provement or deterioration in the symptoms corresponded respectively with the regular use of the oil, or its discontinuance.

The cases selected to exemplify the present volume have been taken chiefly from the records of my experience during twenty-two years. They are a very small sample compared with the whole number under my care during that period; but they are selected, not as being more favourable, but simply because they remained under observation for a year and upwards, and therefore gave the opportunity of more correctly judging of the results of treatment than those seen for a shorter time; and although this very ground of selection implies that the cases eventually became chronic, yet many were acute in the first instance, and their surviving into the chronic state may fairly be ascribed to the treatment. When I state that the average duration of life in Phthisis has during my experience of forty years been at least quadrupled, or raised from two to eight years, I say what is below the actual results, as calculated by my son; for of the 1,000 cases, 802 were still living at the last report, and many of these are likely to live for years to come.

Before entering into the details of the treatment of Consumption in all its varieties, I will give a brief general view of my usual plan of treatment. As we have been led to conclude that consumption is essentially a disease of degeneration and decay, so it may be inferred that the treatment for the most part should be of a sustaining and invigorating character. Not only the most nutritious food, aided by a judicious use of stimulants and of medicinal tonics, but pure dry air, with such varied and moderate exercise in it as the strength will bear, and the enlivening influence of bright sunshine and agreeable scenery, and cheerful society and occupation, are among the means best suited to restore the defective functions and structures of frames prone to decay.

ANTIPHLOGISTIC TREATMENT.

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This is the most comprehensive view that can be taken of the means found to be most effective in the prevention and cure of consumptive diseases; but when we come to examine the details of cases, we find that the treatment is by no means so simple a problem, and that varied and even opposite remedies are required to control the different morbid actions concerned in developing or in aggravating the malady. Inflammation is by no means an essential part of pulmonary consumption, and yet, as we have seen, many cases originate in inflammation, and in many more this process is mainly instrumental in aggravating and spreading the destructive ravages of the disease; therefore remedies that may be called antiphlogistic frequently have to be used in its treatment.

I apprehend that most practitioners in this country are agreed in considering that consumption should be generally treated on a tonic and sustaining plan; and that the nourishment and strength of the system should be supported by varied tonics and cod-liver oil, as well as by the most nutritive articles of diet. But when the disease is ushered in with symptoms of acute bronchitis or pneumonia, with its attendant fever and scanty disordered secretions, it is obvious that such treatment is wholly unsuited for the occasion; and that remedies of the mild antiphlogistic kind, such as salines with or without antimony, blisters, and cataplasms, and sometimes even moderate leeching or cupping, will give most relief, and will prepare the patient for the safe administration of the sustaining class of remedies. In former years in this country (as still in many places abroad), the antiphlogistic and starving plan was carried on too long and too far: I fear that some of my early hospital cases are open to this imputation: but it appears to me that there is now a tendency too much to the opposite extreme, so that consumption is treated too exclusively with tonics, stimulants, and full diet. I quite admit that this is the better extreme of the two;

and it may fairly be stated that the sooner, and the more constantly, patients can be treated on this plan, the better. But in case of active inflammation, continued heat of skin, hard racking cough (dry, or with viscid and tinged expectoration), much pain or soreness of the chest or side, it answers well to withhold or withdraw the stronger stimulants and tonics, and for a time-it may be a few days. only to substitute cooling and soothing remedies, with moist epithems or counter-irritants on the chest, and, more rarely, local depletion. But this discipline, which is exceptional, should as soon as possible be replaced by what may be called the antiphthisical treatment, by codliver oil and tonics, and a more generous diet. The transition need not be abrupt. So far as regards codliver oil, and the mild acid tonics, with which I generally combine it, the change may be made long before the inflammatory complication has subsided. A dose of these may be given after the morning, and perhaps after the midday meal, whilst still the saline is taken in the evening and night, and whilst blisters or other counter-irritants are in full operation.

So soon as the diurnal heat of skin subsides and the cough becomes less urgent, and the urine more free, the salines may be replaced by a mere cough linctus, if that be needed; the counter-irritation moderated, and the tonic, given with the oil, gradually strengthened by the addition of small doses of salicine, quinine, or iron. These two last tonics are of great use where they are well borne, as their influence in strengthening the muscular system and in improving the condition of the blood is greater than that of any other drug; but their use requires discretion and watchfulness, for they often increase the lingering or intercurrent inflammations, with their attendant pain, constriction, cough, and viscid expectoration, and not unfrequently they derange the functions of the

COD-LIVER OIL-MODE OF ACTION.

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stomach and bowels. It therefore often happens, where the patient cannot be seen frequently, that it is safer to be content with a milder tonic-such as calumbo, cascarilla, or chiretta, which may be continued for weeks and months together in conjunction with the oil, than to give those that are more powerful, but which by occasional disturbances may prevent the continuance of the remedy.

But the great remedy, more essential and more effectual than any other, is the cod-liver oil; and we may well bestow a little consideration on the mode of using it to the best advantage.

It is now pretty generally admitted by the profession that the pure, pale oil, simply extracted from the fresh, healthy livers of the fish, is that most suitable for the majority of patients, as being less unpalatable and at least as efficacious as the impure kinds. Since I first recommended this pure oil (London Journal of Medicine, January, 1849) it has been so extensively prepared and used that it is now one of the most important articles in the materia medica; and the universality of its introduction is a strong proof of its claim to public favour.

On the mode of operation of the oil, and on the best methods of administering it, I have little to add to what I published fifteen years ago (Principles of Medicine,' 3rd edit., p. 487). The subject will again be under consideration in the details of Treatment; but I may here give a brief summary of my opinions and experience on the subject.

Cod-liver oil, when taken into the system in sufficient quantities, and for a sufficient length of time, acts as a nutrient, not only adding to the fat of the body, but also promoting the healthy growth of the protoplasm and of the tissue-cells, and in some way, as an alterative, counteracting the morbid tendency to the proliferation of the

Y

decaying cells of pas, tubercle, and kindred cacoplastic and aplastic matters.

That its efficacy depends much on its being absorbed freely into the blood, and through the circulation pervading all parts of the body, and thus reaching to the very seat of morbid deposits and formations.

That the more fluid part of cod-liver oil surpasses all other oils and fats in the facility with which it forms emulsions, which are tolerated by the stomach and readily absorbed into the blood, without causing the nausea and bilious derangement that commonly result from an excess of fat food. This peculiarity may depend on the biliary and other matters contained in the oil, and which in other instances of disease are found to act beneficially on the liver and other secreting organs.

That the best time for the administration of the oil is immediately after, or, to those who prefer it, at or before, a solid meal, with the constituents of which the oil becomes so intimately blended that it forms a part of the chymous mass, and is less likely to rise by eructation than when the oil is taken into an empty stomach. From this chymous mass, the oil, being absorbed through the lacteals with the chyle, is less apt to disorder the liver, than if absorbed through the veins of an empty stomach.

That as the use of the oil should be continued for a long time-perhaps for months, or even years—it is of great importance to conciliate both the palate and the stomach by giving it in a vehicle which may agreeably disguise its flavour and strengthen the stomach to bear it. For this purpose an aromatic bitter, such as the compound infusion of orange-peel, acidulated with a mineral acid, both to help to cover the taste of the oil, and also to suit the stomach, which should be duly supplied with acid during digestion, generally answers well. Syrup may be added according to the taste of the patient;