them of a thin, smooth, adventitious coating, which has taken on all the ordinary functions of a serous membrane. Under these circumstances the lungs are often more or less pinched up and have their edges rounded by the contraction which uniformly attends the organization of all such albuminous deposits. In a few instances, the pleuræ have been found studded with tubercles.

The treatment in chronic pleurisy must of course be very gentle, and consist chiefly of very moderate local depletion, blistering, or other forms of counter-irritation, mild mercurials, in combination with anodynes and diaphoretics; and afterwards, diuretics, tonics, and nourishing diet. Should the effusion be so abundant as greatly to oppress the breathing, paracentesis thoracis may be had recourse to with safety and occasionally with success; the lungs readily recovering their power of expansion in consequence of the small extent or total absence of adhesions in such cases.

PHTHISIS PULMONALIS.

Phthisis is a Greek word, signifying corruption or consumption, and as applied to the present disease, it must be considered as indicating one mode in which a certain morbid state of the constitution manifests itself. That state may be called the tuberculous condition or diathesis, and approaches very near to, if it be not identical with, the scrofulous diathesis.

The symptoms of phthisis pulmonalis are liable to great variation; but the most characteristic are, cough, with some peculiar modifications of the expectoration, accompanied by general emaciation, gradually increasing dyspnoea and debility, with hectic fever. To these must be

added certain indications afforded by percussion and auscultation, dullness on percussion over the affected part of the lungs, respiration imperfect or inaudible in some parts, puerile or crepitant in others, and as the disease advances attended with mucous and gurgling rattles, and bronchial or cavernous respiration, bronchophony, and pectriloquy. The history and progress of phthisis vary with regard to all the symptoms. It is in some cases an acute, in others a chronic disease. It may run its whole course in a month or six weeks, or it may continue for many years.

The tuberculous constitution.-Before entering particularly and technically into the history of phthisis, a few words may be said respecting that condition of the system upon which it appears greatly to depend, and without which, acting as a predisposing cause, it is even doubtful whether the disease ever arises. This condition has been denominated the tuberculous diathesis,-a name derived from the tendency which is evinced under its influence to the deposit of a peculiar matter in various organs and tissues of the body, forming irregular masses of greater or less extent, of a more or less opake, yellow, or white matter, at first hard, but gradually softening down into a state approaching suppuration and yielding an unhealthy curd-like pus. The peculiar condition of the body, of which this tendency to tubercular deposit is one marked feature, is most widely diffused; and as it is most decidedly a state which is propagated from generation to generation, passing from parents to children, it is not difficult to understand how the intermarriages of families may spread the morbid tendency more and more generally abroad; but besides this there is little reason to doubt that it is capable of being generated de novo, or, what is nearly equivalent, that the slightest sparks of the disease,

hidden and unperceived for generations, may be fanned into a flame by the exposures and the excesses of the rich and the luxurious, or may be nurtured into a smouldering but no less consuming fire by the privations and irregularities to which poverty is subject. The signs of this tuberculous constitution are often discoverable at the earliest periods of life, frequently develop themselves strongly within the first years in the form of actual disease, and still more often are indelibly fixed in the whole constitution, form, and appearance, whether circumstances combine to call forth the more diseased manifestations of its existence, or the individual remain through life in the enjoyment of uninterrupted health.

There are two conditions of outward appearance which belong peculiarly to the tuberculous constitution, and so different are they, that nothing but the fact of their frequent association with tubercular disease would lead us to consider them as marks of a similar condition of the body. In the one we find what may truly be called the sanguineous temperament, the fair complexion, light hair and eyelashes, blue eyes, slender form, long fingers and contracted nails, fine white and regular teeth; or in the male, the ruddy complexion, with the hair and whiskers inclining to red, and with these associated a peculiar liveliness, activity, and susceptibility of mind. In the other we have the dark and swarthy complexion, or perhaps the opake white skin, with black eyes, long dark eyelashes, dark hair, the thick upper lip, and often a more sturdy form, short fingers, and nails wide and large, with the slower intellect and less energetic disposition. In the individuals of both these classes we find that disease is apt to run on and to become marked by peculiar symptoms of irritability, which after a time we discover to

depend on slower or more rapid changes in the glandular system, and in the membranes both mucous and serous. We find the digestive organs easily deranged, the process of assimilation performed imperfectly, even when actual disease has not yet developed itself; and in nothing does the general susceptibility to impressions show itself more remarkably than in the readiness with which the bronchial tubes and the air-passages become affected with inflammation, producing repeated colds and protracted coughs.

It is then in persons of these temperaments and of this condition that phthisis pulmonalis generally manifests itself, and it is of the utmost importance to bear this in mind, as it will lead us to view the disease in its constitutional rather than its local bearings, inducing us, as far as possible, to anticipate and prevent the disease, or meet it in its first approaches rather than await its complete establishment, when unfortunately our best means will generally prove but palliative, serving only to prolong life a little, and render the progressive stages of a fatal disease less irksome and less oppressive.

History. As may well be expected from the different circumstances under which this disease appears, the history of its progress is subject to very great varieties; but the symptoms of its approach are frequently so insidious, as to escape for a time the most anxious observation. A slight cough, almost without expectoration, is the first specific symptom which is added to the general indications of a somewhat delicate constitution. At first this is scarcely sufficient to excite remark; by degrees, however, it increases and becomes troublesome, especially when the patient wakes in the morning, while the expectoration is more decided, but so purely mucous in its character as to allay suspicion for a time. The cough continues, the

glairy mucus is changed for a more opake secretion, one or two scarcely perceptible streaks of blood are occasionally seen in the sputa, but easily ascribed to the bleeding of the nose, the gums, or the throat. The pulse, which is tranquil before rising in the morning, is accelerated as the day advances. Now the breathing is discovered to be shorter than usual, a quick walk or the exertion of ascending the stairs becomes irksome; the body perceptibly emaciates; the pulse ranges permanently from 90 to 100 and 120; the respirations approach to 30 in the minute, and pains more or less transient are experienced in various parts of the chest; the appetite becomes capricious; if the patient be a female, the catamenia are gradually diminished and cease altogether; morning and evening exacerbations of hectic fever, with shivering, dry heat, and perspiration, supervene; the expectoration becomes profuse, consisting of clots of mingled mucus and pus; at intervals of some days or weeks a little blood may show itself, and occasionally amounts to more decided hæmoptysis; the voice becomes weak, or hoarseness of a more fixed or a more transient character occurs. The fits of coughing are sometimes severe, and if they come on after a meal are frequently followed by the rejection of the food. The nights are disturbed, sometimes by cough, sometimes by burning heats, and towards the morning by profuse perspirations. The bowels are irregular, sometimes confined, at others greatly purged; the tongue being generally loaded at its root, or bespeaking by the redness of the tip and edges the irritable condition of the intestinal canal. Thus gradually proceeding, and so slowly advancing that it is only by comparing the condition of the patient with his state a week or a month before, we can discover the decided progress which the disease has made,