A treatise on pulmonary consumption, comprising an inquiry into the causes, nature, prevention, and treatment of tuberculous and scrofulous diseases

Front matter

YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

COLLECTION OF

Preface

The greater part of the following Treatise first appeared as an article in the Cyclopaedia of Practical Medicine, under the head of Tubercular Phthisis. In publishing it as a separate work various alterations and additions were required : these I have endeavoured to supply as fully as the short space of time which has elapsed since its first appearance permitted. That the work might have been rendered more perfect by deferring its publication I readily admit; but after mature consideration I venture to lay it before the public without further delay.

PREFACE.

If I am not greatly deceived, the view which I have taken of tuberculous diseases is calculated to lead to a more successful method, both of prevention and treatment, than has hitherto prevailed. With this impression on my mind I feel myself justified in submitting my views and opinions to the consideration of the profession, — well aware, that, if erroneous, the task of correcting them is not very likely to originate with their author, and that, if well founded, the efforts of an individual can avail little in procuring the general application of them.

Although I have entered more particularly into the history of tuberculous disease of the lungs, or pulmonary consumption, my observations will be found to be applicable to the whole class of tuberculous and scrofulous diseases. They all originate in the same constitutional disorder, acknowledge the same remote causes, and admit of the same rules of prevention ; and, I may add, that the same mode of treatment is essentially applicable to the whole.

preface;. xi

The total inefhcacy of all means hitherto adopted for diminishing the frequency or reducing the mortality of this class of diseases, is of itself sufficient incitement to us to seek for some other method of remedying the evil ; and it is evident to me that this can only be done, with any reasonable prospect of success, by directing the attention to such measures as are calculated to prevent the hereditary transmission of the particular morbid state in which the formal disease originates, and to correct the predisposition to it in infancy and youth. It is, accordingly, on this part of my subject, which involves the consideration of the Origin, Causes, and Prevention of the disease, that I have more especially dwelt.

I cannot but be aware of the great difficulties which present themselves to the accomplishment of my views regarding Prevention ; and that these can never become generally applicable until the public is fully impressed with the necessity of attending to them. This furnishes me with another urgent

Xll PREFACE.

motive for the publication of" the present work ; as it is only by the combined exertions of the profession that the public can be influenced in such a case. And here I hope I may be allowed to calculate the more surely on the support of my medical brethren, because, in setting forth my views and opinions, I make no pretension to originality or peculiarity of doctrine. Much that is contained in the following pages is already known to the more intelligent and experienced of the profession, and the only credit I can claim, is the having, perhaps, placed the subject in a more striking point of view, and advocated it with a degree of earnestness commensurate with its importance.

The subject, in the comprehensive view which I have taken of it, involves so many momentous considerations, and embraces so wide a range, that some points deserving notice may, no doubt, have escaped me, while others may be regarded as too lightly treated: still I trust it will be found that

PREFACE. X1U

I have omitted nothing of real importance. If zeal for the accomplishment of my main object has induced me to enter into and dwell more fully upon some parts than others, the conviction of their paramount importance must be my apology. My great aim has been to point out the nature and causes of the constitutional affection in which tuberculous diseases have their origin, and on those to found rules for prevention and treatment.

By diminishing the disposition to this most destructive of all human maladies, we shall not only reduce the sum of its daily victims, but we shall raise the standard of public health, and at the same time advance the moral excellence of man, augment his mental capabilities, and increase the sphere of his usefulness ; for it need not be stated, that without sound bodily health, the intellectual powers languish and decay. Our subject, therefore, is one which not only concerns personal feelings and social happiness, but

XIV PREFACE.

involves the well-being of society at large, and the intellectual as well as the physical character of nations. And when we further consider that the disposition to tuberculous diseases, and the deterioration of health which this implies, are evidently, to me at least, on the increase, assuredly no higher object than that to which the present work is devoted can engage the attention of the physician ; and if I succeed in awakening a more general interest in the profession towards it, and in pointing out a surer path for observation, I shall not have laboured in vain.

Respecting the alterations which have been made in my work since its original publication, I may state that the whole has been carefully revised, much the greater part re-written, and considerable additions made to almost every chapter ; more particularly to those on the Causes and Prevention. But I am fully sensible that much is still wanting to illustrate this the most important part of

PREFACE. XV the subject, and that the labours of many men and of many years will be required to complete a work which I consider as only just begun.

I may further state that I have avoided entering into theoretical discussions ; my object being to adhere, as closely as the nature of the subject would admit, to the simple results of observation, and what appeared to be legitimate deductions from them. There being also a probability that my work, from the importance and general interest of the subject, may pass into the hands of the public, I have endeavoured to divest my language as much as possible of technical terms.

London, June 30, 1835.

BY THE SAME AUTHOH, SECOND EDITION,

A TREATISE

ON THE

INFLUENCE OF CLIMATE

IN THE

PREVENTION AND CURE

CHRONIC DISEASES OF THE CHEST, DIGESTIVE ORGANS, ETC.

Contents

PAGE

Dedication ......... t

Preface .... ..... ix

Introduction 1

Chap. II

TUBERCULOUS DISEASE OF THE LUNGS, OR PULMONARY CONSUMPTION PROPERLY SO CALLED .... 22

Sect. I. The more common or general form of consumption . . .... 23

First stage 23

Second stage 29

Third stage . 33

r b

XV111 CONTENTS.

Sect. II. The more marked varieties of consumption . 36 Acute or rapid consumption

Febrile consumption ... .41

Latent consumption ... .53

Consumption in infancy and childhood . . 60

Chap. III. Particular Symptoms And Signs Of

CONSUMPTION 69

Sect. I. Symptoms ....... 69

Dyspnoea . . . 82

Expectoration . . . .84

Pain of chest 96

The pulse ... .97

Hectic fever . . 99

Perspiration . . ... 100

Thirst . . . 102

Diarrhoea .... .102

Emaciation ..... . 104

Aphthae l06

Sect. II. Physical signs 108

Respiratory movements . .110

Percussion

Auscultation

110 111

Value of the physical signs . 112

Chap. IV. Morbid Anatomy Of Tuberculous Disease. 118

Sect. I. The seat, consistence, form, and chemical composition OF TUBERCULOUS MATTER

CONTENTS. XIX

Sect. II. Morbid anatomy of pulmonary tubercle. 123

Granulations . . . . . . .124

Crude tubercle 126

Tuberculous infiltration 126

Softening of tubercle 129

State of the lung around tubercles . . .131

Chap. VI. Diseases Which Attend And Complicate

CONSUMPTION . . .144

Sect. I. Diseases of the organs of respiration . . 145

Ulceration of the epiglottis . . . . 145

Ulceration of the larynx ..... 146

Ulcerations of the trachea . . 147

Affections of the pleura . . 149

Perforation of the pleura . . . . 151

Sect. II. Diseases of the abdominal viscera . . . 155

Morbid conditions of the stomach . . . 156

Enlargement of the stomach . . 159

Ulceration of the intestines . . 159

Disease of the liver . . 161

Fistula in ano . . ... 163

Chap. VII. Duration Of Consumption . 165

XX CONTENTS.

Chap. VIII. Statistical History Of Consumption 170

Sect. I. Prevalence and site of tubercles at different

PERIODS OF LIFE 170

Sect. II. The influence of sex in determining the prevalence OF CONSUMPTION . . . 182

Sect. III. The influence of certain occupations in inducing CONSUMPTION .... . 185

Sect. IV. The influence of climate in the production of

consumption .... 203

Sect. V. Increase or decrease of consumption? . 210

Chap. X. Causes Of Tuberculous Disease 219

Sect. I. Hereditary origin of tuberculous cachexia . 220 Sect. II. The causes of tuberculous cachexia in individuals NOT HEREDITARILY PREDISPOSED . . 227

Improper diet 230

Deficient exercise .... . 233

Excessive labour ...... 234

Imperfect clothing .... . 234

Want of cleanliness ...... 235

Abuse of spirituous liquors .... 235

Mental causes 236

Contagion ... .238

CONTENTS. XXI

Sect. III. Causes determining tuberculous disease of the

lunos 239

Bronchitis 240

Pneumonia 243

Eruptive fevers 251

Scarlatina 252

Variola 253

Chap. XII. Prevention Of Consumption And Of Tuberculous Diseases In General

Sect. I. Prevention as regards parents .

Marriage — Health of parents .

Pregnancy ......

Sect. II. Prevention as regards children

Prevention of the disease in infancy

Suckling ....

Clothing

Bathing ....

Residence .....

Prevention of the disease in childhood

Exercise . . ...

Clothing .

Education Prevention of the disease in youth .

Chap. XIII. Treatment Of Tuberculous Cachexia 306

Introductory remarks 306

Strumous Dyspepsia 307

Alteratives 311

Taraxacum • 319

Sarsaparilla . 321

Alkalis . 321

Mineral waters 323

Sulphureous waters 324

Chalybeate waters 324

Evacuants ...... 325

Purgatives 325

Emetics . . 327

Tonics . . 328

Iron 328

Bark . 329

Bathing 329

Cold bath 329

Cold sponging 330

Tepid and warm bath . . . . . .331

Medicated baths 332

Travelling, sailing, climate .... 332

Chap. XIV. Treatment Of Pulmonary Consumption 335

Sect. I. General remedies . . . . 335

Bloodletting 336

Emetics 341

Digitalis . 358

CONTENTS. XXU1

Sect. II. Local remedies ... . 360

External remedies . . ... 360

. 361 362 363 364

. 364 366

. 366 367

Counter-irritants ...

Rubefacients ...

Blisters

Pustular eruptions .

Issues and setons Inhalation ....

Dry fumigations .

Tar vapour

Watery and medicated vapours . . . 369

Chlorine .... . 370

Sect. III. Treatment of particular symptoms . . 374 Cough . . .374

Pain of chest . ... 383

Nausea and vomiting .... 385

Hectic fever 335

Perspiration 3 gg

Diarrhoea . ... . 337

Sect. IV. Treatment op the advanced stage . . . 389

Sect. V. Treatment of varieties and complications of

consumption. ... . _ 39^

Acute consumption 391

Acute febrile consumption ... . 392

Bronchial consumption . . . 393

Complications ...... 394

Sect. VI. Regimen ... .... 394

Concluding remarks .... 398

A

TREATISE

ON

ETC. ETC.

Introduction

The term Phthisis, or Consumption, was originally applied in a very vague manner to a variety of chronic diseases, having scarcely any character in common except emaciation. As the knowledge of morbid anatomy became more precise, the most frequent cause of the phenomena usually grouped under the name of Consumption, was discovered to be disease of the lungs, and hence pulmonary consumption not only attracted far greater attention than any other form of the disease, but many of the other forms were found to resolve themselves into this, or to be mere complications of it ; the primary cause of the emaciation and other

B symptoms, being discovered, on examination after death, to be seated in the lungs. Pulmonary consumption was therefore adopted as the generic name of the disease, and was divided into various species according to the particular affection of the respiratory organs upon which the symptoms were supposed to depend.

At length, Laennec, finding, in the course of his extensive researches into diseases of the chest, that tubercles formed almost the sole cause of consumption, proposed to restrict the term Phthisis to the disease produced by tubercles in the lungs; and since the publication of his valuable work in 1819, which forms an important era in our knowledge of pulmonary pathology, the term has been so restricted in France. The accuracy of Laennec's opinions has been fully confirmed by his countrymen Louis and Andral, whose minute and laborious investigations have given a precision to our knowledge of the subject, which was unattained before their time. But, notwithstanding the great advantages which have resulted from these pathological researches, they have tended to keep up the idea that consumption is a local disease, referable to a local cause ; and thus the investigation of the constitutional origin of tubercles, — by far the most important part of the subject, — has been neglected. Before we can hope to acquire an accurate knowledge of consumption, we must carry our researches

GENERAL REMARKS. 3

beyond the pulmonary disease, which is only a secondary affection, the consequence of a preexisting constitutional disorder, — the necessary condition which determines the production of tubercles.

An imperfect acquaintance with this morbid state of the system has led to great discrepancy of opinion concerning the nature and causes of tubercles. There are many, even at the present day, who regard tuberculous disease of the lungs as the result of inflammation ; an opinion which I regard as not only erroneous, but productive of a very mischievous practice. Inflammation of the respiratory organs may, no doubt, give rise to tubercles, but not, I believe, in a healthy constitution.

Chronic inflammation of the different tissues of which the lungs are composed, is often accompanied with symptoms closely resembling those produced by tuberculous disease; and the distinction between them becomes, in some cases, very difficult, — more especially after the tuberculous disease has existed for some time and become complicated with inflammation. Hence inflammatory and tuberculous diseases have been, and still are often confounded, and even considered by many in the light of cause and effect. This error originates not so much in the nature of the subject, as in a want of correct observation ; and I am of opinion

b2 that when such inflammatory affections are carefully traced to their origin, they may, in a very large proportion of cases, be discriminated from pure tuberculous disease. That the distinction is not more frequently made, is owing more to our own imperfect and careless inquiries into the history of the cases which come before us, and to our negligence in examining minutely all the signs and symptoms which they present, than to any real obscurity in the nature and characters of the diseases themselves :— The truth is, that in the highly-tuberculous constitution, tuberculous disease of the lungs very often steals on in a slow, insidious manner, making considerable progress before it manifests itself by any remarkable local symptoms, or its existence is even suspected by those who regard consumption as originating in inflammatory affections of the lungs. In such examples of latent tuberculous disease, an attack of catarrh, a slight inflammation of the pleura, or of the lungs, or hemoptysis, is not unfrequently the first circumstance which excites the attention or awakens the fears of the patient and his friends ; and to this accidental occurrence, to which the presence of tubercles in the lungs renders the person peculiarly liable, the origin of all the future mischief is attributed. I can readily imagine that an ordinary observer should arrive at such a conclusion ; and, ascribinothe disease to that which first presented itself to

ORIGIN OF CONSUMPTION. O

his notice, should consider the ' neglected cold,' the ' inflammation of the lungs,' or the ' breaking of a bloodvessel,' the original cause and source of all the subsequent evil. But, after the light which has of late been thrown upon the nature and diagnosis of tuberculous disease, it may well excite surprise that medical men should still regard these affections as the chief causes of Phthisis. In a vast proportion of cases of this nature, a more minute inquiry into the patient's previous state of health, would have led to the conviction that those affections were consequent upon, or at least subsequent to, the existence of pulmonary tubercles, or that they had occurred in a tuberculous constitution, by which their effects were modified. In another part of this treatise I shall have occasion to state the grounds upon which this opinion rests, and at the same time shall endeavour to show that tuberculous disease of the lungs may be detected long before it generally is, — that what is usually considered the early is in reality an advanced stage of the disease, — and that tubercle is a secondary affection, originating in a peculiar morbid condition of the general system.

One of the principal objects of the present work is to shew that tuberculous disease, whether in the lungs or elsewhere, has its origin in a morbid state of the constitution, in some cases hereditary, in others induced from various causes, independent of any hereditary predisposition ; and to attach the proper value to those pulmonary diseases which are considered by some as the real causes of consumption, but by others, more correctly, as determining causes merely, and often only complications.

If I succeed in giving a satisfactory exposition of this, the most important, but hitherto the most neglected part of the subject, I may hope to lay the foundation of a sounder pathology of tuberculous diseases, and to establish a more rational and more effectual mode of prevention, and a more successful method of treatment than has hitherto prevailed. No physician, acquainted with the morbid anatomy of Tuberculous Consumption, can for a moment indulge the hope that we shall ever be able to cure what is usually termed ' confirmed consumption,' if we except the small proportion of cases in which the tuberculous deposit is confined to a very limited portion of the lung. We might as reasonably expect to restore vision when the organization of the eye is destroyed, or the functions of the brain when the substance of that organ is reduced by disease to a pultaceous mass, as to cure a patient whose lungs are extensively disorganized by tuberculous disease. The records of Medicine afford too strong proofs of the truth of this statement ; for it may be fairly questioned whether the proportion of cures of confirmed consumption is greater at the present day than in the time of Hippocrates ; and, although the public may continue to be the dupes

EXTENT OF THE SUBJECT. 7

of boasting charlatans, I am persuaded that no essential progress has been made, or can be made in the cure of consumption, until the disease is treated upon different principles from what it hitherto has been. If the labour and ingenuity which have been misapplied in fruitless attempts to cure an irremediable condition of the lungs, had been rightly directed to the investigation of the causes and nature of tuberculous disease, the subject of our inquiry would have been regarded in a very different light from that in which it is at the present period.

By a knowledge of the causes of the morbid condition of the system in which tuberculous disease has its origin, we may reasonably hope to prevent the occurrence of the latter in many cases, and in a small proportion to arrest its progress during the early stage ; and by carrying our researches still further back and investigating the circumstances in the health of the parents which predispose their offspring to tuberculous disease, we may also hope to diminish the hereditary disposition. This is, no doubt, opening a very wide field of inquiry ; but it is most certain that, unless we enter into the subject in its fullest extent, we shall do little that will prove effectual in diminishing the frequency, or reducing the mortality of this very prevalent and most destructive malady.

In the long catalogue of human infirmities, tuberculous diseases are undoubtedly the most deserving the study of the physician, whether we regard their frequency or mortality. Confined to no country, age, sex, or condition of life, they destroy a larger proportion of mankind in temperate climates than all other chronic diseases taken together. In this country, and over the whole temperate region of Europe and America, tuberculous disease of the lungs causes probably a fifth-part of the whole mortality ; and in some districts, and even in whole countries, the proportion is much larger. It has been calculated by the late Dr. Young, Dr. Woollcombe, and others, from the best data which the bills of mortality afford, that in Great Britain and Ireland, consumption causes one fourth-part of the deaths that occur from disease. If we add to consumption, tuberculous disease of the glandular and nervous systems, of the large joints, of the spinal column, &c. and deduct the mortality which occurs during the first months of life, 1 shall probably be within the truth in stating that a third-part of the mortality of this country arises from tuberculous diseases : if to this frightful destruction of mankind we add the numerous crippled and disfigured sufferers whom we daily meet with, and couple these results with the painful reflection that the predisposition to tuberculous diseases is transmitted from the parent to the offspring, it will surely be unnecessary to press upon medical prac-

IMPORTANCE OF THE SUBJECT. 9

titioners the claim which this class of diseases, above all others, has upon their earnest consideration.

The subject considered in this comprehensive manner possesses a degree of importance unquestionably beyond any other in the whole range of medical science : and I do not hesitate to express my conviction that in proportion as the medical practitioner is acquainted with the remote and exciting causes of tuberculous disease, so will he be enabled to treat successfully a large number of the diseases which come under his care : this remark applies more especially to the diseases of of childhood and youth, — for it is during this early period of life that tuberculous disease is so easily generated, and that so much may be done to destroy the hereditary tendency to it.

To those who have not maturely considered this subject in all its bearings, I may appear to attach too much importance to it ; but I feel confident, nevertheless, that my opinions will be borne out by future inquirers, and by those of my professional brethren who are best acquainted with human pathology.

A very important question in the history of tuberculous diseases naturally presents itself to our consideration in this place, viz. their increasing or decreasing frequency. Every member of the profession has too ample opportunities of satisfying himself of the extensive prevalence of strumous diseases; but some doubts may exist as to their being comparatively more prevalent at the present time than they were some fifty or a hundred years ago. The labouring classes of this country are certainly in the enjoyment of more comfort in regard to their food, clothing, and lodging, at the present period than they were half a century back ; but although this circumstance favours the probability of a diminution of tuberculous diseases, it may be doubted whether such abatement has not been counteracted by the more general indulgence in the use of ardent spirits which prevails at present among this class of the people.* But whether tuberculous diseases have diminished or not during the last half century among the labouring part of our population, I am of opinion that they have increased in the middle and upper ranks. This is a subject of great moment. If it were clearly shown that these diseases were gradually abating among all ranks of the people, we might perhaps leave them in the hope that their diminution would keep pace with the improvement of society. But if, on the contrary, we arrive at the conclusion that scrofulous diseases are on the increase, and that the health of the middle and upper ranks of society is progressively

This subject will be treated more fully in the chapter on the Statistics of Consumption.

INCREASE OR DECREASE. 11

declining, we shall have the strongest reasons for inquiring into the causes which lead to such deterioration of health.

That a general delicacy of constitution and a proneness to scrofulous diseases are on the increase, is a conclusion the accuracy of which I leave to be decided by the experience of the profession.* We have all an opportunity of observing and comparing the state of health of the rising generation with that of their fathers and grandfathers. On taking a survey of the constitution of these three generations, I think it will be found, in a large proportion of instances, that the deterioration of health is progressive from father to son. I am far from believing that this observation always holds good ; but I do believe that it generally does : at least, such is the conclusion to which I have been led from personal observation.

* The terms Scrofulous and Strumous, when strictly applied, have the same import as Tuberculous, and are used in this sense in the following pages.

Chapter I. Tuberculous Cachexia

As I shall have frequent occasion, in the course of the present work, to refer to that morbid condition of the system which precedes and attends tuberculous disease, I shall commence by giving a brief view of the characters by which it may generally be recognised. It is proper, however, to premise that, although distinct and sufficiently recognisable, these characters are so variously influenced by the age, complexion, temperament, and other circumstances of the individual, as to make it a matter of considerable difficulty to describe them. It must also be observed that the morbid condition upon which they depend is itself progressive, and therefore varies in intensity.

By the term Tuberculous Cachexia, I designate that particular morbid condition of the system which gives rise to the deposition of tuberculous matter, on the application of certain exciting causes, which have no such effect on a healthy system. This disorder of the constitution, noticed by various authors under different names,

(latent scrofula, scrofulous diathesis, &c.,) was, I believe, first described under the present appellation in my work on Climate.*

Tuberculous Cachexia may exist from birth, or may be acquired at almost any period of life, from infancy to old age. When of hereditary origin, it is manifested by a peculiar modification of the whole organization, — in structure and in form, in action and in function.

The countenance generally affords strong indications of the presence of this affection ; in early childhood it has a pale, pasty appearance, the cheeks are generally full, and the upper lip and nose tumid. If the complexion be dark, the colour of the skin is generally sallow; if fair, it has an unnatural white appearance, resembling blanched wax rather than healthy integument; and the veins are large and conspicuous. At a more advanced period of youth, the character of the constitution is still more clearly indicated by the countenance. The eyes, particularly the pupils, are generally large, the eye-lashes long ; and there is usually a placid expression, often great beauty of countenance, especially in persons of a fair, florid complexion. On the other hand, in those of a dark complexion, the features are generally less regular,

* " The Influence of Climate in the Prevention and Cure of Chronic Diseases of the Chest, &c."

and the skin is commonly coarse, and of a sallow, dingy hue ; although there are many exceptions to this, in the fine dark eye, regular features, and delicate skin of such persons. But it is far more easy to distinguish than to describe with accuracy the tuberculous physiognomy, as it varies in every intermediate shade, between the pale, faded, but changing colour of persons little under the influence of this morbid condition, and the peculiar permanent sallow cast of countenance which attends the confirmed cachectic state.

In early infancy there is little remarkable in the form of the body; it is generally large, but has not the firmness of health. As the child increases in age, we find that the different parts are not well proportioned, and there is a want of symmetry in the whole. The head is often large, the trunk small, the abdomen tumid, and the limbs are unshapely, being either large and clumsy, or disproportionately slender with large joints: but this is only the case in the more perfect examples of hereditary tuberculous cachexia. The growth of the body is also generally unsteady in its progress; very often it is slowly and imperfectly developed ; in other cases it is unusually rapid, particularly towards puberty.

The physical powers are generally below the usual standard. The limbs, though full, are soft, and have neither the form nor the firmness of health.

The circulation is generally feeble, as is indicated by a weak pulse and cold extremities. This state of the circulating system forms, I am disposed to believe, an element in the tuberculous constitution ; at least I have rarely found it wanting, and regard it as affording an explanation of many of the phenomena of the disease. A full development of the body and great muscular power are not, however, incompatible with a degree of tuberculous cachexia. Several of our celebrated pugilists have died tuberculous. Independently of their bearing on the present subject, such examples deserve attention, as showing the effect of training in increasing the strength even of the tuberculous system.

The functions of organic life are all more or less imperfectly performed, but those more immediately connected with nutrition, particularly the digestive function, are most evidently deranged. Digestion is rarely well performed ; the bowels are irregular, more frequently slow in their action than the reverse, and the evacuations have not the appearance which they are known to possess in health. The urinary secretion, also, deviates from the healthy characters, being commonly turbid, particularly when the bowels are costive. The cutaneous functions are very generally in an unhealthy state ; the skin is either soft and flaccid, or dry and harsh, and chronic eruptions of the dry, scaly character, are frequent. In general the insensible perspiration is defective, although copious partial perspirations are common, particularly on the feet, where they often have a fetid odour. But of all these disordered functions, that which claims our principal attention, because it is the primary one, and from it arise most of the others, is the disorder of the digestive organs. The dyspepsia of the tuberculous constitution has peculiar characters by which it may generally be known. These have been fully and accurately described by Dr. Todd, under the name of Strumous Dyspepsia ;* a condition of the digestive organs which is not only present in the hereditary strumous constitution, but is capable, I believe, of generating this constitution, and of leading ultimately to tuberculous cachexia. In Dr. Todd's opinion, " it presents a more characteristic feature of this habit of body than any physiognomical portrait which has yet been drawn of it. In this respect it is more to be depended on than either the fine skin, the clear, delicate complexion, the light hair, large blue eyes, and dull sclerotica of one variety ; or the foul, dull, swarthy-coloured skin, the sallow complexion and swollen countenance, the dark hair and tumid lip of the other. It betokens, indeed, little familiarity with scrofula to connect it with any