is the safest and surest remedy, and, therefore, should not be neglected. Some practitioners fear the depressing effects of bleeding ; but, on the contrary, much greater evils flow from the mental anxi- ety and physical depression incident to hemoptysis, than could possibly arise from the judicious abstraction of blood. When the hemorrhage is very profuse, inducing great weak- 496 THERAPEUTICS OF PHTHISIS. ness, full doses of gallic acid, alum, with sulphuric acid, should be given, the utmost quietude enjoined, the cough relieved by anodynes, and the patient allowed pellets of ice, while the usual external applications are at the same time required. Many of the ancient physicians resorted to the external applica- tion of cold; and Van Swieten states that Felesco, a celebrated physician of Rome, not only gave cold water internally, but applied sponges, dipped in cold water, to the naked breast. It is probable, indeed, that in profuse and dangerous hemorrhage, the application of ice to the chest might prove salutary, but its employment would certainly require caution and discrimination, and should not be long continued. Pellets of ice, however, may be taken freely internally; and the apartment should be well ventilated with fresh and cool air. 4. Treatment of Dyspnea.—This symptom occurs in phthisis when connected with an asthmatic constitution, a nervous or excitable state, or in the advanced stage of the disease. When resulting from an asthmatic complication, stimulants, antispas- modics, and even nauseants become necessary. Among the antispasmodics lobelia, asafcetida, and valerian will be found preferable; but it is not often necessary to resort to nauseants. The following preparation will often act with remarkable effi- ciency, especially when the attacks are paroxysmal: & Tinct. Lobelia inflat. Fluid Ext. Valerian, Lac Asafoet. aa 3) M. Give a tea-spoonful every hour, until relief is obtained. Morphine may be added to this mixture, or to the lobelia alone, if the other ingredients are objectionable. In the nerv- ous variety of dyspnea, valerian, asafcetida, and morphine, or Dover's powder, will act beneficially. If any marked degree. of congestion exists, dry cups and other counter-irritants must be added to the list. The dyspnoea of the advanced stage is _ irremediable, but may be mitigated by counter-irritants, anti- ij ii VA '' spasmodies, anodynes, and stimulants, or by the moderate inhalation of chloroform or ether. TREATMENT OF INCIDENTAL SYMPTOMS. 497 5. Treatment of Hectie Fever and Night-sweats——Hectic fever, depending on the advanced condition of the tubercular disease, general and local, does not admit of cure; nor can the tendency to night-sweats, which arises from the same source, be entirely removed. But, while these secondary symptoms can not be entirely suspended, they may be so far mitigated as to contribute materially to the comfort of the patient. The fever can be best mitigated by anodynes, diaphoretics, and tonics. Thus, mor- phine, solution of the citrate of potassa, acetate of ammonia, and quinine are the most efficient agents; and, as the object is to allay irritation, the anodynes become the most appropriate med- icines. The following, among other formule, will be found useful : R Lig. Potass. Cit. Zijss. Morph. Sulph. gr. ss. Syr. Limonis, 3ss. M. Dose: half an ounce, as circumstances may require, Sponging the body with tepid water, acidulated with vinegar, or salt and water, will generally prove grateful and refreshing, and often mitigate the evening exacerbations of fever. The attention of the physician, however, is usually directed to the colliquative sweats which follow the evening exacerba- tion of hectic, and which prove uncomfortable and debilitating to the patient. So long, however, as the fever continues, the period of remission will be marked by the occurrence of per- spiration, and hence the treatment of the two are intimately associated. It has been found by experience that quinine, the mineral acids, oxide of zinc, and some of the astringents, such as gallic acid, prove most beneficial. My own experience is In favor of quinine and sulphuric acid, and oxide of zine, which may be given separately or combined. The following often suc- _ceeds: ER Quin. Sulph. 5j. Acid. Sulph. dil. 3ij. Aq. Menth, Pip. 3jss. Syr. Limonis, 3ss. M. Dose: 3j as may be required. 82 ye ao. ae Re 498 THERAPEUTICS OF PHTHISIS. The following pills will often prove efficient: | R Oxide Zinc, Quin. Sulph, 44 grs. xv, Acid. Gallic, 3ss. M. Ft. pil. xv. One pill three or four times a day. The oxide of zinc has been particularly extolled, but it has appeared to me inferior to the other articles named ; but it may be, at times, advantageously combined with quinine. Dr. The- ophilus Thompson particularly commends four grains of the oxide of zinc, with the same quantity of extract of henbane. A very efficient night pill, in such cases, consists of four grains of zine, two of quinine, and the eighth of morphine. But I would advise that the zinc be not long continued. In addition to these remedies, sponging the surface with acids and astrin- gents proves useful, while the bed-clothing is made light, and the room well ventilated. 6. Indigestion and Diarrhea.—Andral made the observation, many years ago, that in persons dead of phthisis, the mucous membrane of the stomach exhibited various morbid conditions, among which he enumerated redness, with more or less thick- ening, especially at the great curvature; softening, with or without redness; a dark slate color; thickening, or hypertrophy, extending beyond the mucous tissue, and consisting in indura- tion and tubercular deposits. He concluded, finally, that one- half of those who die of phthisis are subject to chronic or acute. gastritis. These facts, together with the more recent observations, clearly prove that the stomach and intestines are strongly prone to derangement in the advanced stages of phthisis, and that the consequent impaired digestion constitutes an important symptom. We can not, however, concur in the opinion of An- dral, that these affections are so commonly inflammatory; on the contrary, they are much more frequently due to simply impaired nutrition, general and local, or to mere functional derangement. It is true, however, in a certain proportion of TREATMENT OF INCIDENTAL SYMPTOMS. 499 cases, that the mucous membrane becomes strongly injected, in circumscribed patches; to which the symptoms of indigestion, associated with slight pain and tenderness, succeed. If an individual has not been habitually dyspeptic, anterior to the advent of phthisis, the gastric derangement usually comes on at a somewhat advanced period; or if it supervenes early in the disease, the exciting cause may be traced to injudicious medication, the use of indigestible food, or to the improper em- ployment of alcoholic stimulants. The pathological conditions may, in a general sense, be re- ferred to the following varieties: Inflammatory excitement; impaired biliary and mucous secretion; nervous derangement; and simply loss of tone. The former condition, consisting of moderate vascular excitement, but sufficient to induce slight tenderness on pressure, a little increase of thirst, intolerance of stimulating food and drinks, with a tendency to constipation, often arises in the early stages of the disease, as a consequence of taking too large quantities of stimulating food and drinks. When this occurs the stimulants should be withdrawn, a few leeches applied to the stomach, occasionally followed by a blis- ter, the administration of simple purgatives, and the patient kept for a time on farinaceous diet. This simple course will usually relieve the stomach from its embarrassment, and permit its functions to be restored; but if neglected, or the stimulants be improperly continued, the morbid action may be goaded into permanent inflammation, with all the consequences of organic changes of the mucous membrane. I can not but think that a vast amount of mischief arises from the incautious continu- ance of stimulating food, under the circumstances indicated ; and that the fear of debility, either from the withdrawal of stimulating aliment, or the application of a few leeches, is an evil incomparably less than the dangers arising from over- excitement. , In another form of dyspepsia we find marked evidences of deranged secretions, such as constipated bowels, loss of appe- tite, coated tongue, and so on. This condition will frequently be observed in persons of the bilious temperament, and where cod-liver oil has been freely exhibited. The temporary occur- 500 THERAPEUTICS OF PHTHISIS. rence of this variety of derangement is best corrected by the administration of Pil. Hydrarg., followed by mild aperients, such as fluid extract of senna and rhubarb. The diet should be carefully regulated, and the usual tonic medicine withdrawn until the gastric derangement subsides. In another variety of deranged secretions we find no evidences of biliary affection, but the patient is troubled with frequent acid eructations, showing impaired secretion of gastric juice, with a predominance of acids. This condition is not infre- quently due to exhaustion from over-feeding, mental anxiety, or undue bodily fatigue. The most effectual remedies, after the removal of the cause, will be found in the moderate use of tonics and stimulants, and a judicious limitation of food. Among the tonics, quinine, bismuth, nitrate of silver, and tine- ture of bark will be found the most efficacious. I have often derived great benefit from the following compound: FR Quin. Sulph. grs. x. Bismuth Nit. 5j. Calc. Phos. 3ss. Sac. Lac. 3]. M. Divide in x powders, And take as circumstances may indicate. The addition of a small quantity of capsicum will frequently be found to increase the action of the tonic. The nitrate of silver, in many of the forms of diarrhoea, even where considerable irritation exists, is often useful, especially combined with bismuth, thus: R Argent. Nitrat. gra. vj. Bismuth. Nitrat. Ext. Lupuli, aa 5ij. M. Ft. pil. xij. ' A pill to be given two or three times a day. Nervous dyspepsia, although less common than the preceding varieties, is occasionally observed, especially in persons of a nervous temperament, and possessing naturally delicate digest- ive powers. It is evinced by painful sensations in the epigas- TREATMENT OF INCIDENTAL SYMPTOMS. 501 trium, as often when the stomach is empty as during digestion, but is free from the signs of inflammatory action. Such exam- ples may be cured or alleviated by the use of anodynes, tonics, and stimulants. The preparations of opium, conium, hyoscy- amus, or, what is sometimes better, the extract of Indian hemp, are the most reliable agents. The valerianate of quinine, co- nium, and iron may be employed with benefit. Thus: BR Quin. Valerian. Pulv. Ferri, 44 grs, xv. Ext, Conii, 3ss. M. Ft. pil. xv. ‘ ’ One pill may be given morning, noon, and night, When simple debility exists, that is, a loss of digestive power without any special evidences of inflammatory action, deranged secretions, or impaired innervation, the simple tonics and stim- ulants are the proper remedies. The use of small quantities of brandy is one of the most efficient agents; it imparts action to the stomach, promotes digestion, and improves the appetite. It should be taken just before, and repeated an hour or two after meals. The quan- tity should always be small, often not exceeding a tea or des- sert-spoonful. Quinine and the vegetable tonics generally will prove useful; and the muriated tincture of iron will, at times, produce highly beneficial results. I have, also, known com- mon salt, in five-grain doses, materially assist in restoring the tone of the stomach under these circumstances. Tn those more advanced conditions, when impaired digestion is a part of the progressive debility and tubercular derange- ment, a palliative course embraces the whole duty of the physician. With this view we prescribe anodynes, antacids, stimulants, and tonics, according to the wants of each patient, without any expectation of affording more than ‘temporary relief. With these views we resort to morphine, lime-water, nitrate of bismuth, hydrocyanic acid, conium, and Creosote, naphtha, and tar-water are occasion- and the latter is especially commended by Dr. allaying sickness brandy, similar agents. ally beneficial ; Turnbull, who believes it is serviceable in « 502 THERAPEUTICS OF PHTHISIS. and vomiting, while, at the same time, it relieves fever and checks perspiration. The same general: remarks will apply to the diarrhea of advanced phthisis. The opiates and astringents constitute the ‘ classes of medicines usually employed; and among’ these, morphine, bismuth, nitrate of silver, and tannin are the most valuable. But it will be found in these cases that medicines speedily lose their effects, and, therefore, require to be changed. And this remark applies to every agent connected with the advanced stages of the disease; indeed, we are often required to substitute an intrinsically inferior article simply to secure a new action on the system. 7. Thoracie Pains—The causes capable of producing thoracic pains, are inflammatory action, limited congestion, and nervous irritation. If clear evidences of pleuritic inflammation exist, we should at once resort to the abstraction of a few ounces of blood by cups, the application of a blister, and the internal administration of anodynes. But if local congestion alone be the cause, dry cups, sinapism, or other derivatives will usually prove sufficient. If, on the contrary, the pain be of nervous origin, the veratria ointment, or the exhibition of anodynes internally, will prove most advantageous. The external ano- dyne applications are usually most efficacious when applied between the shoulders; although, at times, they may be used immediately over the seat of pain. Dry friction, also, by in- vigorating the capillary circulation, will often prove beneficial in both the congestive and nervous forms; or the combination of stimulating liniments will subserve the same purpose. SECTION VI. TREATMENT OF COMPLICATIONS, The more common complications which we meet with in phthisis, are pneumonia, pulmonary congestion, bronchitis, pleu- TREATMENT OF COMPLICATIONS. 503 risy, disease of the larynx, diseases of the heart, and derange- ment of the liver. 1. Pnewmonia.—Pneumonia is liable to occur in phthisis, as a complication of the essential morbid action of tuberculosis, Limited inflammation (or inflammatory softening) is a necessary attendant upon tuberculous softening ; but the pneumonia which is here alluded to occurs as an independent disease, and is pro- duced by the ordinary causes which induce idiopathic inflam- mation of the lungs. Thus, a tuberculous subject is exposed to a cold, damp, or variable atmosphere, and the consequence is pneumonic inflammation, more or less extensive. The tend- ency, in such cases, is to develop inflammation in the vicinity of the tubercular masses, and hence pneumonia of the upper portion of the lungs is quite common. But this rule is by no means uniform; for examples have frequently come under my observation, in which the disease involved also the base of the lungs. The treatment of pneumonia, as it occurs at the apex or the base, presents some peculiarities, and hence the neces- sity for the distinction. Inflammatory action of the lungs, during the progress of phthisis, is always to be regarded as a most unfortunate event; for the intercurrent morbid action promotes the exudation of tubercular matter, and hastens the softening of tubercles; and its occurrence should, therefore, not only be carefully guarded against, but, on its supervention, prompt and efficient remedial measures are imperatively demanded. As a precautionary measure, patients should be instructed to avoid unnecessary exposure to a cold, damp, and variable atmosphere, and to pro- tect the system, by proper clothing, against the evil effects of sudden transitions from heat to cold. The measures necessary for the removal of this complication, vary with the activity of the inflammation, constitution of the patient, and other incidental conditions. If the inflammation is located in the lower lobes, with decided reaction in a con- stitution not greatly debilitated, the abstraction of blood will be found not only beneficial, but even essential to the welfare of the patient. The impression that any amount of bleeding will necessarily augment the tuberculous dyscrasy, and, there- 504 THERAPEUTICS OF PHTHISIS. fore, be productive of more harm than good, is, I am satisfied from extensive observations, positively erroneous. On the con- trary, the mitigation which follows bloodletting will more than counterbalance the debilitating effects of depletion. The quantity of blood abstracted, however, must be carefully proportioned to the condition of the patient, but should never be large. The most appropriate method of bleeding is by means of cups, which proves equally efficacious with any other mode, while we secure, at the same time, the valuable effects of counter-irritation. Cupping to the extent of five or six ounces, repeated or not, as circumstances may indicate, will serve to check the inflammatory action, and prepare the way for other remedies. If the symptoms are somewhat active, we may next resort to antimony and opiates, either in the form of tartar emetic and morphine, in solution, or pulv. Doveri and pulv. antimonialis, in powders. But whatever the form in which these agents are employed, they should be administered cau- tiously, and in small quantities; for while their discreet use must prove highly beneficial, any excess of debilitating medi- cines becomes injurious. In addition to a mild antiphlogistic course, counter-irritation should never be neglected; indeed, it constitutes one of the most important remedial measures, after appropriate depletion, Dry cups, sinapisms, blisters, and, finally, pustulants, may be brought into requisition according to the indications of the case. The repeated applications of blisters is often highly val- uable, especially after depletion, or in those examples which do not require antiphlogistic remedies. Sinapisms, and hot tur- pentine stupes may often be used with great advantage, espe- cially at a period too early for blisters. In those examples in which the grade of action forbids anti- phlogistics, dry cups, sinapisms, turpentine, and pustulants be- come appropriate, while at an early period sustaining remedies, medicinal and nutritive, must be brought into requisition. When the inflammation is located in the upper lobe, and in immediate relation with tubercular deposits, a different course is required. Even idiopathic pneumonia, in this location, re- quires less depletion than when located at the base; and when TREATMENT OF COMPLICATIONS. 505 occurring as a complication of tubercles, debilitating agents should be cautiously used, or entirely interdicted. The most judicious course of treatment consists in counter-irritation, very moderate (if any) use of antimonials, a properly regulated diet, and the occasional use of salines. Very minute doses of anti- mony, not exceeding the twelfth or sixteenth of a grain, may be often advantageously employed; and if the cough is much aggravated, opiates may be added. But decided and persistent revulsives and counter-irritants, such as dry cups, blisters, and pustulants must be sedulously employed until the inflammatory symptoms subside. In both varieties of the disease, it becomes necessary to sus- pend the usual remedies, if they be of a tonic and stimulating character, employed in the general treatment of phthisis ; and, also, to regulate the diet according to the degree of fever, and the strength of the patient, and to employ mild cathartics as may be required. And in returning, again, to the usual reme- dies, it is important that the transition should not be too early, otherwise subacute inflammation may be kept up with the most injurious consequences. 2. Pulmonary Congestion.—During the progress of phthisis, ‘persons of a delicate constitution and weak circulation, and who become exposed to the causes which ordinarily induce pneumonia, are liable to pulmonary congestion, which is evinced by some degree of dyspnea, at times slight febrile movement, and locally by the frequent occurrence of the subcrepitant rhonchus. The physical signs are most apparent at the base, but at times may be absent. It is not usual to find the disease obstinate or protracted ; but in some examples it may advance to actual inflammation, although usually stopping short of con- solidation. The proper treatment consists in dry cups, sina- pisms, turpentine, and blisters. Depletion would generally prove injurious, while even stimulants, such as ammonia and quinine, become appropriate. - 3. Bronchitis.—The occurrence of acute capillary bronchitis during the course of phthisis, demands prompt and efficient treatment. If decided febrile action, with aggravation of cough, supervene, blood may be abstracted by means of cups, followed 506 THERAPEUTICS OF PHTHISIS. by sinapisms or blisters. The internal remedies should embrace anodynes, antimonials, and purgatives. My own experience leads me to place great reliance on opiates, alone or combined with antimony or ipecac. If the secretion of mucus becomes abundant, no agent will so speedily arrest it as opium; while, at the same time, the anodyne proves grateful and soothing to the patient. When the activity of the disease has been sub- dued, or in cases where the morbid action has been passive from the beginning, the stimulating expectorants, combined or not with alkalies, become appropriate remedies; and the fol- lowing formula, among others, may be advantageously used : kK Fluid Ext. Cimicifuga, Syr. Senega, Vin. Picis, 44 3). Lig. Potass. ss. M. A drachm to be taken every four or six hours. Pustulation of the chest with croton oil, and the inhalation of anodynes, become useful as the disease advances. Purga- tives, also, contribute to the relief, and even mercurials may be necessary when, as often happens, the liver becomes engorged or inactive. 4. Pleurisy—The occurrence of pleurisy sufficient to excite fever, should be met promptly with the local abstraction of blood, the application of blisters, and the exhibition of anti- mony and opium. These remedies should be, of course, propor- tioned to the violence of the disease; thus, a limited pleurisy, evinced by pain and friction-murmur, but without fever, requires merely blisters and anodynes, while the more extensive and acute demands bloodletting. The importance of pleurisy, under these circumstances, relates rather to its secondary effects, namely, the exudation of lymph, and the subsequent adhesion of the pleural surfaces. Such a condition materially interferes with the expansion of the lung, and, therefore, proves detri- mental in phthisis. It becomes important, therefore, to limit the plastic exudation, as far as possible, and thus arrest the evil of adhesions. The existence of pleuro-pneumonia constitutes a TREATMENT OF COMPLICATIONS. 507 formidable condition, which should be treated in accordance with the preceding principles. 5. Diseases of the Larynz.—The affections of the larynx, which usually require attention, are erosion, ulceration, follicular dis- ease, oedema, and general inflammation. These various condi- tions are liable to occur in different cases, and always prove exceedingly annoying and injurious to the patient. As a gen- eral remark, topical applications, especially the nitrate of silver, become indispensable. When, however, much tenderness exists, the application of leeches, counter-irritants, and anodynes are required. The general principles, however, of treating these affections of the larynx are given under the head of laryngeal phthisis, and, therefore, need not be enlarged upon in this con- nection. 6. Diseases of the Heart——Two opposite conditions of the heart occasionally require attention during the progress of phthisis, namely, hypertrophy and weakened action. Hypertrophy is evinced by strong impulse and increase of the dull space; it more commonly occupies the right ventricle. When this latter condition exists, the blood is driven with undue force into the lungs, which proves, to a certain extent, prejudicial. It doubt- less augments the tubercular deposits, induces congestion and dyspnoea, and predisposes to hemorrhage. With the view of lessening this action, occasional cupping over the cardiac region, and the internal exhibition of veratrum viride, or digi- talis, may be productive of good. At the same time, the patient’s exercise should be somewhat restricted, and he should be especially enjoined to avoid protracted walks or sudden exertion. A weakened action of the heart may depend on dilatation, with thinning of the walls, and softening of the fibers. Such conditions materially embarrass the circulation, and, therefore, affect tuberculous patients in an unfavorable manner. The treatment must be mainly tonic and stimulating, very nearly similar to that which is appropriate for the phthisis itself; but, _ as special remedies, we may mention brandy, quinine, and iron, _) 7. Derangement of the Liver—The liver is liable to functional and organic derangement, aside from the more specific lesion of 508 THERAPEUTICS OF PHTHISIS. fatty degeneration. It occasionally becomes inactive, partially engorged, or even decidedly irritated. Hepatic phthisis has been described by most writers; but, instead of constituting a distinct species, it is usually simply a complication. But the derange- ment of this organ always exercises a most prejudicial influence over the progress of phthisis, and should, therefore, be promptly treated. Mercurial alteratives, and counter-irritants are the proper remedial measures; followed by muriate of ammonia, taraxicum, or nitro-muriatic acid. The muriate of ammonia is a remedy of considerable value, and may, at times, even super- sede mercurials. If the patient is taking tonics and stimulants, especially cod-liver oil, they should be suspended during the alterative treatment; while quinine may be employed with the view of preventing undue debility. In the preceding remarks on the treatment of the diseases which more commonly complicate phthisis, but little reference has been made to the current treatment of the primary affec- tion. It may be stated, therefore, in general terms, that it is often necessary to suspend the specific treatment, or, at least, to modify it in a material manner, so that it may not conflict with the management of the complication. But it should be re- marked that much care is requisite in this respect; for, while we endeavor to prevent the interference of incompatible modes of treatment, it is also important to sustain the system, especially if much enfeebled, by the continuance of tonics and stimulants. Hence, even opposite modes of treatment must occasionally be more or less combined. TREATMENT OF INFLAMMATORY AND ACUTE PHTHISIS. 509 CHAPTER II. TREATMENT OF INFLAMMATORY AND ACUTE PHTHISIS. Tue varieties of phthisis, which are embraced under this head, are quite different in character, and require almost oppo- site modes of treatment; nevertheless, for convenience sake, the two forms will be mentioned in connection. The varieties here referred to are the inflammatory and the acute. These terms are employed, as heretofore explained, to represent different forms of disease, or, at least, different in their etiological rela- tions. Thus, the inflammatory species indicates that form in which pneumonia, bronchitis, or pleurisy has acted as the in- ducing cause, and which becomes chronic; while the term acute phthisis is intended to represent that rapid tuberculosis which, by its own force, destroys life in a comparatively short space of time. 1. Treatment of Inflammatory Phthisis—It has already been shown, in the section treating of the varieties of phthisis, that pneumonia, bronchitis, or pleurisy is capable, under certain circumstances, of becoming the inducing cause of phthisis; that is to say, inflammation of the pulmonary structures, occur- ring in the tuberculous constitution, becomes capable of develop- ing tubercles, which pass more or less rapidly through the stages of deposit and softening. In such examples, the pneumonia, instead of undergoing resolution, becomes chronic, and thus goes on conjointly with the tuberculous disease. It is, indeed, chronic pneumonia complicated with tubercular deposits. But, in other cases, the pneumonia is secondary in occurrence, but in its gen- eral progress, bears the same relation to the tubercular disease. Hence, it is a point of the highest importance to prevent the 510 . THERAPEUTICS OF PHTHISIS. occurrence ot these inflammatory affections in persons whose constitutions are predisposed to tuberculosis, or, when they do occur, to seek their removal as speedily and as completely as pos- sible. The treatment of the initial inflammation, therefore, is legitimately embraced in the treatment of inflammatory phthisis, Pneumonia leading to phthisis is presented under three forms, which it is important to distinguish: 1. Pneumonia of the lower lobes. 2. Pneumonia of the upper lobes. 3. Vesicular Pneu- monia. These several forms exhibit different characteristics, which should be clinically separated. I will advert first to pneumonia of the lower lobes. The treatment of pneumonia occurring in the tuberculous constitution embraces many points of difficulty, especially in relation to the propriety of depletion. The first practical axiom, however, which it is important to understand, is, that the dis- ease should be met promptly and efficiently. With this view, I should not hesitate, in pneumonia of the lower lobes, to ab- stract blood, and employ antimony and morphine; but, at the same time, extreme or very active depletion is uncalled for, and may prove injurious. A moderate abstraction of blood by cups, and small doses of antimony and morphine, are the appropriate remedies for the early stage; but, speedily following this, de- cided revulsive action on the surface should be resorted to, either in the form of rubefacients or vesicants. Dry cups may ‘ollow the wet; sinapisms, turpentine stupes, and, finally, blis- ters, according to the stage of the disease and condition of the patient, are our most valuable remedies. Cathartics, also, are highly valuable, and even smart purgation should not be deemed improper. For this purpose the mercurials, alone or combined, are not only safe, but valuable remedies; indeed, the liver is usually engorged, and the cholagogue action of mercury is highly important. No apprehension need be entertained in - relation to the evil effects of mercury as a purgative or chola- gogue, while its good effects can scarcely be secured by any other agent. It is not desirable, however, to urge the mercu- rials to the point of ptyalism; for although the clinical facts are few which indicate its evil effects, yet we rather dread its secondary influence on the plastic elements of the blood. TREATMENT OF INFLAMMATORY AND ACUTE PHTHISIS. 511 ‘When the violence of the disease has been checked, it is important to promote the absorption of the plastic exudation, and thus prevent the occurrence of chronic disease; for it can not be doubted that it is the duration of the local affection which constitutes the great danger. Our ability to promote the absorption of lymph is somewhat limited; nevertheless, there are some remedies capable of accelerating the removal of the exudation by interstitial absorption. With this view we should continue the.counter-irritants, (blisters or pustulants,) and ad- nunister internally the iodide of sodium or potassium, the former being preferable. An excellent compound is the following: & Fluid Ext. Cimicifuga, Syr. Senega, 44 33j. Iodide Sodium, 3j. M. A tea-spoonful to be given three times a day. This preparation stimulates the pulmonary capillaries, and thereby promotes absorption. At the same time, the strength should be carefully sustained by tonics, particularly iron, and nutritious diet. The cod-liver oil is inappropriate so long as fever remains, but may be used when the disease becomes chronic. When the disease becomes chronic, and tubercles are found among the morbid products, we can no longer depend on anti- phlogistic treatment; but the chief reliance must be placed on tonics and nutrients, very nearly in the manner we would treat ordinary cases of chronic phthisis. There are, however, a few precautionary precepts which deserve consideration. In the first place, we must not change from the partial antiphlogistic course to the purely tonic and stimulating agents too abruptly; instead of this there is an intermediate course, embracing coun- ter-irritants, diaphoretics, quinine, and iron, which will be found beneficial, while cod-liver oil and brandy would prove too ex- citing. We may safely continue, also, the use of the iodides, in conjunction with iron, so as to secure the combined effects of sorbefacients and tonics. I greatly prefer, in such cases, the separate administration of iodine and iron; for example, the 512 THERAPEUTICS OF PHTHISIS. iodide of sodium administered before meals, and a simple prep- aration of iron after eating, will usually succeed better than the iodide of iron. Quinine, iron, and morphine, in small doses, will often prove eminently serviceable in this stage of the dis- ease, Another important practical rule is, to avoid overfeeding. In this form of inflammatory phthisis I have found it exceedingly injudicious to permit the patient to indulge in a full and stim- ulating diet; on the contrary, while the food is sufficiently nourishing, it should be nicely adapted to the wants of the system, and not of a character, or in sufficient quantities, to prove oppressive to the digestive organs, nor to introduce too much nutritious material into the blood. The powers of sec- ondary assimilation are greatly weakened, and crowding the system with nutritive elements, especially the nitrogenous, be- yond its capacity to completely dispose of them, must lead to unfavorable secondary changes. In the main, a bland farina- ceous diet, with moderate quantities of animal food, adapted, in quantity, to the stage of disease, will be found, in the end, better than to urge upon the patient full meals of highly stim- ulating food. In the last place, decided and protracted counter-irritation should be resorted to, in such forms as the circumstances may indicate. As a general rule, I prefer blisters to pustulants, and even setons and issues may become highly valuable. I believe, . however, that the application of tincture of iodine will frequently & most beneficially, and probably aid directly in resolving the consolidated lung. Inflammation of the superior lobes is of more serious import than the preceding, and demands a somewhat different course of treatment. The pneumonia located in this portion of the pulmonary structures manifests less activity, in all its aspects, than when in the lower portion of the lungs; thus, there is less fever, cough, and sputa, and the disturbance of the respiratory movements is often inconsiderable. Hence the treatment can not be, to any considerable extent, depletory, but we must rely on revulsives, diaphoretics, or the mildest febrifuges. Occasion- ally a few cups may be applied, but more commonly dry ones TREATMENT OF INFLAMMATORY AND ACUTE PHTHISIS. 513 will be preferable; while, internally, Dover’s powder, with pul- vis antimonialis, are more judicious than morphine and tartar emetic. Blisters should speedily follow cups, and the alterative action of iodine may be resorted to at an early period. The iodide of sodium or of potassium may be given at an early pe- riod, and will often act beneficially in removing the adventitious deposits. The strength must be early supported; and as tu- bercular deposits take place, or rapidly extend, the treatment scarcely differs from that which is appropriate in chronic phthisis. The inflammatory deposits will usually give way under the use of iodine, iron, and blisters; while the subsequent treatment, if tubercles become developed, must rest on those principles which govern our course in the ordinary forms of the disease. The third variety of pneumonia is the vesicular form, which gives rise to the gray granulations. As previously explained, this form of so-called tuberculosis is due to inflammation and the exudation of lymph, at least approaching an organizable quality. The disease is often very extensive; indeed, I have known examples in which the physical signs could be heard in every portion of the lung, from base to apex. In this form of disease hepatization does not occur; nor is there a direct tendency to resolution, or, more remotely, to softening. Thus, the affection is obstinate, and often fatal without further change of structure. In the treatment, moderate depletion is usually requisite ; but as the febrile reaction is not very decided, bleed- ing should generally be employed only to a limited extent. A few cups, followed by fomentations, with small doses of anti- mony, are usually all the depletory agents required. As the febrile action subsides, the iodide of sodium is required ; and my impression is, that its continued use exercises an important influence over the semi-plastic granulations ; while, at the same time, counter-irritation, by means of pustulants, is preferable to blisters, especially on account of the extent of tissue involved, which is often a whole lung. This is the variety of tubercle which Rokitansky thinks may become “ cornufied,” that is, slightly shriveled and hardened, by which all tendency to increase or to softening is lost, and the granules remain inert. I think the preparations of iodine, 33 514 THERAPEUTICS OF PHTHISIS. even by inhalation, together with counter-irritation, after the subdual of the primary fever, are the most reliable measures to ‘ arrest the progress of these morbid deposits. The treatment of the laryngeal variety differs from that of the simple chronic form of phthisis, in the necessity for agents directed to the fauces, larynx, and trachea. The constitutional treatment is, in part, the same; that is, in both varieties tonics and nutrients are demanded, but in the laryngeal form stimulants are scarcely admissible. Indeed, as a general rule, alcoholic preparations prove injurious, by increasing the laryngeal irri- tation; and if any form of stimulants can be tolerated, it will be the malt liquors, but even these may prove prejudicial. The local remedies must be varied to suit the peculiarities of different cases. When the disease is detected in an early stage, leeches often prove eminently useful ; indeed, I am fully persuaded, that in the initial stage the judicious employment of leeches, counter-irritants, and the internal application of the nitrate of silver, may arrest the disease. The application of leeches, conjointly with tonics, particularly the chalybeates, can not be safely omitted ; for, inasmuch as the arrest of the disease depends largely on the subdual of the local affection, depletion becomes an indispensable remedy. Internal applications, such as the nitrate of silver, and counter-irritation, all succeed far detter after the abstraction of a small quantity of blood. This is, therefore, one of the forms of phthisis in which depletion is imperatively demanded. Various topical applications have been recommended, among which the nitrate of silver, in solution, stands pre-eminent. There can be no doubt in relation to the power of the solution of this agent to subdue chronic inflammation of the fauces and larynx, and hence its great utility in this form of phthisis. The strength of the solution and mode of its application must vary according to the circumstances of each case. Asa rule, we should commence with the weaker preparation, (about ten grains to the ounce,) and gradually increasing the strength to two scruples, or a drachm of the salt to an ounce of distilled water, if the condition seems to require it. As to the mode of application, the sponge is generally preferable, and it should be applied first » TREATMENT OF INFLAMMATORY AND ACUTE PHTHISIS. 515 to the fauces, and afterward passed down to the larynx, the aperture of which should usually be penetrated. It is not necessary, however, always to enter the larynx, for the applica- tion to the fauces, and the sponge pressed on the epiglottis, will often be sufficient. When, however, the irritation is per- sistent, the larynx should be penetrated, if it can be accom- plished with facility. It will be found that great differences exist in different persons; in some cases the parts are too irri- table, and the formation of the throat so narrow and contracted, as to render the operation difficult. However, where excessive irritability of the larynx exists, that condition may be lessened by the cautious application to the adjacent parts; or, what is still better, the patient may be made to inhale a little, chloro- form, which will greatly facilitate the operation. If the sponge is employed for the purpose of entering the larynx, it should not be very large ; indeed, the ordinary whale- bone and sponge, as sold in the shops, is altogether too large for this purpose. But instead of sponge, the curved syringe may be employed, and, in the hands of some, will often succeed the best. Or, if both these methods fail, the salt may be introduced by insufflation. For this purpose, the nitrate of silver may be diluted with sugar of milk, made into an impalpable powder, and introduced through a glass tube. The strength may vary from one to three grains of the salt to ten of sugar of milk; but the pure nitrate of silver may be inhaled without risk, as I have often witnessed. One grain of the mixture, placed in a glass tube, having the caliber of the eighth of an inch, and passed far back over the tongue, may, by a forcible inspiration, be inhaled with but trifling inconvenience. Any other article, such as nitrate of bismuth, acetate of lead, tannin, etc., may be used in a similar manner. Vapors and gaseous medications may be inhaled with advant- age. ‘Tar, volatilized by boiling, creosote, chlorine, hydrocy- anic acid, conium, preparations of opium, and all similar articles, may, at times, become valuable. When there is copious expec- toration, of a purulent character, tar, creosote, and similar agents will prove most valuable; but if a high grade of irritation exists, without copious secretion, the anodynes will be most 516 THERAPEUTICS OF PHTHISIS. appropriate, such as tincture of conium, hydrocyanic acid, a watery solution of opium, ete. The vapor from a decoction of poppy-heads, or a watery solution of opium, will often prove very soothing, and especially when the tinctures can not be borne. In addition to these measures, counter-irritation, by means of croton oil, tincture of iodine, or blisters, becomes indispensable. Pustulation with croton oil will generally succeed best, but all in turn may become necessary. The treatment of laryngeal phthisis may be thus summed up: leeching, counter-irritation, nitrate of silver, and various vapors and gases, as topical applications, together with tonics and nutrients, such as the chalybeate preparations and cod-liver oil. Stimulants, however, should be used cautiously or entirely avoided. The sulphurous mineral waters will often prove val- uable in this form of phthisis, and, when practicable, may be employed conjointly with the general treatment. 2. Treatment of Acute Phthisis—The acute variety of phthisis, as that term is usually employed, admits of but little treatment; that is, it is evidently a form of disease in which the morbid action is so extensive, and the changes so rapid, that all modes of treatment prove futile. It is, indeed, a condition in which the system is, as it were, saturated with tubercles, and the lungs become speedily infiltrated with the morbid deposits; and the changes which occur after the deposition are equally rapid, softening and elimination taking place in a most speedy man- ner. So rapid, indeed, are these changes, and so inveterate is the morbid action, that all remedial agents are placed at defiance, and the disease marches steadily on to a fatal issue. If the physician deems it expedient to attempt more than the simplest palliation, he may resort to extensive counter-irritation, stimulants, and tonics; but these agents will do no more than retard the progress to a very limited extent, and often, indeed, seem to make no sensible impression on the march of the disease. SPECIAL QUESTIONS IN THE TREATMENT OF PHTHISIS. 517 CHAPTER III. VF SPECIAL QUESTIONS IN THE TREATMENT OF PHTHISIS. TuE preceding remarks embrace a systematic account of the principal remedies, medicinal and hygienic, which have been found useful in phthisis; but some of these, about which differ- ences of opinion exist, demand a more extended notice, among which may be enumerated climate, sea-voyages, gestation, and topical medication. 1. Change of Climate—The subject of climatic influences in the treatment of phthisis has necessarily attracted a large share of attention; and while some have expressed the greatest con- fidence in the efficacy of particular localities, either to prevent or cure the disease, others have appeared almost entirely skep- tical in regard to such influences, and therefore counsel patients to remain at home. Doubtless this whole subject has been rendered obscure by a want of attention to the peculiarities of each individual case, including the stage of disease, the tem- perament of the patient, his cast of mind, and mental cultiva- tion. And, as intimated in a former section, the different stages of the disease require very different climates, and hence no single locality can reasonably be expected to meet the wants of all patients. The great desire appears to have been to secure a mild and equable climate, in which the atmospheric vicissi- tudes are limited, and the extremes of heat and cold restricted within moderate limits. But while these conditions of climate are undoubtedly adapted to a certain class of patients, others require altogether different atmospheric influences, in order to secure the benefits arising from a change of climate. There are two classes of persons who may reasonably anticipate beneficial 518 THERAPEUTICS OF PH'THISIS. results from a change of climate: 1. Those in the precursory stage, or the early period of local deposits; 2. Those in whom softening has commenced. These conditions are widely differ- ent, and demand climates of almost opposite qualities. 1. The Climate adapted to the Precursory Stage, or the early Period of Tubercular Deposits.—The first question which arises in this connection is this: Should patients in this early stage of phthisis be placed in a mild and equable climate, such as Madeira, and there be permitted to remain? It seems to me that every rational consideration forbids such an idea, and that patients so situated must necessarily suffer serious injury. In these early stages of phthisis, patients are already beginning to feel the depressing effects of disease, and, therefore, require all those influences, hygienic and medicinal, which impart tone to the system, and thereby invigorate the nutritive functions. It cannot be presumed, however, that a mild and equable atmos- phere will produce this result; on the contrary, the very monot- ony of the atmosphere must lead to depression, and thereby increase the debility. In order to promote health, the atmos- phere should be subject to some degree of perturbation, and even rapid changes, provided these variations are not great or extreme. The steppe of Kirghis, where consumption is almost unknown, is remarkable for its rapid changes, and even severe winds. But it is evident that these changes, in order to promote health, must be restrained within reasonable limits; for, as already explained, such patients manifest comparatively low calorific functions, and, therefore, do not well sustain a very great degree of cold. The extremes of temperature generally prove injurious, and phthisical subjects should select climates free from such elements. It should be remarked, also, that long-continued cold is depressing, and consequently extreme Northern latitudes can not be recommended for consumptives. On general principles it does not appear judicious to send per- sons predisposed to phthisis, or those in whom the local disease has already commenced, to climates colder than those to which they have become accustomed; for it has often been observed that such changes are apt to give rise to the disease, even when, SPECIAL QUESTIONS IN THE TREATMENT OF PHTHISIS. 519 the class of persons were at home comparatively exempt from it. In a general sense, therefore, persons predisposed to phthisis, or in whom the local disease has already commenced, should seek a moderately warm and dry atmosphere of considerable alti- tude, and which is subject to sufficient commotion to render it occasionally exhilarating, but free from great extremes. A very warm, stagnant, and moist atmosphere, with but little elevation, would manifestly prove injurious, and there is sufficient ground to justify the conclusion that where the disease is far ad- vanced, tropical regions are unfavorable. The conclusions, how- ever, in regard to the effects produced by hot climates, have been usually drawn from cases in which the disease was more or less advanced, and, also, from soldiers and sailors, classes of persons most unfavorably situated. Making allowances, there- fore, for these advanced cases and unfavorable conditions, there is no positive evidence to prove that warm, but changeable climates are inimical to those laboring under incipient phthisis, while analogical redsoning, as well as the general laws of the economy, strongly favor the view that warmth, ceteris paribus, so far revolutionizes the system as to exercise a favorable in- fluence over this class of patients. It is evident, however, that the favorable influences of warm climates is very strictly limited to the incipient stages, while we have abundant testimony to prove that when the disease has become established, and the system debilitated, but little epee | can be derived from warm regions, while, on the contrary, great injury will often result. Various opinions, however, have been expressed on this subject, and many contradictory statements made; but it is probable that the differences arise almost ex- clusively from confounding several distinct questions. Thus, the prevalence of phthisis among the natives or resident popu- lation of a warm country, and the effects of the same climate on new residents laboring under advanced phthisis, are obviously very different questions; nor can laws be applied to a civil population, permanent or transient, which have been deduced from statistics derived from the army or navy. It is remarked by M. Rochard, that in the torrid zone tuber- culosis marches with more rapidity than in Europe; that 520 THERAPEUTICS OF PHTHISIS. physicians of the colonies (French) protest against consump- tives being sent thither from France, and that soldiers and sailors attacked are sent home. The reports of Colonel Tulloch also show that English sailors suffer in a larger proportion in Southern latitudes than at home. These facts, however, are not conclusive in the premises; indeed, they simply establish the unhealthfulness of Southern latitudes, without proving that they contribute to the production of phthisis, or that they may not, under certain contingencies, prove salutary to those predisposed to the disease. Take, for example, Gaboon, where the mortality from epidemics is frightful, yet of nine hundred and fifty-two patients, there was not a case of phthisis, and of thirty-one hundred and forty-four marines only six were consumptive. By reference to the article Geography of Phthisis, it will be observed that, in many warm or tropical regions, phthisis is rare, which_ establishes the general fact, that it is not simply heat which proves so injurious, but that the condition of the patient, as well as the other elements of climate, such as altitude and moisture, are the qualifying conditions. The general fact may be more correctly stated by saying, that patients with decided phthisis are not benefited by hot climates, and that the disease advances with greater rapidity in tropical than in temperate regions. When the system has become debilitated by tubercular disease, the prostrating effects of hot climates prove injurious; but those merely predisposed to the affection, or in whom it has made but little progress, may be as much benefited as others are injured by the change. But most of the statistics on this subject have been drawn from the army and navy, and, therefore, can not properly represent what would occur in civilians. It can not be presumed that, sailors, exposed to extremes of heat and moisture, with a diet ill adapted to ward off or relieve tuberculosis; or soldiers, crowded in camps and barracks, and exposed to hardships, scanty diet, and the influences of bad air; could be regarded as fair repre- sentatives of what would occur in persons free to select their own residence, diet, exercise, and medication. Persons seeking the tropical regions would naturally select those localities known to be adapted to pulmonary affections, and would, in SPECIAL QUESTIONS IN THE TREATMENT OF PHTHISIS. 521 addition, be surrounded by all those influences which so mate- rially contribute to health and comfort. Hence, the statistics drawn from the army and navy are utterly fallacious as applied to civilians. On the European continent, the milder regions presumed to be favorable to consumptives, embrace the southern portions of France, and many points in Italy. But, as will be seen by reference to the section on the geography of phthisis, the disease is quite common in these countries, and hence, the favorable influence, if any, is due to the general effects of change of cli- mate, rather than to any special influence arising from those localities. It must be evident that patients residing in England, sur- rounded by a cool and moist atmosphere, would often be mate- rially benefited by changing, during the winter, to the south of France or the north of Italy, or of migrating to even warmer latitudes. But if the disease has made any marked progress, and even moderate debility is present, these milder regions should be abandoned during summer, and patients should seek the more bracing atmosphere of cooler latitudes, and even mountainous regions. And so, too, of our own country. The residents of the Northern states migrate with advantage to the South during winter; but, on the return of summer, the insalu- brious regions of warm latitudes are abandoned, and patients retrace their steps to the North. In this manner a constant change is secured, while patients avoid those extremes which prove so dangerous when the vitality has been lowered by dis- ease. 2. Climate adapted to the Stage of Softening — When phthisis has advanced to the stage of softening, patients require a mild and equable climate, moderately dry, and comparatively free from sudden changes. The vitality in such cases is too much re- duced to bear the rigors of cold regions; and if patients in this condition reside in Northern latitudes, they are measurably con- fined in-door during the winter, and consequently suffer trom privations of fresh air. Consumptive patients require out-door exercise; and hence they should be placed in such regions as will permit regular exposure in the open air without incurring 522 THERAPEUTICS OF PHTHISIS. the risk of inflammatory diseases from cold. In regard to moisture, a medium condition is important; an atmosphere loaded with vapor becomes oppressive and always injurious, while excessive dryness induces irritation of the mucous mem- brane of the air passages, and often contributes to the develop- ment of bronchial inflammation. Hence, mountains on the one hand, and plains or sea-shores on the other, are equally to be. avoided. In relation to particular localities, the general principles developed in the preceding remarks will be a sufficient guide; but in estimating the qualities of each place, special reference must be had to the condition of the patient on the one hand, and the altitude, moisture, temperature, and prevalence of . winds on the other. European patients go to the south of. France, Italy, Rome, and to the Island of Madeira; while in the United States, they seek the same regions abroad, and the southern latitudes of our own country. So far as the United States is concerned, I think we have localities superior to those abroad, except, perhaps, the island of Madeira. The south of France, as it is usually understood, embraces regions very different in their climatic conditions, which was long ago pointed out by Sir James Clark. Thus the southwest of France, with a mean annual temperature of fifty-five degrees, is rather moist and relaxing, and, therefore, not well adapted to © patients in a state of debility. But, as remarked by Sir James Clark, it may benefit consumptives who suffer with bronchial irritation, or dyspepsia arising from inflammatory action of the mucous membrane of the stomach. This range of climate in- cludes L’Orient, Nantes, La Rochelle, Bordeaux, Montauban, Pau, and Toulouse. The southeast of France, embracing Provence, Montpelier, Marseilles, Aix, and Hyéres, is quite different from the south- west; the climate has been characterized as dry, harsh, and irritating. The northerly winds are harsh and severe in winter, and, therefore, not adapted, as a general remark, to consump- tives. Such climates are favorable to relaxed systems, requiring the invigorating effects of a dry and cool air; but, as a rule, \. they are not adapted to the stage of softening, The little vil- SPECIAL QUESTIONS IN THE TREATMENT OF PHTHISIS. 523 lage of Hyéres, situated two miles from the shores of the Medi-. terranean, is regarded in France as well adapted to a winter” residence for consumptives. Nice is esteemed by many as one of the most favorable locali- ties; but Rochard declares it far inferior to Hyéres. M. Barth remarks, that being on the borders of the sea, it is consequently exposed to rains and fogs, that it is traversed by a current which brings humidity, and its temperature is lower and more variable than Hyéres. It is exposed, remarks Rochard, to east winds, especially in March and April; and Fodéré observes that the variations of temperature are frequent, and many of the Eng- lish who seek health there, speedily die. Dr. Pugh observed that many English, on arriving at Nice, were attacked with inflammatory fever, and all suffer more or less with the lungs. M. Bricheteau states that at the hospital one-seventh of the mortality is from phthisis; and hence, Andral remarks, it is injudicious to send consumptives to Nice.* During the winter, however, the climate of Nice presents some very favorable ele- ments; thus, it is protected from the winds of the north and northwest by the Alps, and its atmosphere is comparatively dry, and its temperature mild. The mean temperature of win- ter is forty-eight degrees, and of spring fifty-six degrees. The place may be regarded as healthy, except that the prevalence of east winds during the spring induces inflammation of the lungs and catarrhal affections, and acute and chronic gastritis are common diseases. There are no facts to prove that Nice has any special claims as a resort for consumptives. The atmosphere is rather irri- tating, and, therefore, would prove injurious if much laryngeal or bronchial disease existed ; while the tendency to pneumonia during the spring, would render a sojourn at that period hazard- ous in many cases. It might prove beneficial in persons of a lymphatic temperament, or those in whom softening was un- attended by irritation of the mucous tissues. Italy, from its pure air and brilliant skies, has been highly extolled as a resort for consumptives; but the ideal probably * Rochard. 524 THERAPEUTICS OF PHTHISIS. greatly surpasses the real.“ Some localities, however, are great- ly superior to others. Genoa is subject to rapid changes; and its diseases most prevalent are rheumatism, pneumonia, catarrhs, and phthisis, one-sixth of the deaths being from the latter disease. Florence is equally exposed to sudden transitions, and the vicinity of snow-clad mountains gives its winds, during winter and spring, an unfavorable character. Pisa is more protected, and pos- ‘sesses a milder atmosphere; it is well sheltered from the north and east winds, and its winter climate is regarded as the most equable in the country. It is a milder and softer climate than Nice, and consequently will agree better with patients advanced to the stage of softening. Waples bears a strong resemblance to Nice; it possesses a dry and consequently exciting atmos- phere, and is, therefore, best adapted to persons of a lymphatic temperament, and those in whom but little irritation exists. _ But its temperature is variable, the sirocco is often severe, and hence is not well adapted to advanced cases of phthisis. Rome ( more favorable for consumptives. It is, however, a moist and elaxing atmosphere, and, therefore, many patients in a state of debility would be injured by a prolonged residence. Sir James Clark, however, bears testimony to the favorable in- fluences of this climate; and he declares that he has frequently known persons laboring under grave symptoms of phthisis re- (sored after a short residence in Rome. The character of the climate is best adapted to persons of a nervous temperament, and in whom much mucous irritation predominates. “ Venice possesses a more equable climate than most contiguous +. » places. M. Carriere declares that it would be difficult to invent ' ; a climate more favorable to consumptives. Of twelve hundred 3 patients admitted to the hospital, only seven or eight were con- sumptives. 2 c The island of Madeira, which has been forcibly, if not truly, - styled the city of refuge for consumptives, possesses a reputation superior to any other place or country. It is situated in the North Atlantic, lat. 32° 28’ N., long. 160° 54’ W.; and is de- scribed as a “mass of basaltic rock,” consisting of bold scenery, with a remarkably equable temperature. The greatest heat SPECIAL QUESTIONS IN THE TREATMENT OF PHTHISIS, 525 does not exceed 74° Fahr., and the lowest does not fall below 63°. Different opinions, however, have been expressed in re- gard to its beneficial influences in cases of consumption. Drs. Gourlay, Mason, Burgess, and others, assert that no malady is more common in Madeira than phthisis, while Dr. Heineken was led, by his own observation, to a more favorable opinion. Dr. Renton also affirms that the prevalence of phthisis in Ma- deira has been greatly overrated by Dr. Gourlay; and Sir James Clark, having carefully examined the facts reported by Drs. Renton and Heineken, expresses the opinion that phthisis is not a common disease in this island. Conflicting opinions have been expressed in relation to the moisture of the atmosphere, and other qualities of the climate of Madeira. Dr. Mason, who was a consumptive, and spent some years in the island, represents the atmosphere as being saturated with moisture, during the principal part of the year, being, in fact, worse than London; that it is impossible to prevent iron from being rapidly oxydized, while deliquescent substances speedily imbibe moisture; that the temperature is quite variable; and, finally, consumption and scrofula are com- mon diseases. These are most unfavorable statements; but it is probable the picture has been overdrawn. Thus, at Madeira rain falls on seventy-three days in the year, while at London the number reaches one hundred and seventy-eight. The rains generally fall at particular seasons, especially in autumn, while the air of the remainder of the year, says Sir James Clark, is generally dry and clear. The following statistics, furnished by Dr. Renton, throw some light on the effects of this climate: ‘Cases of confirmed phthisis.........:cccssssesrsseereseoseressseseescsseessasenenes 4T Died within six months after their arrival at Madeira,..........++6 32 Went home in summer, returned, and died........cccseceeccerecnenes 6 Left the island, of whose death we have heard............ssssseeeees 6 Not since heard of, probably dead.........cssssecessssessetssersevessees 3 526 THERAPEUTICS OF PHTHISIS. Cases of incipient phthisis........sccccsessesssccenaccessesssseesvssseeessseates 85 Of these, there left the island much improved, and of whom we have good AccOunts......scccsecssssensecerescenecsesscneseseeesscceeseeeers 26 Also improved, but not since heard Of.......sssssesecsescereseverserenees 5 Fave since died.......sccsssscssscsssesensscnenceasesescaneetesasasensosserentes 4 Total ...ccssseccersenstseseneeerenoeses $e ete eneretancanencesereces 35 These figures, if to be taken as literally true, simply show, what might have been anticipated, that the climate afforded no relief to those far advanced in the disease, but probably -hastened their death; while, on the contrary, of those in the incipient stage, a large proportion were permanently benefited. The statement, however, in relation to the incipient cases, prob- ably requires some qualification ; for it is not certain, nor even probable, that they were all cases of the character assigned them. Still, with all due allowances for errors, we must regard the statement as highly favorable. The statistics furnished by Dr. G. Lund, as given by Boudin, are highly valuable, and furnish some important facts on the subject. Of one hundred phthisical patients who arrived at Madeira, in various stages, the disease was arrested in thirty-seven in the first stage, five in the second stage, and five in the third stage. In the same number, eleven, in the first stage, continued to progress, seventeen in the second, and twenty-three in the third stage. The following were the general results: LIVING. Hirst Stagernsscssnssuvesesasveadiise.sesasiiioeosandencsccees 43 Second stage....ccsssccsseceensecccersssessssevscceeseeeees 13 | = 66 Third SLAC ie cactiacsincvvesadeiereseacesiu aaa sdacandperesess 10 DIED. FRIPSt Bt GO sacansscvseyen debtavssices asacstecdeavsisedevaesdeeos 5 SOCOM SAGO csc sess dedetesnecawesuunecasseceaseecasniaeanes 11 }= 34 hired. lage vwcdescevaewe de csus covessiesavacsssssavsveseaasions n} —- 100 The length of time during which the disease remained ar- My SPECIAL QUESTIONS IN THE TREATMENT OF PETUISIS. 527 rested appeared sufficient to justify the conclusion that it con- stituted a cure. Thus, in the first stage, it had been arrested from four to ten years in thirteen; three years in two; eight to twenty months in eleven; seven to twelve months in eleven; and there had been relapses in two only. In the second stage: In one subject ten years, with one relapse and a second arrest; in a second subject arrested five years; in three others, fifteen months; in one of these a relapse, new arrest for three months, and then had good health. Third stage: In one arrested twelve years; two, eight years; two others quitted the isle after three years. In those in whom the disease continued to advance, its prog- ress appeared somewhat slower than usual. Hence, the author concludes that, in the first stage of phthisis, the chances of arrest of the disease are infinitely greater at Madeira than in England, France, or any cold climate. And, indeed, these, with other facts, justify the conclusion that the island of Ma- deira, although scarcely the city of refuge for consumptives, is highly favorable to that class of patients, especially those not advanced beyond what is called the first stage. The preceding remarks, in relation to residences for con- sumptives, refer to the winter season; but it is, at the same time, to be remembered, that, in most instances, a summer res- idence in a cooler climate is equally important. This subject, however, will be further developed as we advance, and especially with reference to the United States. THE CLIMATE OF THE UNITED STATES. The selection of a winter residence in the United States for consumptives is a most difficult task. Unlike our brethren of Europe, we have no cities of refuge—no Madeiras or Hyéres—to which patients can be directed; while probably some of our most favorable positions are but little known, and others present too few accommodations to be made available for invalids. In addition to these difficulties, some differences of opinion have existed among American physicians as to whether consumptives should be directed to warm or cold climates. Dr. Forry, and, 528 THERAPEUTICS OF PHTHISIS. after him, Dr. Drake, entertained the opinion that consumption was more prevalent in the southern than the northern lati- ‘tudes of the United States; and hence, it was a fair induction, that patients laboring under this malady should be sent to cool instead of warm latitudes. The premises, however, are evi- dently false, and, therefore, the induction erroneous; for, as previously shown, the statistics on which this opinion was based were drawn from the United States army, and, therefore, did not truly represent the condition of the resident population. A majority, however, of the profession of the United States who reside in the Eastern, Middle, or Western states, incline to send their patients South, and their destination may be Louisi- ana, Texas, Florida, South Carolina, or even Cuba. But in all this great extent of country, there are but two particular locali- ties which have had much celebrity as resorts for consumptives, and these are Florida and Texas. Nor are there in either of these states any celebrated cities or watering places to which patients can resort; we have here no Hyéres, Venice, or Rome; and, indeed, one of the great objections which invalids encounter is an actual want of accommodations, to say nothing of attrac- tions, which are so important to some temperaments. The climate of Florida is warm, humid, and relaxing. With a mean annual temperature of about seventy degrees, and an atmosphere saturated with vapor, the humidity, it will readily be conceived, is extreme. The dew point being high, a slight reduction of temperature renders the atmosphere moist. It is true some of the interior points, such as Tallahasse, are less objectionable than the coast; but every portion of the country possesses the elements of climate previously mentioned. St. Augustine, to which consumptives have often resorted, is pecul- iarly unfavorable; and few have resided long in that locality _ without serious injury. Patients who have resorted thither have informed me that they found at once the climate unpro- pitious, and that it was often seriously injurious. The inference from these facts is, that the climate of Florida, taken in a general sense, is not adapted to phthisical persons advanced to the stage of softening, or in whom much debility exists. And so far as cases of this character have come to my SPECIAL QUESTIONS IN THE TREATMENT OF PHTHISIS. 529 knowledge, they have invariably been seriously injured,—the debility increased, suppuration extended, and the disease as a whole made rapid advances. We are not prepared to say, however, that in the early stages of the disease, (especially the precursory period,) the results may not be different; indeed, there are some facts to show that even in this moist and relaxing climate, the revolutionary influences of the change may avert the impending tuberculosis, or even arrest incipient deposits. 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