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OBSERVATIONS
THE DISTINGUISHING SYMPTOMS
            OF
    THREE DIFFERENT SPECIES
            OF
                THE
-CATARRHAL, THE APOSTEMATOUS,  v
              AND THE
         TUBERCULOUS:
;OME REMARKS OX THE REMEDIES AND REGIMEN BEST FITTED FOR
 THE PREVENTION, REMOVAL, OR ALLEVIATION OF EACH SPECIES.
 TO WHICH IS ADDED,
AN APPENDIX,
PREPARATION AND USE OF LACTUCAR1UM, OR LETTUCE -
                OPIUM.
J
BY ANDREW DUNCAN, Sen.M.D.F.R.&A.SS.Ed.
        PHYSICIAN EXTRAORDINARY TO THE KING,
  AND SENIOR PHYSICIAN TO THE PRINCE REGENT FOR SCOTLAND;
ONE OF THE PHYSICIANS IN ORDINARY TO THE PUBLIC DISPENSARY
      FOR THE CITY AND COUNTY OF EDINBURGH, ETC.

   FIRST AMERICAN, FROM THE SECOND LONDON EDITION'.;:.* ■

                "      " *xo¥#X
      PHILADELPHIA: X/.,^r,r.^*
PUBLISHED BY COLLINS & CROFT,
     No. 73, MARKET STREET.
   W. Brown, Printer, Prune Street.
           1819. 

i* 
                  TO






         HIS ROYAL HIGHNESS














  PRINCE REGENT OF THE BRITISH DOMINIONS,






      THIS SHORT TREATISE,






  AN ATTEMPT TO ALLEVIATE HUMAN MISERY,






BY ENDEAVOURING TO IMPROVE THE HEALING ART,





          IS HUMBLY DEDICATED,





BY A FAITHFUL SUBJECT OF THE BEST OF KINGS,





   AND ONE OF THE OLDEST MEMBERS OF THE HOUSEHOLD OF






          THE  PRINCE OF SCOTLAND,






               ANDREW DUNCAN, Sen. 
 
A LETTER
                     TO

    Sir GILBERT BLAINE, Baronet,
ONE OF THE PHYSICIANS IN ORDINARY TO HIS ROYAL
       HIGHNESS THE PRINCE OF WALES.

 Mr Dear  Friend,
     More than forty years have now elapsed
 since I first began to deliver medical lectures
 at Edinburgh; and I have often reflected, with
 satisfaction, that you were one of the first of
 my  hearers.  Since that time, though our  dif-
 ferent sit -ations in life have prevented frequent
 intercourse, yet we have never ceased to be
 steady friends; and I have often had occasion
 to admire the integrity of your life as well as the
 solidity of your judgment.   Permit me, there-
 fore, to present to you, as an  early pupil, a
                   a 2 
6
candid critic,  and a steady friend, this short
Treatise on Pulmonary Consumption; a disease
which has long been ranked, and which, I am
afraid, must still be ranked, among the oppro-
bria.medicorum.  But we have no reason to
despair of obtaining farther  improvements in
practice, either for the prevention,  cure, or
alleviation even of  phthisis.   I  now, there-
fore, take the liberty of submitting to the public
in general, and to you in particular, the result
of my own observations; and after you  have
carefully perused this little work, I confidently
trust, that in return you will favour me with
your opinion respecting the conclusions I have
drawn from my practice.  Some of these con-
clusions you may  have  found confirmed, and
others refuted by your experience.   I am
anxious to learn in what conclusions we agree;
and  in what we differ.   If,  therefore, more
urgent business will permit you to communi-
cate  to me the result of your observations on
pulmonary consumption, I shall esteem it  a
singular obligation;  for, although  now in the
seventieth year of my age, I am not yet too old 
7
 to learn; and it will give me no slight degree of
 satisfaction once more to become the disciple
[ of a quondam pupil, by whose judicious and
 candid remarks I have often before been in-
 structed.
         Believe me to be,
            Yours ever and sincerely,
               ANDREW DUNCAN, Sen.
    Edinburgh,   )
   20th JYw. 1813.  \

   P. S. Since the date of the above letter, three
  years have been added to my life.   And dur-
  ing that period, I have witnessed not a few de-
  plorable cases  of  phthisis terminating fatally.
  But from all that I have  seen, I  am still more
  confirmed  in  my  opinion, that those prac-
  titioners err much who consider phthisis as
  always an incurable affection.  In the incipient
  state even of  tuberculous  phthisis,  a cure
  may often be effected; and  even in  the very
  last stage of every species much may be done
  towards alleviation of human misery.   Hence,
  you will not be surprised, that your quondam 
8
preceptor, even in the evening of life, should
consider phthisis as  an  object well  meriting
both his and your attention.
                   Ut supra,        A. D.
  October 20th, 1816. 
PREFACE.
  I here present to the public a very short
Treatise, on a very important subject.  With
little difficulty, I might have extended it to a
much greater length.   A  particular relation
or even a selection of those cases from which
my observations have been deduced,  might
have filled a large volume.  My object, how-
ever,  has been to  lay before the intelligent
reader, not the  detail,  but the  result of ex-
perience, and to state merely the conclusions
I have  drawn  from the facts  which I have
witnessed in watching the progress of pul-
monary consumption.
  If  these conclusions  have  not been very
generally erroneous, they have afforded useful 
x
PREFACE.
instruction to myself; and if an attentive perusal
of them  shall afford similar  instruction to
others, the object which I have in view by this
publication will be completely  obtained.

    Edinburgh,  )
   Nov. 30, 1813. J
  In the second edition of this short Treatise
now presented to the  public, the  attentive
reader  will not find  many alterations.   And
although, by the  observations  which  have
been communicated to me by intelligent medi-
cal  friends,  as well as  by cases  which have
fallen under my own care, I might have swell-
ed it to  a very considerable size ; yet, as my
sole aim has been to  communicate merely
the result of experience, the size of the pre-
sent edition will be found very little augmented.
To the  account, indeed, of the preparation
and use of  the  Lettuce Opium, or Lactu-
carium, as I  have named it, some interesting 
preface.
xi
additions have been made.   And let me here
observe, that besides the use of that article in
phthisis  pulmonalis, I have found it  highly
beneficial in various other affections.

   I have particularly  employed it with great
advantage in many cases of Rheumatism,—a
disease, which, I need hardly observe, is, in
Britain, both a very common and a very pain-
ful complaint.   It  is  not,  however, in every
 condition of rheumatism, that benefit is to be
expected  from lactucarium.   That disease,
 as well as phthisis,  has been divided into a
 variety of different species.   Sauvages, in his
 elaborate  System, has pointed out fifteen dif-
 ferent species, all of them, in his  opinion, de-
 serving attention, from the difference in prac-
 tice requisite for  combating each  particular
 species.  But the greater part of practitioners
 are not disposed to follow him in  such minute
 distinctions.

    Even from the earliest periods  of medicine,
 however, two states of this disease have been 
Ml
PREFACE.
 established, from the circumstance of their re-
 quiring very different modes of cure.   These
 are almost universally known in Britain by
 the appellations of Acute and Chronic Rheu-
 matism.  And Dr. Cullen, to whose nosologi-
 cal labours the medical world are very much
 indebted,  has viewed these  modifications of
 the disease as differing so much from  one an-
 other, that he has defined each as a separate
genus.  To  the  acute  rheumatism, he has
 appropriated  the  name of Rheumatismus; to
 the chronic that of Arthrodynia.   The defi-
nitions which he  has given of each of these
genera are accurate and judicious; and while
they point out the obvious symptoms in which
these  genera  differ  in their  appearance,
they also clearly demonstrate to the attentive
reader, that the two affections must differ in
their nature,  and must  require  a different
mode of treatment.

  It is not without great diffidence that I ven-
ture to dissent from an authority  in the prac-
tice of medicine, foi» which I have uniformly 
PREFACE,
xiii
maintained the highest veneration.  But in
the clinical wards  of the Royal  Infirmary,
and in my Lectures illustrating the cases which
I have there an opportunity of treating, I have
for many years pointed out a distinction in
rheumatism,  which,  with a view  to actual
practice, seems to me to be more useful than
the distinctions either of Sauvages  or of
Cullen.

   I am of opinion, that, with the view to a suc-
cessful cure, four  different modifications of
rheumatism are especially to be had in view.
And these I have in  my Lectures distinguished
by the names  of Rheumatismus Inflamma-
torius, Initabilis, Atonicus, and Paralyticus.
They cannot with propriety be considered as
different stages of the same disease.  For al-
though it be true, that the most common pro-
gress of the affection is from the inflammatory
to the irritable  state, and that the jrritable of-
ten terminates in the atonic, and this again in
the paralytic state; yet each modification may
occur  separately and independently of any 
XIV
PREFACE.
other.   The rheumatismus irritabilis, in par-
ticular,  every day takes  place without  any
preceding inflammation, or at least any pre-
ceding  fever.    The  rheumatismus  inflam-
matorius, with a high degree of fever, and  evi-
dent marks of local inflammation at particular
joints, not unfrequently supervenes, after the
disease  has previously existed in its  irritable
state for a  considerable time.  And in some
though  rare  instances,   the  rheumatismus
paralyticus is the very first form under which
the  disease appears, without any preceding
marks either of inflammation, irritability, or
even atony.  Hence, notwithstanding the com-
mon progress  of  rheumatism, there is,  I
think, good reason for establishing in the genus
rheumatismus,  the  four  species which have
been mentioned, especially  as they  require
very different modes of cure, and as they can
readily  be distinguished  from each other by
obvious symptoms.

   On the subject of  rheumatism,  especially
with a view to point out the distinction of the 
PREFACE.              XV
four species from  each other,  and the par-
ticular modes of cure best adapted for the re-
moval of each, it  is now many years since I
stated my sentiments very fully, in a course of
lectures, delivered at Edinburgh, on the prac-
tice of medicine.  Since  that, I  have often
repeated these observations, in  an abridged
form, when illustrating, by  clinical lectures,
the cases of patients who were under my care
subjected to rheumatism,  in the  Royal Infir-
mary.  In that hospital, all the four species of
this disease  which I have mentioned, are al-
most every day to be met with.

   It was once my intention  to have made my
observations and  opinions on rheumatism,  as
well as on consumption, the subject of a sepa-
rate publication.   But that intention, from
different considerations,  I  have now relin-
quished.  I shall however, probably soon submit
these Observations to the examination of my
friends, without having recourse to the press.
It is mv intention to place my manuscripts  on
this subject in the Library of the Royal Col- 
XVI
PREFACE.
lege of Physicans of Edinburgh, where I have  .
already deposited  more  than  fifty  volumes,
written with my own hand, containing practi-
cal remarks on cases which have fallen under
my own observation.

   By this measure, I am not without hopes,
that the experience which has  afforded  use-
ful lessons to myself, may be of benefit to some
of my younger brethren in the college.   The
presumption, indeed, is, that very few of them
will find either leisure or inclination to  read
much of these manuscripts;  but the volumes
themselves, even without being read, will at
least afford to  future members of  the  Col-
lege an example of industry,  for the advance-
ment  of a science which aims at the allevia-
tion of human misery.

   On the present occasion, I shall merely take
an opportunity of stating, in a very fefv words,
the grounds of distinction between the  four
species of rheumatism which I have elsewhere
attempted to  describe at considerable length. 
PREFACE.             XVii
The rheumatismus inflammatorius, then, is
chiefly distinguished by the concomitant fever,
by the obvious swelling of the joints, and by
the aggravation of the pains from the action of
external heat.  In the rheumatismus  irrita-
bilis there is no concomitant fever, and there
is rarely any swelling of the joints, but the
pains are greatly  aggravated by heat,  par-
ticularly by the heat of the bed.  In the rheu-
matismus  atonicus, on the other hand, the
pains are relieved by heat, as is mentioned in
Dr Cullen's definition  of  arthrodynia or
chronic rheumatism; fever is very rarely ob-
served, and an obvious local affection  of the ,
pained parts  is often present, even under the
form of distortions and nodosity  of the joints.
The last species,  the rheumatismus paraly-
ticus, which, though less common than either
of the others, is, however,  not of unfrequent
occurrence, is chiefly distinguished by the loss
of muscular strength in the limbs most affect-
ed, without, however, any diminution of sen-
sibility, but often with a wasting of muscular 
XVni            PREFACE.
flesh in those limbs which have been long
subjected to the severe pains.

  By these marks the four different modifica-
tions of rheumatism, which have been men-
tioned, may, I think, be readily distinguished
from each other in actual practice.  And it is
almost unnecessaiy  to add, that the cure in
each must be attempted on very different prin-
ciples.   The intentions of cure, which, in my
opinion,  are to  be aimed at in each, I have
long  since  stated  in  another publication,
K-rids of Lectures on the Theory and Prac-
ti; ; of Medicine.   Here I shall only observe,
that while in the  rheumatismus inflammato-
rius, the great object to be  aimed at  is the
di'X aition  of increased action  by powerful
ev tenants,  blood-letting and  sudorifics, the
rh  : uiatismus atonicus is only to  be success-
fully  combai'd  by the restoration  of due
vigour  from cold bathing and similar tonics.
While, again, in the removal and alleviation
 of the rheumatismus irritabilis, much may be
 done,  by counteracting the effects of morbid 
PREFACE.
XIX
sensibility and irritability.    For  answering
this intention, I have found no remedy of equal
efficacy with opium, and I doubt very much
whether any  medicine will ever be discover-
ed, operating with  equal power in alienating
pain, allaying  action, and inducing sleep.  Its
sedative powers are fully confirmed by the ex-
perience of ages.   Yet it is by no means ap-
plicable in every case,  or in every constitution
where sedatives are required.  For some time
past, I have also often with great advantage
employed lactucarium, or  lettuce opium, as
it has been called, from its very great resem-
blance  to opium  obtained  from  the papaver
somniferum.  I have  found it, in particular,
a very efficacious means of alleviating pains,
and procuring sleep in  the night, to some rheu-
matic patients, who, if they had  taken opium,
would, during the course  of next day, have
been subjected to  great sickness at  the sto-
mach, and other distressing symptoms.

   Edinburgh,   )
  Oct. 20, 1816.  $ 
 
CONTENTS
                                                 Page
Introduction,  respecting the different species into which
  Pulmonary Consumption or Phthisis may be divided       1
CHAP. I.—Description of the Pneumonic Symptoms in Catar-
  rhal Phthisis        .....      f
CHAP  II.—Description  of the Pneumonic Symptoms in
  Apostematous Phthisis      .      -     -     -     14
CHAP. III.—Description of the Pneumonic Symptoms in Tu-
  berculous Phthisis  -----     22
CPAP. IV—Observations on the Hectic  Fever attending
^ Phthisis     ......     28
CHAP. V.—Observations on the symptoms in the Last Stage
  of Phthisis    -            -      -     -     -     37
CHAP.  VI.—Observations  on  the Diagnosis in cases of
  ! hthisis     -     -                  -     .46
CHAP. VII.—Observations  on the general  plan of Cure in
  Phthisis     ------     58
CHAP VIII.—Observations on particular Practices employed
  in Phthisis, recommended by Eminent Writers,   -     66
Appendix      --•--..    131 
 
OBSERVATIONS
                    ON

PI LMONARY CONSUMPTION.
              INTRODUCTION.

  OF all the diseases to which the inhabitants of the
British Isles are frequently subjected, Pulmonary Con-
sumption, or Phthisis Pulmonalis, as it is denominated
by the best  medical  writers, may justly be reckoned
one of the most fotal.   The deaths which it  occasions
happen chiefly to those who have arrived at the most
engaging period of life, the period of youth.   Hence
they are most deplorable.   It is not therefore wonder-
ful, that this disease should  have  claimed  particular
attention from the most eminent medical writers.   But
notwithstanding the study and labour of ingentous and 
1NTR0DUCT10JS.
 discerning men for many ages, pluliisis pulmonalis still
 continues to be an opprobrium to the healing art; and
 the prospect of wiping off this  opprobrium, by  com-
 municating to the public a successful  method of  cure,
 is not great.   There is no reason, however, to despair
 of making some progress  in  this  important  object;
 and if medical practitioners  were enabled  to distin-
 guish the different modifications under which this dis-
 ease appears, at its commencement much good might be
 done.   For in the earliest  stages, the best  chance is
 at least afforded of combating this  dangerous disease.

   The following  remarks on  that interesting  subject
 are the result  of  observations  made with fidelity and
 attention for  more than half a century:  And if they
 shall enable future writers  to improve the means of
 distinguishing the different  modifications of Pulmona-
 ry Consumption from each other, they  may be produc-
tive of some benefit to mankind;   and I am convinced,
that, in  some instances  of this disease, they will be
the means of accomplishing a  c«re.   By  proper
treatment, adapted to each particular modification from
 an early period of the  disease, there can  be no doubt
that many valuable lives may be  saved.

  By Phthisis Pulmonalis, or Pulmonary Consumption,
is to be understood that affection   in which a general 
INTRODUCTION.                 3
wasting or consumption of the body arises from a dis-
ease of the lungs. - Among eminent  writers,  it has
been a subject of dispute whether phthisis  pulmonalis
can ever be considered as a proper idiopathic disease.
By many it has been regarded merely as  symptomatic
of other affections, particularly of haemoptysis, ca-
tarrh, scrofula,  pneumonia, and several, other genera.
But there  can, I think, be no doubt that it  may justly
be considered as an important genusby itself; and that
it not unfrequently makes its approaches in  such a gra-
dual and imperceptible manner, as to be  beyond the
power of art, before it be certainly discovered to exist.

   In every instance of this affection, that modification
©f fever, which has been termed Hectic  Fever, is ob-
served some time before a fatal conclusion takes place.
And this fever principally, perhaps even  "i&lely, arises
from the absorption of purulent matter, or rather from
the absorption of a sanious or vitiated purulent matter,
which produces in the human system effects  much more
deleterious than the  absorption  of mild  pus, void  of
any  peculiar foetor, or other strong sensible qualities.
Such a sanious matter, however, when generated in the
lungs, may be afforded from different causes.   Hence,
among those writers who have considered  phthisis  or
tabes pulmonalis as a generic disease, that genus has
been divided into mnnv different species.   Tn the Sys- 
4                 INTRODUCTION
tern of Sauvages, twenty species are enumerated un-
der this  genus.   But from such minute  subdivisions,
no  benefr. and  much inconvenience  arise.    Hectic
fever,  indeed, produced by purulent matter  absorbed
from the hmgs,  may arise from  many different  acci-
dents,  and from  many different  diseases: And thus it
cannot be denied, that there is a foundation for many
different species of phthisis.  But  after, in these cases.
consumption is induced, such species can neither be dis-
tinguished from  each  other by  the symptoms, nor do
they require  a  different mode of cure.   A more sim-
ple view, therefore, of the divisions of this genus, may
be taken with advantage.

   In  the division of any genus of disease into spe-
cies, two great  objects are to  be  had in view.   The
first and principal object is  to point out such species
as  require  a different  mode of practice from  each
other.   And the second object is to point out those spe-
cies which can be distinguished from each other by ob-
vious  symptoms during  the life of the patient.   The
distinction from  each  other,  of species which  can be'
discovered only  by dissection after death, serves mere-
ly to perplex and puzzle, without being of any material
benefit.   On this general ground, and with  these ob-
jects in view, in pulmonary consumption, three different
ycdes may be pointed o-t, which may not only be dis- 
INTRODUCTION.
5
tinguished by obvious symptoms during the life of the,
patient, but which also require considerable difference
in that mode of treatment best fitted for the removal
of each.

   These species may, I  think, be denominated the
Catarrhal, the  .dpostemalous,  and  the  Tuberculous
Phlhhls.  The principal circumstance in which these
species differ, and which necessarily requires variety in
the mode  of treatment, is the difference in the  source
from  whence the purulent matter is  derived.    In the
first modification, it is merely separated from an  in-
flamed surface,  in  a  manner similar to the separation
of pus from a  blister-issue.   In the  second modifica-
tion,  it is furnished from an abscess of a considerable
size, which may be formed in the cellular substance of
the lungs, as well as  of  any other part of  the human
body.   In the  third, it is  furnished from \a- tubercle, or
from the parts surrounding a tubercle, terminating in
suppuration; and commonly yielding, not proper puru-
lent matter, but rather an  ichorous sanies, somewhat
resembling that  which is often yielded by lymphatic
glands, in cases of scrofula, when scrophulous tumours
terminate in suppuration.   But the distinction  of each
of these modifications, during the life of the patient, can
only be drawn from an accurate account of the symp-
toms with which they are.commonly" attended,  And 
6
INTRODUCTION.
with that intention, a short history of each is sirb
joined.   •

   In every modification of phthisis, the symptoms may
be referred to  three heads: the pneumonic, or pulmo-
nary symptoms; the symptoms of hectic fever; and the
supervening affections, or what may be termed the con-
sequent symptoms.   The  morbid affections, however,
referable to the two last heads, are very much the same
in all the species mentioned above.  The hectic fever
in  particular, 'though most exquisite  in tuberculous
phthisis, is an essential attendant of all the three;  and
it is always principally, often  entirely, in the pulmo-
nary symptoms, that the three species obviously differ
from each other.   In describing these affections, then,
 with a view to the diagnosis,  it  will be sufficient  to
 give a separate account of the  pneumonic  symptoms
 accurring  in each different modification of pulmonary
 consumption Which has been mentioned. 
¥
                  CHAPTER I.                   .

DESCRIPTION OP THE PNEUMONIC SYMPTOMS  OCCURRING
              IN CATARRHAL PHTHISIS.

    This modification  of Phthisis generally begins in
  a manner very  similar to ordinary catarrh,  arising
  from accidental exposure to cold-   But after the peri-
  od at which that affection may be expected to decline,
  some symptoms are observed to increase.  The cough
  becomes very severe through the day; but is generally
  remarked to be much aggravated on first going to bed.
  The patient .becomes  affected with  some  degree of
  dyspnoea, even when in an erect posture;  but this is
  commonly  increased by  a horizontal position.   In
  general it  is not particularly increased by lying on one
  side more than on the other, and the patient sleeps with
  equal ease  on  either side.   He  is  not affected with
  any fixed or constant pain at the breast.  But he com-
  plains of a general sense of soreness in the thorax, and
  not  unfrequently he is affected with  pretty severe, 
8              SYMPTOMS OCCURRING

though transitory pains, so-netitnes in one side, some
times in the other.

   With the continuance of these symptoms, a change
takes place in  the appearance of the matter expectorat-
ed. • The expectoration, as is commonly indeed the
case in catarrh, when degenerating  into its  chronic
state, becomes of a white or yellow colour. But it does
not acquire that remarkable degree of viscidity which
is the characteristic of thickened mucus.  It  is soon
observed  to have  a  peculiar disagreeable  taste aiid
smelj.   The odour which it emits becomes somewhat
fetid, particularly upon being burnt in the fire. These
changes, however, in thesfrXble qualities of the gut-
ter expectorated, are by no means such as to give-cer-
tain evidence of its being of a purulent nature.

   In most instances, there  is no appearance of blood
in the matter expectorated.  If blood does appear, it
is only in  streaks, and is merely accidental, adhering
to the expectorated matter without any intimate union,
and arising from the rupture of some small superficial
vessel.  The expectorated matter itself  has  an uni-
form appearance; yet there is good reason to conclude,
that it is a mixture X pus and mucus.   This appears
from adding it to water.  It will often be found, that,
in a short  time, a considerable  portion of it  sinks to
the bottom of water in a less tenacious form than that 
IN CATARRHAL PHTHISIS.            9
portion which swims on the surface; and  where such
a separation does not spontaneously take place, it may
frequently be affected by agitation in the water.

   In some cases, without any spontaneous separation,
the whole of the expectorated matter will be suspended
in the middle'of the water in a pyramidal shape, and
can neither  be properly said to sink nor  to  swim.
Where a portion of the expectorated matter  sinks  to
the bottom of  the  water, there can be  little  doubt,
that it contains pus as well as mucus ; but  when it
neither sinks nor swims,  and  cannot be  separated by
agitation, there is room  for hesitating respecting its
contents.   And if  a determination  cannot be formed
from its specific  gravity, we can as little form a cer-
tain judgment from its colour, consistence, and smell.
For in all these particulars, pure mucus  may have a
very exact resemblance to a mixture of pus and mucus.

   Such, however,  is the difference  of treatment requi-
site in every species of phthisis, from  that  which is
 proper in  catarrh,  that it  is of great importance  to de-
termine, whether the expectorated  matter does  really
contain any pus or not.   For this is the chief circum-
stance, by which, before the occurrence  of  distinctly
marked hectic fever, the presence of catarrhal phthisis
can be determined. 
10            SYMPTOMS OCCURRING
  Besides the tests of purulence, therefore, which  arc
afforded by the appearance of the matter expectorated,
by the smell, and by immersing it in water,  other and
more certain tests hare  been sought for; and inquiries
on this subject, if they have  not led to certainty, have
at least done something.

  An experimental investigation of a proper chemical
test, for distinguishing pus from mucus, when discharg-
ed from the lungs by expectoration, was proposed as
the subject of a prize  question, by the Harveian  So-
ciety of Edinburgh, in the year 1777.   On  that occa-
sion the prize  was adjudged to a Dissertation written
by a very able and ingenious  young man, Mr Charles
Darwin,  son to the  celebrated  author of the Zoono-
mia.   By the  untimely  death of that  excellent youth
he was prevented from  prosecuting his discoveries, or
from publishing to the world what he  had discovered.
But Dr Erasmus Darwin, after the death  of  his son
Charles, published  an account of these  experiments,
as well as some other  manuscripts which  the  young
man had himself intended for publication.   Without
entering minutely into  the subject, it may be sufficient
to observe, that Mr.  Darwin drew from his  experi-
ments  the following conclusions.

   1  Pus and  mucus  are both soluble  in sulphuri* 
             in  catarrhal  phthisis.            11
acid, although in very different proportions, pus being
by far least soluble.

  2. The addition of water to either of these solutions
decomposes it.   The mucus thus  separated   either
swims on the top of the mixture, or forms large floc-
culi suspended in it;  whereas the pus  falls to the bot-
tom, and forms, on agitation, an uniform turbid mixture.

  3.  Pus is diffusible through diluted sulphuric acid,
though mucus is  not.  And the  same also occurs with
water, or a solution c( sea-salt.

  4.  Nitrous  acid  dissolves both pus  and  mucus.-
Water added to  the solution of  pus produces a preci-
pitate, and the  fluid above becomes clear and  green;
while water and the solution of  mucus form a turbid
dirty-coloured fluid.

   5.  Alkaline lixivium dissolves,  though sometimes
with difficulty, mucus, and generally pus.

   6.  Water precipitates pus  from such a mixture,  but
does not precipitate  mucus.

   7.  Where alkaline lixivium does not  dissolve pus,
it still distinguishes it from mucus,  as it  then prevents
its  diffusion through water. 
12             SYMPTOMS OCCURRING

  8.  Coagulated  lymph is  neither soluble in concen-
trated nor diluted sulphuric acid.

   9.  Water produces no change on a solution of serum
in alkaline lixivium, until after long standing, and then
only a very  slight sediment  appears.

   10. Corrosive sublimate  coagulates mucus, but does
not coagulate pus.

   If these conclusions be well founded, and if they hold
at least generally, although not universally, it appears,
that strong sulphuric aci<' and water, that diluted sulphu-
ric acid, and that caustic alkaline lixivium  and water
will serve to distinguish  pus from mucus;  that the sul-
phuric acid can distinguish it from coagulable lymph; and
the alkaline lixivium from serum. When, therefore, any
one entertains  doubts about the composition of expec-
torated matter, let him dissolve it in sulphuric acid,
and in  caustic alkaline  lixivium,  or  the aqua potassae,
as it  is  now styled in the  Edinburgh Pharmacopaia.
Let him then 'add pure water  to  both solutions.   If
there be a  precipitation in  each,  he may be assured
that some pus  is  present. But if there be a precipitation
in neither,  it is  a certain  test, that the  expectorated
matter consists entirely of mucus. 
             IN CATARRHAL PHTHISIS.           13
  These are, perhaps, the best criteria yet discovered
for ascertaining whether expectorated matter does or
does not contain a mixture of pus.  Where it is found
to be  merely mucus,  we may safely conclude, that
the disease is entirely catarrhal;  but where a mixture
of purulence, though to a small extent only, is detect-
ed, we may conclude that it is an  incipient phthisis,
even  although  no symptoms of hectic fever have yet
taken place, or have not been obviously  observed. 
CHAPTER II.
DESCRIPTION  OF  THE PNEUMONIC SYMPTOMS  OCCUR-
       RING  IN  THE  APOSTEMATOUS  PHTHISIS.

   That  modification  of  pulmonary  consumption
 which may be termed the Apostematous, and  which
 immediately arises from a large abscess formed within
 the thorax, is more distinctly marked than  the catar-
 rhal phthisis. It is a less frequent disease than the catar-
 rhal;  but when occurring, it is more generally fatal.

    The former, as has already been  observed,  is very
 commonly ushered in by cough, with copious expecto-
 ration,  and is  almost universally  excited by the action
 of external cold, or rather of sudden  transitions  from
 heat to cold.   To these transitions the human  species
  are perhaps more exposed in Britain than in any other
  country.    The  present  species of  phthisis,  again,
  which depends upon a large apostema within the  chest,
  may be excited by a variety  of  dffferent  causes.  It
  may be produced by any accident giving rise to an in- 
At'OSTF.MATOUS  I'llTHISls.           15
ilammatory affection, either in the lungs, or  in those
membranes by which they are surrounded; and an in-
flammation of the thoracic  viscera, terminating in a
state of suppuration, is perhaps as frequent as a simi-
lar termination from the inflammation of any other part.

  One of the most frequent causes from which an ab-
scess in  the chest derives its origin, is an haemorrhage
taking place from the lungs.   This, indeed, is so much
the  case, that Dr Cullen, in his Nosological System,
has not considered  phthisis as a  proper genus of dis-
ease, but has merely ranked it under the genus of hae-
moptysis, and viewed it as a sequela of that affection.
But this  I am inclined to consider as a very erroneous
view of  one of the most important  genera  of disease
to which the human body is subjected.

  That, however, the apostematous phthisis  often be-
gins with a profuse spitting of blood, is unquestionable.
Haemorrhage, when occurring from  the  lungs, as well
as from other parts of the system, may be either of the
active  or passive kind.   Both these modifications of
haemorrhage, when occurring  even  to  a great degree,
have not unfrequently  a  speedy  termination, without
any  bad  consequence;  or at least without producing
phthisis.   As well as the vessels of the nose in epistax-
is, those  of the lungs, when ruptured, may be healed 
PNEUMONIC  SYMPTOMS
by the first intention.   Nay,  haemorrhage from  the
lungs, as well as from  the  nose,  may  sometimes be
even salutary, by removing a plethoric state.  Yet, in
many instances, both active  and passive haemorrhage
from the lungs terminates in that species of inflamma-
tion, which has been termed the suppurative; and this
more frequently happens as a consequence of haemor-
rhage from the lungs, than from any other part of the
body, probably in  consequence of that constant state
of motion to which the lungs are subjected in respira-
tion.  Haemoptysis, then, may justly be esteemed one of
the chief causes from which a large  vomica or aposte-
ma in the lungs derives its origin.

   But it is by no means the only source of the apos-
tematous phthisis.  Even larger abscesses than  those -
commonly  arising  from haemorrhage  are not unfre-
quently observed from other causes.   The lungs them-
selves, and the membranes by which they are surround-
ed, it is well  known,  are frequently subjected to  a
state  of  active  inflammation;  and inflammation in
this, as well  as in other parts of the  system, may ter-
minate in a state of suppuration.  Thus, apostematous
phthisis  may be induced from  several genera, referred
to  the  order of phlegmasia,  which affect the  lungs;
from pleuritis, peripneumonia,  or suppurative inflam-
mation from other diseases of the lungs. 
IN APOSTEMATOUS PHTHISIS.         17
   Besides these  genera of disease, suppurative inflam-
mation, giving rise to a large abscess within the chest,
may proceed  from  accidental injuries to that part
of the body.   Thus, a large apostema in the lungs
may be the consequence of a  severe  blow  received
upon the chest, or a wound of the lungs from  a sword,
a bullet, or the like.   Many other causes might also be
enumerated, as at times producing an  abscess of the
lungs.   But the particular causes by  which  such ab-
scesses are commonly produced, may be referred to one
of the three general heads already mentioned, haemor-
rhage, phlegmasia, or injury to the  breast.

   When, from any particular cause, an  apostema  is
formed in the lungs, those pneumonic symptoms  with
which it is attended  are in several respects  very  dif-
ferent from the pneumonic symptoms which occur in the
catarrhal phthisis; and in the apostematous  phthisis,
the pneumonic symptoms are very different before  the
rupture of the abscess, from what they are afterwards.

  In most instances  of the apostematous phthi-is,  the
first  symptom  of the  affection is a fixed pain of  the
breast.  This pain is not indeed in general excruciat-
ing;  but it is almost constantly felt to some degree, and
is commonly referred to some one particular spot. For
the  most part, it is rather a  gruvative  than an acute
                       b 2 
18            PNEUMONIC  SYMPTOMS
pain; but it is not unfrequently of the pulsating kind.
Whatever the nature of the pain may be, it is very com-
monly attended with some degree of dyspnoea. With that
dyspnoea the patient is sensibly affected, even when in an
erect posture: but it is in general much increased in  a
horizontal position; and it is often particularly aggravate
ed when the patient lies on one side rather than the other.
Often it happens that the patient  can  breathe  only
when he lies on that side in which the apostema is situ-
ated; the  reason of which is abundantly obvious.

  With this state of respiration, there occur  frequent
and  severe fits of coughing; but for  some time  these
are attended with very little or even  no expectoration.
In this, then, there is a manifest difference  between
catarrhal and apostematous phthisis:  For the former
is from the beginning attended with copious expectora-
tion;  but in  the latter species, the most remarkable ap-
pearances are those which  occur on the bursting of the
apostema.   This event is generally preceded, or at
least attended, by a slight degree of bloody expectora-
tion, probably arising from a rupture of the vessels of
the integuments.   When  this occurs, it is almost im-
mediately succeeded by  a copious  discharge  of pure
purulent matter.   This pus is sometimes coughed up
at once, to the extent of several ounces, nay, when the
apostema is very large, even  of several pounds: in so 
           IN  APOSTEMATOUS PHTHISIS.          19

much, that it not unfrequently threatens, and has some-
times even given rise to suffocation.

   The  matter thus discharged has  the  same  appear-
ance, the  same smell, and other  sensible  qualities
which are observed  in pus, when it is  discharged by
opening a large abscess situated on any part of the
surface;  and  although it be discharged by coughing
from the lungs, it is in general without any mixture of
mucus.   Hence, by the simple test of sinking in water,
as  well as by the smell  and taste  of  the  patient by
whom it is expectorated, it may readily be distinguish-
ed from the mixture of purulent and mucaginous matter
expectorated in catarrhal phthisis.

   After the first copious discharge ensuing on the im-
mediate rupture of the apostema, the preceding symp*
toms  are commonly  somewhat alleviated.  This  is
particularly the case with respect to the pain of the
3ide and dyspnoea.  The gravative or pulsating pain,
referred to a particular spot of the breast, is  in general
much diminished.   The dyspnoea also is much allevi-
ated;  and after a copious discharge, the patient finds
that he ean breathe with  equal  ease when lying on
either side.

   Often, also, soon after the rupture of an apostema.in 
* 20            PNEUMONIC SYMPTOMS
 the  lungs, the cough becomes much less severe than
 formerly: For, although  the  fits of  coughing may be
 more frequent, yet they are  no longer fruitless efforts,
 but are sooner terminated by free expectoration.  Still,
 however, there is in general, for some time  after the
 rupture of the vomica, a discharge, in consequence of
 coughing, of the  same matter as when the rupture first
 took place.    But in  no long time, the matter expecto-
 rated has less the appearance of pure pus.   It acquires
 a thinner consistence, and not unfrequently a  reddish
 tinct.   When this last occurs, it may always be con-
 sidered as arising from some mixture of blood.

    After the expectoration arrives at this state, the hec-
 tic symptoms, if thev had not before taken place, are
 soon observed; or, if they were before  obvious, they
 are  soon much aggravated.

    From a free discharge of the purulent  matter, even
  after a considerable  degree of hectic fever has taken
 place, some  chance is certainly afforded of the healing
 of .he ulceration, and the recovery of the  patient.  But
 more frequently, from an increase of the  hectic fever,
  and from what may  be called its consequent symp-
 toms,  colliquative sweats, colliquative diarrhoea, and
 the like, this  modification of phthisis has a fatal termi-
  nation. 
IN APOSTEMATOUS PHTHISIS.
r>d 1
  Distinctly marked apostematous phthisis  may some-
times occur, where the purulent matter cannot be con-
sidered as formed in the lungs, but where, in conse-
quence of preternatural adhesion and rupture,  it has
made its way from the liver to the lungs.   A very re-
markable  instance  of this, modification of apostema-
tous phthisis, from which a  complete recovery took
place, occurred in  a son of mine, an officer in the ser-
vice of the Honourable East India Company in Bengal.
During his illness, he lived in the house of Dr Alex-
ander Campbell, at that time Secretary to the Medi-
cal  Board at Calcutta,  and was attended also by Dr
Francis Balfour,  then at the head of the  Medical
Board.   From both these gentlemen, since their  return
to Britain, I  have  had very  accurate accounts  of his
disease.   But I shall only at present, observe, thai the
purulent matter, expectorated in great quantities from
the lungs, was indubitably formed in the  liver; that,
notwithstanding the formidable appearance of his com-
plaint, and the diseased state to which both the lungs
and liver  were subjected, he had a complete reco-
very without finding it necessary to return to Britain;
and that be has since been the  father of  a numerous
family of healthful children born in India. 
22
                CHAPTER  III.

DESCRIPTION OF THE PNEUMONIC SYMPTOMS OCCURRING
           IN  THE TUBERCULOUS PHTHISIS.

  Of all the  species of phthisis, the Tuberculous is
both the most  frequent and the most dangerous. That
it should be the most frequent is, perhaps, in some de-
gree, the consequence of its arising from the  greatest
variety  of exciting causes.   But  however numerous
and varied these exciting causes may  be, all of them
operate  as giving rise to this modification of  phthisis
on one  general principle, viz. as inducing those pecu-
liar  tumours  termed  tubercles,   which have been
found in the lungs of patients who have  died  of this
modification of phthisis.

  The appearance of these tumours has been accu-
rately described by several eminent writers on morbid
anatomy.  Here, it is sufficient to observe, that  they
are in general  found under the form of hard substances,
tvhich,  when cut, appear to be solid bodies of a whitish 
             TUBERCULOUS PHTHISIS.            2J

colour.   Respecting their nature, different  opinions
have been  entertained.   Some suppose  them  to  be
entirely  inoiganic  bodies, formed of the coagulable
part of the circulating blood.   And that they  are often
incapable of being penetrated even by the finest injec-
tions, is certainly true.   But a more  common opinion
is, that each tubercle may be considered as a lympha-
tic  gland in a particularly  diseased state;  that  this
diseased condition is the consequence of scrofula; and
that the tuberculous phthisis may in every instance be
considered as scrofula affecting the lungs.

   In support of this doctrine, there are many probable
arguments; and,  among other things,  this opinion is
corroborated,  from its being a well known  fact,  that
tuberculous phthisis is often observed as a  hereditary
disease in  scrofulous families; from its occurring most
frequently at  a particular period of life, between  the
age of fifteen  and twenty-five;  and from the striking
resemblance which may  often be observed  between
tubercles of the lungs and diseased mesenteric  glands,
producing tabes or phthisis mesenterica in those  who
are evidently subjected to hereditary scrofula:  For in
the mesentery, the diseased  tubercles, though  they
were unquestionably at first lymphatic or lacteal glands,
are equally inorganic as tubercles of the lungs.   But,
without offering at present any further observations on 
;m
PNEUMONIC SYMPTOMb
the nature of those tumours which give rise to that
modification  of phthisis which may be denominated
the Tuberculous, I shall proceed briefly to describe the
symptoms with which it is commonly attended.

   Of all the modifications  of phthisis, the pneumo-
nic  complaints which  occur in  the tuberculous are
the least alarming.  Hence, this species often subsists
for a considerable time before it awakens the attention
of the patient.   This the rather happens, because the
fever with which the -tuberculous phthisis is  attended
at its commencement is in general accompanied with
high spirits.  And from this state of exhilaration, even
to the latest  periods of the disease, patients affected
with tuberculous phthisis have  often no apprehension
of  their own danger,  though  approaching death be
manifest to every spectator.

   At the commencement-of tuberculous phthisis, nei-
ther the cough nor dyspnoea  are by any means ur-
gent; and in many instances, even to the very end of
the affection, there  hardly occurs any expectoration.
The cough, in general, is of  the short  tickling kind,
without being  violent, and may be termed rather a tus-
fsicula than a lussis.   But wi:ile it takes place without
any great uneasiness, it  is still troublesome, from being
very frequent,   Notwithstanding, however, these fre~ 
            IN  TUBERCULOUS  PHTHISIS.          25

quently repeated efforts towards expectoration, the irri-
tating cause is not removed, and those slight fits  of
coughing, terminating without the smallest expectora-
tion even of mucus, are again speedily renewed.

   In most cases no remarkable pain of breast attends
the tuberculous  phthisis; and when pain occurs, it  is
neither fixed to any particular spot, nor is it constant.

   In many instances, no dyspnoea whatever  occurs  in
the tuberculous phthisis; or, at least, difficulty of breath-
ing  is  observed  only  upon motion or exertion.   When
the patient remains  at  rest, the  breathing is perfectly
free; and it is very little if at all affected by change in
the position of the body.   Contrary to what happens
in the apostematous  phthisis,  the patient can lie with
equal  ease on either side.

   In this state of the pneumonic complaints they very
 seldom alarm the patient.   And if they give any alarm
to others,  it is only in general from their long continu-
 ance,  and from their occurring in habits with whom
 there  is reason  to  suspect predisposition to phthisis.
 That this tussicula is the first stage of tuberculous con-
 sumption, is chiefly inferred from  the remarkable loss
 of strength, and evident  wasting of the  habit with
 which it is soon attended.
o 
26'             PNEUMONIC  SYMPTOMS
  In the  incipient state  of the tuberculous phthisis
this frequent tickling cough is in general also accompa-
nied with a peculiar change in the appearance of the
eyes.   The red vessels which are observable in the
tunica adnata of those in a state of health, are no longer
obvious, and that part of the eye obtains very much the
colour and appearance of a pearl.

  To these slight  pneumonic symptoms, even without
the occurrence of any  expectoration whatever, either
purulent or mucaginous, distinctly marked hectic fever
often  supervenes.   In other cases,' however, after the
cough has been  long dry,  as it is called, some degree of
expectoration occurs.   But  in  almost no instance has
it the appearance either of proper purulent matter or of
blood.  Sometimes a slight tinct of blood is observed;
but never such a degree of haemoptysis as is often ob-
served to precede  apostematous  phthisis.  Most fre-
quently, the matter expectorated is a thin watery fluid
slightly tinged with blood; and it has very much the
appearance of  that sanies  which is often discharged
from scrofulous sores.   When this state  of  expectora-
tion takes place, hectic fever is seldom wanting to a
^reat  degree,  and it soon assumes that form which has
been denominated the Hectica Exquisita, in contradis-
tinction to the chronic form, which that modification of
fever most frequently assumes. 
            IN TUBERCULOUS PHTHISIS.           27
  After having thus briefly described the pneumonic
symptoms in each of the three different species of phthi-
sis pulmonalis, we shall  next proceed to give some ac-
count of the hectic  fever which may be considered as
common to all the species. 
^
                 CHAPTER  IV.

OBSERVATIONS ON  THE  HECTIC  FEVER  IN PHTHISIS
  PULMONALIS, ATTENDING THE SECOND STAGE  OF
  THE DISEASE.

  The hectic fever, which attends every species  of
pulmonary consumption, particularly those three spe-
cies which have been now described, has very much
the same appearance in all of them; and, indeed, symp-
toms  nearly  similar attend hectic  fever, when con-
sumption or  tabes arises from  suppuration occurring
not in the lungs,  but in other  parts of the body, and
yielding  ill-conditioned pus.

   Although several opinions, differing very much from
each  other, have been entertained by able pathologists
respecting the cause of hectic fever, yet the most pro-
bable conjecture is, that in all  these cases, it is  the
consequence of ill-conditioned pus being absorbed by 
PHTHISIS PULMONALIS.
29
the valvular lymphatics, and thus introduced into the
mass  of blood.  It must, however, be allowed, that,
with respect  to the operation  of this cause, all practi-
tioners are not agreed.  Some  contend,  that it arises
merely from a certain irritable state of the system, in-
duced by the absorption of pus.  But still, even accord-
ing to this hypothesis, hectic fever is ultimately  an ef-
fect of absorption.  And when we consider the influ-
ence  of certain articles introduced into the  circulating
system, in immediately inducing fever, there is great
reason  for presuming, that absorbed  ichorous  matter
may immediately give rise to  hectic symptoms.

   Of this a strong presumption is afforded, from experi-
ments which have lately been made,  by injecting dif-
ferent fluids  into  the blood-vessels of living animals.
It  has been found, that small quantities of milk, and
other bland fluids, may thus  be  injected without any
inconvenience.  But it has also been found, particular-
ly in the trials which have been  made de chirurgia in-
fusoria renovanda, that the  injection, even of small
quantities, of acrid fluids, such as an infusion of senna,
a decoction of guaiac, or the like, have the effect of ex-
citing fever  in a  very short  time.  Without entering
into the consideration of conjectures  as to  the  imme-
diate cause of hectic fever in pulmonary consumption,
it is sufficient to observe, that it often follows the dis-
                        c  2 
30                 HECTIC  FEVEU
 charge of purulent matter by expectoration, particular-
ly when  that matter, in place of appearing under the
form of mild thick white pus, assumes more the ap-
pearance  of a bloody sanies.

   The hectic fever is very generally not of a continued
.form, but consists of  repeated paroxysms;  or at least,
 although  quickness of pulse, and  some  other febrile
 symptoms, may be constant, yet, in this fever, there
 are very remarkable remissions  and exacerbations.
 These  exacerbations are very  generally ushered in by
 a sense of coldness; often  even  to such a degree as to
 induce shivering.   It is however but seldom that the
 cold stage in the  hectic paroxysm arises to the same
 height as  in  proper intermittents; and  in most in-
 stances it is rather a partial  than a general sense of
 coldness; that sensation being more especially felt at
 particular parts, as in the  handsr the feet, or along the
 course of the spine.   But, even in these places, how-
 ever disagreeable  the sensation may be,  there merely
 takes place a sense of coldness, without any real cold:
 For when the parts to which this sensation is referred,
 jre  accurately examined  by the thermometer, the}
 ^e found still  to  possess  the natural degree of heat.

    To this coldness or shivering, a sense of increased
 heat soon succeeds   'This sensation is very common- 
IN PHTHISIS PULMONALIS.
31
ly in some degree  extended over  the whole body.
But it is also more  especially felt at particular places.
Often there occurs a peculiar glowing heat in the face;
and this is commonly attended with manifest flushing
of the  countenance.   This redness, however, is not
always general, but is  frequently under the  forns  of  a
circumscribed redness  in  the most prominent parts of
ihe cheek.

   If the heat be sometimes  partially increased in the
lace,  it  is often still  more  so  in other  parts of the
body.   This  is particularly felt  in the palms of the
hands,  and in the soles of the feet;  but notwithstand-
ing the sensation of heat in these  parts, even when  it
is almost intolerable,, there is still no obvious redness,.
nor indeed any change of appearance, in the part tof
which it is referred.   It consists merely  in a sense of
burning heat, often attended with a parched  state of
the skin at the part thus affected..

   With the augmentation of heat,  there is also  very
commonly an increase of the celerity of the  pulse dur-
ing the hectic paroxysm;  and sometimes it is so quick
that it can hardly  be  accurately  numbered.  But irt
many  cases, it is not much  more accelerated  during
the paroxysm than  during the  remission.  For after
the commencement of the hectic state, the  pulse with 
32                HECTIC  FEVER
most patients is considerably quicker than it was be-
fore, seldom being observed under 100, and frequently
above 120 strokes in the minute.   This want of com-
plete apyrexia  often affords a diagnosis between hectic
and quotidian intermittent fever. For in all the intermit-
tents, the pulse in the intervals between paroxysms
returns to the natural standard.

  In  some instances of hectic fever, the pulse is full
and soft.   But more  frequently it is small and hard
both during the paroxysm and also  during the inter-
mission.

  Another  circumstance commonly attending the hec-
tic paroxysm is some degree of thrist; but it is seldom
that this symptom is considerable.   Thirst  almost
never takes place to the same degree as in other mo-
difications  of  fever;  and  in very  few cases  is the
tongue either parched, or  covered with indurated mu-
cus, giving what is called a furred tongue.   In gene-
ral, during the whole course of the disease, even  during
the time when  the paroxysm is most severe,  it con-
tinues moist.   It has  in many cases an  uncommonly
glean and red appearance:  And in the last stages of
the disease, it is  often found in an  abraded and even
in an ulcerated state.  But this appearance may be
considered  as unconnected with the  fever  itself, and 
             IN PHTHISIS PULMONALIS.            ^O

probably in general arises  from the condition of the
matter discharged by expectoration.  But as the tongue
is very rarely observed to be parched, so the thirst  is
seldom augmented to any considerable degree.

   While the thirst in hectic fever is in general not very
considerable, it has also been remarked, that the appe-
tite  for solid food is  rarely so  much diminished as in
ether  fevers;  and sometimes,  even in  the  very  last
stages of  the disease, when the  hectic  symptoms  are
most acute, the appetite is uncommonly keen. Phthisi-
cal patients have repeatedly been observed to make a
hearty dinner of beef-stakes a very few hours before
death.

   Besides the  want of thirst, there is also another par-
ticular in which hectic fever  differs from  most other
modifications of  that disease.   It is without that dis-
tressing  symptom  attending most  idiopathic fevers,
 which has been termed the anxietas febrilis,—a sen-
 sation  which cannot easily be  described,  but which
 rarely fails to  be well remembered by any one who has
 laboured under  idiopathic  fever, particularly of the
 typhoid type.  So far are hectic patients from being af-
 fected with this febrile anxiety or depression,that they in
 general entertain sanguine hopes of a speedy recovery;
 and during the severity of the  paroxysm, they are often 
34
HECTIC FEVER
observed to have a peculiar flow of spirits, and uncom-
mon quickness of genius.

   The symptoms thus occurring in the  cold  and hot
stages of the hectic paroxysm,  in a short  time begin to
subside;  and after continuing for a few hours, they of-
ten terminate without any obvious  appearance.   This
is particularly observed to be  the case with those pa-
roxysms  which take  place  about  mid-day, or in the
forenoon, if  the patient be not confined to bed.  In
other cases, however, the cold and hot fits of the hectic
fever are succeeded by  sweating,  in a manner similar
to what happens in the intermittent paroxysm.  Sweat-
ing is particularly remarked to occur when the patient
is in bed during the hectic accession.  Accordingly, it
is a common consequence of  those cold and  hot fits
which occur during the night; and,  indeed,  profuse
sweating, when the patient first awakes in the morning,
may be considered as one of the most common symp-
toms of the hectic fever.

   The urine of patients subjected to hectic fever, par-
ticularly what is discharged during or soon after the pa-   «
roxysm, is  for the most part high coloured. Upon stand-
ing, there soon occurs a separation of what has been
termed furfuraceous matter; a matter having some re-
semblance to the bran of wheat.   But it seldom hap 
             IN PHTHISIS PULMONALIS.           35

pens that this matter sinks to the bottom of the urine;
and it is  but very rarely that the lateritious sediment of
the urine, where a matter is deposited resembling brick-
dust, which is so common after the paroxysm of the in-
termittent fever, is observed in the hectic fever.

   The discharge by the belly in hectic fever is for the
most part but little affected.   For a long period, in the
chronic  form of this fever,  itiS not attended with that
bound state of the belly which is the common concomi-
tant of other fevers.   At least, long after hectic parox-
ysms have been distinctly observed,  the discharge by
the bowels often continues nearly in the natural state;
and it is only  in the latter stages of the disease  that
the colliquative diarrhoea comes on. Hence, it has been
called a  consequent symptom.

   For the, most part, at an early  period of phthisis,
particularly in the tuberculous, the menstrual discharge
is observed to become very scanty, and often entirely
to cease.  But this is hardly to be considered as parti-
cularly connected with the  hectic fever;  and the same
observation may be  made with respect to the remarka-
ble loss  of strength and exhaustion of the  habit which
 which occur in the progress of this disease, although  it
 must be allowed, that these  symptoms always take place 
36        SYMPTOMS IN  THE  LAST STAGE.
the most rapidly where the hectic fever is what has been
termed the most exquisite or acute.

   With respect to the recurrence of the  paroxysms of
the hectic fever, the same type has not  always been
observed.  By some writers,  indeed, the paroxysms
have been alleged to occur with great regularity twice
every day; the first attack  taking place  about  noon,
and the second before d^dnight, and commonly termi-
nating with sweating early in the morning.    It has
been more generally observed, that a paroxysm occurs
after eating, especially after dinner.   But the parox-
ysms of the hectic fever are by no means observed to
return with the same regularity as in  any type of in-
termittent  fever  having a daily  paroxysm, whether
quotidian or double tertian.    In  most  instances, one
accession only is observed in the  course of the day.
In other  cases, two,  or even  three  accessions may be
observed in the same length of time.  But these do not
occur with any regularity,  or  at  any fixed time: And
they are  often distinctly observed  to be excited  either
by taking food, or by the action of external cold, at
whatever period of the day the patient may have been
exposed to the action of these causes, particularly of
el51d. 
37
                  CHAPTER V.

OBSERVATIONS ON THE SYMPTOMS OCCURRING IN  THE
 LAST STAGE OF PHTHISIS  PULMONALIS;  WHAT  MAY
 BE TERMED THE SUPERVENING OR CONSEQUENT SYMP-
 TOMS.

   \fter the hectic fever has been observed for some
lime, and particularly if it be of the acute or exquisite
kind, some symptoms, which  had before taken place,
are very rapidly augmented; and  others, which had
not been observed, supervene.  These have, in general,  ^
been considered as  sequelae of the hectic fever.  But
it may, perhaps, be a matter of doubt, whether,  with
strict propriety, they can be called consequent symptoms.
Perhaps, like  the hectic  fever itself, they are merely
symptomatic of the progress  of the  disease,—of the
absorption  of  an ill-conditioned purulent or ichorous
matter from the lungs.  But still the probability is, that
if  not induced, they are at  least much aggravated by
the hectic fever.   And whatever  their cause may be. 
 38        SYMPTOMS IN  THE LAST STAGE
 they may certainly be  considered as constituting the
 third stage of the disease.

   At the head of the consequent symptoms, as one of
 the most obvious, emaciation  or  wasting of the habit
 may justly be mentioned.  It is indeed true, that, even
 from the beginning of every  species of  phthisis,  the
 usual fulness  or plumpness of the patient is somewhat
 diminished.    But after  the hectic  fever has subsisted
 for some time, this emaciation is very much increased.
 It is obvious, on examination  of any part of the body.
 It evidently appears from  clothes,  which were before
 tight, becoming too wide, and  it is still  more certainly
 demonstrated by the loss of weight.  But in no part of
 the body is it more conspicuous than in the face. This
 is so much the case, that  the fades Hippocratica, as it
 has been called, where every  bone of the face is pro-
minent, is, perhaps, more frequently observed in pulmo-
nary Consumption  than  in any other disease.   But
 when the trunk of the body is examined, the  state  of
the spine shows projection of the bones to as  great a
degree,  in parts remote from the face.   In short, in the
last  stage of phthisis   the patient often  becomes  as
it were  a living skeleton.

  In this emaciation, there can be no doubt  that there
occurs a diminution both  of fluids and  solids;  and 
             OF PHTHISIS PULMONALIS.            39

 that the loss in some degree extends not merely to the
 softer solids, but even to the firmest and hardest, to the
 bones themselves.   But  of all the parts of the body,
 there is reason to believe, that this change in appear-
 ance chiefly arises from the consumption of fat; a sub-
 stance which, in the temperature of the  human body,
 may be considered as of an intermediate  consistence
 between solid and fluid; and a substance which, it  is
 well known, readily admits of removal by the valvu-
 lar lymphatic absorbents, after it has been deposited
 in the membrana adiposa in any part of the body. That
 during the course of phthisis pulmonalis much fat is
 removed from the cells of this  membrane, and very
 little deposited in them,  cannot be doubted.   This is
 clearly demonstrated by the dissection  of those who
 have died of pulmonary consumption; for  it  is then
 found that the fat is entirely removed, not only from
 the surface, but also from the interior parts; and hardly
 a vestige  of fat  is to be  found either  at  any of the
 joints, about the heart, or even in  theNomentum, parts
 in which it is certainly most necessary for  the purpo-
 ses of the animal economy.

  With the emaciation, it cannot at all seem wonderful
that a state of debility should occur.  A loss o'f muscu-
lar vigour, as well as evident wasting of the habit, is
indeed one of the earliest symptoms of phthisis.  Those 
40          SYMPTOMS IN THE LAST STAGE
subjected to any modification of the disease, soon bt
come incapable of their usual exertions; and after even
very slight action, they feel an uncommon degree of fa-
tigue.   But this debility rapidly increases  in the last
stage of the  disease, and particularly where the hectic
fever is very acute.   The loss of strength is sometimes
even greater than in proportion to the evident exhaust-
ion of the body, and might lead to the supposition, that
in such cases there was  a greater absorption from the
muscles than even from the fat.

   Some writers have considered this debility as the sole
and primary cause of the disease; and  entirely over-
looking the  obvious morbid affection of the lungs, they
have placed phthisis at the head of the scale of asthenic
diseases, as  they have termed them, and accordingly
have inferred, that pulmonary consumption is to be cur-
ed by the use of stimulants, increasing excitement.  But
this reasoning, though lately a  fashionable  doctrine,  is
too absurd,  and the practice too pernicious, to be adppt-
ed by any man of common understanding. Debility is a
necessary consequence of the  continuance  of almost
every disease,  and must necessarily occur in phthisis
as well as in others.   But it rapidly increases towards
the last periods of phthisis, when there is reason to be-
lieve that the circulation has almost everv where failed 
OP PHTHISIS PULMONALIS.           41
in  the extreme vessels.  It is a consequence  not the
cause of the disease.

  Of the failure of circulation  in the extreme vessels
in phthisis, evidence is afforded in the appearance of the
countenance, and particularly in the appearance of the
eye.  It is indeed true, as has already been remarked,
that in  the  paroxysm of the hectic fever, a circum-
scribed  redness of the cheek is often observed.  But at
other times  there  is  very generally  an uncommon
paleness of the countenance, and indeed of the surface
over the whole body, clearly demonstrating a want of
red blood in the extreme vessels.   This also manifest-
ly appears  in that change  which the tunica adnata of
the eye undergoes.  In a state of health, some red ves-
sels are in general obvious in this part of the eye.  But
as  phthisis advances, these gradually  disappear, and
the whole of the adnata becomes of  a pearly white
colour.

  Another remarkable appearance  which often takes
place on the surface of the  body in phthisis, and" which
is probably also the consequence of want of circulation
in the extreme vessels, is that the hairs are observed to
fall off, a necessary consequence  of the want  of nou-
rishment supplied at their'bulbs.   To a similar want
of  nourishment is  probably also  to  be referred the
                         p2 
42         SYMPTOMS IN THE LAST STAGE
crooked, wreathed, or adunque shape, as it has been
called, which the nails often  assume in the last stage
of pulmonary consumption.

  To a want of due propulsion of blood to the extreme
vessels, it is not  improbable also that  the condition of
the menstrual discharge commonly attendant on phthisis
is to be attributed.   It must indeed be admitted, that
in some instances of pulmonary consumption, the men-
ses continue  regular to their  periods, and flow in the
usual  quantity to the very last  stage of the  disease.
But much  more frequently, the discharge is scanty or
altogether  wanting,  even  from  the  commencement.
And from this circumstance, phthisis  in its first stages
is sometimes mistaken for amenorrhoea.  But  what-
ever maybe the condition of the menstrual flux in the
beginning of the disease, a total want of this discharge
in most cases very soon supervenes after the hectic fe-
ver is distinctly marked.

   When  regard  is  paid to  the remarkable loss of
strength with which phthisis is  attended, it  is not
 wonderful that towards the close of the  disease oede-
matous swelling  of  the, legs  should often  appear.
This  symptom,  however, notwithstanding  the  great
debility, is neither  universal, nor very troublesome.
And in some cases, after it has  taken place to  a  con- 
OF PHTHISIS PULMONALIS,           4$
siderable  degree, notwithstanding  the  progress   of
phthisis towards a fatal conclusion, and  the increase
of the weakness of the patient,  it  again  decreases,—
an evident proof that the action of the absorbent ves-
sels is not so much weakened  as  that of the muscles
subservient to voluntary  motion.   Perhaps also from
the  condition  of the  circulation,  the  tendency  to
effusion may be diminished.

   It has already been remarked, that even during  the
accessions of the hectic fever, the tongue is rarely  ebr
served to be parched.  On the  contrary, it  often  as-
sumes an uncommonly red, and what may be  called a
raw  appearance.  But the affection of this organ often
goes farther; and both upon the tongue and other parts
of the mouth, aphthous spots appear, which in the end
 degenerate into ill-conditioned ulcers.  These aphthae
and consequent ulcerations are particularly observed
in the apostematous phthisis, when  the expectoration
of purulent matter is considerable,  and when, in place
of the appearance  of  mild pus, the discharge has  de-
generated into  an ichorous  state.  This affection of
the mouth has by some been ascribed, and probably
not without reason, to the action of the  expectorated
matter on  the mouth.

  To the  same cause, acting on  other parts of  the 
 H         SYMPTOMS IN THE LAST STAGE
 alimentary  canal,  especially  on the intestines, has
 been ascribed  another  symptom, very common and
 very distressing,  the colliquative  diarrhoea, which
 often occurs in the  end  of phthisis, and which cer-
 tainly has  often very great  influence in hastening a
 fatal termination of  the  disease.   That •colliquative
 diarrhoea may  in  some  instances-arise from purulent
 matter brought from the lungs to the mouth,  and after-
 wards swallowed, maybe true.   But certain it is, that
 this  diarrhoea often takes place where there is no ex-
 pectoration ofpurulent matter, particularly in cases of
 tuberculous  phthisis.  Hence, it must often arise  from
 some other cause;  and perhaps it  is with greater jus-
 tice attributed to the influence of absorbed acrid  mat-
ter exerted on the intestines, after entering the blood,
 and to the general debilitated state of the system which
phthisis induces.  But whatever  its cause may be,
there can be no doubt  that it is one of the supervening
 symptoms, which contributes very much to bring the
disease to a  fatal termination.

   But of all the supervening symptoms,  there is  per-
haps no one which tends more io the rapid exhaustion
of the patient than the colliquative sweats.  These,  as
has already been observed,  somedm-s  occur ev;u  at
an early period of the hectic  fever,,'■■•   i. particularly
observed in  the morning,  after  an  exacerbation ha.': 
             OF PHTHISIS PULMONALIS.           45

taken place  during the night.   But they  are by no
means to be  considered as  similar to those  sweats,
which constitute the third stage of an intermittent pa-
roxysm.  They  are by no means productive  of the
same relief from fever.   They cannot be said to induce
an apyrexia. ' On the contrary, an evident increase of
weakness and languor is  very generally the  conse-
quence of their being long continued and profuse; and
this equally  happens pdiether they be extended over
the  whole body,  or  confined  to particular places.
These colliquative sweats, even when the most pro-
fuse,  are not unfrequently confined to the  head and
shoulders; and when this is  the case, the progress  of
the disease to a fatal termination  is usually the most
rapid.

   With these supervening symptoms, and the continu-
 ance of the hectic fever, it  is by  no means surprising,
that the disease, after arriving at this  state, should in
almost every case have  a  fatal  termination.   Though
the mental faculties continue distinct at the commence-
ment of the hectic fever, yet dilirium  of  the low kind
at length  necessarily arises, as the  consequence of a
very debilita'ed state, and is in general  a  prelude t©
the death of the patient. 
u;
                  CHAPTER VI:

    OF THE 'DIAGNOSIS IN  PHTHISIS PULMONALIS.
                        *
   The diagnosis in cases of phthisis pulmonalis may
naturally be referred to two heads.  First, The means
of distinguishing phthisis from other diseases;   and,
Secondly,   The means of distinguishing the  different
species of phthisis from each other.

   With regard to the distinction between phthisis and
other diseases, in most cases, at least, there is  no great
difficulty.  Although in the beginning of phthisis, there
is  certainly no symptom  which can be held  forth as
pathognomonic or peculiar to pulmonary consumption,
and not occurring in any other affection,  yet there are
different  symptoms always attendant  on  phthisis,
which in   many  other diseases are  never observed.
Even in the very earliest stages of this affection, there
is  always  more or less  cough;  and this  cough is very
generally  attended with some degree both of dyspncea 
              OF THE DIAGNOSIS, &C.            47

and  of pain  of breast.    Sometimes, indeed, in  the
earliest  stages  of phthisis,  what takes place in  the
way of coughing, may be termed rather tussicula than
tussis.   Still, however, cough exists at least under a
certain form.  Wherever, therefore, cough, with  the
concomitants already mentioned, is entirely awanting,
it may with certainty be  concluded,  notwithstanding
great loss of strength, wasting of the  habit, quick-
ness of pulse, and other  hectic symptoms, that pulmo-
nary consumption does not occur, and that the tabes or
phthisis to  which  the patient is subjected, must pro-
ceed from some other cause than an affection of the lungs,

   The only difficulty, therefore, of distinguishing  be-
tween phthisis  and other diseases, is in those  cases
where cough, with some degree of pain of breast,  and
dyspnoea, takes place. This, however, not unfrequent-
ly happens in catarrhal affections, the consequence of
accidental exposure to cold.   Catarrh has often  many
symptoms  in common  with  incipient phthisis.   But
this similarity in a particular manner takes  place, be-
tween common catarrh from cold, and  that species
of pulmonary consumption which has been described
under the title of the catarrhal phthisis.

   In that modification of phthisis, indeed, the disease,
as has already been remarked, often subsists for a con- 
 18              OF THE  DIAGNOSIS
 siderable time in a state which  may strictly and pro
 perly be  denominated catarrh; and it is only from the
 catarrhus dfrigore, that a  degeneracy takes place into
 the phthisis  catarrhalis.   It is therefore by no means
 surprising that cases should  occur, in which it is very
 difficult to determine when the catarrh ends, or when
 the phthisis  begins.

   With a view, however, of directing the best mode
 of treatment, it is always desirable that a practitioner
 should be able to say with certainty, as soon as possible,
 whether the  disease  be catarrh or consumption.  And
 those marks  by which catarrhus a frigore is  distin-
 guished from phthisis catarrhalis, with still greater cer-
 tainty serve to distinguish catarrh from other  species of
 phthisis.

   Where cough, apparently  arising from  exposure to
 cold,  has subsisted for  some length of time, although
 not severe, but merely under  the form  of  tussicula,
 some suspicion  may be entertained of phthisis, when
that cough comes to be attended with manifest wast-
ing of the  habit, and  remarkable loss  of  strength.
That  these  symptoms, indeed, are often  the  conse-
quence  of  mere catarrh,  cannot be denied; yet they
are seldom to the same extent, or make the same rapid 
             IN PHTHISIS PULMONALIS.           49

progress, where the affection  continues to be merely
catarrhal, as when it degenerates into phthisis.

  The suspicion  arising from the circumstances that
have been mentioned, cough combined with wasting of
tile habit, and loss of strength, is much corroborated,
if the patient be still at an early period of life, particu-
larly  between the age of fifteen and twenty-five: Not,
indeed, that phthisis may not  ensue as a  consequence
of catarrh at other periods of life; but it is chiefly at
the early and  vigorous periods of life that consumption
is a consequence of catarrh.   In  advanced life, obsti-
nate  catarrh much more frequently degenerates into
the chronic state, or what has been called  the  catar-
rhus senilis.

   Besides the circumstances  which have already been
mentioned, another ground  for  distinction  between
phthisis and  catarrh  is  afforded  by the state  of the
pulse.  In phthisis, quickness of the pulse is a much
more  frequent  symptom than  in catarrh.  This,  in-
deed, can by  no  means  be depended upon by itself;
nor is it always to be met with at the commencement
of the disease.   In some instances of phthisis, it is only
an occurrence  late in the disease; and in cases of
;iiere catarrh, it not unfrequently takes place, especially
at  the commencement of the disease.   But when pre-
                         K 
50               OF THE DIAGNOSIS
ternatural quickness of the pulse continues for a  con-
siderable  time, it is  much more  frequently observed
where acute catarrh terminates in phthisis, than when
it degenerates into the chronic state.

  From these different particulars, in the greatest num-
ber of cases a diagnosis may be formed, with a  con-
siderable  degree  of certainty, between  phthisis  and
catarrh, even in the early stages of the disease.    But,
when in conjunction with  these, it appears,  from  the
tests  already mentioned, that the matter expectorated
contains a mixture of pus, there can  be no doubt  that
the patient  is  subjected to  pulmonary consumption.
When to the pulmonary affections  hectic fever super-
venes, and when to these are superadded the consequent
symptoms, particularly colliquative sweats  and colli-
quative diarrhoea, we have not only  certain evidence
that the patient is subjected to phthisis, but may with
great probability  conclude that the disease will have a
fatal termination.

  If, however, it be important in practice to distinguish
phthisis from  other diseases;  so it is also  of conse-
quence to distinguish  the  different species of phthisis
from  each other.  Three  species  have been pointed
ou« as deserving particular  attention, the catarrhal, the
apostematous, and the tuberculous: And the following 
IN PHTHISIS PULMONALIS.
51
observations with  regard to each, will point out those
marks by which they may be most readily distinguished.

   The  catarrhal   phthisis may occur  at  any  age,
while the two other species, but particularly the tuber-
culous, are most frequently  observed at a certain period
of life,  between the  age of fifteen and  twenty-five.
There is ground, therefore, for suspecting this species
when symptoms indicating phthisis are observed at that
period of life, when the other two species are less fre-
quent.  Catarrhal phthisis takes place with any habit;
while the apostematous is  most frequent with the san-
guine habit, and the  tuberculous with those who are
known to have a scrofulous constitution.   Hence some
ground for distinction is afforded from attending to the
habit of the patient.

   But if a diagnosis may in some degree  be derived
from predisposition,  catarrhal  phthisis  is  still more
strongly marked by attending  to the occasional cause
by which it is more immediately  induced.  In  most
instances, this  modification of pulmonary consumption
has its commencement from the obvious action of cold,
inducing at first a  simple  catarrhal  affection.  Thus,
then, it  begins  with all  the ordinary symptoms of the
catarrhus a frigore; and in this respect from the com-
mencement is different from the two other modifications 
52               OF THE DIAGNOSIS
of phthisis.   In a short time, it is distinctly character-
ized by the state  of the cough;  for it is soon attended
with copious expectoration.  It is marked also by the
state of pain at the breast   In most instances, the pa-
tient is not affected with any such pain; and when it
does occur, it is not confined to any particular  part.
The dyspnoea in this species, as well as in the aposte-
matous, is aggravated by an horizontal posture; but it
is peculiar to the catarrhal  consumption, that the dysp*
noea is relieved by expectoration, even  although  only
to an inconsiderable degree.  It is also marked by ano-
ther circumstance respecting the affection of breathing.
In this species, the patient, when in an horizontal  pos-
ture, can lie with equal ease on either side.

   While the  catarrhal consumption  is  thus  attended
with many peculiarities, so  there are also various symp-
toms which afford evidence of the apostematous. When
phthisis evidently occurs, there is some presumption of
its  belonging to this species,  where the  patient  has
been previously of a vigorous and plethoric habit,  par-
ticularly when with these   habits it occurs during the
prime of life.  This presumption  is strengthened, if
there be at the same time no marks of a scrofulous ha-
bit in the person affected;  and if  upon due enquiry it
shall be found, that the patient has no  hereditary dis-
position to scrofula, that no scrofula has been observed 
IN PHTHISIS PULMONALIS.
53
in his family, and  that none of his  near connexions
have  died of phthisis.   There   is also reason for
inferring  the  existence  of this  species, where the
patient has formerly been subjected to  active haemor-
rhage, either from  the lungs,  or  even  from  the  nose.
This  inference  may  be  drawn with  still  greater
confidence, where  symptoms of  phthisis immediately
succeed to a considerable degree of haemoptysis.   And
there is almost certainty, that the phthisical symptoms
proceed  from an  apostema in the chest, when  they
are the immediate consequence of a violent  inflamma-
tory affection of the pneumonic kind.  A similar con-
clusion respecting the species of  the disease may also
be drawn where phthisical symptoms follow soon after
 wounds  penetrating  into the thorax,  blows upon the
 chest, or similar accidents.  In  short, a considerable
 degree of local inflammation within the chest,  from
 whatever cause it arises, may certainly terminate in an
 apostema.

   But besides the ground for diagnosis, which is afford^
 ed by a knowledge  of  the exciting causes, marks of
 this species are also afforded from the symptoms with
 which it is attended.  There is always reason to infer,
 that phthisis is of the apostematous  kind, where the
 patient has  long been  subjected to  fixed pain in the
 breast;  where he  is affected with constant dyspnoea,
                      e2 
34               6F THE DIAGNOSIS
even in an erect posture, and where that dyspnoea is
attended with a sense of weight and oppression at a
particular part of the breast.   This conclusion may
especially be drawn when the dyspnoea is much in-
creased by a horizontal posture, and when  the patient
lying horizontally can breathe only with facility on that
side to which the pain and sense of oppression are re-
ferred.

   A distinction of this  species  from the two  others
is also afforded by the  state of the cough.  It is not the
short tickling cough or tussicula which attends the tu-
berculous consumption.  The fits of coughing are  as
violent as those which occur in catarrhal phthisis; but
they are not, as in that species, attended with copious
expectoration.  For a considerable  time  little or no
expectoration occurs :  Thus, the case is very different
from what happens either in the  tuberculous or catar-
rhal phthisis.

   But, above  all other  circumstances, apostematous
phthisis is characterised by  those symptoms which im-
mediately ensue on the rupture of the vomica.  On
that event a copious purulent discharge, under the form
of expectoration, puts the nature of the case beyond
all doubt.   That the discharge then taking place con- 
IN PHTHISIS PULMONALIS.           55
sists almost entirely of pus is sufficiently demonstrated
to the patient himself both by the smell and taste; and
if the  practitioner be present when the rupture takes
place,  he also  can have no doubt with regard to the
nature of the expectorated matter. Even at after periods,
this species is distinctly characterised by the nature of
the expectoration.  Both by its smell, its  specific gra-
vity, and its  chemical relations to acids and to alkalies,
it will be found to consist principally of pus, with very
little mixture of mucus.

   The last  species,  or  the  tuberculous  consumption,
ls the most difficult to distinguish at its commencement.
It is what may justly be called a very insidious disease;
and it has often made considerable progress before any
important affection is supposed to exist.    The cough
at  the  commencement is hardly so considerable as to
claim notice ;  while the extenuateoLhabit  and loss of
strength with which it is attended are often ascribed
to  other causes.   But there  is always some presump-
tion that these are the incipient state of the tubercu-
lous phthisis, when they take place between the  age of
fifteen  and twenty-five,  and are found to continue for
some time, notwithstanding the use of those practices
which  are in general successful in catarrh.   There is
still stronger ground for presuming incipient  phthisis J
of  the tuberculous kind, when these symptoms are at- 
56
OF THE DIAGNOSI9
tended with quickness of pulse, and  when  they occur
with those who are known to be of a scrofulous family,
and  especially if other  children of the same family
have, at the  same  period" of life, fallen  victims  to
phthisis.

  But even where there is not this mark of hereditary
scrofula in the family, the symptoms  mentioned above
always give strong suspicion  of  tuberculous  phthisis,
when they occur  with those  who are  of that fair com-
plexion  and delicate make which is very common with
such as are of scrofulous  constitution.

  There is also reason for suspecting tuberculous phthi-
sis where the symptoms above mentioned have  begun
without any obvious existing cause, such as injuries  to
the breast; where the pain, when it does take place, is
not fixed to any particular spot; and when dyspnoea does
not occur, or if occurring, is only distressing upon mo-
tion of the body,  or any  considerable exertion on the
part of  the patient.

  But above all other marks, the tuberculous phthisis
is characterized by the peculiarity of the cough which
takes place both at  its commencement and during its
course.   The  cough  which attends   the  tuberculous
phthisis  is, as has already been said,  of the short tick- 
IN PHTHISIS PULMONALIS.             57
ling kind, denominated a tussicula.   For a  longtime
it seems to proceed from some accidental irritation, and
is attended either with no expectoration, or merely with
the expectoration of a small quantity of mucus. Where
a more copious expectoration does happen, it is neither
viscid mucus nor purulent matter  mixed with mucus.
The matter expectorated is often clear and limpid, with
a reddish tinct;  and is  rather a bloody sanies than
even ill-conditioned pus.

   When bloody expectoration takes place in this spe-
cies at an early period, it can hardly  be  said to be un-
der the form  of haemoptysis.   The discharge of  blood
is never considerable at once, and it is very seldom pure
blood, being  in general intimately mixed with a large
proportion of thin limpid mucus.

   From due attention to those diagnostics which have
now been pointed out,  pulmonary consumption may be
most readily  distinguished  from other diseases; and
when it does occur, the three different species  which
have been pointed out  maybe most readily distinguish*
ed from each other. 
5S
                 CHAPTER VII.

 OBSERVATIONS  ON THE GENERAL  PLAN OF CURE IN
             PULMONARY  CONSUMPTION.

   In the different modifications of phthisis pulmonalis,
 and particularly in the three different species which
 have been now described, the general plan of cure va-
 ries considerably.   It is indeed  true,  that there are
 some general intentions which are to be had in  view
 in every instance of phthisis.  Thus,  it must  always
 be an object with the practitioner to counteract, as far
as he is able, the effects of purulent  absorption.  It  is
 in every case an object of importance to obviate those
effects which purulent absorption produces on the sys-
tem; or, in other words, to alleviate the urgent symp-
toms of the disease.   These, however, are merely pal-
liative indications, and a radical cure of the disease  is
to be obtained only by a removal of that source  from
which the purulent absorption arises.   The means of
 effecting this removal must, in the different species, be 
            GENERAL PLAN  OF CURE, &C.         59

accommodated to the nature of that particular  source
from whence the purulence is furnished.

  In the catarrhal phthisis, the source of that purulent
matter which produces the symptoms is a mere inflam-
ed surface,  in some degree similar to what produces
purulent matter in the case of a blister-issue.   Here,
therefore, the first object which is naturally to be aim-
ed at in the  cure is, to produce a change in that state
of separation which takes place from the surface of the
branches of the trachea, and of the membrane forming
the air-vessels of the lungs.   But it is also a second ob-
ject of no less importance, to restore the natural condi-
tion  and state of action of those superficial vessels from
which this separation is afforded.

   For obtaining the first of these ends, it is in most in-
stances necessary to diminish that impetus with which
the blood circulates  through the system  in general.
But it is still more requisite to diminish  that impetus
with  which it circulates through the vessels of the lungs
in particular; for  in catarrhal  phthisis, the impetus of
circulation in these vessels is very generally augmented.
A diminution of this impetus may be obtained in dif-
ferent ways.   But very generally this may be  effected
more readily by those means  which give a determina-
tion ef blood to other parts at some distance from the 
t
 60            GENERAL PLAN OF CURE
 lungs, than by an action on the vessels  of the lungs
 themselves.

   The second leading indication in the cure of catar-
 rhal phthisis, the restoration of a natural condition to the
 superficial vessels of the lungs, from which a separation
 of pus is afforded, may be brought about chiefly in two
 ways; first, by strengthening the tone ofyfcnese vessels;
 and, secondly, by giving such a condition to the system
 in general, that the restoration of proper  tone  to these
 vessels may be brougtit about by the  operations of  the
system itself.   Hence, with the view of fulfilling this
 indication, much more is  to be derived from regimen
 than  from medicines, and particularly from gentle ex-
 ercise, pure air, and mild nutritious diet.

   In  the  apostematous phthisis, the purulent  matter
which gives  rise to  the wasting of the habit, loss of
 strength, and hectic fever, is  separated at a particular
part of the lungs, and is  often, even when locally accu-
mulated at that part in considerable quantity, so inclos-
ed that it cannot be discharged;  for the apostema  is
often formed by a thick cyst or bag containing the
rulent matter.   Thus,  the  purulent  matter,  althouj,
lodged in the substance  of the lungs, eveh to the extent
of many ounces, has no communication with any branch
of the trachea.   In other cases, however, even before 
IN PULMONARY CONSUMPTION.         61
the vomica can  properly be said to be ruptured, some
communication with the air vesicles, and passages for
air, takes place.   But whether there be any  opening
into these, giving an opportunity for purulent expecto-
ration or not, it is still  from this source, the apostema,
that the absorption of matter giving rise to consumption
is afforded.                                     i

   In this species of phthisis, then, it must be evident,
that a first and  principal object is to  discharge that
purulent matter which is  collected in the apostema.
For accomplishing this, when the cyst remains entire,
the  first requisite  is, that it should  be ruptured;
and for this purpose, measures may sometimes be ad-
vantageously employed by the physician;  such, for ex-
ample,  as concussion  of the  system by the action of
vomiting, of coughing, or the like.   But very general-
ly, the  rupture of the apostema is trusted to^ the opera-
tions of nature; and in most instances, in no long time.
particularly if the vomica be large, a spontaneous rup-
ture will occur.

   In every case, after an opportunity for discharge is
 afforded, whether by an intentional or spontaneous rup-
 ture of the apostema, that discharge is to be promoted;
 and this may be done by encouraging frequent and free
 expectoration.  Such expectoration, it is almost unnc-
                          F 
GENERAL  PLAN  OF CURL
oessary to observe, is chiefly effected by coughing.  And
in the greater part of instances, sufficiently frequent
and  strong coughing is  induced from that irritation
which is  given to the lungs and trachea  by the puru-
lent matter itself; but in some instances, for promoting
free expectoration, other  measures may be  employed
with advantage, such as  the steam of water, of vine-
gar, of sulphuric  ether, or similar vapours.

  After a discharge of that  purulent  matter  which
had been collected in the  abscess has been obtained, it
becomes a second object  in apostematous  consumption
to prevent the farther separation of purulent matter
from the ulcer which is thus formed.  This, however,
can only be accomplished in a manner  similar to what
happens when  ulcers are formed in  other parts.   On
the bursting or opening of an abscess, a diminution and
final termination of the discharge are only to be brought
about by the gradual healing of the ulcer.  This healing
of ulcers,  however, in the lungs, as well as other part*
of the body, may justly be considered as a process of
nature, and is only to be accomplished by the operations
of the system itself.

  But there can be no doubt, that, on some occasions,
the efforts  of nature, in conducting the healing process,
may be promoted and forwarded.  This healing process 
IN PULMONARY CONSUMPTION.         63
requires that state of action of the  vessels,  which,.in
contradistinction to  the suppurative, has been  termed
the adhesive inflammation.  It becomes, therefore,an ob-
ject of importance to induce this state of inflammation
as far as it can with safety be  done.   And with  this
view,  by  the  judicious  use,  sometimes  of  tonics,
sometimes of  stimulants,  sometimes of  astringent
medicines, much good maybe obtained.

   The  third and  last, species of. consumption to be
spoken of, the tuberculous, depends on what are term-
ed tubercles formed in  the  lungs,  and which are pro-
bably  diseased and indurated glands attached to the
lymphatic  system.  These, as well as scrofulous tumors
in other parts  of the body, depending also on  the  in-
duration and  enlargement of lymphatic  glands, may
often long remain in  an  indurated  state.  But such
tumors  in the lungs, as well as similar tumors else-
where,  may be considered as having constantly a ten-
dency and even a progress to a state of suppuration.
And suppuration at these tubercles may take place, not
merely in the  indurated body itself, which sometimes
becomes  as it were an inorganic  substance, but  in
those parts by which it  is  immediately surrounded;
the tubercle merely  acting in exciting the suppurative
inflammation, in the same manner as a lead-shot,or any 
64            GENERAL PLAN OF CURE
similar  foreign  substance, introduced into the lungs.
would do.

   It  is  in but very few cases of tuberculous phthisis
that a single or solitary  tubercle only exists  in  the
lungs. In the greater number of instances, as is demon-
strated by numerous dissections, many tubercles exist
in the lungs at the same time.   And when some have
already  terminated in a state of suppuration, or have
induced the separation of ill-conditioned purulent mat-
ter from the vessels immediately in contact with them,
others remain only in the progress towards a state of
suppuration.  And  from this circumstance many pheno-
mena of the  disease may  be explained; particularly
the recurrence of phthisical symptoms in a patient for
several years together every spring, and  their cessation
during the summer.  This may be considered as hap-
pening in a manner precisely similar to scrofulous sup-
purations, scrofulous ophthalmia, or the like,  returning
frequently during a series of years, at almost stated times.

   Wherever tubercles formed in the lungs can be re-
moved without terminating in suppuration, or inducing
suppuration  in  contiguous parts,  this removal is  un-
questionably a matter of the  utmost  consequence.   In
tuberculous phthisis, it is an object of great importance,
wherever it  can  be  accomplished, to  bring about a 
IN PULMONARY CONSUMPTION.        65
resolution or removal of the tubercles, while they re-
main in their indurated state.

   But this resolution or removal  may be  accomplish-
ed with some of the tubercles,  although  not with all
of them; and  where  many exist, it may reasonably
be expected that some of them will  terminate in sup-
puration.   Where   such a termination takes place,
it  is but  very  seldom that  the ulcer, thus  formed,
yields  mild purulent matter.   Like  scrofulous  ul-
cers in other parts  of the  body, those ulcers in the
lungs which are the  consequence of tubercles, often
give out merely an  ichorous sanies.   In this species
of phthisis, therefore,  a second great  object  in  the
cure is,  to alter  the state of action of  the  vessels,
either  in  the  tubercle itself, or in  the  surrounding
parts, so as to produce the separation  of proper puru-
lent  matter.

   With  the separation  of proper  purulent  matter,
the  adhesive inflammation, by which alone an ulcer
can  be healed,  is intimately connected; and it is alone
by the healing of  the ulcer that the  disease can be
cured.   If, however, this object can  be accomplished
by the aid of proper remedies, or even if the opera-
tions of nature in accomplishing  it can be aided, a re-
covery may take place even from this  must idarming
and  dangerous species of consumption, the  tuberculous.
                        f 2 
%       66
*
                CHAPTER VIII

OBSERVATIONS ON  PARTICULAR PRACTICES EMPLOYED
  IN PHTHISIS PULMONALIS, AND WHICH HAVE BEEN
  RECOMMENDED BY EMINENT WRITERS.

  From the view which has beeiLgiven of the general
principles on which the cure of pulmonary consump-
tion is to be conducted, it must evidently appear, that,-.
for  answering the indications which have been pointed
out, many different remedies may be employed; and
■there is perhaps  no affection in which a greater variety
of practices have been recommended.

  While some of these practices are applicable to one
species and one condition  of the disease only, others
are in some degree applicable perhaps to all the three
species which have been described, and may even be
advantageously employed to fulfil different intentions in
each.   But although it has of late been  alleged by an
eminent writer,  that the digitalis purpurea is as certain
a remedy for phthisis,  as the cinchona is for intermit- 
               modes of cure, &lc.             67

tent fever, yet every candid practitioner  will readily
allow, that hitherto no panacea, no effectual remedy for
pulmonary consumption, is discovered.

  In particular instances, however, certain  remedies
may not only tend to alleviate the distress of the patient,
but may at least assist in the accomplishment of a com-
plete  recovery.  This will  more fully appear from a
few observations on the principal practices which have
in this disease been recommended by the most eminent
practitioners.

   This subject might easily be  extended to a great
length, when it is considered how many different reme-
dies have  been recommended in  phthisis,  and  how
much has been said with regard to each.   From what
 1 have seen in actual practice, I might say much, both
in confirmation and  in refutation of the  sentiments of
others respecting particular remedies.  But  my object
 is to  deliver not the detail, but the  result of my own
 observations; and I shall  therefore confine myself to
 a few remarks on what I consider as the most important
 modes  of cure, either from their beneficial or preju-
 dicial effects.

   At the head of the practices which have been re-
 commended in pulmonary consumption, blood-letting 
68                modes  of clre-
may justly be mentioned.  There are several  indica-
tions in phthisis, which it is well fitted to fulfil, especi-
ally as diminishing the impetus  of blood through  the
system in general,  and through the lungs in particular.
In this way large and repeated blood-lettings may effec-
tually  prevent haemoptysis, or inflammation from  any
cause, from terminating in a state of suppuration. Re-
peated small bleedings  in phthisis  have also been
strongly recommended, for  counteracting successive
inflammations resulting from tubercles.

   The use of repeated blood-lettings in phthisis seems
first to have been introduced by that singular practitio-
ner Dr Dover, to whom, it must be acknowledged, that
medicine is indebted for several  important practices;
particularly for the introduction of his sweating pow-
der, long known in the shops under the name of Dover's
Powder, and  still  much employed under the appella-
tion of the pulvis ipecacuanhas compositus.   Dr Dover
considered phthisis as entirely an inflammatory disease.
And he directed blood-letting to a small  extent at first
every  !ay, for twelve or fourteen days  successively;
and afterwards every second or third day for a consider-
able length of time.  In this way, even by small blood-
lettings, very considerable quantities  were abstracted;
and there  are cases on  record,  in which, before the
disease proved fatal,  blood-letting  had been performed 
             IN PHTHISIS  PULMONALIS.           69
upwards of fifty times.   There can, however,  be no
doubt that this was a great abuse of a very useful reme-
dy.  The treatment was found to be by no means  a
successful one; and although these blood-lettings might
afford temporary relief,  yet the  probability  is, that
they shortened the life of the patient.

   On the grounds, indeed, which have already been
stated, blood-letting may in some instances prevent the
occurrence of the disease,  and in others overcome it
in its incipient state;  but it is to be remarked, that do
practice tends more to reduce  the strength of the body
than blood-letting.  Loss of strength, however, occurs
at a very early period of phthisis, and is one of the
first alarming symptoms.  The pulse in this disease is
often quick, when it is neither full nor hard;  and the
quickness depends much more on increased irritability,
than on increased tone of the vascular system.  Hence,
it is often observed,that blood-letting, in place of dimin-
ishing, increases the quickness of the pulse in phthisi-
cal patients;  and in every case it occasions an addition-
al  loss of strength.   There  can be no  doubt, there-
fore, that it  must often  be prejudicial.   That  it has
been so, I am fully convinced from what I have fre-
quently seen  in practice;  and I have no doubt in assert-
ing, that in hundreds of instances,  starvation and blood-
letting have hastened the death of phthisical patients. 
*0                MODES of  cure
With regard to its use in this disease, it may be justl\
observed, in the words of an elegant writer, Nocet per
se, prodest casu.

  As blood-letting has often been employed in phthisis,
so recourse has frequently been had to blisters.   Epis
pasties have in this disease  been used in different forms,
particularly under the form of proper blisters, and of
blister-issues, or setons.  It may also be observed, that
in some instances they  may be employed  with advan-
tage in all the three different species of phthisis'.  In
every species of the disease, blisters are often  a means
of relieving the cough:  for  even   when  they have no
tendency to  remove the  stimulating cause producing
cough, as when it arises from a tubercle, yet  they di-
minish the effect of the stimulus.   In most instances^
also, they diminish  increased sensibility in the neigh-
bourhood of those parts to which they are applied. This
is particularly the consequence of  their  application  to
the  neighbourhood of inflamed parts: for by exciting
a new morbid action, that  which  previously took place
at the inflamed part is sometimes suspended,  often di-
minished.  Thus, they are useful rather from the im-
pression  which  they  make on  certain  subcutaneous
nerves, and the consequent inflammation which they in-
 duce, than from their  evacuant power. 
             L\ PHTHISIS PULMONALIS.           71

  But even as evacuants they are of some  service in
phthisis, by producing a discharge from the general
system, and perhaps still more  by changing the  dis-
tribution of the  fluids, and the balance of circulation.
While, however,  with the  intention of evacuating.
the greatest effect is to be  expected  from proper blis-
ters;  with  the view of changing determination, more
benefit may be derived from blister-issues,  or from
setons.

   Blisters, and still more blister-issues, are particular-
 ly useful in the catarrhal phthisis: for in that  modifi-
 cation of the disease, derivation from the  lungs is of
 the utmost  consequence.   By this  means,  a change
 may often be affected in that state of suppuration which
 takes place from  the  internal  membrane of the lungs,
 and the purulent discharge may thus be converted into
 ,the natural  mucus.   On the  same principles they are
 useful in catarrh.  Hence, they may be considered as
  particularly adapted to that period of the disease, when
  a catarrhal has a disposition to degenerate into a phthi-
  sical affection: and  for my own part, I am acquainted
  with  no  remedy from which I have seen  so much
  benefit, in the incipient state of catarrhal phthisis, as
  from blister-issues on the breast.

     In the apostematous  phthisis, blisters  and  blister- 
72                MODES  OF CURE
 issues are also of  considerable service, particularly
 while the vomica remains entire.   For there is reason
 to presume, that this evacuation both tends to  remove
 matter from  the  vomica,  by increasing absorption,
 and that it also affords an  outlet for the matter  thus
 absorbed from the circulating mass.   But after a  rup-
 ture of -the apostema  has  taken place,  and  after an
 opportunity is thus  afforded for  a free discharge of
.the purulent matter Jby expectoration, less benefit  is
 to be expecleoSfreKl issues; and  as every evacuation
 has a tendency to  increase debility, issues are in some
 degree exceptionable.

   Perhaps on the  same ground  they are still more
 exceptionable in  the  tuberculous  phthisis.    In  that
 modification  of  the disease,  I have never in my  own
 practice observed any decided  advantage  resulting
 from the employment of them; and in some instances,
 besides evacuating, they are productive of great incon-
 venience,  as  exciting  irritation and pain.   Circum-
 stances, however,  not  unfrequently  occur, indicating
 their use even in the tuberculous phthisis; particularly
 if that species be attended with considerable expecto-
 ration of  mucus, which is  at  least sometimes the
 case." Even  in tuberculous phthisis,  therefore, the
 use  of issues  is by no means to be entirely forbid.
 But,  upon the whole,  they are less beneficial  in  that 
             IN PHTHISIS  PULMONALIS.          73
species  of consumption than  in the other two, par-
ticularly than the catarrhal,  in which they are often
highly useful.

  Among other remedies in phthisis pulmonalis, some
have  very strongly recommended the use  of emetics.
These,  in certain circumstances,  are applicable also
to all the three species of pulmonary  consumption;
and perhaps  they may be useful on a greater variety of
grounds than either of the practices already mentioned.
In the catarrhal phthisis, the induction of full vomiting
is often  highly useful as an  expectorant:  for in that dis-
ease,  as well as in chronic catarrh, both the cough and
dyspnoea arise from viscid  matter accumulated in the
branches of the aspera arteria; and, next to coughing,
nothing so immediately produces a discharge  of that
matter as Jhe action of vomiting.  But besides  operat-
ing as an expectorant, the  action of an emetic is also
useful in catarrhal phthisis, from the general agitation
which it occasions.   By this there can be  no doubt
that a very great temporary change  is induced in the
mode of circulation.   By  the action of vomiting, the
blood is propelled to the extreme vessels in every part
of the body, particularly to the extreme  vessels  on the
surface.  Thus, there  is produced a derivation from
the  lungs, and a consequent  change in  the  state of
separation at that part of the system; and superficial
                          G 
74
MODES OF  CURE
vessels which before  secreted a purulent matter, nun
thus come to  yield a more natural secretion.   In  this
way, they may tend to produce a radical cure.  But as
far as I can judge from my own observation, they  are
chiefly useful in catarrhal phthisis, as obviating symp-
toms, particularly cough and dyspnoea, by promoting
expectoration.

   If, with the intention of promoting expectoration,
emetics are often  productive of good effects in  the
catarrhal, on the same ground they are still more use-
ful in the apostematous phthisis.  Where, indeed,  we
have reason to  conclude that there is a large vomica
in the lungs, but that it still remains  entire, and while
our wish is  that it should not be burst, emetics must
carefully be avoided.   But where, without a  rupture
of the  vomica a cure  cannot be expected, we possess
no practice by which a rupture can be more readily  ob-
tained,  than  by the action of vomiting; and  after a
rupture of the apostema has taken place, whether spon-
taneously or by artificial means, emetics may be of
great service, as promoting the evacuation.  Thus, in
apostematous phthisis,  they  may  be advantageously
employed with different intentions.

   The intentions now pointed out are seldom to be  an-
swered  in  the  tuberculous consumption.   For there, 
IN PHTHISIS PULMONALIS.          75
'die promoting expectoration will rarely alleviate either
cough or dyspnoea.  But in tuberculous phthisis, eme-
tics have been perhaps more extolled than in either  of
the other species;  and if  they have  really the effect
which some eminent practitioners have alleged, much
may be expected from them. It has been contended, that
by emetics a resolution of tubercles in the lungs may be
brought about; and in the most dangerous species of the
disease even a radical cure will be effected, if the tuber-
cles can be removed. These tubercles, as was formerly ob-
served,  are probably tumors of the scrofulous kind; and
oflate,amongother proposals for discussingscrofulous and
other glandular tumors, emetics have been recommended.
They have particularly been advised for removal  of a
swelled testicle. When, indeed, the testis is in a state of
acute inflammation, emetics are not to be recommended.
But when swelling and hardness remain after  the ac-
tive inflammation is gone, they have been extolled by
some practitioners as more  useful  in removing that
swellin'g than any  other remedy.   On this ground, it
has  been inferred,  that  they may be advantageously
employed against other  glandular tumors,  even those
of the scrofulous kind.   Accordingly, the frequent use
of emetics, repeated twice, or even thrice, in the course
of a week,  for some length of time,  has been strongly
advised; and-cases  have been published, in which this
practice is said to have effected a radical cure in tuber- 
16
MODES OF CURE
culous phthisis.  I must acknowledge,  that I cannot
say very much in favour of this practice from my own
experience.   And I have never yet met with any  in-
stance-of tuberculous phthisis,  in which I had reason
to believe that  emetics produced a radical  cure.   I,
however, by no means consider them  as being so dan-
gerous  a remedy as the repeated small  blood-lettings.
I have never seen any bad effect from the prudent  use
of them: And in most instances of tuberculous phthisis,
I have found them, in the early stages of the disease,
productive of some temporary relief, probably as giving
temporary determination to the surface of the body.

   Those practitioners who have recommended emetics,
have differed somewhat with regard  to the particular
emetic which ought to be employed. Some have advis-
ed the  use of ipecacuanha.  And certainly where  full
vomiting is required to  a moderate degree, there is no
article  on  which greater dependence  can be put.  But
Dr Marryatt and others  give the  preference to what
he has termed the dry vomit, that is, an emetic  opera-
ting without the introduction of any great quantity of
fluid.   The dry vomit  recommended by him is com-
posed of sulphat of copper and tartrate of  antimony;
and it has the effect of exciting vomiting  immediately
upon being swallowred.  My excellent friend, the  late
Dr Simmons, in his Essay on Consumption, mentions.. 
                IN PHTHISIS PULMONALIS.           77

   that in two cases he had experienced benefit from this
   emetic,  after vomits of ipecacuanha had been given
   ineffectually.   Where very frequent repetition is to be
   tried, this dry vomit is perhaps to be preferred.   But I
   must confess I have no expectation, that, by the use of
   any emetic, a removal of tubercles from the lungs will
   be often obtained.  And where the  chief  intention in
   the use of emetics is to promote expectoration, the ipe-
   cacuanha  is  perhaps  the  best  that  can  be em-
   ployed.

     A considerable variety of medicines  of the   refri-
   gerant kinds, have been strongly recommended by dif-
   ferent practitioners for combating phthisis in its inci-
   pient state.   Refrigerants, which, while they tend  to
   produce a sense of coolness, at the same time  diminish
   the impetus of circulation, may seem well suited to a
   disease which by some has been supposed to be always
   of an  inflammatory nature;  and although  they  do not
   immediately remove a plethoric state, yet they perhaps
   tend to diminish the inflammatory diathesis even more
   effectually than the repeated blood-lettings.  Hence, it
   is not wonderful that recourse  should have been had to
   them, and that in certain circumstances they should even
-  have been productive of material advantage.  Accord-
   ingly, at different periods, different  articles of the re-
   frigerant kind have been  highly fashionable.   Acids
                        g2 
78
MODES OF CURE
and neutral salts, particularly nitre, have by some prac
titioners been strongly recommended in phthisis.

   Among the former, recent vegetable acids, such  as .
that obtained from lemons, oranges, or other acescent
fruits, were at one time highly extolled.  Lemons,  in
particular, taken to a very great extent, were, on the
authority  of a late eminent London physician, repre-
sented as an almost  infallible remedy in phthisis.   I
have been told, his own observation on  this subject was,
that, although  the lemon juice often  did not succeed
with others, yet with him it seldom failed.   There  is,
however, too much reason to believe,  that, even under
the very best management, lemon juice will very rare-
ly, if ever succeed in curing any species of phthisis,
where the disease is certainly characterized; and there
is a high probability, that many of those cases in which
it was said to produce a cure,  though supposed to  be
phthisis, were merely catarrh.  Judging from what I
have myself observed  in practice, I have no doubt in
asserting, that the powers of lemon juice, and of other
articles abounding with vegetable acid, in  combating
phhisis, have  been by some practitioners greatly over-
rated; nay,  that  the  indiscriminate  use of vegetable
 acid, as  well  as  of  repeated blood-letting, in pulmo-
 nary consumption,  has been attended with very se-
 rious evils.
/ 
IN PHTHISIS PULMONALIS.             79
  I must, however, also remark, that from recent ve-
getable acids, and particularly from the acid of lemons
or oranges, I have often  experienced good effects  in
particular cases of phthisis. These acids can be taken
without inconvenience to a much greater  extent than
either the acetous or the  mineral acids. And wherever
refrigerants are indicated in phthisis, the recent  vege-
table acids are perhaps the  best.  There are certain
circumstances in which they may be proper in all the
three species of consumption.  But they will no more
cure tuberculous phthisis than they will cure scrofula,
when affecting the submaxillary or other subcutaneous
lymphatic glands; aYid there is as little reason to hope,
that a large abscess in the  lungs  can be  combated  by
the use of them.

>  They may perhaps sometimes prevent the inflamma-
tion which occurs in tubercles, from passing into a
state of suppuration: or they may be useful in combating
inflammation from  injuries to  the  breast, where  that
 inflammation would otherwise terminate  in  an apos-
 tema.  They may also be useful where frequent returns
 of haemoptysis threaten a  termination in suppuration.
 But after an abscess has occurred they are of little
 service.  And as far as  my  observation  goes, they are
 chiefly  beneficial in those cases where there is reason
 to dread that catarrh will  degenerate into phthisis'. 
80
MODES OF CURE
   Besides different acids, various other articles have
 been frequently used  in  phthisis, the good effects of
 which are probably to be ascribed to their power  as re-
 frigerants.  Recourse has particularly been had  to the
 nitrate of potass, and to  the supertartrate of potass,
 both of which, but particularly the former, have very
 great influence  in  exciting  a  sense of coldness from
 their action on  the  stomach, and are certainly  jusily
 entitled to the appellation of refrigerants.   The for-
 mer, has  been much  employed  in cases of haemop-
 tysis, and the latter is often useful, both  as  a  refri-
 gerant and gentle laxative, in those cases where, with
 symptoms  threatening  phthisis,  there'  takes  place a
 bound state of the  belly.   But they seem to me  to be
 inferior in efficacy to the  recent  vegetable  acids; and
 unless where these disagree  with the stomach, neither
nitre nor cream of tartar  will probably be much em-
ployed merely as refrigerants.

   When these neutrals are had  recourse to with con-
sumptive patients, they are used rather with the  view
of correcting some other article, than with any expec-
tation of deriving benefit from the neutrals themselves.
Thus, it has been strongly recommended  to conjoin
nitre with the  gum myrrh, an article afterwards  to be
spoken  of.  And it is not improbable,  that both this
and the cream  of tartar might be  advantageously added 
IN PHTHISIS  PULMONALIS.          81
to some other of the heating balsams, as they have been
called;  and that by this combination, while  good ef-
fects are obtained from these balsams, certain bad ef-
fects which some have attributed to them might be
counteracted.   Thus, in different conditions of the dis-
ease various  refrigerants may be employed with ad-
vantage.

  Of all the remedies which have of late been  fashion-
able in phthisis, none, perhaps, has been so highly ex-
tolled as the digitalis purpurea.   One practitioner, as
has already been remarked, represents it as  being as
efficacious in the cure of phthisis, as the Peruvian bark
is in cases of intermittent fever.   But extensive  expe-
rience  has already clearly  demonstrated to many dif-
ferent practitioners that this is a mere chimera.  The
foxglove has unquestionably a wonderful influence on
the state of the  pulse.  Under proper management, it
produces a slowness of the pulse, not perhaps to be  ob-
tained from any other  medicine yet discovered.  In
phthisis, however, the pulse is often quickened to a re-
markable degree. And it has been the opinion of some,
that, by reducing it to the natural  standard, from  the
employment of digitalis, consumption may be overcome.
But it is almost unnecessary to observe, that the quick-
ness of pulse in phthisis is merely  symptomatic, and
that the reduction of it even below the natural slmd- 
82                MODES OF CURE
ard, can have no effect either in removing a tubercle,
or in healing  an ulcer in  the lungs.  Hence, on this
ground, it is in vain to expect a radical cure from its
use.  That in certain cases, however, it may be em-
ployed with advantage, I am very far from denying.

   The  foxglove, besides that in general it diminishes
the celerity of the  pulse, in  most instances  also ope-
rates as a very powerful diuretic.   It is, however, well
known, that a free  discharge of urine has often great
influence in relieving the breast.  This  is clearly de-
monstrated by the benefit obtained from different diu-
retics in chronic catarrh.   In this way digitalis may be
highly useful  in catarrhal  phthisis',  and a diminution
of the celerity of  the pulse may certainly somewhat
alleviate the hectic fever.  But I am sorry to say, that,
for my own part, I have not  witnessed any great bene-
fit from  digitalis in  any case of phthisis; and  I have
seldom  been able,  by means of this article,  so far to
diminish the celerity of pulse in phthisis, as to bring it
even to the natural  standard.   It would seem, that in
this disease, such is the influence of the causes quick-
ening circulation, that even the*power of the  digitalis
is not able to counteract them.

   While cow's-milk, in various  forms, as an article of
dietfRas been very generally recommended to phthisi- 
              IN PHTHISIS PULMONALIS.          83

cal patients, some particular kinds  of milk have been
viewed even as effectual remedies in that disease. With
this intention, women's milk, mare's milk, but particu-
larly ass's milk, have been by some  highly extolled.
Some kinds of milk may  certainly agree better with
particular stomachs than others.  But there can be no
doubt, that none of them operate upon any other prin-
ciple than as a mild and nutritious  article of aliment;
and therefore, that no  benefit  is to be expected from a
small quantity.  From  ass-milk, which has often been
directed to the extent only of a gill in a day, no benefit
is to be expected, unless it be taken to the quantity of
at least half a pint twice a-day.  When thus  used, I
have  often found it beneficial to patients highly debili-
tated; and I am much deceived, if it has not in some in-
stances contributed to the removal of tuberculous con-
sumption in its  incipient state;  only, however, from
aiding the operations of nature, by  strengthening  the
patient.   Butr such is  its influence in this  way, that,
in the incipient state of every instance of tuberculous
phthisis, it should be recommended.   Where the sto-
mach  of the patient can easily digest it,  the same  ad-
vantages may be derived from cow-milk,  and that, too,
in its richest  state, under the form of what have been
called the afterings, that is, the last  portion of milk
drawn from the udder of the cow at any  one period of
milking.   These afterings, as has been found by accu- 
84
MODES OF CURE
rate observation, certainly contains a much greater pro-
portion of butyraceous matter than is to be  found in the
first drawn milk, and this  last drawn portion  of  the
milk is unquestionably the most nutritious.  But often
cow-milk, even of the ordinary richness, cannot be di-
gested.   In that case, however, it may still be success-
fully  employed in a diluted state;  and  diluted cow-
milk, with the addition of a small portion of sugar, will
make a  very good substitute for ass-milk, where that
article cannot easily be obtained.

   The whey of goat-milk, is another article in  which
many practitioners put great confidence.    From  goai-
whey, as well as from ass-milk, .1 think  I have often
seen very great advantage, particularly in  the incipient
state of tuberculous phthisis.  I have known more than
one instance where a patient of a scrofulous  family
had for several successive  springs alarming phthisical
symptoms, which were entirely removed  in the course
of the summer, by leaving Edinburgh,  and drinking
goat-whey in the Highlands.  This could not be at-
tributed to any nourishment obtained from the most
watery part of the milk, deprived both  of the  oleagi-
nous  and coagulable matter. But it has been supposed
by some, that goat-whey may acquire particular vir-
tues from an  impregnation given to the milk by those
herbs on which the goat feeds in her native hills. For 
             IN PHTHISIS PULMONALIS.          85

this, however, there is  just as little foundation as for
the supposed medical virtues of ass-milk.  I have, for
my own part, no doubt in attributing the whole benefit
of goat-whey, to pure  air, gentle exercise, and  the
change of temperature of the season during which re-
course is usually had to it.  In proof of this, I have of-
ten observed the same benefit by removal from a town
residence  to  comfortable  country quarters, where no
goat-whey was to be had.  A change of, situation to
pure air and a temperate atmosphere, will often be
found of material advantage.  And it is with these in-
tentions  alone  that I ever  think  of recommending
goat-whey quarters.  But from removal to these during
the summer season, I have often  seen great benefit in
the incipient state of tuberculous phthisis.

  iFor patients  in the incipient  state  of a  pulmonary
consumption, sea voyages have often been  highly ex-
tolled.  These have been recommended in every spe-
cies of the disease;  and on different grounds they have
been imagined to  be productive of advantage.  By
some, they have even been supposed useful as exciting
sea-sickness.  But more  generally the benefit observed
from them has been attributed  to two other circum-
stances: to the  pure air which the patient must neces-
sarily breathe when at sea; and to the  constant state
of motion to which the body is subjected when on ship-
                        H 
80
MODES 01'  CURE
  board.   Some have even thought, that particular bene-
  fit may be derived  from breathing  sea-air,  which is
  well known to be often impregnated with saline matter.
  That on all these grounds  some benefit may be deriv-
  ed from it, I would be far  from denying; and I have
  known some instances of patients who were suspected
  to labour under tuberculous phthisis, for whom, on the
  very first alarm of the disease, a  long sea-voyage has
  been recommended, and who have returned free from
  every  complaint.   But in the catarrhal and apostema-
  tous phthisis  nothing is to be expected, either from
  the  air or exercise which   a  sea-voyage  affords,  nor
  from the inspiration of a  saline  atmosphere.   And
  even in the tuberculous phthisis, after the disease is so
  far  advanced as to be distinctly marked, I have never,
'' formy own part, known any benefit from a sea-voyage;
  while, on the other hand, phthisical patients in  a very
  debilited state, at sea in stormy weather, are  subjected
^ to so many and so great inconveniencies,  that I have
  often known  those who have attended such  patients
  deeply regret that the  practice had been tried.

    Unless, therefore,  where sea-voyages are necessary
  for transporting a patient  from Britain to another cli-
  mate, they are, in my  opinion, very rarely  adviseable.
  But few remedies have been  more generally recom-
  mended by eminent practitioners  for combating phthi- 
!N PHTHISIS PULMONALIS.           8*
sis, than a change from Britain to a more steady and a
more temperate climate. A voyage to Lisbon, to Mont-
pellier, to Messina, and other places  in the south of Eu-
rope, with a residence there for some length  of  time,
have been strongly recommended. While these situations
from the wars lately prevailing in Europe, were subject-
ed to the danger of invading armies, Madeira,the Canary
Islands, the Azores, and Bermuda, have been  advised,
with a similar intention.  And there can  be no doubt,
that, in these climates, exercise in the open air may be
employed much  more  regularly, and-with much less
risk, than in the variable and  cold climate  of Britain.
Yet a change to any climate  has very little, or rather
no influence,as tending to a radical cure of the disease;
and the greater part of those patients from Britain who
have had recourse to this practice,  after phthisis has
been distinctly marked, have only gone to breathe their
last in a foreign climate.

  The different modes of cure which  have  now  been
mentioned,  are perhaps the principal practices which
have been recommended by the  most eminent practiti-
oners  in the earlier  periods of pulmonary consumption.
And where phthisis can be  combated  by medical aid,
it is chiefly to be done in the incipient state. But even
from the  advanced stages of the disease,  natural  reco-
veries have sometimes  taken  place.  Hence,  then, 
88                MODES OF CURE
though artificial means of cure, or remedies, strict!)  ^
called, are frequently unsuccessful, yet there are main
cases where a practiti oner, who has had no opportunity
of seeing the patient  till the  disease  has  arrived  at
what may be called a  confirmed  state,  may  recom-
mend them with some prospect of  benefit.

  Among the articles  employed in advanced  periods
oi phthisis, there are perhaps few with regard to which
greater controversies have  subsisted  than  respecting
the cinchona, or Peruvian bark, as it has been common-
ly called.

  There areseveralcircumstancesinphthisis,fromwhich
cinchona would seem naturally to be indicated.   But,
on the other hand, there are circumstances from which
it might be concluded to be adverse to the nature of the
disease.   This controversy cannot perhaps be yet de-
cided from any facts that have been published respect-
ing the  employment of cinchona in  phthisis.   For if
it be said that there are cases recorded in which it has
been used with advantage, it may on the  contrary be
observed, that there are others in which it has manifest-
ly been productive of bad effects.

  Cinchona might, a priori, be concluded to be useful
in phthisis, both as a means  of healing ulceration of the 
IN PHTHISIS PULMONALIS.           89
lungs, and as counteracting those effects which arise
from  the  absorption of purulent matter.  It is well
known, that in cases where ulceration takes place on
different parts of the surface of the body, the discharge
of purulent matter is often altered and meliorated un-
der the  use of Peruvian bark.   It has also been ascer-
tained,  by many accurate  experiments, that few arti-
cles of the materia medica possess a greater antiseptic
power;  and in many  cases, cinchona has  been found
efficacious in checking hectic fever arising from ulcers
in different parts of the body.  On these grounds, then,
there is at least analogy for supposing that it may be
useful  in  phthisis.

   On  the other hand, however, it  is well known that
the common Peruvian bark, the cinchona lancifolia, has
very generally  a tendency to check expectoration; and,
in  many  instances, the principal  chance  of cure  in
phthisis depends  on free  expectoration.  But besides
this, cinchona has also a tendency to produce in the
human  body an increased action of the vascular system,
and a disposition to inflammation;  hence it may  tend
to  support rather  the suppurative  inflammation, than
the adhesive process.   On these grounds, then, there
is reason  to fear, that the good  effects which may be
expected  from it, may be even  more than counterba-
lanced; and certainly its use in  phthisis has, from ex-
                       h2 
90
MODES OF CURE
perience,  been much condemned by many  eminent
practitioners.

   Those,  however, who indiscriminately condemn the
use of cinchona in every  instance of phthisis, have
gone too far.  It must indeed be allowed,  that it has
by no means the same powerful effect in checking hec-
tic fever, as in stopping the paroxysms of intermittents, to
which the hectic paroxysms have in many respects a re-
semblance.  In certain cases of phthisis,  it may do mis-
chief. But this  may in a great measure be avoided by pru-
dent management; and I have directed it in several in-
stances, in which, if I have not  been much deceived, it
has been productive of material benefit.

   In the tuberculous phthisis, it can hardly indeed be
expected, that cinchona will cure those ill-conditioned
 ulcers which  take place  in  the lungs:  For it is well
 known, that scrofulous sores on other parts of the body
 are not to be  healed by the use of it.   And although
 in tuberculous phthisis, little is to be dreaded from  its
 influence as checking expectoration, yet more is to be
 apprehended from it than in any other species of phthi-
 sis; for there is reason to  fear,  that it may encourage
 the  inflammation  of different tubercles in succession.
 and thus lead to more numerous suppurations.

   In the catarrhal phthisis, from its influence in check- 
IN PHTHISIS PULMONALIS.
91
ing expectoration, it may be thought to be seldom ad-
missible.   For in that species of the disease,  free ex-
pectoration is particularly necessary.   And if the cin-
chona be imprudently thrown in, to a great extent, it is
not wonderful that dyspnoea should be induced, or, if it
existed before, should be augmented.   But whether an
increase of dyspnoea wilLbe the effect of its use or not,
can be determined  only by a prudent trial.  When
dyspnoea is not induced or aggravated by its  employ-
ment, the best effects are often observed to arise from
it.   It is sometimes beneficial, not merely as restrain-
ing colliquative  sweats and  other excessive discharges,
which very much weaken the patient; but it has even
some tendency to a radical cure of the disease. In this
way, it has in some  cases very considerable influence,
both  from altering that  state of secretion which in
catarrhal phthisis takes place from the internal surface
of the lungs, and also from  restoring to the secreting
vessels at the lungs  that condition and  that, tone on
which the natural secretion in a  state of health de-
pends.

   If cinchona be sometimes admissible  and useful in
the catarrhal phthisis, it is no less so in the apostema-
tous.  It is never, perhaps, adviseable soon  after the
rupture of a  large vomica has taken place; for at that
period, the only chance of recovery depends on free 
<J2
MODES OF CURE
 expectoration. But when the discharge from the lungs,
 after  a copious  evacuation of well  digested pus has
 taken place,  degenerates into a more ichorous fluid,
 cinchona  may be  of  great  service.  Under its use,
 the appearance of the matter  expectorated is, in  some
 cases  at least, soon much changed for the better. And
 I have had reason to think, that,  from its  influence,
 the adhesive  inflammation has been induced, and an
 ulcer  in the lungs has thus  been healed, where  that
 event  would not  otherwise have taken place. To this
 species of consumption, then, it  is, perhaps,  better
 fitted  than to any other;  and from what I have seen in
 practice, I have do doubt, that in those cases in which
 it is not productive of immediate inconvenience  from
 restraining expectoration', . it  will  be  productive  of
 beneficial consequences.

   In cases of phthisis, cinchona may be exhibited in
 various forms.   The choice  will in  some degree be
 regulated by  the state of the patient's stomach.  But
 under  whatever form if be  given,  it is very  generally
 proper that its use should be begun in small doses; for
 by this means, the practitioner will best be able to judge
 with  certainty whether  its  good or bad effects will
preponderate.   In phthisis,  those objects which the
practitioner would wish to accomplish by means of the
cinchona, are in general to  be  obtained, not from its 
             IN PHTHISIS PULMONALIS.           $3

action  on the stomach, but from its introduction into
the system; and  therefore they may  be more readily
obtained when its active principles are previously ex-
tracted by a proper menstruum, than  when they  must
be extracted  from the woody part in  the stomach it-
self.   One of the best and safest forms under which
the cinchona can be employed in phthisis, is, perhaps,
the simple  watery  infusion;  and under this  form,
where  cinchona is to be tried, its use ought always to
be begun.  If the watery infusion be  found to be at-
tended  with advantage, the  practitioner may  with
greater freedom venture to employ it  in a more  active
form; and recourse may be had with  advantage  either
to the extract or to the powder  of the bark; yet, upon
the whole, it will, perhaps, in a majority of cases, be
exhibited with greater safety and most advantage when
acted upon by a watery menstruum, either under the
form of infusion or decoction.

   If practitioners have differed in ^opinion with regard
to the  effects of cinchona in phthisis,  differences no
less considerable have taken place with regard to ano-
ther set of  medicines,  the vegetable  balsams, as  they
have been  called.   These have  derived the name  of
balsams from a  supposed power of promoting the heal-
ing of wounds and ulcers.  At one time, many of them
 were highly extolled in  pulmonary consumptions.  The 
94                 MODES OF CURE
balsamum  Giliadense, Canadense, Copaiva, and seve-
ral others, have each  had  their  day of  fashion, and
have each fallen into deserved neglect.  Many  argu-
ments have been brought to prove, that the  balsams
and gummi-resinous substances which have by some
been recommended in phthisis, as they possess a heat-
ing and stimulating power, must be prejudicial in that ■
disease.   They have particularly  been  condemned by
the late eminent Dr Fothergill, in  a paper in the
London Medical  Observations,  in  which  he brings
many arguments to show, that the use of them in phthi-
sis has been adopted on mistaken  principles, and fol-
lowed without  due consideration; and he cone hides,-
from his own observations in practice,  that  tlity are
prejudicial.  His opinion respecting them has of late
been very generally adopted.

  That in many cases they  may  have  done  harm,  I
do not deny; but those who  condemn the use ofihem
indiscriminately seem to me to carry the matter too
far.  In particular cases of consumption, I am dispos-
ed to think favourably of some of  them, and especially
of that gummi-resinous  substance^-  which has  been
denominated- myrrh,—and which is the produce of a
tree, with regard to the botanical history of  which we
are still much in the dark.  Even since Dr F other-
gill's condemnation of the balsams,  this article has 
IN phthisis pulmonalis.
95
been highly extolled in phthisis, by several  accurate
observers, particularly by Dr Simmons, in his  valua-
ble Treatise on Consumption. He considers it as coun-
teracting the effects of \ibsorbed  ichorous pus, from
its antiseptic powers; and that it does  possess these is
universally  allowed.  Hei\ce, whatever bad  Effects
it  may have in other respectV it may thus be of use;^
and the inconveniencies  dreaded from  its immediate
action  on the stomach, as heating, may  in  some de-
gree be obviated by giving  it combined with a refrige-
rant, nitre or supertartrate of potass.  Accordingly, the
gum-myrrh has been directed to be taken to the extent
of twenty or thirty grains thrice  a-day, united with an
equalquantity of either of  these articles.   And the
testimony of Dr Simmons, in support  of its efficacy,
has been confirmed by numerous  observations ofDrs
Griffiths, Fordyce, Saunders, and others.

   To their experience I can also add the result of ex-
tensive observation in my own practice.  For, although
I can by no means represent it as having often produc-
ed a cure, yet in some  instances I think I have seen
the best effects from it.   I have used gum-myrrh  fre-
quently in  all the three species of pulmonary consump-
tion, but not in all of them with  equal  advantage.   In
the catarrhal phthisis,  less benefit is to be derived
from  it  than  in the  other two species.   In the tuber- 
?>b                MODES OF CLRK
 culous I have  sometimes  thought  it was of service;
 but of all the modifications of the disease, I have found
 it most useful in the apostematous.   In more  than one
 instance, if I have not been much deceived, it  has con-
 tributed very considerably to bring  about a  complete
 recovery.   In  such cases,  therefore, I consider it as
 well entitled to a fair trial;  and for my own part, at
 least, I have  not observed  any bad effects  resulting
 from its use.

   In treating of balsams in  phthisis, it may not, per-
 haps, be improper to mention another  article, which,
 although a quack  medicine, has of  late been highly
 extolled by  some regular practitioners, viz. that which
 has been sold under the  name of  GodboWs  balsam.
 The use of  this  article  in phthisis I  have had  many
 opportunities of observing.  Of its composition I know
 nothing: for, although the  receipt sworn to and record-
 ed in Chancery, by the patentee, has  been  repeatedly
 published, yet no medical man, in the least acquainted
 with the materia medica,  will for a  moment  suppose,
 that it is prepared  according to that specification.
An  ingenious  chemist in  Edinburgh  has,  indeed,
bestowed a great deal of pains in analyzing  Godbold's
 balsam, and  sells, at a much lower  price, a  balsam
which he considers ro b • \ery nearly, if not precisely,
the same with that of Godbold;  and as  far as 1 have 
IN PHTHISIS  PULMONALIS.          97
been  able to observe,  the  effects of both are nearly
the same.  Of both these  articles I am inclined to
think rather favourably; but I can by no  means say
much  for  either.  I have  met with no instance,  in
which, by either, a cure of phthisis has been obtained;
nor do I believe that either of them  will cure  phthisis
in any case.  I have indeed met with different cases,
where catarrh, with alarming  appearances,  has been
entirely removed during their use;  and from such cases
being mistaken for phthisis, they probably  derive their
present high reputation.  But all the benefit I have
ever  observed  from them  in any  case is merely the
mitigation of cough.

   Among other  active medicines,  recourse  has  been
had, in phthisis, to  mercury,  to  sarsaparilla, and  to
mezereon;  but I have never witnessed benefit  from
any of  them, and if they ever do  any good, I am in-
clined to think, it will only be in  those cases where
phthisis has been excited by a preceding venereal affec-
tion,  and where the virus of syphilis has not been fully
overcome.

   I can also, from my own experience, say  very little
m favour either of the tussilago farfara, or of  the lichen
islandicus.  Any good effect which has ever been observ-
ed from these, I am inclined to attribute entirely to  the 
98                MODES OF  CURE
 vegetable mucilage which they contain, tending to allay
 cough, by operating as a demulcent.   Of the  cicuta
 or hemlock, the conium maculatum of Linn^us, I am
 inclined to think more favourably. With patients of a
 scrofulous  habit,  subjected  to  symptoms threatening
 tuberculous phthisis, I have sometimes  imagined that
 the conium, in conjunction with  cinchona,  has had a
 good effect in preventing the occurrence of phthisis.

   Sea-water, and mineral waters, particularly those of
 the sulphureous kind,  and the Bristol waters, have by
 some been strongly recommended, even in the confirm-
 ed stages of  tuberculous  phthisis,  from  the affinity
 which that modification of the disease bears to scrofula.
 In the prevention of this species, they may perhaps do
 some good. But after tuberculous phthisis is distinctly
 marked, although  in some respects they may seem to
 be indicated, yet in others  their  operation is unfavour-
 able, particularly if taken to such an extent as to pro-
 duce  a purgative effect.   Accordingly,  they are now
 very little if at  all  employed after phthisis can  with
 certainty be affirmed to exist.

  While, for resolving tubercles or healing ulcerations
 in the lungs, many medicines have been  taken  inter-
nally, some  modes of  cure have been recommended,
with the view of acting topically on the diseased parts. 
IN PHTHISIS PULMONALIS.
99
In this  way, different ^articles have been  directed to
be inhaled into the lungs,  under the form of vapour.
From applications in this way, very high expectations
have  been held  out by  some eminent practitioners,
particularly the  late Dr Beddoes;  and indeed it was
entirely with the view of determining their  efficacy,
that he  established what he styled the  Pneumatic In-
stitution at Clifton.   The inhalation of a larger  pro-
portion  of carbonic  acid  gas than is usually con-
tained in  common atmospheric  air, has  particularly
been  advised;  and although it be  well  known  that
the inspiration of it in  a concentrated  state  proves
suddenly  fatal  even to the human  species, yet, when
it is diffused in the atmospheric air inspired, it may be
taken with impunity, and it has been directed in phthi-
sis, with a view to its antiseptic power.  But even if it
wrere  to operate as a very powerful antiseptic  at the
ulcerated  parts, yet it is much to be doubted how far it
would have any influence as  curing phthisis.  It might
indeed perhaps in some degree correct that putrid mat-
ter already separated from the ulcers in the lungs; and
thus might mitigate for a little the violence of the affec-
tion  even of the hectic fever.  But I  am  inclined to
think, that nothing  is to be expected from  it either as
giving ulcers in the lungs a tendency to heal,  or in the
removal of tubercles. 
100              MODES OF CURE
  Of this practice, however, I  can say nothing  from
my  own experience; and  I have  heard  nothing from
others tending to confirm its success.   I have not even
been informed of a single  reputed cure of phthisis at
the  Pneumatic Institution,  where this practice may be
supposed  to be employed  in  the most efficacious
manner.

  A similar remark may perhaps  be  made respecting
the  inefficacy of resinous  effluvia introduced into the
lungs, when obtained by burning tar, rosin, or similar
substances.  These vapours also have been recommend-
ed,  and I have known them tried in  several instances;
but  I never could observe  any good  effect from them.
On  the contrary, by exciting cough, I have often seen
them productive of very great inconvenience.  Th at
in some instances they may have had  the effect of in-
ducing the  adhesive inflammation, in cases of aposte-
matous phthisis, I would not deny;  and hence I would
by no means represent them as  altogether improper.
But I am inclined  to think, that they will seldom be
attended with much advantage, and that often they will
be productive of very great inconvenience.

  Among other vapours taken in  by  inspiration,  that
which is exhaled from a cow-house  has been strongly
recommended by some practitioners.   To obtain this. 
IN PHTHISIS PULMONALIS.         101
it has been enjoined to phthisical patients to live in the
midst of cows; to be in that company not only during
the day, but during the night  also, the  patient having
with  that intention a  proper  bed placed in the cow-
house.  This mode of cure has been  highly extolled
by one  practitioner, who has published the case of a
French lady of quality, in which it is said to have been
attended with a  most wonderful effect.   But I have
never seen this practice tried, and  I must own  I have
no confidence in it.  I fear much,  that any phthisical
patient submitting to live in  a cow-house would  be
subjected to great inconvenience, without any material
benefit.

   If the inhalation of any vapour, which has hitherto
been  recommended,  shall  be found  advantageous in
phthisis, I should  be inclined to think, that  benefit
might be expected from the vapour of sulphuric  aether.
This  has been highly extolled by one practitioner of
eminence, Dr Richard Pearson  of London.   In  a
paper of his, published in the Edinburgh Annals of
Medicine 1796,  a particular account is given  of  this
practice; and'he observes, that he has found the  saluta-
ry operation of sulphuric aether applied to the lungs,,
under the form of vapour, to be greatly  promoted by
several volatile substances  that are soluble  in  it;  but
by none more than the conium maculatum.   By ma- 
102              MODES  OF CURE
cerating a sufficient quantity of the dried leaves oi the
hemlock in sulphuric  aether, for the space of three or
four days, or at most of a week, and by occasionally
shaking them together, a very saturated tincture is obtain-
ed. The proportion which Dr Pearson has in general us-
ed was about half a drachm of the powdered leaves of
the conium to an ounce of the aether.   One or two tea
spoonfuls, either of pure aether, or of this impregnated
fluid, is put into a tea-cup or wine glass, and held  up to
the mouth. The patient is directed to draw in the vapour
which arises from it with the breath, continuing it till
the whole tea-spoonful or two of aether be evaporated.
This process he directs to be repeated three, four, or
 even five times in the course of a day, for a month or
six weeks, according  to  circumstances.  From this he
affirms that the best effects will often be obtained.  He
does not indeed recommend it in every modification of
phthisis;  but he considers it as best suited to the florid,
or what is commonly termed  the  scrofulous consump-
 tion.

    Since I first read Dr Pearson's publication on this
 subject, I have repeatedly  directed to patients the in-
 halation, both of pure aether, and of aether impregnated
 with hemlock; and in different cases it has appeared
 to me tabe productive of considerable benefit.   It has
 •ften had very great influencein relieving both the dysp- 
             IN PHTHISIS PULMONALIS.          103

ncea and cough.   But I have found it particularly use-
ful as promoting expectoration, in those cases where vis-
cid -mucus, mixed with a  large proportion of purulent
matter, could not be discharged from the lungs without
very distressing cough.   I have never, indeed, found
the employment of it followed by a cure, either  in the
catarrhal, or any other species of phthisis;  yet,  from
what I have seen, I am  convinced,- that, in  different
conditions of phthisis, it may be employed with advan-
tage.

   Another practice recommended in phthisis, the  effi-
 cacy of which has been supposed to depend on  certain
 vapours, is the bano  de  tiera, or  earth  baths,  as they
 have commonly been called, where the patient  is  con-
 fined for some time in a pit newly dug in the earth. This
 practice has in particular, been  recommended  by  Dr
 Simmons, as well as several other eminent writers; and,
 he endeavours to account for its efficacy, from the anti-
 septic powers of the exhalations from the earth, which
 will thus have an opportunity of being absorbed at the
 surface of the body.  The earth-bath I  have never di-
 rected for any patient; nor have I ever witnessed the
 employment of it.   But about thirty years ago it was
 tried  in a few cases at Edinburgh; and according to the
 information which I have  received, in all  these it was
 attended with  a bad effect, always  aggravating the 
104              MODES OF  CURE
cough, and not unfrequently inducing a hectic  parox-
ysm.  When it was employed even during the warmest
weather in summer,  it excited a distressing sense of
coldness.

  After ^what has now been said of some of the prin-
cipal remedies which have been recommended in phthi-
sis, I shall next offer a few remarks concerning regi-
men  in this disease.  Perhaps  a  greater number of
cures in phthisis have been effected  by regimen than by
medicine, especially  if under the head of regimen be
included,  not merely diet, but air, exercise, and similar
circumstances.   To  treat  of  all  these,  however, at
length, would require a very extensive discussion.  All,
therefore, that  is now proposed is, to make a few re-
marks on some of the principal circumstances.

  It has been but too common to  prescribe the same
diet in every species of phthisis pulmonalis, and at eve-
ry  period of the disease.   By many,  those labouring
under phthisis  have been  altogether interdicted from
the use of animalfood.  They have either been entire-
ly confined to vegetable diet; or at the  utmost have
been indulged with a small proportion of milk,—a fluid
which, as an article  of diet, m;iy be considered as in
some  degree  intermediate between  the vegetable  and
animal kingdom.  That this  plan  may in some cases 
              IN PHTHISIS PULMONALIS.         105

be proper, I would not deny; but I have no  doubt in
asserting, that such starvation has often been  attended
with a bad effect,  and has hastened the death of the
patient. The very extraordinary doctrine lately contend-
ed for by a remarkable London physician, Dr Lambe,
is too absurd to deserve any refutation, notwithstanding
the parade of learning with which he attempts to sup-
port it.

   Others, on the contrary, observing the great loss of
strength which occurs in phthisis, have absurdly sup-
posed,  that it is a disease altogether depending on  a
high degree of debility.   With the view of combating
this, they have recommended a very full diet, of the
most stimulating food.  But from this,  there can be no
 doubt, that equally pernicious effects have resulted, as
from the opposite plan of mere vegetable diet.

   It is unnecessary to observe, that the  diet best accom-
modalft to the human species is of a mixed  nature.
With  almost all nations the  articles of diet which they
employ are taken  partly from the animal  and partly
from the vegetable kingdom.  The former,  however,
is upon the whole more stimulant than  the latter, which
often  exerts even a refrigerant effect  on  the human
system.  But besides  both animal  and vegetable sub-
stances, the food of all the human  species, at the very 
106
MODES OF CURE
earliest period of life, consists principally of an article
which may be considered as in some degree intermedi-
ate between the vegetable  and animal  kingdom, viz.
milk.  For although it be immediately afforded from
the breasts of the mammalia, yet it does not, like other
animal fluids, and those animal solids used in diet, run
directly into the putrefactive process, but is, in the first
instance, like vegetables, subjected to an acescent fer-
mentation. Milk, however, furnishes a mild and Nutri-
tious aliment, not only to infants, but to adults.

   In judging of that diet which is best suited tp parti-
cular conditions of certain diseases,  due attention must
be paid to its  effects upon  the  system.   These effects
are chiefly of  two kinds: They either  arise from the
immediate influence which  alimentary matters exert
upon the stomach, or  from the  influence which they
have as entering the mass of circulating fluids.   With
regard to  the effects arising from an action on the sto-
mach, alimentary articles differ from each otherTas be-
ing more  or less  stimulant.   From the immediate in-
fluence which some  of them exert, in consequence of
their action on the sentient extremities of the nerves of
the stomach, their stimulant effect is extended over the
whole system, and is clearly indicated, both by an aug-
mentation of the celerity and momentum of the  pulse,
and  by an increased  sense of heat.    Other articles, 
'♦
           IN PHTHISIS PULMONALIS.            107

again, are of so mild and bland a nature, that they pro-
duce no' obvious effect; while there are certain articles
which evidently demonstrate their possessing what have
beencalled refrigerant qualities,by inducing both a sense
of coldness, and diminishing the impetuous circulation.

   From the influence of different alimentary matters,
as entering the system, their effects vary chiefly as they
are more or less nutritious.  Some articles certainly af-
ford a much larger proportion of chyle than others, when
taken to the same extent, or to  the same weight; and
some articles yield a much richer and more nutritious
chyle than others. For there is every reason to believe
that the same varieties may  take place with regard to
the chyle of animals as with regard to their milk. The
last-mentioned of these fluids, in the case of that ani-
mal the milk of which is  chiefly  employed   as an
article of diet, the cow, is  well known to be much af-
fected by  the food on which she is supported: hence
the superiority of the milk of a cow fed on old pasture
over that of the very same animal when fed on turnip,
Nay, there can be no doubt, that, by the  copious in-
troduction of water into the stomach of the  animal,
the watery part of a cow's milk bears a much greater
proportion  to  the oleaginous and coagulable parts, to
the butter and  cheese, than it  does  when she  is re-
strained to  a small quantity of  fluid.  Accordingly, 
108
MODES OF CURL
it has been alleged,  that certain dealers in milk em
ploy artifical  means of exciting  thirst in  their cows.
that the animal may be induced to drink a large quan-
tity of water.   In consequence of this, a larger quan-
tity of watery  milk is drawn from the animal, the na-
tural  milk being as it were watered in  her udder.
Thus,  when milk is even fresh drawn from the cow
at the door of  the patient,' it may still, strictly speak-
ing, be but milk and water.

   From what has now been said, it  follows, that the
articles  commonly  employed" for nourishment, may
with  propriety be divided into four kinds of diet: the
stimulant, the  refrigerant, the nutritious, and the spare.
In a great majority of those diseases requiring a spare
diet, particularly those accompanied with plethora, and
occurring in the sanguine temperament, as in haemor-
rhagies, inflammations,  or the  like,  it  is  proper that
the diet should not only be of the  spare,  but that it
should also be of the refrigerant kind.  On the other
hand, in most  of those diseases  in which a stimulant
diet is  indicated, where it is necessary to support the
impetus of  circulation,  and  to counteract a state  of
debility and exhaustion, the  diet, while it is stimulant,
should also be nutritious.  Hence, it has with  many
been a general rule always to combine the refrigerant
with the sparediet, and the stimulant with the  nutritious 
IN PHTHISIS PULMONALIS.          109
  This general rule has in particular been often observed
in giving directions with regard to the diet of phthisical
patients; and in my opinion, the observance of it has of-
ten done much mischief.  It has been supposed by some,
thatevenwhen a phthisical patient is in the most exhaust-
ed condition, and in a state  of the utmost debility, there
still prevails  in die system  an inflammatory tendency;
and that the  quickness of  the pulse,  even  when it is
the  weakest  and  most commpressible, still contra-
indicates the employment of any food, either  stimulant
or even  nutritious.  Accordingly, while to patients, in a
state of the utmost exhaustion and emaciation, as marked
by the fades  Hippocratica,  they have directed repeated
small bleedings,  they  have also  strictly enjoined the
the most spare and refrigerant diet.  With this view they
have directed that the whole aliment employed should
be entirely taken  from  the  vegetable  kingdom;  and
they have recommended principally, not the most nu-
tritious  vegetables, as the farinaceous grains and muci-
laginous roots, but those of the refrigerant kind, as the
acescent fruits,  and  cooling  laxative greens.   From
these they have  concluded, that, while such support
may be afforded to the  system as  will  prevent great
uneasiness from hunger, nothing is to be apprehended
as increasing a plethoric state; and from the influence
which these  refrigerant vegetables exert upon the  sto-
mach, they have at the same time expected, that they
                          K 
110               MODES OF CURE
would prove useful,  as diminishing the celerity of tin
pulse, and the impetus of the blood.

  From these circumstances, such diet may seem par-
ticularly adapted to the earliest stages of phthisis  in
some cases, especially where there is  reason to dread
that either frequent haemorrhagies from the lungs,or an
active inflammation within the chest,will terminate in an
apostema; for, in order to prevent such a termination,
while a considerable  discharge by blood-letting is requi-
site, it is  certainly proper to avoid those articles which
can furnish a large supply  of rich chyle, even although
they should be, like  milk, of the very  mildest nature.
Hence, in certain stages of the apostematous phthisis,
it may be proper to enjoin a diet entirely of refrige-
rant vegetables; or, when these  do not satisfy hunger,
it may be  proper to allow no  other addition to  the ve-
getable diet than a small quantity of milk,  and that,
too, not in its richest state, but as deprived of its most
nutritious part.   Hence, some have  advised  butter-
milk in preference to fresh drawn cow's milk, or have
directed that the fresh cow's milk should be employed
somewhat diluted, and with  the addition  of a small
quantity  of sugar.   By this means,  in  its sensible
qualities, and probably also in its effects on the system,
it will approach nearly to ass's-milk;  for there can be
no  doubt, that  ass's-milk,  and  even mare's-milk. 
            IN  PHTHISIS PULMONALIS.           Ill

differ principally from cow's-milk, in containing a less
pritn-M'tion of the butyraceous and coagulable or cheesy
tr   er, and  a larger proportion of  the saccharine, or,
p: :iiaps more properly, the saline part.  But, although
Ibi   -:!iet  maybe well fitted for the beginning,or rather
for  he prevention of apostema, yet, after an apostema is
really formed, and  after, by the bursting of that apos-
tema, an opportunity is  afforded for  a  free discharge
of purulent  matter, it is no longer adviseable.   On the
contrary, a  more nutritious diet is essentially necessary
for giving the ulcer a chance of healing, by which alone
a recovery can be expected.

   In the incipient state of the catarrhal phthisis, the
diet should  be nearly the same as in the beginning of
the apostematous; for here also there is in some de-
gree an inflammatory affection of the internal surface
of the  lungs.  Hence,  whatever will  much  augment
the  impetus of circulation is to be avoided.   But even
in the incipient state of catarrhal phthisis, there are
not  the same reasons for wishing to diminish  the im-
petus of circulation as in the apostematous; and when
the patient  is much debilitated, the system requires to
be recruited and supported.  Hence, though stimulant
articles are to be shunned, yet advantage  may be de-
rived from  nutritious aliment; and to  this species of
phthisis, eyen from the  commencement, a more libe- 
112              MODES OF  CURE
ral diet is well suited.   WThere milk agrees  with tht
stomach, it is as little stimulant, and  often  as easily
digested, as  any vegetable; and accordingly, in dif-
ferent forms, it  may  constitute  a considerable part  of
the diet with  advantage.

   Respecting the proper diet in tuberculous phthisis,
much difference in opinion has  taken place.    On the
one hand, it has been contended, that here the greatest
danger  is  to  be dreaded  from inflammation and con-
sequent suppuration at the tubercles; and on this ground,
the most spare and the most refrigerant diet  has  been
strictly  enjoined.  But, on the other hand, it has been
alleged, that this modification of  the disease derives
its origin from a scrofulous  constitution;  and  that,  to
other modifications of scrofula, low diet is by  no means
best accommodated.   On the contrary,  there  can be
little  doubt, that scrofula is often produced by- a very
poor and meagre way of life, and  that  it is a much
more common disease with children who  are half starv-
ed, than with those who are well fed.   On this  foot-
ing, therefore, by soir.e, a generous, and  even a stimu-
lant diet, has  been advised.  Of these   two opposite
opinions, neither, perhaps, is to be altogether adopted.

   In the tuberculous, as  well  as  in  other species  of
phthisis, in the incipient state, it is unquestionably an 
              IN PHTHISIS PULMONALIS.          113

object of importance to avoid inflammation; but, not-
withstanding every  precaution, inflammation  at  the
tubercles, terminating in  ill-conditioned suppuration,
will often occur; and when it does take place, it is only
by a certain degree of vigour in the system, that proper
suppurative and adhesive  inflammations can be induc-
ed.   The healing of tuberculous ulcers in  the  lungs,
as well as of scrofulous sores at other parts, is only to
be expected from recruiting and giving vigour  to the
system.   In this state of  the disease, therefore, a nu-
tritious diet is  naturally  indicated; and, indeed,  the
evident marks of exhaustion point out the propriety of
a due supply.   Besides these particulars, a liberal and
nutritious diet is often  indicated in  this  species of
phthisis by the feelings of the patient; for  it is by no
means uncommon to observe even  a craving for animal
food; and it may be remarked, that in very rare in-
stances only  are  such calls of nature entirely to be
neglected.   In  every case  some indulgence  to the
cravings of  nature is perhaps adviseable; and  the
practitioner should form his judgment,  not from pre-
conceived opinion, but from the effects which he ob-
serves in any particular case after a  trial  is made of
those  articles for which a  craving occurs.  Judging
from my own experience,  I have no hesitation  in  as-
serting, that, in most instances of tuberculous phthisis,
and during almost the whole course of the disease, a
                      k2 
114               MODES OF CURE.
nutritious diet may be employed with great advantage;
and that, on the contrary, a rapid progress of the affec-
tion to a fatal conclusion, is the consequence  of a very
abstemious and refrigerant diet.

   While, however, I am thus an advocate for a nutri-
tious, 1 would by no means advise  a stimulant diet for
patients subjected  to tuberculous  phthisis-   A great
part of the diet in this species also may, with advantage,
consist of milk.   The animal food selected should  be
nutritious,  but  at the same time mild.    Animal.sub-
stances of an alkalescent  nature  are to  be   avoided.
The animal food employed should always be  plainly
dressed. It may be thus taken to some extent in a solid
state;  but it  should be chiefly used under the form of
good animal broths or animal jellies.

   The same general regulations which have been given
with respect to diet, in some degree also apply to the drink
of phthisical patients.  To a certain  extent,  the natu-
ral cravings of the  patient are  to be attended to, and
the quantity of drink is to be regulated by the degree
of thirst which may take place.   From the use of mere
diluents quenching thirst, no inconvenience will arise.
The  appetite of thirst may be freely indulged,  even
during the time of colliquative sweats and colliquative
diarrhoea.   Care  need only be taken  to direct such 
IN PHTHISIS PULMONALIS.           115
fluids as have not  a particular tendency to increase
these evacuations.   Nothing is to  be dreaded  from
pure spring-water taken cold from the fountain.   No
supposition is  more groundless  than that of viewing
pure spring-water as a poison; and the purification of
it by distillation, which some have recommended, in
reality injures it as a  diluent for quenching thirst in
place of improving it.   With profuse sweatings, how-
ever, acidulated drinks are  to  be preferred to  pure
water;  and with  diarrhoea,  drinks  of  a  mucilagi-
nous  nature ;  but toast water, and  milk  diluted with
water, may be employed in almost any case. In certain
instances, it may be proper, in conjunction with dilu-
ents, to mitigate thirst by acescent fruits, oranges, ta-
marinds, or the  like. Drinks of the cordial and stimu-
lant kind are  rarely admissible;  but when there is a
strong craving for these, they should not altogether be
denied.   The safest and best that can be employed is
wine diluted under the form  of negus.  I  can recollect
only one instance where the patient, a young girl, had
a craving for spirits,—a liquor to which in health she
had been altogether unaccustomed.   In that case the
patient  was indulged in the use of diluted spirits to a
small extent; but the disease in a short time had a fatal
termination; the spirits, so far as I could judge, produ-
cing neither a good nor bad effect.
   If attention be  necessary  to the aliment of patients
labouring under phthisis, it  is no less requisite to the 
116
MODES OF CURE
air  which they breathe.  It has  often been  thought,
that very great benefit in phthisis has been obtained by
a change of air, even from one part of Britain to ano-
ther.   Many have  attributed the  good effects  which
have followed removal from other parts of Britain to
Bristol, much more  to the  patient's breathing the pure
air of Clifton, than to any efficacy in the Bristol waters;
but no more peculiar virtue can, in my opinion, be at-
tributed to the air than to the water of Bristol.   There
can, however, be no doubt, that it is beneficial  to a
phthisical patient, to be removed from the air of towns,
contaminated by the smoke of many fires, and from any
situation even in the country where the atmosphere is
peculiarly cold and moist.   When removed to warmer
climates, a moist atmosphere, and a hot situation conjoin-
ed with moisture, or with noxious exhalations, are equal-
ly to be avoided. A pure and a dry atmosphere, as far as it
can be obtained, is to be selected: Andif,before the com-
mencement of the disease,  the patient has come from a
healthy situation in the country to live in a large town, a
removal to his native air will in general be advantageous,
not merely as affording a purer atmosphere, but as put-
ting it  in his power to enjoy amusement with the com-
panions of his youth, and have  perhaps the  attendance
of affectionate relations.

  But  while  pure and dry air  are sought for, the tern 
            IN  PHTHISIS PULMONALIS.         117

perature of the air is not unworthy of attention.   Ex*
tremes of heat and cold, whether in the open air or in
the chamber in which the patient is kept, are equally
to be shunned; but of the two,  from the  extreme of
cold most is to be apprehended.  The  winter cold of
the external air in Britain can seldom be borne with-
out injury;  and where circumstances prevent a change
of climate, it is often advantageous even for a patient,
although he may have sufficient strength to take exer-
cise in the open air, to confine himself to the house dur-
ing the coldest months  in the winter, and never to al-
low the atmosphere of his room to be under forty-eight
degrees, or what is  commonly marked  temperate on
Fahrenheit's scale.

   But confinement to the  house in Britain is not more
necessary as  a means of guarding against cold than
against the sudden vicissitudes of the weather. Hence
the advantage of removing for the winter months to  a
more southern and more steady climate.  It has  been
advised by some, that phthisical patients should reside
near the sea.   In such a  situation,  in  every climate,
both the cold of winter, and heat  of summer, are some-
what moderated.  But it has been imagined, that be-
sides the temperature, peculiar advantage may be deriv-
ed from sea-air.   Of  late, however,  a very  different
doctrine has been held.   Dr Carmichael  Smyth, in 
118
MODES OF CURE
a late valuable treatise on consumptions,  alleges,  both
from  his  own  experience and that of other eminent
practitioners, that sea-air  is very  generally prejudicial
to phthisical patients.   I must, however, observe, that,
in my own practice, I have seen nothing tending tocon-
firm this opinion.  Whether near the sea, or at  a dis-
tance from it,whatis chiefly tobe sought for is a comfort-
able situation, where the patient may breathe pure air.

  After what has been said of the temperature of the
air, it is hardly necessary to add  any thing respecting
clothing.   This must be entirely accommodated to the
situation of the patient.  While care is taken to guard
against an uneasy sense of cold, it is equally necessary
to shun what will  induce sweating; and the patient
should neither be oppressed with a load of bed-clothes,
nor fatigued with the weight of wearing apparel.   The
object aimed at should therefore be, to obtain moderate
warmth, combined with lightness; and for this purpose
it will in general be advantageous to wear thin flannel
or cotton cloth next the skin.  These are  particularly
beneficial, where the patient  sweats much,  as,  from
absorbing moisture, they prevent  that sense of coldness
which arises from a linen shirt, while at the same time
they support uniform circulation at the surface.

   Besides the discharge by the surface, attention must 
IN PHTHISIS PULMONALE,.          119
also be paid to the discharge by the bowels.   Inconve-
nience always arises from a state of constipation.   But
still more is to be dreaded from  the induction of  diar-
rhoea.   When constipation occurs, therefore, the most
gentle laxatives  should alone be employed; and  it  is
much more desirable to obtain a regular discharge by
diet than by any medicines.

   While it is of importance to regulate the discharges
 from the body,  so it is also of very great consequence
 to regulate the  passions  of the mind.   The state  of
 mind should be kept as equable as  possible.  In this
 disease, however, more perhaps is to  be dreaded from
 the exhilarating than from the depressing  passions.
 For it has been marked as a peculiarity of phthisis, that
 the patient is almost never  apprehensive of danger.
 During the febrile accessions in particular, in place  of
 that anxietasfebrilis, which is ihe constant attendant of
 idiopathic fever, there is often  such a  flow  of spirits,
 as to require  being moderated;'or at least, it is necessa-
 ry to shun what will tend farther to exhilarate.  At the
 same time, it is equally necessary to avoid what will
 depress the patient; and  even where  there is very faint
 expectation of recovery, the chance  of such an event
 will be diminished, by endeavouring to make the  pa-
 tient fully sensible of his own  danger. 
 120              MODES OF CURE
   Exercise in various forms has been strongly enjoin-
 ed as a mode  of-cure  in every  different  species of
 pulmonary consumption.  Although there is very lit-
 tle probability that it will remove ulceration, either
 from a tubercle or apostema, yet it is so much connect-
 ed with the support of the general health, that without
 it, other practices can have much less effect.  It should
 always, therefore, be advised, wherever the strength of
 the patient and the state  of the weather will  admit of
 its being taken; and it should be carried as  far as he
 is easily able to bear without fatigue. Of all the modes
 of exercise, Avhere the patient has  sufficient strength,
 none  is, perhaps, preferable to  walking.   It  tends  to
 support equal  and natural heat, and to promote regular
 circulation through the whole body, even  to the  infe-
 rior extremities.   But it  must be allowed, that this ac-
 tive exercise is much more apt to  induce fatigue, than
 passive exercise, mere motion,  or modes of gestation,
 as they have been called.  Of all modes of gestation,
 gentle riding on horseback, is giving exposure to  free
 and fresh air, is, perhaps, the best. Where the patient
 wants strength  fortius, advantage may  still be deriv-
 ed from riding in a carriage,  or even from  being car-
 ried out in  a chair.

   A mode  of motion still more  gentle than  either of
these  may  be obtained  from sailing.   This, indeed. 
             IN PHTHISIS PULMONALIS.          121

yan hardly be  called exercise, though there be a very
considerable degree of motion; and one eminent prac-
titioner, Dr Carmichael Smyth, in a late treatise on
the subject, is of opinion that mere motion is much su-
perior to any exercise.  That  constant motion, without
fatigue, may thus be obtained, is certainly true.  But
notwithstanding this, I would by no means recommend
a long sea-voyage, for obtaining such permanent mo-
tion.   In long voyages, a patient  may necessarily ex-
pect to be sometimes subjected to bad weather; and
on such occasions a weak invalid is  unavoidably ex-
posed  to  numberless  inconveniencies.    To obtain,,
therefore, the  good effects of this mode of motion,
without these inconveniencies, I would prefer a situa-
tion near the sea, or some navigable lake, where  sail-
ing might be employed every day when the state of the
weather was favourable.

   As possessing  all the  advantages of that  motion
which is given by sailing, without almost any bodily
exertion whatever, Dr  Carmichael Smyth, in a late
publication on  the effects of  swinging employed  as  a
remedy in pulmonary  consumption and hectic fever,
has  very  strongly recommended  that motion which
may be given to the body in a chair properly suspend-
ed.  This mode of motion may in most  situations be
with advantage employed either in the open air or in
                         L 
122                MODES OF CURE
any large room, when exposure to the  external  atmo-
sphere is judged improper.   I  have  accordingly di-
rected it in many cases, and  I have been led to con-
 clude, that it was used not altogether without advan-
tage.   I consider  it as,  upon the  whole,  preferable
to the motion which  is  given by a spring-chair, or
spring-deal.   But it  has by no  means answered in
my practice those expectations, which, from the peru-
rusal of Dr Smyth's account, I was led to expect from
it;  and of all the modes of exercise which have been
advised, judging from  my own observation, I  am in-
clined to consider walking on foot, as, upon  the whole,
productive  of the greatest advantages.

  Having thus stated my sentiments respecting the re-
medies and regimen which have been most highly
recommended in phthisis  pulmonalis, and from which,
when  properly  adapted  to the  circumstances  of
the case,  there  is, in my  opinion, the best  chance
of recovery,  I shall  conclude my observations with a
fery few remarks  on  the means of obviating urgent
symptoms.

  It  is  a  fortunate  circumstance for  the  feelings of
every medical practitioner, that, even in those diseases
where the prospect of recovery is the  most faint, and
where there is next to certainty of an approaching dis- 
              IN PHTHISIS PULMONALIS.          123
 solution in no long time,  he still  has it often in his
 power to, protract the period of life, and to alleviate the
 distress of his patient.  In many cases of phthisis, this  is
 all that he can reasonably expect to accomplish.  The
 means by which it is to be accomplished must be much
 varied according to  circumstances; and the success  of
 the remedies which  are  employed to obviate urgent
 symptoms must depend very much on the prudence and
 penetration of the physician, exerted at the moment.  It
 is, therefore, altogether unnecessary to treat of these  at
 any length; and I shall here merely take notice of three
Symptoms, which, before a fatal termination takes place,
 are very distressing in most instances.   These are, the
 colliquative sweats, the* diarrhoea, and the'cough.

   Colliquative sweats can hardly, perhaps, be called
 a  distressing symptom.   They  are  productive of  no
 pain, and of little uneasiness  to the patient.  They  do
 not even prevent sleep, but they tend  very much  to
 debilitate  the  patient; and, perhaps  more than any
 other circumstance, have the effect, even at an early pe-
 riod of the disease, of inducing the loss of fat and  of
 flesh, and even that appearance which  marks  the ut-
 most degree of exhaustion, the fades Hippocratica. By
 the loss of strength, however, the chance of  recovery
 is certainly vere much diminished.   Hence, though a
 free cuticular discharge is often a means of alleviating 
124               MODES OF CURE
 cough,  and of removing catarrh threatening phthisis.
 yet profuse sweatings in such circumstances are always
 to be dreaded; and where the patient complains much
 of loss  of strength,  are  always to  be  moderated.
 For this purpose, gentle means of checking them must
 be employed.  They may always be stopped by the ex-
 posure  of the surface to cold  air; but from this much
 greater  evil than benefit will in most instances result.
 To obtain good effects  from the  action of cold upon
 the  surface  great  prudence is necessary.  The bed-
 clothes  are to be made, gradually only,  thinner and
 lighter;  and the same prudence is to be  observed  in
 thinning the dress of the patient.   Nothing, however,
 in my opinion, tends more to counteract this symptom
 with safety than substituting for thick flannel the  use
 of cotton-cloth.   Cotton shirts and sheets are equally
useful in absorbing sweat as woollen next the skin; and
 they give comfortable warmth, without the same  de-
gree of  heat which  arises from flannel.  In  the way
of medicine,  various articles may be employed;  but
I have found nothing so advantageous as  the prudent
use of the sulphuric acid properly diluted.

  The diarrhoea, which often  occurs in phthisis, can
in no degree be supposed to contribute to the  recovery
of the patient.  It  is,  indeed, of advantage in every
instance of phthisis to prevent costiveness; and it u 
IN PHTHISIS PULMONALIS.          125
 always a desirable circumstance to  keep the bowels
 rather  loose  than  otherwise; but  this  should  be at-
 tempted to be obtained rather by diet than by medicines.
 When  medicines  become necessary, the*hiost  gentle
 emollient cathartics are to be employed; for  it ought
 to be the object of the practitioner, particularly in the
 tuberculous  phthisis,  merely  to evacuate from  the
 alimentary  canal,  and  not from  the "system.   When
 catharisis is once induced, it is not always easily stop-
 ped;  and frequent discharges, under  the form of stool,
 weaken the system little  less than profuse sweating.
 When diarrhoea, therefore, occurs spontaneously,  it is
 always to be stopped,  or at  least moderated; but this
 also should  be done rather by diet than by medicine;
 by  shunning  the  use of those  articles  which   are
 observed to increase it,  and by employing what  are
 found to moderate it.   This is often obtained  by mild
 mucilaginous broths, particularly  veal broth, or melt-
 ed calf-foot jelly, and  by  the use of rice  in  different
 forms.  Where medicines are necessary, I have found
 nothing better  than  the extractum catechu,  either
 under the  form of electuary or infusion, adding such
a proportion of the  tincture of opium as the  circum-
 stances of the  case may admit or require.

  Of all the symptoms which require to be mitigated,
 >herc  is none which more frequently demands the at-
                        jl2 
126
MODES OF CURE
tention of the practitioner than the cougb.   The action
of coughing, as has formerly been observed, is often
necessary in the apostematous phthisis, for discharging
from the lufTgs great quantities of purulent matter; and
the suppression of that discharge is often  immediately
productive of  very great inconvenience; but unless as
tending to evacuate either their purulent or- mucaginous
matter from the  lungs, it is never beneficial; and it is
often highly distressing to the patient, both during day
and night,  even  when it occurs under the form of tussi-
cula merely, in the tuberculous phthisis.  The employ-
ment, therefore, of such articles as will tend to mitigate
it is often necessary.   For this  purpose, an almost
infinite variety of articles, either  of the demulcent or
sedative kind, may be employed with advantage. Even
when it is altogether impossible to remove that irrita-
tion which induces the convulsive action termed cough-
ing, the effects of the irritation may yet be often  sus-
pended or diminished, and that by substances possess-
ing a sedative power,  acting either on the fauces, or
on the  system in  general.   Of all  these  substances,
none is so useful or so powerful as opium, which, in-
deed, I am inclined to consider as the most  valuable
medicine yet discovered; for, to use the words of the
illustrious  Sydenham, Sine Mo manca sit et claudicel
medicina;  and judiciously  administered, according to 
IN PHTHISIS PULMONALIS.          127
circumstances, it may be productive of the greatest ad-
vantage.

  But opium, valuable as  it is, can by no means be
represented as free from inconvenience in this disease.
There are some individuals, with whom, from peculi-
arity of constitution, it always disagrees, and who can-
not employ it, even in a very small quantity, without
great inconvenience, confusion of head,  vertigo, sick-
ness at stomach, vomiting, and various other distressing
symptoms.  Hence, recourse has been had to a variety
of other sedatives, both with the view of allaying inor-
dinate action, and of procuring sleep.   Where opium
cannot be employed, different articles of this kind, par-
ticularly the preparations  of the  hyoscyamus niger,
and humulus lupulus, have often beeen  used with  ad-
vantage;  but of  all the substitutes for opium which I
have ever employed in'practice, I have found none from
which I have seen so great benefit,  as from the prepara-
tions formed from the inspissated whitejuice of the com-
mon garden lettuce.  Ever since  the days of Galen,
among the Romans, who employed  it as a soporific in his
own case, this article, like the papaver somniferum, and
 many other plants yielding a milky juice, has been known
 to possess a power of inducing sleep; but  for a long time,
 although  constantly cultivated  as  a salad, it has been
 almost entirely neglected as a soporific.   A few years 
128              MODES  OF CURE
  ago, some circumstances drew my attention to this ar-
  ticle; and I  lately published, in the Memoirs  of the
  Caledonian Horticultural Society, an account of differ-
  ent trials which I  had made  with it.  My  intention
 was to call the attention of  industrious gardeners to
 this subject as an article of trade.  These trials I shall
 not here  repeat, but only observe, that of all the medi-
 cines which I have employed  for alleviating  cough in
 phthisis,  and  indeed as a sedative in many  other dis-
 eases, next to opium, I have found no article  so bene-
 ficial  as that substance,  which some  have lately deno-
 minated  lettuce opium,  and which I termed lactuca-
 rium.  But of this article, a more full account is given
 in the Appendix.   And  in the present edition, I  have
 been enabled  to enrich that Appendix, by communica-
 tions from different friends, on the preparation and use
 ef lactucarium.

   Since the first edition of this short treatise  was pre-
 sented to  the  public, phthisis pulmonalis has been the
 subject of several different interesting publications; and
 I may particularly  mention, as  well deserving notice,
 one by Dr Henry  Herbert  Southey, of London,
 Physician   to  the   Westminster -Hospital,   entitled
 Observations on Pulmonary Consumption; and another
by Dr William Barrow  of Liverpool,  entitled  Re-
starches on Pulmonary Phthisis, from the French of M 
             IN phthisis pulmonalis.          129
 Bayle.  From both these works,  an attentive reader
may derive useful information.   But of all the treatises
I  have ever seen on  consumption, what I hold to be
the most valuable is a work published last year by  Dr
Thomas Young of London, physician to St George's
Hospital,  entitled A Practical and Historical Treatise
on Consumptive Diseases, deduced from original obser-
vations, and collected from authors in all ages.   In that
elaborate  work, the truly learned author has given a
medical history of pulmonary consumption from the
days  of  Hippocrates, to the publication of DrSou-
they's observations in 1814.  He has there presented
to the reader the most interesting facts respecting  the
history,nature, and treatment of this formidable disease,
recorded by authors of the  greatest celebrity, of every
age and nation,  who  have  cultivated  medicine as a
science.   It is therefore a work which, in my opinion^
will be highly instructive, not only to the young practi-
tioner, but which may be perused with advantage, even
by the oldest and most experienced of the profession.

   Although there is but too much reason to fear, that,
notwithstanding the united labours of  all who  have
written upon this subject,  pulmonary consumption
will still continue to be a very dangerous and fatal dis-
ease, yet I would fain hope, that, duringthe present pe-
riod,  some progress has  been made in the mode of com- 
130              MODES OF  CURE, &C.
bating this formidable  complaint with success.  And
I need not add, that, although in the course of nature,
my employment  in the practice  of medicine is now
drawing very near to a conclusion, it will yet afford me
very great satisfaction  to learn  still farther improve-
ments from succeeding writers on Phthisis Pulmonalis 
APPENDIX. 
I
*-
t 
APPENDIX.
  As the Memoirs of the  Caledonian  Horticultural
Society will not probably be in the  possession of ma-
ny medical practitioners, it is  presumed that the fol-
lowing extract from that work  may  not be unaccept-
able to the reader.
Observations on the preparation of Soporific Medicines
  from common Garden Lettuce, by Dr. A. Duncan,
  senior, read in the  Caledonian Horticultural  Society,
  6th March, 1810, and printed in the 1st volume of
  their Memoirs, p. 160. et seq.

  Opium, or the  inspissated  white  juice which ex-
udes from the capsule of the  papaver  somniferum,
                        m 
134
APPENDIX.
 when wounded, has long been allowed to be one of tiie
 most useful articles employed in the alleviation or cure
 of diseases.  The  high  encomium bestowed upon it
by the illustrious Sydenham,* has been fully confirm-
 ed by  the  testimony  of  succeeding practitioners  in
every nation.   It is, however,  much to be regretted,
 that  there are individuals  of  the human species,
with whom, fro m  peculiarity of habit, opium  seldom
fails to produce distressing  consequences.   There
 are  also conditions  of disease, in  which it may be
 very necessary to induce  sleep, or allay pain,  though
 circumstances  occur  by  which  the use  of opium
 at that time is contra-indicated.  Hence it has long
 been a desideratum  in, the healing art,  to discover
other powerful quieting  medicines.  For,  although
 it is hardly to  be  expected that  an article  will ever
be  discovered, so  extensively useful as opium, yet
 a good  soporific  may be  found, which,  with some,
 will have less influence,  either as  exciting sickness
 at stomach, as occasioning confusion of head, or as in-
 ducing a state of constipation.
  It has been the opinion of many,  that all the milky
juices spontaneously exuding from wounded vegetables
possess somewhat of the same sedative power with the
  * " Ila necqssarium est  Opium, in hommis periti manu, ut
"'sine illo  manca sit,  ac claudicet  medicina,"—Sydenham, dt
Dysenteria anni 1660, &c. 
APPENDIX.                 135
milky juice  of the poppy.  Few plants in  Britain
afford such milky juice more copiously than  the com-
mon garden lettuce, the  lactuca  sativa of  Linnaeus;
and every one must have observed, that this jiiicc when
spontaneously inspissated by the heat of the sun on the
wounded plant, soon assumes the dark colour of opium;
while, at the same time, it possesses  in a high degree
the peculiar,  and, I may say, specific taste, which dis-
tinguishes'that  substance.   Besides this, it is a well
known fact, that lettuce was much  used by the ancients
as a soporific.

   These circumstances led me to turn my thoughts on
some method of collecting and preparing this  exuda-
tion, that  I might try its effects in  the practice of me-
dicine.   And, after several trials of different modes of
preparation, those which I shall now briefly describe
are the best methods I have yet been able to discover.

   I dedicated to this experiment, in my  garden at St
Leonard's Hill, near Edinburgh, a small bed  of that
variety of lettuce,  which is commonly  known  among
gardeners  by  the name of ice lettuce.   I allowed the
plants, about a hundred in number, to shoot up, till the
top of the stem was about a  foot above the surface of
the ground.   I then cut off about an inch from the top
of each.-   The milky juice immediately began to ris<- 
136                 APPENDIX.
above the wounded surface.   Though then of a white
appearance, it had next day formed a black,  or dark-
coloured incrustation, over the surface where  the stem
was cut off.  I found.it impossible to separate this by
scraping, as is done with the milky juice exuding from
the head of the poppy, when it has assumed the form
of s opium.   I therefore cut off with a sharp knife a thin
cross slice of the stem, to which the whole of the dark
coloured opium-like matter adhered. This was throwr
into  a  wide-mouthed  phial,  about half filled with
weak spirit of wine, the alcohol dilutum of the Edin-
burgh Pharmacopoeia, formed of equal parts of rectified
spirit and water.  By this menstruum, the whole black
incrustation on the thin slice of the stalk was dissolved;
and the spirit, as may be readily concluded, obtained
both the colour and taste of the black incrustation.

   Each of my plants,  in  consequence of the fresh
wound  inflicted by the removal of the thin cross slice,
afforded a fresh incrustation every day. And by  throw-
ing these into the phial, I soon obtained  what I con-
cluded to be a saturated solution of the  exudation from
the lettuce, or rather of the milky juice in its inspissat-
ed state.  It was then  strained  off, to separate  the
pure solution completely from  the   thin slices  of the
stalk.   To this strained spirit, which had nearly both
the appearance and  taste of the ordinary laudanum of 
APPENDIX.                137
the shops, I have given the name of solutio spirituosa
succi spissati lactuca.  From trials made with this so-
lution, both on myself and others, I have no doubt that
it  is a  powerful soporific.   But to obtain a form in
which it might be exhibited, with greater  certainty as
to the dose, I evaporated the spirit,  and thus  brought
the residuum to a dry state.   In this state, it has very
much the appearance of the opium imported  into Bri-
tain, particularly of that which is imported from Ben-
sal, and which is  a much softer substance than  the
Turkey opium.   To this opium-like substance, I have
given the name of  lactucarium.  And from some trials
which I have made with it, when exhibited under the
 form of pills, it appears to me to  be little inferior in so-
porific  power to the opium which is brought from Ben-
gal, which in  general  is  much inferior  in  power to
Turkey opium.

   From the lactucarium thus obtained, I  have formed
 a tincture, by dissolving it to the  extent of one ounce
 in twelve of weak spirit,  which is  the  proportion of
 opium to spirit, in the liquid laiidanum of the  Edin-
 burgh college." To this formula I have given the name
 of tinctura lactucarii.   I consider it as the best formula
 I have yet been able to contrive for obtaining the sopo-
 rific and sedative powers of the lactuca sativa.    And
 in diiierent cases,  I have, I  think, seen manifest good
                          m 2 
138
APPENDIX,
effects from it, both as inducing sleep,  allaying muscu-
lar actioo, and alleviating pain,  the  three  great quali-
ties  of opium, which demonstrate it  to be one of the
most powerful sedatives.  At present,  however, I  in-
tend nothing more but to communicate to the Caledo-
nian Horticultural Society a method of preparing a so-
porific medicine from common lettuce.  For ascertain-
ing more fully its medicinal effects, I am at present en-
gaged in a series of trials, which may, perhaps, be like-
wise communicated to them.

   Meanwhile it will afford me great satisfaction,  if
the  above  short account  shall draw the  attention of
others, particularly of professional gardeners, to the
same subject, and shall lead to the  discovery of a bet-
ter method of obtaining an useful  medicine, from  a
plant so easily cultivated  in every garden.   Perhaps
this important object might be somewhat forwarded, if
the  Caledonian Horticultural  Society  were to propose
a prize, as a reward to the person who should be most
successful in preparing a soporific  medicine from the
milky juice of the lactuca.  But it  should be an essen-
tial condition of that prize, that he should send them,
 not only a specimen of the  substance prepared, but
 also an exact account of his method of preparing it 
APPENDIX.                 139
  In consequence of the above suggestion, the Caledo-
nian Horticullural Society, at the  Quarterly Meeting
on the 6th of March, 1810, agreed to propose a Prize
Medal for each of the two following questions:

   1. For the best method of preparing a soporific me-
dicine from the inspissated white juice of the common
garden  lettuce.   Specimens  of  the medicine to be
produced.

   2.  For the best method  of preparing opium in Bri-
tain, and.the most advantageous manner of cultivating
poppies for that purpose.
  In consequence of the Memoir on Lactucarium, read
to the Caledonian Horticultural  Society by Dr Dun-
can,-  two  distinguished  professional  gardeners, Mr
Henderson at Brechin, and Mr Gorrie at Rait, have
transmitted to the Society excellent specimens of let-
tuCe-opium, with  an account of their methods of pre-
paring it.   From what they have done, there is reason
to hope, that  it may be  easily prepared to a great ex-
tent in Britain. 
140
APPENDIX.
   Mr Thomas Carmichael, teacher  of languages,
at the Sheriff-Brae, Leith, has, during the summer sea-
son, 1813, prepared for sale a considerable quantity of
lactucarium; and three different preparations from that
article, compounded according to the annexed formu-
las, may be had at the shop of Mr William Moffat,
apothecary, Nicolson's Street, Edinburgh.

   Mr Moffat has now also for sale another preparation
from lettuce, which the Royal  College of Physicians
in Edinburgh have agreed -o introduce into a new edi-
tion of their Pharmacopaeia, at present in the press, the
succus spissatus lactucoz sativoz.   This is prepared in
the same manner  as succi spissati   of the aconitum,
belladonna, hyoscyamus, &c; and  has  been usefully
employed both under the form of pills and lozenges, for
the preparation of the last of which  a formula is sub-
joined.

   From the second volume of the Memoirs of the Cale-
donian Horticultural Society it will be seen,  that a
Prize Medal, for a paper on the first of these subjects,
was awarded to Mr Henderson at Brechin, 8th De-
cember 1812;  and  for a paper, on the last subject, to
Dr Howison   at Douglas, on the  14th of December
1813.  These  papers have since been published in thr
Memoirs of the Society. 
APPENDIX.                 141.
 Further Observations on  the preparation of a Soporific
   Medidne from common Garden Lettuce, communicat-
   ed to  the  Caledonian Horticultural  Society by Dr
   Duncan, senior, and read 14th November, 1811.

   From the  writings of  the most eminent medical au-
 thors,  it  appears, that garden  lettuce was employed
 many centuries ago, for the purpose of procuring sleep.
 Galen, who flourished  about  the  commencement of
 the Christian era, mentions it frequently in his writ-
 ings.  And  it  is said, that in  an advanced  period of
 life, when distressed for  want of sleep, he used it with
 success.*

   Among the moderns this article has not been altogether
 neglected.   Some observations and experiments  have
 been made repecting its  medical powers, both in Eng-
 land and in America; particularly by Dr Cox of Phila-
 delphia, and  Dr George Pearson of London.

   About  two  years  ago,  I read to the  Caledonian
 Horticultural Society,  a  short account of a method of

  • " Hypnoticam esse jam  cognoverunt veteres: Celsus, qui
papaveri ides adjung t; Galenus, qui sibi  ipsi senex insomnis
vesperi lactuca comesa somnum conciliavit."—Murray,  Appa-
ratus Medic, vol i. p. 109. 
142                 APPENDIX.
 preparing a soporific medicine from  this plant.  That
 account so far  engaged the attention of the  Society,
 that they proposed  a prize medal as  an  honorary re-
 ward, for the best method of preparing a soporific me-
 dicine from  the  inspissated white juice of the  common
 garden lettuce.

    I am happy to learn, that some ingenious men have
 not 4>eei% neglectful of this subject;  and I would fain
 hope, |hat even our inconsiderable premium may lead
 to  an  honourable and useful  competition.   Among
 others,  I have  myself made  farther trials with this
[ vegetable; and I now present  to the Society specimens
 of five  different  preparations of lettuce,  all of  which
 may, I think, be usefully  employed in the  practice
 of medicine.

    Of the method of preparing  the first,  second, and
 third of these, viz.  1.  The  spiritous  solution, or tinc-
 ture of the dried juice; 2.  The extract, which I for-
 merly  styled  lactucarium, and  which is prepared by
 the evaporation  of that solution  or  tincture;  and, 3.
 The tincture of the lactucarium, which is prepared by
 dissolving that  substance in  diluted  spirits of  wine,
 I have nothing to add to what I formerly  related to
 the society.   I may, however, observe,  that, from re-
 peated  trials, 1  have  found all  of them  to be  useful 
APPENDIX.                 143
soporifics.  But the preparation of these requires much
time, and  great attention;  and in preparing.lactuca-
rium, it may be easily injured by the improper applica-
tion of heat.

   The  two additional  preparations  which  I now
present to  the  society, the  inspissated juice, and the
tincture of the leaves of lettuce, may be made very
easily, and at  a very trifling expence.  Although not
so  powerful  as   the solution  or  extract,  prepared'
from the  inspissated milky juice; yet they will, I am
persuaded, be  found, upon  trial, to be highly useful  in
the practice of medicine.

  Method of preparing the Inspissated Juice of Lettuce,
       or the Succus  Spissatus Lactucoz recentis.

   Take any quantity of the leaves and stalks of the
 lettuce, when the  plant  is nearly ready to flower.
 Bruise them well,  and including them  in a  hempen
 bag, compress them  strongly till they yiekl their juice.
 Let this juice be evaporated in flat vessels, heated with
 boiling water.  Let the evaporation be  continued till
 the expressed juice  be  reduced  to the consistence of
 thick honey.

    According to  the trials  which I have made, twelve 
144                 APPENDIX.
pounds of lettuce will  yield about eight ounces of in-
spissated juice.

Method of preparing  the Tincture of Lettuce leaves,
  or the  tinctura foliorum siccatbrum lactucoz sativas.

  To one ounce of the dried leaves  and stalks of the
lettuce cut  down,  add  eight ounces  ©f the diluted
alcohol of the Edinburgh Pharmacopoeia.   Let  the
vessel containing this mixture be kept for a week in
a warm place, shaking it  frequently.   Let the liquor
then be  strained  through paper,  and kept for use.
About fifty drops may be taken for a dose.
Additional observations on the Lacluca, presented to the
   Caledonian Horticultural  Society, by Dr Duncan,
   sen. andread May 1,1812.

   In two  former short communications to the Society,
I have given an account of a method of preparing, from
the common garden  lettuce,  different articles, which
may, I am convinced, be employed  with advantage in
the practice of medicine.  To these I have given the
following  names. 
APPENDIX.                  145
       1.  Solutio sued spissati lactucaz,
   Prepared from  the  inspissated juice spontaneously
exuding from the plant when wounded.

      2. Lactucarium,
   An extract prepared by evaporating the above  solu-
tion or tincture.

       3.  Tinctura lactucarii,
   Prepared by dissolving lactucarium  in proof-spirit
of wine.

       4.  Succus spissatus lactucm,
   Prepared by inspissating the  expressed juice of the
recent plant.

       5.  Tinctura foliorum lactucm,
   Prepared by extracting the  active  powers of the
lettuce, from the leaves of. the  dried plant, by warm
infusion in proof-spirit.

   To my former observations  I can now add,  that,
 during the course of  last winter, I have made  many
trials  of  these articles,  both in  hospital and in pri-
 vate practice.   I have particularly employed the  first
 and the  fourth of these preparations, in the clinical
 wards of the Royal Infirmary, where their effects were 
140                 APPENDIX
observed by many attentive  and ingenious student*
They have witnessed the benefit which may be deriv-
ed from them in procuring sleep,  in  alleviating pain.
and in allaying inordinate action, particularly trouble-
some cough.  I am therefore not  without hopes, that
when the experiments I have made are more generally
known, they may have the  effect  of calling the atten-
tion* of other medical practitioners, and of some intelli-
gent  gardeners, to a  subject, which, in  my  opinion,
is of considerable  importance.
   Respecting the preparation  of the lactucarium, I
have lately  been  favoured, by my  ingenious friend
Mr John Young, surgeon  in  Edinburgh,  with  the
following letter:

              To Dr Duncan, senior.
                   Edinburgh, 5th October, 1816.
Dear Sir,
   Your zeal in promoting the interests of science, and
of that branch of knowledge in particular which belongs
to our profession,  induces  me  to  lay before you  the
annexed observations, on a new method of collecting
the milky juice of the lactuca sativa, and also  of  the
papaver somniferum, both in Britain and  other coun- 
APPENDIX.                 14"<
tries.   I am induced to take this step,because iftnow,
that if you think my method  of collection of any use,
it cannot be recommended to the public through a bet-
ter channel than you;  and because I know that you
have, for some time past, been engaged in a series of
trials, for ascertaining more fully the medicinal effects
of lactucarium.   In the mean time, I shall be glad to
know your  opinion with regard to  the observations  I
now send you:   And I shall  be glad to have the ho-
nourof communicating to you whatever "else may oc-
cur to me on this subject.
      I am, dear Sir,
           With much esteem, yours,
                                  John Young. 
148
APPENDIX.
   Observations onthemethod of obtaining Lactucarium, 01
     Lettuce opium, from the Lactuca Sativa of Linnteus,
     the  common Garden Lettuce.   By Mr John Young.
     Surgeon in Edinburgh.

                         Edinburgh, October, 1816.
     In collecting lactucarium  last  year, according to the
   methodrecommendedby Dr Duncan, senior, in the Me-
 % moirs of the Caledonian Horticultural  Society, I found,
   that it not only occupied much time, but that I was of-
   ten disappointed of the substance which I expected to
   obtain, from its being washed off by rain.  It occurred
   to me, that the milky juice of the lettuce might be  im-
   mediately collected from the plant in great abundance,
   by absorbing it on cotton soon after it  exudes from the
   plant, and while it yet continues in a liquid  state; and
   by afterwards inspissating it by a moderate heat, com-
   municated from a water or vapour bath.

     I accordingly adopted that method this year.   I had
_  the ice-lettuce planted in rows;  and when  the top of
   the stem was about a foot above the ground, I then cut
   off about an  inch from the top of each plant.   The
   milky juice immediately began to rise above the wound-
   ed surface.   I cut off the tops of all the plants before
   I began to collect.  But  after the portion which had 
APPENDIX.                 149
exuded was removed  by the  cotton, I found that the
milky juice ceased to exude,  until I had made another
wound.   I began to collect,  at the end of the border,
where I made the first incision, and then cut off a thin
cross slice from the stem  of  each plant, leaving fresh
wounds as I went along.   These I found covered with
milky juice each time when I returned to where I set
out.  But after going  round the plants about five or six
times, in the way mentioned,  they ceased  to give out
any more milky juice at that  time.   But this process
may be repeated two or three times in a day.

   In the manner above described, I have collected more
of the milky juice in  one  day, than I did last year in
five days, when it was not removed till it had acquired
a dry state and black  colour.   Having mentioned to a
friend my mode of collecting the milky juice in its re-
cent state, by means of cotton, he suggested the use of
a wet sponge for that purpose.  This, I  find,  answers
better than the cotton;  the juice being both more com-
pletely  removed from  the  plant,  and more easily ex-
pressed, than from the cotton.  The milky juice  col-
lected in this way into a tea-cup, or  any similar vessel,
soon acquires a dark brown colour, like opium obtain-
ed from the papaver somniferum, and has all its other
sensible qualities. Hence it may justly be distinguish-
ed  by the title of lettuce-opium, although, perhaps,
                       n2 
150                APPENDIX.
less confusion would arise, from employing the name
which Dr Duncan has adopted, that of lactucarium.

  From  what I have observed respecting this method
of collecting the milky juice from  the lactuca  sativa,
it is my opinion, that in the same manner, opium might
be procured in this country from the papaver somnife-
rum, equal, if not superior, to any foreign opium,  Dr
James Howison, who was for some time employed by
the Honourable  East India Company to superintend
the preparation of opium in Bengal,  has published an
essay on  that subject in the first volume of the Memoirs
of the  Caledonian  Horticultural Society, page 368,*
which  contains many important observations respecting
the preparation of opium in Britain.  But the  method
of collecting the milky juice from the plant by means
of cotton or a sponge, possesses many advantages which
cannot be obtained by the  flask which he proposes, or
by  the knife and cup  of the Hindoos:  For by their
method of collection, a considerable quantity of the
milky juice, exuding from the head of the poppy, must
be lost.  But by  preparing  opium in Britain, a  still
greater advantage would accrue.  It would be  obtain-
ed in a perfectly pure state, which  is by no means the
case with  the opium  which is brought  to us from
abroad.
  * A Prize Medal was awarded to Dr Howison by the Caledo-
ledonian Horticultural Society for this communication. 
APPENDIX.
151
  By Mr Young's process, I have no doubt that lactu-
carium may be obtained, with much more ease, and to
a greater extent, than by the method which was com-
municated to the public in the  former edition of these
observations. But in whatever way the lactucarium or
lettuce-opium may be prepared, I am convinced, both
from my own  experience, and  from the  observations
of several  of my friends, that from the common lettuce
cultivated in our own gardens, we may obtain an use-
ful sedative medicine for allaying pain, and procuring
sleep  in  those  constitutions with  which  opium, the
most useful of all medicines yet discovered, cannot be
employed without producing very disagreeable conse-
 quences.   In proof of this, I shall only subjoin the fol-
 lowing letter from my  intelligent friend  Dr James
 Anderson, an eminent accoucheur in  Edinburgh, who
 has very extensive practice in the diseases of women
 and children, and who has often employed lactucarium,
 particularly in puerperal cases. 
152
APPENDIX
               To Dr Duncan,  senior.
                         Edinburgh, 28th October, 1816.
My Dear Sir,
   In  consequence  of  a conversation with you  some
some years ago, I was led to pay particular attention
to the effects of lactucarium in certain cases.

   I have seldom been disappointed when it was exhibit-
ed in a proper dose, to promote rest, and allay irrita-
bility.  I have observed that, when  the  dose had not
been sufficient to procure sleep, my patients  still obtain-
ed from it comparatively easy nights, being freed from
hot skin, inclination to toss al)out, and similar uneasi-
ness.

   For these four years I have used it with  success for
such patients as  disagree with  opium.   In no  case
have I observed consequent nausea, costiveness, or irri-
tation of the  skin, produced by it.

   It is gratifying to observe with how much thankful-
ness it is taken by such valetudinarians as are excluded
from  the use of opium from its distressing effects  upon
them.   Two ladies of my acquaintance, the one sub-
ject to spasms in  the stomach, and the other to frequent
attacks of irregular gout,  have for these three years 
APPENDIX.
153
reared lettuce plants, and made a tincture for  them-
selves, which they have employed in their own  cases,
with great relief: And from what I have seen, I have no
doubt, that when lactucarium becomes more an object
of attention with medical practitioners, it will be gene-
rally used where opium cannot be administered.

       I am, my dear Sir,
              Yours, with respect and esteem,

                                James Anderson.
• 
154                APPENDIX.
Formul.k for different preparations of Lactucarium, a
  substance obtained from the inspissated white juice of
  the common garden lettuce, acording to the method
  described in the Memoirs of the Caledonian Horti-
  cultural Society, Vol. I. p. 160.

     1: Tinctura lactucarii.
  Recipe Lactucarii, unciam unam;"
          Alcaholis diluti, libram unam.
   Digere per dies septem, et per chartam cola.

     2. Pilule lactucarii.
   Recipe Lactucarii, gr. xij.
          Pulvern rjflicis  glycyrrhizai, scrupulos
               duos.
 Subige cum syrupo simplice, ut fiatmassa, ad  pilulas
 formandas apta; et divide in pilulas  duodecim.

  3.  Trochisci  GLYCYRRHIZjE  cum lactucario.
     Recipe Lactucarii, drachmas duas;
           Tincturae toluiferae  balsami,  unciam di-
              midiam;
           Syrupi simplicis, uncias octo;
           Extracti glycyrrhizae glabrae, aqua calida
              moliti,
           Gummi  mimosae Niloticae in pulverem triti.
              ntriusque  uncias quinque. 
                   APPENDIX.                 155

Primo, tere lactucarium  bene cum  tinctura;  dein,
paulatim  admisce syrupum et extractum; postea sen-
sim insperge pulverem gummi mimosae Niloticae; et
tandem exsicca, ut fiat massa, in trochiscos formanda.
singulos grana decern pendentes.

      4.  Trochisci succi spissati lactuca.
    Recipe Succi spissati lactucae;
           Extracti glycyrrhizae glabrae;
           Pulv. gummi  acaciae Arabicae, singulorum
             partem unam.
   Haec optime terantur simul, et cum  aqua fiat massa,
 in trochiscos formanda.
THE EN I 
 

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