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Phthisis

PHTHISIS PHTHISIS (a Greek word, QSimc, signifying 'corruption,' 'decay') was formerly used as a generic term to signify a wasting or consumption from any cause, and was afterwards more distinctly specified, according to the organ in which it was supposed to originate: hence we had a Phthisis Hepatica, P. Mesenterica, P. Pulmonalis, &c.; but the word is now restricted to the disease produced by tubercles in the lungs, and commonly known by the name of consumption. An acquaintance with this disease, from which neither age . nor sex is exempt, and no part of the habitable globe is free, whose ravages extend even to the brute creation, and whose course when once begun can rarely be stayed, whose commencement is frequently so insidious, and whose termination so fatal, must, above all others, be interesting; for if by any precautions its development can be prevented, it is only by a knowledge of those influences which most frequently give ri>e to it that we can hope to attain our object. I Morbid Anatomy of P/Uhisis.—Jha local morbid changes peculiar to Phthisis are only the result of previous changes in the general system, an hereditary or acquired predisposition, cognizable by the physical condition of the patient, and by a disordered state of various functions; 'and which, though very generally accompanied with a feeble organization, is not inconsistent with too great development and inordinate action of particular parts, and even with considerable physical power of the system.' By far the most important and characteristic morbid change that occurs in Phthisis consists in the development of tubercles wherever thoy may be found: but as if is in the lungs that they first and most frequently manifest themselves, we shall describe them as they are seen in those organs. Tubercles of the lungs first appear in the form of small, grey, semi-transparent granulations, which gradually enlarge and become opake in their centre: the opacity increases, till the whole mass becomes of a dull yellowish-white colour. After a certain time thoy soften, empty themselves into the bronchial tubes, and give rise to excavations mote or less considerable. In this way, almost the whole of both lungs may be invaded by a succession of tubercles, their healthy structure being absorbed as the tubercles become deposited, or involved in the destructive process consequent upon their softening. Tubercles, unlike inflammation, almost invariably commence at the summit of the lungs, where, as well as being more numerous, they are usually found in a more advanced stage of development than in any other part. The successive eruption of fresh tubercles is an important feature in this disease, as it explains the occasional recovery of patients labouring under consumption. A crop of tubercles may appear in the lungs, go through the various stages above described, and give rise to all the symptoms of confirmed Phthisis; yet provided the conditions which gave rise to them are removed, no fresh eruption may take place, and the patient shall recover. The relative frequency of tubercles in other organs differs considerably in the adult and in the infant. In the former, M. Louis, our greatest authority in all matters connected with Phthisis, has, with one exception, never observed them in any organ without their existing in the lungs; so that he regards their presence in these last viscera as a necessary condition for their development in other parts. But in the infant this does not appear to hold good; the bronchial glands being more frequently affected than the lungs, in the proportion of 87 to 73. The brain and its membranes are likewise more subject to tuberculous deposits in the child than in the adult. The next most important lesion which is met with in phthisis is ulceration of the intestinal canal. The ulcers may vary in number, form, and size, but they all present specific characters peculiar to this disease and to no other, and exist in five-sixths of the cases which terminate fatally. The third peculiarity in reference to phthisis is the change that the liver undergoes; to which the French pathologists have given the name of 'Foie Gras,' or fatty liver. Lastly, ulcerations of the epiglottis, larynx, and trachea occur so frequently, and with such uniformity of type, as justly to lead to the belief that they are a part of the disease. But besides these morbid changes, which are peculiar to this disease, complications of various kinds occur which are common to it. and other chronic diseases. By far the most frequent of these are inflammations of the Pleura; so that it is extremely rare, in making the post mortem examinations of persons who die of phthisis, not to find the lungs adherent, in part, or entirely, to the walls of the chest. Inflammation of the substance of the lungs is likewise a frequent complication in the latter stages of phthisis.

Symptoms of Phthisis.—These generally commence with a slight cough, which at first excites no attention, but is regarded as a simple cold. The breathing is not seriously affected, nor is the appetite impaired. After a time the cough increases in frequency, and is accompanied by expectoration of a clear frothy saliva: the breathing and pulse become a little hurried after meals and towards evening: and at this lime of the day there is frequently experienced a slight degree of chilliness, followed by heat, which continues during the greater part of the night, and is succeeded towards morning by perspiration. The patient likewise becomes somewhat paler, and is languid and easily fatigued. In some instances the first symptoms are preceded by a more or less copious haemoptysis. In the second stage of Phthisis the cough becomes more frequent, especially during the night, and if violent, it sometimes occasions vomiting; hoarseness, or loss of voice, is not unusual: the expectora tion changes its character; it is less frothy, and more opake; containing small particles of a yellowish curd-like substance; or the sputa arc streaked with dull yellow lines; and haemoptysis is pretty frequent, but in genera', not abundant; the breathing and pulse are more hurried: the fever is greater; and the perspirations more regular and copious, pains in the thorax, denoting pleuritic inflammation, often occur; and the languor and emaciation still increase. In the last stage of consumption there is nearly always profuse diarrhoea, and the sweats and expectoration are more copious: the latter becomes more uniform in composition, and is separated into roundish distinct masses, with flocculent edges. The emaciation and debility keep pace with the other symptoms; and the feet and ankles swell towards evening: the appetite generally declines in the same proportion, and the patient dies in the extreme degree of marasmus, not (infrequently flattering himself to the last with a speedy recovery. In females the menstrual d.scharge almost always ceases when hectic fever is established; and occasionally even before that is the case, which has led to a popular opinion that the disease in such cases arises from the suppression. Such are the ordinary symptoms presented by Phthisis in its most usual form; but varieties exist in the order and duration of the morbid phenomena. Thus, tubercles may be developed in the lungs, and remain for a considerable period without exciting either cough or expectoration, or even any important general symptoms. In other cases they give rise to intense general symptoms; as fever, emaciation, anorexia, before they excite cough or expectoration; the latter appearing only a short time previous to death. To these cases the term Latent Phthisis has been applied: and what is remarkable in them is, the absence of appreciable organic alteration in organs whose functional derangement was most violent; while the only viscus really affected seems functionally healthy. The term AcutePhthisis is applied to those cases in which the disease goes through all its stages with unusual rapidity. It occurs most frequently in the young, and in those weakened by some previous disorder. In popular language it is designated galloping consumption. Chronic Phthisis is the reverse of the last, and comprehends all those cases in which the progress of the disease is unusually slow and generally intermittent.

Diagnosis of Phthisis.—Auscultation and percussion are the chief means by which we arrive at the diagnosis of phthisis [auscultation; Percussion]; but there are several collateral circumstances which must be taken into consideration in order to form a correct opinion as to the nature of the disease. It is at the commencement of phthisis that an accurate diagnosis is of most importance, and in which the stethoscopic signs are least evident. We shall be therefore more particular in enumerating the indications at this period, than in accurately describing the acoustic phenomena which are present at a more advanced stage of the disorder. As bronchitis is the disease with which phthisis is most liable to be confounded, we shall place in juxtaposition the principal points in which they differ. In the greater number of cases of phthisis the cough comes on without any evident cause, and many months may elapse without expectoration. This apparent absence of cause and dryness of cough are of themselves very remarkable, and differ from what occurs in simple bronchitis. Thoracic pains, when present in the latter affection, are generally felt in the middle of the sternum; while in phthisis they are situated in the sides of the chest and between the shoulders. Hajmuptysis, from the commencement or during the progress of cough, is frequent in phthisis, and is almost a certain sign of the presence of tubercles ; whereas this symptom never occurs in bronchitis. Out of twelve hundred patients affected with various diseases, not including cases of amenorrhcea or those arising from external violence, M. Louis found that not one, with the exception of phthisical cases, had experienced this symptom. Auscultation gives us little or no aid in the earliest stages of phthisis, and when the stethoscopic signs first manifest themselves, they are such as result from an increased density in the structure of the lung, and not from the presence of fluid in the bronchi, as is the case in bronchitis. Thus the expiration, which in health is scarcely audible, becomes more distinct; the voice more resonant; the sound elicited on percussion duller. These alterations in the respiration and in the signs produced by percussion, like the development of tubercles, take place from the summit to the base of the chest; and at first are almost constantly confined to the upper lobe of one side Inbronchitis the sounds result from fluid in the bronchi, and originate in the loner part.of the chest, and usually on both sides. In ihe more advanced stages of phthisis its diagnosis is less difficult, aiul is mode from a consideration of the sputa, which we have already described, and from the signs furnished by percussion and auscultation. These are now decisive; the upper parts of the chest are dull on percussion; the respiratury murmur is strong, coarse, or even cavernous under the clavicles; and the voice listened to in the same situation gives rise to that peculiar phenomenon termed pectoriloquy. If there should be much fluid in the lungs, resulting from the patient's not having lately expectorated, we then have a mucous rattle in all those parts of the chest corresponding with the seat of the disease; and where cavities containing fluid exist, the air passing through this produces that gurgling noise to which the term gargouillement has been applied by the French. The space in which these different changes take place is at first limited; but it daily increases, and in some instances, where the entire upper lobe of the lung is converted into numerous excavations, the respiration is coarse and more or less tracheal throughout its whole extent. The diagnosis of latent phthisis is not difficult, provided we make use of the proper means for ascertaining the condition of the pulmonary organs; the evil is, that the attention is directed exclusively to those functional derangements which we have spoken of when describing latent phthisis, while the real Mat of the disease is overlooked.

Duration and Mortality of Phthisis.—Various circumstances affect the duration of phthisis, as age, sex, constitution, occupation, season of the year, climate, &o. In the upper ranks of life, where patients have all the advantages that a proper regimen, change of air. and good medical treatment can afford, the average duration of the disease is considerably above that exhibited in the table below.

The mean duration of 314 cases exhibited by this table is 23 months, including the extreme cases; but 162, or more than half of the cases, terminated in 9 months; and the greater proportion of them between the fourth and ninth month By excluding those cases which terminate within four months, and those that exceed four years, the average duration of the remaining cases is eighteen months. With regard to the mortality from phthisis, it varies in different climates, ages, sexes, races, and occupations. In England and Wale*, according to the 'Report of the Registrar General of Births, Deaths, and Marriages,'lately published, it is 19 55 per cent, of the total number of deaths, or 3 82 annually out of 1000 living. In France it is about the same. On the eastern frontiers of the Cape of Good Hope, where the atmospheric vicissitudes are sudden and great, the thermometer in summer sometimes varying from 110° to 64°, and in winter from 75° to 32° in the course of a few hours, it is only 3J. Premising that a greater number suffer from phthisis among the military than the civil population, the following table, from Major Tulloch's 'Statistical Reports," shows the number of men attacked annually by phthisis out of 1000 of white troops, at each of the following stations:—

Nearly two-thirds of this mortality arise from consumption. Thus, in his native country the negro appears to suffer from these diseases in a less proportion than British troops in their native country; but so soon as he goes beyond it the mortality increases, till in some colonies it attains to such a height as seems to preclude the possibility of his race ever forming a healthy or increasing population. The Hottentots in our army at the Cape of Good Hope suffer more from diseases of the lungs generally than the European troops; while the proportion of those who die from phthisis is about the same. In both cases the mortality is below the average, as is seen in the table before referred to.

The natives of some tropical climates seem so little subject to diseases of Ihe lungs, that among 74,850 native troops serving in the Madras presidency, the deaths, by every description of disease of the lungs, did not, on the average of five years, exceed one per 10UO of the strength annually. The period of life above puberty at which the greatest mortality from phthisis occurs is between 20 and 40, as will be seen by the following table; and it is worthy of remark that although the number of deaths from phthisis is more considerable from 20 to 40 than from 40 to 60, the general mortality is less in the first than in the second period. Died of phthisis at the following ages: —

Age. Deaths. Louis. Mtiyle. Total. 15 to 20 . . . .11 10 = 21 20 30 . . . . 39 23 = 62 30 40 . . . . 33 23 = 56 40 50 . . . . 23 21 = 44 50 60 . . . . 12 15 = 27 60 70 . . . . 5 8 = 13

In respect of sex, consumption destroys more females than males, in the ratio of 4155 to 3771. This includes the whole of England and Wales, but does not hold good as regards some cities and most of the mining districts. In these the pursuits of a large portion of the male population seem particularly inimical to health, and raise the mortality from phthisis nearly to what it is in the female, and in some places even above, as will be seen in the following abstract from the Registrar-General's Report:— Died of phthisis from July 1st to December 31st, 1837, in the metropolis, whose estimated population on the 1st of October, 1837, was 1,790,451, and in the unions of the counties of Cornwall, Devonshire, Dorsetshire, Somersetshire, and Wiltshire, whose estimated population at the same period was 1,723,770— Males. FcmaleB. Metropolis. Counfies. Metropolis. Counties. 1947 1325 1930 1466 Died of phthisis from July 1st to December 31st, 1837, in the counties of Essex, Gloucester (except Bristol and Clifton), Hereford, Norfolk (except Norwich), Suffolk, Sussex, and Westmoreland, whose estimated population on the 1st of October, 1837, was 1,776,980; and in the districts of Aston, Bath, Birmingham, Bristol, Cambridge, Carlisle, Clifton, Derby, Dudley, Exeter, Leeds, Leicester, Liverpool, Manchester, Maidstone, Newcastle-on-Tyne, Northampton, Nottingham, Salford, Sheffield, Stoke-on-Trent, Sunderland, Wolverhampton, and West Derby, whose estimated population at the same period was 1,762,710— Males. Females. Cities. Counties. Cities. Counties. 2118 1363 2130 1703

These tables point out generally the influence of occupation in the production of phthisis. In cities the majority of the male labouring population is engaged in the arts, trades, and manufactures, and generally for many hours together in ill-ventilated apartments, and in unhealthy postures of body. In the country the pursuits of the same class of persons are chiefly agricultural.

Having now considered the mortality of phthisis in connection with climate, race, age, sex, and occupation, we are enabled with greater advantage to examine into those causes which appear to be most active in its production.

Causes of Phthisis.—The causes of phthisis, says Sir J. Clarke, may be divided into 'the remote and the exciting, or those which induce the constitutional predisposition, and those which determine the local deposition of tuberculous matter after such predisposition is established. The one class of causes operates by modifying the whole system; the other, by determining in a system so modified the particular morbid action of which tuberculous matter is the product.' Of the remote causes, or those which induce the constitutional predisposition, perhaps the most powerful is that which arises from hereditary transmission; not that an individual born of consumptive parents will himself necessarily fall a prey to the same disease, but only that, when exposed to those influences which we are about to enumerate as determining the tuberculous cachexia, he will be more likely to become affected than one born of healthy parents. Next to hereditary transmission of the consumptive diathesis, the causes most active in producing this state of constitution are, a sedentary life, more especially when associated with a confined posture of the body and impure air; bad quality or insufficient quantity of food; insufficient clothing; excessive mental or bodily labour; mental depression; and abuse of spirituous liquors. In fact, all those agents which operate in depressing or lowering the tone of the system generally act as remote causes in the production of phthisis. The more immediate or exciting causes of consumption, those which determine the deposition of tubercles, have usually been attributed to irritants acting locally on the bronchial tubes or on the lungs, whether occasioned by inflammation of these parts or by the mechanical action of irritating bodies upon them. The result of the latest investigations on this subject leave no doubt that the influence exerted in this way has been greatly exaggerated. Pneumonia and bronchitis, the two diseases hitherto regarded as the most frequent forerunners and producers of phthisis, have been shown by M. Louis to exert no more influence in its production than any other disease. They may indeed occasionally hasten the development of tubercles, but they exert no specific effect, and they act only as remote causes in impairing the health generally. These conclusions of Louis, which have been deduced from his own observations in hospital practice solely, receive ample confirmation from the admirable Statistical Reports of the Registrar-General and Major Tulloch, which we have before referred to. The popular error of attributing consumption to cold, the breaking of a blood-vessel, &c., has probably originated from mistaking the effect for the cause. We have shown in a former part of this article that cough and haemoptysis are among the earliest symptoms of tuberculous lungs. With regard to mechanical irritants, as dust of various kinds, noxious gases, smoke, Sec, 'no opinion has been more prevalent,' observes Dr. Cowan, 'than that those who are exposed to the inhalation of the dust of vegetable, mineral, or animal substances, are peculiarly liable to phthisis; and in the supposition that consumption was essentially a disease of the lungs, and in the great majority of instances the result of bronchial inflammation, no conclusion was more natural or more probable. But once remove from the mind the impression of a necessary connection between bronchitis and tubercles, and we feel persuaded that the examination of the evidence brought forward on the subject of dust will terminate in the conviction that this agent exerts at most but a very secondary and unimportant influence in the production of phthisis.' The mortality among tho workmen in some of our manufacturing towns is usually brought forward in support of the doctrine of mechanical irritation. Dr. Knight of Sheffield informs us that there is not an example of a polisher of forks reaching his 36lh year, nor do the artisans in other departments attain a much greater age. But it must be recollected that many of these men work sixteen hours a day in a close atmosphere and confined posture of body, two conditions which contribute perhaps more than any other to the increase and production of phthisis. Nor has the mortality been diminished by the use of magnets, wire masks, currents of air, and moisture, which have been successively tried for the purpose of arresting the metallic particles. In the cases of 887 quarrymen, 557 stone-cutters, and 160 marble-workers, all of them occupations involving the inhalation of dust, M. Benoiston found the proportion of phthisis was less than the general average; but then these are employments carried on in the open air. Dr. Lombard, whose researches are founded on a total of 4300 deaths from phthisis, and 54,572 individuals, exercising 220 different occupations, found, by a comparison of all the professions carried on in the open air and in workshops, that the proportion of deaths from phthisis was d'luble among the latter; and this proportion increased as the apartments were close, narrow, and imperfectly ventilated.

Mr. Watson, a surgeon of Wenlockhead, a mining district, informs us that, out of 74 men working during four or five months for sixteen hours daily in amine where a candle burnt with difficulty, not one was attacked with any pulmonary affection. But whether from the inhalation of noxious gases or from other causes, it is certain that in the majority of the mining districts of this country the mortality from phthisis is high. The number of males attacked by this disease in Cornwall exceeds that of the females in the ratio of 170 to 140, and in the mining parts of Staffordshire, Shropshire, and Worcester, in the ratio of 203 to 191; while in the non-mining districts of Staffordshire and Shropshire, and in the county of Cheshire, the ratio is 656 males to 796 females.

The influence of smoke, when uncombined with other agents of injurious tendency, may, we think, fairly bo called in question. In Leeds, which is certainly tho most smoky place in the whole kingdom, the mortality of females from phthisis is below that of most of our large manufacturing towns, and is not much abovo the average for the. whole of England and Wales. In London likewise this is the case, and in nearly the same proportion, as will be seen in the fallowing table of the relative mortality of females from phthisis in each of the under-mentioned cities, and in England and Waloa:—

Annual Deaths to 100,000 living. Leeds. Binning- Manchester. London. Liverpool. England ham. audWalei. 401 494 510 402 C70 386

It must not be forgotten that in these towns a large proportion of tho female sex is occupied in those kinds of employment that we have before shown to be so prejudicial: how much then must be attributed to the smoke, if the unhealthy occupation were expunged from the account? From what we have advanced against the operation of local irritants as causes of pulmonary consumption, we by no means wish to be understood as deprecating the use of any means calculated to got rid of this source of irritation; but we merely propose to show that they act a very inferior part, and, when unassociated with those circumstances which modify the system in general, their real activity as causes of pulmonary tubercles is problematical. It would not however be fair to omit the mention of one fact, which in t ruth i» the only one that we have met with, in evidence of a direct local irritation giving rise to tubercles. This fact is related hy the late Baron Dupuytren. A boy was brought into the Hotel Dieu for some surgical complaint, of which he died. On examining the body after death, a marble was found impacted in one of the bronchi; around this spot, but in no other part of the body, was found a small crop of tubercles.

A moist and changeable climate has been regarded hitherto as among the most active causes of consumption; and Great Britain, whose climate combines these two conditions in a remarkable degree, has been looked upon as such a nursery for phthisis, that our facetious neighbours on the other side of the Channel have styled it 'LaMaladie Anglaise.' Indeed the notions of atmospheric vicissitudes, dampness, and consumption, seem almost inseparable. However, these opinions have been and still are undergoing a severe scrutiny; and the evidence which we at present possess on the subject tends very strongly to disprove their correctness. Moisture and climate, like all oilier agents, act either locally or generally; popular belief has attributed their presumed prejudicial effects to local action. They tend, it is said, to produce catarrhs and coughs, and consequently consumption. We need scarcely allude again to the fallacy of this opinion. We are in possession of little information on the mode in which climate operates to the production of phthisis. That the disease prevails to a much greater extent in some climes and localities than in others, is an indisputable fact; but it is no less cerlain that its prevalence is not confined to countriesof variable temperature, for many of such countries suffer in a much less degree than those whose thermometric range varies little throughout the year. Nor does it appear that moist climates and localities are more inimical in this respect; indeed consumption is said to be rare in marshy districts; and Dr. Wells has brought forward a variety of interesting observations to prove that the causes of intermittent fever induce a state of constitution which is a protection from consumption; and he says that in countries where one prevails, the other is always absent, or at least much less prevalent. This certainly coincides with what has been observed on the western coast of Africa, the climate of which is moist in the extreme, and where fevers prevail to a frightful extent; yet diseases of the lungs are rare. It has been also observed that tanners, dyers, wool-scourers, brewers, brickmakers, washerwomen, and many other occupations in which the upper or lower extremities are exposed to wet, and the air is charged with aqueous vapours, present fewer cases of consumption than almost any others. Too much weight however must not be attached to these speculations, for accurate statistical data from fenny countries and localities are still a desideratum; and as respects the immunity enjoyed by persons exercising the trades just enumerated, it v.ill be observed that they are all of them employments combining considerable muscular exertion with free exposure to the air. The wages too of this class of persons are generally such as to place them above want. Is phthisis contagious? Tins is a question which has been often discussed, and numerous are the testimonies both on the affirmative and negative side; but the weight of the evidence seems to rest with'the non-contagionists.

Treatment of Phthisis.—This resolves itself into two kinds: first, the prophylactic, or that which has for its object the prevention of phthisis in those who are hereditarily or otherwise predisposed to the disease; and secondly, the curative, or that which endeavours to arrest its progress after tubercles have manifested themselves. Much may be done in the first case; hut experience proves the limited control that we possess over it "in the second. Phthisis, as we have said before—and, as we are anxious to impress this fact upon our readers, we again repeat—is not a mere local disease, or one arising from local causes; but it results from a general depravation or unhealthy condition of the whole system, of which tubercles are only an effect. They may be considered as the last of the embryonic changes previous to the nascencc of the disease in a cognisable form.

This being premised, our prophylactic treatment must he directed towards the prevention or the arresting of the incipient changes which take place previous to the development of tubercles. With this view the most obvious rules are, to avoid all those causes which we have pointed out as tending to produce the tuberculous diathesis. Marriages should be made with greater regard to the health of the contracting parties. Children, especially if sickly, should be reared and educated with less anxiety about their mental progress than their bodily strength. Those professions and trades should be avoided which combine much sitting, with a confined posture of body, as those of tailors, shoebinders, shoemakers, milliners, lacemakers, engravers, jewellers, watchmakers, clerks, &c, all of whom are peculiarly subject to phthisis. Agriculturists, butchers, carters, coachmen, sailors. Sec, are remarkable for their general health and their freedom from this complaint. All occupations therefore that are carried on in the open air should be chosen in preference to those of an opposite kind. Callisthenic exercises, when indulged in with moderation, are healthful, and should by no means be neglected. In short, everything which tends to invigorate the body diminishes disease; and it is proved by statistical facts, that wherever the mortality from disease generally is low, the mortality from phthisis is also low. The curative treatment of phthisis consists in regulating the health generally, and in combating particular symptoms. For the attainment of the first object, the diet should he nutritious, but not stimulant; and the exercise regular, hut gentle, and not too prolonged. Horse exorcise is particularly recommended in the incipient stage of phthisis, and travelling may be safely undertaken in certain circumstances. Of all the modes of travelling, sea-voyages are perhaps the most beneficial; and where much improvement has taken place during the voyage, it would be better to repeat it than hazard the doubtful benefit of a residence on land. The influence of climate on consumption, we are inclined to believe, is imperfectly understood. It has been laid down as a general principle, that the change from a variable temperature to one of an opposite description is in the highest degree advantageous, and,crrteris paribus, we think this may safely be admitted; but in recommending patients to climates which possess this uniformity of temperature, it has been too often overlooked that there are other counteracting circumstances which more than neutralise this advantage. Examples of the mortality from phthisis in many countries which are remarkable for tho equability of their temperature, have been already adduced in a previous part of this article, where it has also been shown that the Madras presidency of India, and the eastern frontier of the Cape of Good Hope settlement, to which may be added New South Wales and South Australia, all of them countries subject to sudden and great changes of temperature, enjoy an extraordinary immunity from phthisis. The practice of sending patients to a foreign country who are in the last stage of consumption, cannot be too strongly reprobated. Much difference of opinion exists on the relative advantages attending a residence on the coast or inland for consumptive patients. From the great benefit of sea-air in all scrophulous disorders, and from a review of the causes of phthisis, we are inclined to think that the sea-coast on the whole is preferable. Where circumstances render removal to an anti-phthisical country impossible, confinement to apartments where the heat is regulated, and the purity of the air as much as possible preserved, during the more rigorous weather of this climate, may be recommended. It must however be recollected that this mode of treatment, being unfavourable to improvement of the general health, should only be enforced when exposure to the air is constantly attended with increase of the symptoms. The invention of the respirator lias in a great measure obviated this inconvenience; and the phthisical patient, when warmly clad and furnished with this instrument, may be allowed to take exercise in the open air, not only with impunity, hut with positive benefit. Among the medicines which have been employed in the general treatment of phthisis, emetics must be first mentioned. It is remarkable, says Dr. Young, that a very great majority of the cures of consumption related by different authors have either been performed by emetics or by decidedly nauseating remedies. It is evident that the effects of vomiting are general, and not confined to the stomach. The mechanical pressure upon the abdominal and thoracic viscera, the influence upon the arterial and venous circulations, the effects upon the nervous system, and the subsequent diaphoresis, all point out that the action of vomiting is general and complicated; and, associated with the benefits resulting from sea-voyages, swinging, &cr, there is every reason to believe that the use of emetics in incipient cases of phthisis is satisfactorily demonstrated.

From the efficacy of hark, sarsaparilla, iron, and iodine, in scrophula and some other diseases attended with constitutional debility, it has been imagined that these medicines must necessarily prove beneficial in phthisis; and there can be no doubt that their tonic properties, when not contraindicated by the existence of inflammation or much febrile excitement, may safely be put in requisition in the treatment of phthisis. Another class of remedies, of a totally different nature, but not less efficacious when judiciouslyapplied, may be calle 1 anti-inflammatory. Such are bleeding, either general or local; mercury, digitalis, counterirritation. The last is one of the most powerful therapeutic agents that we possess, and, like all other remedies, when used in the commencement of disease presents the greatest chance of success. It is inapplicable when much fever is present, and should never be carried to the extent of producing constitutional disturbance.

These are the general remedies employed in phthisis. The more prominent symptoms of the disease require to be combated by particular medicines which we have yet to name, or by a combination of those just enumerated. One of the most constant and harassing of the symptoms of consumption is cough, which, by interrupting sleep and accelerating the circulation, exerts an injurious influence over the general comfort and health of the patient. It may be tranquillised by the application of sinapisms, tartar emetic ointment, or stimulating plasters to the walls of the chest; or the direct local application of the vapours of chlorine and iodine to the internal surface of the bronchial tubes by means of inhalation may be tried. In addition to these measures, the cough may be calmed by mucilaginous mixtures, decoctions of Iceland moss, small doses of hyoscyamus, Prussic acid, opium, aether, &c. Perspirations in phthisis are very common, and when profuse, tend to weaken the patient. They are checked by exhibiting acids. The sulphuric acid given in bark, or the nitric acid in a decoction of sarsaparilla, are the most eligible combinations for combating this symptom. We have seen that the diarrhoea which takes place in phthisis is the result of inflammation and ulceration of the intestinal canal: a knowledge of this fact will at once regulate our treatment. All stimulating food and medicine must be avoided; the external surface of the body generally, and the abdomen in particular, should be kept warm; gentle counter-irritation may be made to the latter, and small doses of rhubarb and opium, chalk and opium, or lime-water and milk, may be given internally. With respect to the treatment of pneumonia and pleurisy, which are so frequent in the latter stages of phthisis, we cannot be too cautious. It must never be forgotten that they are mere complications; and in any depletory measures which may be thought necessary, the original disease upon which they are engrafted must not be lost sight of. On the whole, local bleeding by leeches or cupping is preferable to venesection, and counter-irritation to both. For a full account of haemoptysis and its treatment, see H.SMOPrYsis.

Note - this article incorporates content from The Penny Cyclopaedia of the Society for the Diffusion of Useful Knowledge (1840)

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