895. The phthisis begins, and sometimes proceeds to its fatal issue, in the manner described from 889, to 895, without any appearance of hæmoptysis. Such cases are indeed rare; but it is very common for the disease to advance far, and even to an evident purulency and hectic state, without any appearance of blood in the spitting so that it may be affirmed, the disease is frequently not founded in hæmoptysis. At the same time, we must allow, not only that it sometimes begins with an hæmoptysis, as is said in 864; but further, that it seldom happens, that in the progress of the disease more or less of an hæmoptysis does not appear. Some degree of blood-spitting does indeed appear sometimes in the state mentioned (889, 893), but more commonly in the more advanced stages of the disease only, and particularly upon the first appearance of purulency. However this may be, it is seldom, in the phthisis from tubercles, that the hæmoptysis is considerable, or requires any remedies different from those which are otherwise necessary for the state of the tubercles.

896. I have now described a succession of symptoms which, in different cases, occupy more or less time. In this climate they very often take up some years, the symptoms appearing especially in the winter and spring, commonly becoming easier, and sometimes almost disappearing, during the summer: but returning again in winter, they at length,

after two or three years, prove fatal, towards the end of spring or beginning of summer.

897. In this disease, the prognosis is for the most part unfavourable. Of those affected with it, the greater number die; but there are also many of them who recover entirely, after having been in very unpromising circumstances. What are, however, the circumstances more certainly determining to a happy or to a fatal event, I have not yet been able to ascertain.

898. The following aphorisms are the result of my observations.

A phthisis pulmonalis from hæmoptysis, is more frequently recovered than one from tubercles.

An hæmoptysis not only is not always followed by a phthisis, as we have said above (864); but, even when followed by an ulceration, the ulceration is sometimes attended with little of hectic, and frequently admits of being soon healed. Even when the hæmoptysis and ulceration have happened to be repeated, there are instances of persons recovering entirely after several such repetitions.

A phthisis from a suppuration in consequence of pneumonic inflammation, is that which most rarely occurs in this climate; and a phthisis does not always follow such suppuration, when the abscess formed soon breaks and discharges a laudable

pus: but, if the abscess continue long shut up, and till after a considerable degree of hectic has been formed, a phthisis is then produced, equally dangerous as that from other causes.

A phthisis from tubercles has, I think, been recovered: but it is of all others the most dangerous; and, when arising from a hereditary taint, is almost certainly fatal.

The danger of a phthisis, from whatever cause it may have arisen, is most certainly to be judged of by the degree to which the hectic and its consequences have arrived. From a certain degree of emaciation, debility, profuse sweating, and diarrhoea,

no person recovers.

"

A mania coming on, has been found to remove -all the symptoms, and sometimes has entirely cured the disease; but, in other cases, upon the going off of the mania, the phthisis has recurred, and proved fatal.

The pregnancy of women has often retarded the progress of a phthisis; but commonly it is only till after delivery, when the symptoms of phthisis return with violence, and soon prove fatal.

SECT. II.

Of the Cure of Phthisis.

899. From what has been just now said, it will readily appear, that the cure of the phthisis pulmonalis must be exceedingly difficult; and that even the utmost care and attention in the employment of remedies, have seldom succeeded. It may be doubtful whether this failure is to be imputed to the imperfection of our art, or to the absolutely incurable nature of the disease. I am extremely averse in any case to admit of the latter supposition, and can always readily allow of the former; but, in the meantime, must mention here, what has been attempted towards either curing or moderating the violence of this disease.

900. It must be obvious, that according to the different circumstances of this disease, the method of cure must be different. Our first attention should be employed in watching the approach of the disease, and preventing its proceeding to an incurable state.

In all persons of a phthisical habit, and especially in those born of phthisical parents, the slightest symptoms of the approach of phthisis, at the phthisical period of life, ought to be attended to.

901. When an hæmoptysis occurs, though it be not always followed with ulceration and phthisis, these however are always to be apprehended; and every precaution is to be taken against them. This is especially to be done, by employing every means of moderating the hæmorrhagy, and of preventing its return, directed in 892, et seq. and these precautions ought to be continued for several years after the occurrence of the hæmoptysis.

902. The phthisis which follows a suppuration from pneumonic inflammation, can only be prevented with certainty, by obtaining a resolution of such inflammation. What may be attempted towards the cure of an abscess and ulcer which have taken place, I shall speak of hereafter.

903. I have said, it is doubtful if a genuine catarrh ever produces a phthisis; but have allowed that it possibly may: and both upon this account, and upon account of the ambiguity which may arise, whether the appearing catarrh be a primary disease, or the effect of a tubercle, I consider it as of consequence to cure a catarrh as soon as possible after its first appearance. More especiallý when it shall linger, and continue for some time, or shall, after some intermission, frequently return, the cure of it should be diligently attempted. The measures requisite for this purpose shall be mentioned afterwards, when we come to treat of catarrh