ciated with the deposition of tubercle, and as influenced by the deposition; and the evil has not been in regarding it in this double light, but in giving an undue prominence to the latter, when considering the relation of tubercle to phthisis. In truth, modern views have so engrossed the mind, that one condition in the progress of phthisis has (because it is always found at some period) been raised from the minor to the dignity of the major premiss; and instead of the statement that all cases of tubercle (in the lungs) are phthisis, it is averred that in all cases of phthisis there is tubercle.

We venture to affirm that this consideration is worthy of careful attention in any attempt to obtain a true view of the nature of this disease.

If tubercle be due to pre-existent causes, whatever may be their nature, the disease is not in the tubercle, but in the cause of the tubercle; and the tubercle itself is but a result—an evidence, and all the changes in the tubercle are secondary influences. It cannot be affirmed that the tubercular element of the disease possesses an innate power of destruction such as is found in the elements of cancer, for whatever may be the origin of tubercle in the lung, it is found upon free surfaces, and does not spread by extension; whilst cancer infiltrates the tissues and has the power of extension, and consequently of displacement or destruction. Tubercle itself is a foreign but a passive agent; and all actions, of whatever kind, which proceed about it, originate and are carried on, not by the tubercle, but by the containing tissues. It is placed in the lungs, and accumulates by new deposits; and the subsequent changes are not

due to any disintegrating action in the tubercular element, but in the tissues which contain it.

Hence surely the tubercle is not the essence of the disease, but only one of the results-a result doubtless met with at some, but not at every period in the progress of each case. So long as inquirers fix their attention upon this or any other single product of the disease, they will fail to recognise its true nature; and so long as the aim of the practical man is to find a plan whereby the tubercle may be absorbed or ejected, he also will fail. We therefore think that whilst our age has made the great advance of distinguishing more carefully those cases of wasting which are associated with a particular disease of the lungs from those due to other causes, and has therefore given to us a large group of cases of a similar character, it has greatly erred in fixing its attention upon one of the conditions of the lungs, and regarding it, not as one of many results of diseased action, but as the essence of the disease, and the prime cause of mischief. It has cast aside that minute attention to the general system which was the especial subject of observation of the fathers of medicine, and has been content to concentrate all its powers of observation upon one internal condition which has this in common with the external symptoms, viz., that both are effects of the disease, and not the disease itself. We have limited our cases to one class only, and have spent our time in determining the characteristics of that class, but have made little progress in that higher department of knowledge-the determination of the true nature of the disease.

CHAPTER II.

HISTORICAL SKETCH AS TO THE NATURE AND TREATMENT OF PHTHISIS.

We do not purpose in the following sketch of the opinions which have been hitherto held respecting phthisis, to enter into large detail, but we desire rather to trace the changes of opinion or the additions to the knowledge of the disease which have occurred in large æras of medical history, with a view to show the real amount of progress which has been made since the days of the earliest records of our art. This may be in part effected by the aid of the labours of Dr. Young, to whom the profession is indebted for abstracts of the works of nearly all preceding writers on consumption— accurate, no doubt, and arranged in chronological order, but having the great defect of an absence of scientific arrangement in the direction of the present inquiry, and being consequently of comparatively little value except to the most painstaking medical reader. We think that it will suffice for our purpose if we state in a few words the opinions which were held by the ancient physicians to the time of Galen, those found in the works of the Arabian physicians and the physicians of the middle ages, and lastly, give a short

analysis of the views held by the moderns since the sixteenth century; and since the advance of knowledge during those periods has not been very great, we shall avoid wearying the reader by multiplying quotations.

The leading characteristics of these æras in the knowledge of the disease may be thus epitomised. The ancients confounded phthisis with other diseases, both of the lungs and other organs, attended by wasting, but were yet well acquainted with the disease as we see it at this day. The Arabian physicians and those of the middle ages adhered to the opinion of Hippocrates and Galen, and advanced no new views of the nature of the disease; whilst among the moderns there has been, with advance of time, a gradual limitation of the disease to a tubercular state of the lungs, attempts to describe tubercle, speculations as to its immediate origin, an examination of its relation to scrofula, a consideration as to whether phthisis be essentially a disease of the general system or of the lungs, and a desire to generalise the conditions which mark the consumptive patient. Besides these there have been in all ages disputations as to the relation of hæmoptysis to phthisis, the contagious character of phthisis, and the efficiency of various remedial agents.

THE ANCIENTS.

Hippocrates (fourth and fifth centuries B.C.) describes several forms of consumption under the heads of phthisis, phthoe, and empyema, and mentions tubercle of the lungs, but he does not regard the tuberculous state of those organs as the essential condition of the

disease. His description of a true phthisical case, as the disease is now regarded, is, however, very clear and decided. He includes also such diseases of the lungs as pleurisy and empyema. In a second form he also includes bronchitis, remitting during the summer; and in a third, scrofulous diseases of the spine. In reference to the cause of the disease he considers that the first form, which includes true phthisis, arises from hæmoptysis, and begins with a kind of catarrh, in which acrid matters descend from the head and cause ulceration of the lungs. He affirms that the expectoration in phthisis arises from ulcerations of the lungs, and he describes a test for pus which has held its ground until modern days; but expectorated matters in general were considered to descend from the head. The treatment of the disease may, in its broad outlines, be regarded as that adopted at the present day, viz., the free use of milk, whether asses', mares', goats', or cows' milk, when there was not much fever or headache, a moderate quantity of meat, fat fish, and other fats, with walking exercise for many miles daily, and the avoidance of changes of temperature.

The small portion of the works of Aretaus (second century) which has been preserved is quite inadequate to inform us as to the views of that great master of the art, but the following description of the general evidences of phthisis are as truthful and life-like as any which have been placed upon record :

"There is present, weight in the chest (for the lungs are insensible to pain), anxiety, discomfort, loss of appetite; in the evening coldness, and heat towards