&* V^ftiufiV'Y/,- NLM DQ1E2M73 D "Tvjl.\g« VCLuAnsAs li ARMY MEDICAL LIBRARY ! WASHINGTON | i Founded 1836 : 1 1 1 1 mmwEMB l| Nuixiber 0 ■ -^ C- < u. __ Form 113c, W. D., S. G. O. .1-0 3—10543 (Revised June 13, 1936) NLM001224730 DUE TWO WEEKS FROM LAST DATE «.W QPO 16—71341-1 i i &J&A tic- c ■C> -/? v^; PULMONARY CONSUMPTION: NATURE, VARIETIES, AND TREATMENT. WITH AN ANALYSIS OF ONE THOUSAND CASES TO EXEMPLIFY ITS DURATION. C. f: B. WILLIAMS, M.D., F.E.S, FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; SENIOR CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION, BROMPTON ; FORMERLY PROFESSOR OF MEDICINE AND PHYSICIAN TO THE HOSPITAL, UNIVERSITY COLLEGE, LONDON, AND CHARLES THEODORE WILLIAMS, M.A., M.I). Oxox., FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS J PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION, BROMPTON. PHILADELPHIA: H E N K Y C. L E A. 187 2. VvJFA SHERMAN & CO., PRINTERS, PHILADELPHIA. PREFACE. As some years have elapsed since this book was announ- ced for publication, some apology might be expected for the delay in its appearance. But although I could plead1'per- sonal excuses for this delay, I hope that our readers will find the most satisfactory apology in the clearer light which we have been enabled to throw on our subjects, derived from some of the most recent discoveries in histology. I have long been led to the general inference, that Consumptive Diseases arise from a defect in the living plasma, or forma- tive material, from which textures are produced and nour- ished; but it is only within the last few years that the nature and properties of this plasma or germinal matter have been made known through the researches of Lionel Beale, Recklinghausen, Strieker, Cohnheim, Max Schultze, and others; and it is not until now that we have been able to carry our inferences, connecting this matter with con- sumptive disease, into any precision of detail. The whole subject still teems with matters for further research; and many of the conclusions, to which we have been led by analogy and reason, will have to be brought to the addi- tional test of direct observation and experiment, A very cursory glance through the pages of this work will suffice to show that its great object is practical: to find out and explain what nature and art have done, and may do, in the. treatment of a disease, which has been commonly considered one of the opprobria medici: and the introduc- tion of theoretical views as to its intimate nature is so far from being unpractical or unprofitable, that these views are k iv PREFACE. really the results of extensive observation and experience; and without some generalization of this kind, the multitudi- nous facts and opinions with regard to Pulmonary Con- sumption are at the present day in a state of incomprehen- sible and unmanageable confusion. Any reasonable attempt to bring this chaos into order can hardly be objected to: but the competency of any individual who makes the attempt, mav be fairlv challenged. Tn assuming (or rather resuming) the position of an ex- positor of the nature of Pulmonary Consumption, I trust I may be excused the egotism of alluding to the facts,— that during a period of nearly fifty years it lias been one of the objects of my most constant study: that under the tuition of Alison, Laennec, Andral, and Chomel, I learned what those distinguished men had to teach, at the bedside, and in the dead-house: that in the subsequent twenty years, the knowledge thus acquired was continually applied and extended, especially in St. George's and University College Hospitals, successively; where I attended the wards almost daily, and never missed the post-mortem examina- tions; at the latter hospital always superintending them myself: that during this period the publication of several works sufficiently proved my proficiency in the diagnosis and pathology of diseases of the chest, whilst, in the suc- cessive editions of the "Principles of Medicine," were analyzed and applied the leading facts and opinions in Gen- eral Pathology and Therapeutics: and lastly, that my ex- perience in diseases of the chest in private practice during the last forty years has probably not been exceeded by that of any other physician:—all these proofs of qualification being taken into account, I trust that the present attempt to place in a clearer light the nature and varieties of Pulmo- nary Consumption will not be deemed presumptuous or pre- mature, and will be not the less favorably received in con- junction with an account of modes and results of treatment which give evidence of considerable improvement on any PREFACE. V former experience on record, and afford encouragement to hope for still further success in the future. It is not possible to convey in a few words the views on the nature of Phthisis, to which I have been led by obser- vation and reflection on the facts and opinions of others as well as my own: but the popular terms decline and con- sumption are the most significant which I can employ to ^/ represent them. I believe Pulmonary Consumption to arise \St~ f-itsj from a decline or deficiency of vitality in the natural bio-#/£.<_£ &€£ j)lasrir"6v germinal matter; and this deficiency manifests its ^^ s&enjd effects not only in a general wasting or atrophy of the whole /^^ Vc body, but also in a peculiar degradation, chiefly in the lungs ^^ r and lymphatic system, of portions of this bioplasm into a;/ . -■ . sluggish low-lived, yet rn-oliferating matter, which, instead " S/[ of maintaining the nutrition and integrity of the tissues • ^ , (which is the natural office of the bioplasm), clogs them and ,^ irritates them with a substance which is more or less prone . to decay, and eventually involves them also in its own dis- integration and destruction. This degraded bioplasm, which I will call ptliinoplasm (wasting or decaying forming mate- rial), may be thrown out locally, as a result of inflammation; or it may arise more spontaneously in divers points of the bioplasm in its ordinary receptacles, the lymphatic glandu- lar system; and then it commonly appears in the form of miliary tubercles, scattered through the adenoid tissue of the lungs. I would characterize all consumptive diseases heretofore classed under the terms Tuberculous and Scrofulous, together with the products of low and chronic inflammations, as in- stances of a lowered vitality of the bioplasm; and I would stronglv insist on their being totally distinct, on the one hand, from cancer and other malignant diseases, the charac- teristic of which is a new hind of vitality, a new growth, perhaps parasitic, with new organic elements, foreign to those of the tissues which they invade and destroy; and on the other hand, distinct also from total loss of vitality, death of vi PREFACE. the bioplasm, which would speedily result in decomposition, gangrene, and putrefaction: to such a result phthinoplasms do occasionally lead, but it is not a part of their common history. That this latter distinction is not sufficiently ob- served by some German writers is evident from their apply- ing the term necrobiosis to caseation, which, although a pro- cess of decay from lowered vitality, does not indicate the absolute death of every living part, as in a slough or gan- grene. It wrill be seen in the chapter on Fatty Degeneration (which thirty years ago was a special object of my study), ' that I have traced a resemblance to vegetable life in its pro- cess and products; and, although ultimately destructive, it / is the most gentle step towards the death of the tissues. . , . ^ay> various proofs will be adduced that fatty transforma- tf/uy ^ tionis often ja salutary process, assisting materially in the ^/7 t removal of phthinoplasms and other superfluous products of vf-V"* v/ inflammation. i*4i tew, rpjie preceding imperfect sketch will, I trust, make it ap- parent that the views now offered are not barren specula- tions ; but, if they prove to be well founded, they are largely suggestive of practical measures. The great indication to ( sustain the vitality and sufficiency of the bioplasm, by all available means, medicinal, regiminal, and climatic, will be the first suggestion for the prevention and treatment of con- -7 sumptive disease. A ^second, equally obvious, will be the avoidance of all influences which may injure the bioplasm; generally, by deleterious action on the whole body; or locally, by exciting low inflammations in the lungs or other organs. ? A third indication, more difficult than the others in its ful- filment, is to counteract the injurious effects of phthinoplasms already formed, and to promote their quiescence or removal. It has been our endeavor in the chapters on the Treatment, and in those containing the illustrative Cases, to show how these indications are carried out; and, although in the worst and most rapid forms of disease, we have still to confess that medicine is almost powerless, yet, in those less overwhelm- PREFACE. vii ing, and in those more chronic, which happily constitute the far greater number of cases, we have been able to adduce many proofs (and these might be largely multiplied) that much may be done to mitigate, to prevent, to retard—aye, and even to arrest and cure, this most destructive of human maladies. And here occurs an opportunity, which must not be lost, of saying a strong word on what renders the practice of our art much less successful than it might be if it had a fair chance: I mean the fickleness or indocility of the patients or of their friends. Our recorded cases are dry enough to read, being neither smooth in diction nor sensational in narrative: but they teach this lesson, that those patients benefited most surely and most permanently, who early, and at reasonable intervals, sought for advice, and who implicitly and faith- fully followed it to the best of their ability, during the sev- eral months or years required by the nature of their cases. On the other hand, only irregular and uncertain improve- ment ensued where the advice was imperfectly carried out ;(-, and relapses, serious and even fatal, resulted often from its t J^tS- neglect. This is an old grievance, and we must not cease to , ' ^ ? raise a warning voice against it. The cause lies very much %^.A" in the ignorance and conceit of even the educated classes in\ /%Z $ medical matters, especially of the aristocracy, many of whom yi^i* consider themselves better judges than medical men; and, if' /^, they seek advice, neglect to follow it, or capriciously decide \ to discontinue the treatment—to change the doctor—or, it may be, to try homoeopathy, or some equally absurd form of! quackery—at the very time when the patient's life and re- covery depend on the steady continuance of a plan of rational| treatment. It is awful to reflect on the numbers of valuable; lives that are sacrificed to such ignorance and caprice! and! until the public intelligence becomes sufficiently enlightened to discern the wickedness and folly of this reckless tamper- ing with health and life, our own profession at least should not cease to protest against it. WTe have difficulties enough Mil PREFACE. to contend against in our endeavors to correct and control the decaying tendencies of the frail body, without having them fatally aggravated by the officious interference of ignor- ance and prejudice. The treatment of Pulmonary Consump- tion involves a long watchful struggle with a strong, subtle, and insidious enemy; and to secure any amount of success, the will, the faith, and the hopes of the patient must be per- sistently and patiently on our side. It was mainly the unsatisfactory and inconclusive char- acter of histories of short duration that induced me to select for statistical analysis those cases only which had been under observation for a period of one year and upwards. A large proportion of the patients who seek the advice of a consulting physician come once, and may never be seen or heard of after. In those who repeat their visits within a few weeks or months, changes for the better cannot be relied on without the test of longer time to prove their permanency; and the cases of death occurring within these short periods belong to those acute and overwhelming forms of the disease which art is never likely to control; hajypily these early deaths are so rare that they only slightly affect the average duration of life in all cases. The statistical parts of this work have been entirely exe- cuted by my son, Dr. C. Theodore Williams, who has be- stowed much labor upon them. His assistance in this de- partment has been the more satisfactory to me, because I have neither taste nor talent for that kind of work, which is nevertheless indispensable where precision and accuracy are required. It is necessary to explain that his calculations contained in Chapters XV, XYI, and XXtV are based on the 1000 cases selected (as stated) from my note-books dur- ing a period of twenty-two years; and those only who are familiar with the numerical method of tabulating and calcu- lating facts and results can form an idea of the amount of work required in this investigation. The results appear to be highly interesting, and, although much in accordance PREFACE. ix with the general impressions which I had previously derived from my experience, it is much more satisfactory to have determinate figures to rely on, than the hazy tokens of vague memory. Thejibstracts of cases, occupying six chapters, are not limited to the 1000 cases above mentioned, but are taken from my whole experience, private and hospital; and are selected chiefly to exemplify the matter in the text bearing on the nature, varieties, signs, symptoms, causes, duration, and treatment of Pulmonary Consumption. In the prepa- ration of these cases for the press, and in their arrangement into groups, my son joined his labors to mine, and thus the work has been more rapidly accomplished. The task of se- lection has been difficult; it would have been easier to have increased them two or threefold, as there was abundance of material; but it was judged better to give only representative cases, and not to swell the volume, and try the patience of the reader by numbers which would probably prove too monotonous and tedious to be read. The short fatal cases, I narrated are selected chiefly on account of the post-mortem appearances; and the chronic cases, many of which are still living, give a longer insight into the nature and course of j Pulmonary Consumption than any that have yet been given! to the Profession. 1 The short chapter on the Physical Signs of Consumption is introduced to explain the signs and interpret the terms given in the histories of the cases. It is more than thirty years since the appearance of my last work on the physical sio-ns of diseases of the chest, and it has been for more than twenty years out of print; but I have found no need to change the language which I then used, except in the way of simplification and abbreviation, and to adapt it to describe the varieties in the history of phthinoplasms. I flatter my- self that the views given of the pathology and tendencies of these will render their physical diagnosis more intelligible and easv than it has been generally considered hitherto. X PREFACE. The chapters on Family Predisposition and other causes of Pulmonary Consumption and on Hemoptysis are con- tributed by my son, the statistics bearing on them being derived chiefly from the 1000 cases which he had tabulated from my notes. Some important deductions respecting the origin of Consumption and the pathology of Haemoptysis will be found in these chapters. The Summary view of the treatment of Pulmonary Con- sumption is only slightly modified from that which appeared in the "Lancet" three years ago. In the subsequent chap- ters which consider the«treatment in relation to the forms or varieties of the disease, I have found it convenient to divide it into the three heads, antiphlogistic, antiphthisical, and palliative. Having sketched the kind of antiphlogistic treat- ment required in the inflammatory forms or complications of the disease, I have taken into consideration the remedies which can be called antiphthisical, including cod-liver oil, tonics, and antiseptics. The chapter on Palliative Treat- ment, and those on diet, regimen, and climate in Pulmonary Consumption, I have left to my son, whose experience at the Brompton Hospital, as wrell as taking charge of my patients in my absence, and whose familiarity with the best climates for invalids, well qualify him for the work. It remains for me only to bespeak the indulgence of our readers on account of many shortcomings and defects in the execution of this work. It does not profess to be a complete treatise on its subject, nor to record all the labors and opin- ions of others. Its chief purpose is to communicate the ex- perience and reasonings of a long life largely occupied in the study and treatment of Pulmonary Consumption. 49 Upper Brook Street, September 1st, 1871. CONTENTS. CHAPTEPv I. PAGE Definition of Pulmonary Consumption—Nature and Degrees—Galloping- Consumption— Acute Tuberculosis — Scrofulous Pneumonia—More limited and chronic forms—Various Progress of the disease—Power of Medicine—Unity but not Uniformity of Pulmonary Consumption, 33 CHAPTEE II. PATHOLOGY OF PULMONARY CONSUMPTION. Views of Laennee, compared with those of Andral, Cruveilhier, Alison, and Abercrombie—Original Conclusions of the Author : Consumption produced by defective Vitality and Organization of the Plasma, result- ing from Inflammation or Malnutrition, ...... 37 CHAPTEPv III. PATHOLOGY OF CONSUMPTION. Micrology—Gulliver, Addison, Rokitansky, Lebert, &c.—Cellular Pathol- ogy ; Virchow's Views criticized—Tubercle and Cancer contrasted— Burdon-Sanderson's conclusion on Tubercle ; an Adenoid Hyperplasia— Portal's anticipation of the Lymphatic nature of Tubercle, . . .42 CHAPTER IV. PATHOLOGY OF CONSUMPTION. Relations of Inflammation to Tubercle and other Phthinoplasms: When and how docs Inflammation produce Tubercle ?—The plastic process of Inflammation—Leucocytes, Sarcophytes, or Bioplasts: their forma- tion, migration, and changes—Nature of Bioplasm: Cells not essential- Observations of W. Addison, Waller, Cohnheim, &c, on Migration- Observations on Protoplasm by Max-Schultze, Strieker, and Lionel Beale—Amoeboid properties of Sarcophytes—Effect of Heat—Sar- cophytes the representatives of the Bioplasm—Their Proliferation and Conversion into tissue-cells, pus, and tubercle—Examination of other Phthinoplasms in the Lung—Crowded and Indurated Sarcophytes— Fibrils and Hyaline—Acute and Chronic results—Soft Consolidation Xll CONTENTS. and Caseation—Induration and Fibroid Formation—Carnification— Cirrhosis, resulting from chronic inflammation—Fibroid, identified with Cacoplastic and Contractile—Proofs of its kinship with Tubercle— Different Clinical results of Fibroid—Its Relations to Asthma and Dilated Bronchi—Favorable and unfavorable issues of Consolidations— Although originating in inflammation, being phthinoplastic, they may end in Phthisis—Both inflammation and decay to be counteracted, . 49 CHAPTER V. PATHOLOGY OF CONSUMPTION. Independent of Inflammation—Sarcophytes in the Lymphatics ; subject to the same changes, and producing the same results as those from the bloodvessels—Scrofula of the Lymphatic Glands—Lymphomata—Case- ation—Miliary tubercles, hardened Sarcophytes in the adenoid tissue— Multiplied Lymphatic Sarcophytes, or Leucocytes, produce Leukaemia, 60 CHAPTER VI. PATHOLOGY OF CONSUMPTION. Caseation and Fatty Degeneration of Tissues—Discovered by Gulliver— Proved to be a chemical change, consequent on loss of vitality—Fatty Degeneration the most gentle step to the death of Tissues—A common process of Pathology—Causes softening and disintegration of Tubercle, Fibrin, and Phthinoplasms generally, ....... 62 CHAPTER VII. PATHOLOGY OF CONSUMPTION. Nature of Pus and Suppuration—Pus-cells modified Sarcophytes ; partly liquefied by oxidation—Circumstances favoring it—Proliferation and solvent action of Pus-cells—Result aplastic and destructive, but for conservative ends ; in Abscess ; in suppuration from surfaces—Termina- tion of Abscess in Caseation and Petrifaction—Favorable issues of Sup- puration—Subsequent effects in bronchial glands—Gradations of lymph, pus, and tubercle, ........... 67 CHAPTER VIII. PATHOLOGY OF CONSUMPTION. TABULAR VIEW OF PHTHINOPLASMS, OR ELEMENTS OF CONSUMPTIVE DISEASE AND THEIR RESULTS. Divided into those of the bloodvessels and those of the lymphatic system__ Synthetic view of clinical and pathological varieties of Phthisis__■ Inflammatory Phthinoplasms—Fibroid ; formed from fibrillating plas- ma with less corpuscular elements; tends to contract; causing collapse of the chest, dilated bronchi, and other clinical results, according to sit- uation ; scar-tissue and emphysema; may endure long, and end favora- bly ; or may end in caseation and decay,..... 75 ' CONTENTS. xhi CHAPTER IX. CLINICAL AND PATHOLOGICAL VARIETIES OF CONSUMPTIVE DISEASE. PAGE Inflammatory Phthinoplasms, continued—Corpuscular, being altered Sar- cophytes—Pus and Suppuration, from oxidation and partial liquefac- tion; if healthy, not Phthisical, if unhealthy, often Phthisical; and otherwise part of the Consumptive process—Scrofulous abscess—Sec- ondary suppuration and ulceration—Laryngeal Phthisis—Relations of Fistula and other suppurating wounds to Phthisis—Pyaemia, . . 79 CHAPTER N. CLINICAL AND PATHOLOGICAL VARIETIES OF PHTHISIS. Inflammatory Phthinoplasms, continued—Concrete and inactive Sarco- phytes, in increased numbers, producing red and gray Indurations of the lung: with more fibroid, tending to contract and wither: with more corpuscles, tending to caseate and excavate—Origin from different kinds of inflammation—Comparison with the lung indurations described by Laennee, Andral, and T. Addison—Results contrasted with those of healthy bioplasm or healing, ......... 82 CHAPTER XI. CLINIOAL AND PATHOLOGICAL VARIETIES OF PHTHISIS. Imflammatory Phthinoplasms, continued—Concrete Sarcophytes, more abundant and lifeless, producing Caseous Hepatization, or Scrofulous Pneumonia, ending in speedy fatty softening and excavation—If ex- tensive, soon fatal; but if partial, arrested by evacuation and cicatriza- tion ; or becoming obsolete and calcified—Examples—Caseation often not infecting the system, ......... 85 CHAPTER XIL CLINICAL AND PATHOLOGICAL VARIETIES OF PHTHISIS. Inflammatory Exudations, besides Sarcophytes and Fibroid; appearing in the Expectoration—Catarrhal; marked by products of mucous mem- brane, hyaline mucus, epithelial scales, and saline fluid, attended with much irritation—Albuminous, uncoagulated and seinitransparent; or coagulated and opaque, being pellicular, ramiform, or curdy; resulting from over-distended bloodvessels—Hemorrhagic; characterized by ad- mixture of red blood-corpuscles; from migration from inflamed vessels, as in early pneumonia, or from altered hasmatosine, as in scurvy, . 88 CHAPTER XIII. CLINICAL AND PATHOLOGICAL VARIETIES OF PHTHISIS. Phthinoplasms in the lymphatic system, the chief seat of the Sarcophytes— This subject best illustrated by an examination of the late researches on XIV CONTENTS. the Artificial production of Tubercle—Laennec's observation—Experi- ments of Villemin, Andrew Clark, Burdon-Sanderson, and Wilson Fox —Summary of results of Dr. Fox's experiments; causes of success and failure considered—Some predisposition in the animal necessary, as only certain kinds of animals easily affected; and these chiefly by phthino- plastic, or by foul pus, or other septic matter; but less frequently by wounds or mechanical injuries, without any foreign animal matter— General conclusions:—that in animals so treated is produced a blight- ing and decaying change in portions of their bioplasm, which then be- come seeds of new phthinoplasms in other parts—That the bioplasm or sarcophyte of the lymphatic system is the first seat of this disseminated decay—That septic influences in the body, or in the surrounding air, may have a similar blighting or hi.-tolytic effect on the plastic material of wounds or other inflammations from common causes, rendering their products phthinoplastic and decaying, with a tendency to further dis- semination through the lymphatics—Observations of Drs. Sanderson and Fox, ............. CHAPTER XIV. CLINICAL AND PATHOLOGICAL VARIETIES OF PHTHISIS. Further conclusions on Artificial Tuberculization in Animals, and on the Causation of Phthisis in Man—Nature and progress of Artificial Infec- tion—First local effect, the induration of sarcophytes—Next effect on sarcophytes of lymphatic system, changing them—Similar changes dis- seminated through adenoid tissues of other organs—Is the infecting in- fluence specific poison like that of Contagious diseases?—Facts tend to associate it rather with common noxious or septic influences, capable of blighting or injuring the sarcophytes, as heat does—The most potent infecting matters were those in a state of common corruption—Few animals, except guinea-pigs and rabbits, susceptible of artificial tuber- culization—Spontaneous Miliary Tubercle in Man described—Occasion- ally produced by Bronchial Inflammation or Exanthernatous Irritation ; but more commonly the result of Dissemination through the Lymphatic system, as in Artificial Tuberculization. Clinical experience finds Tu- bercles succeed to unhealthy local suppurations; to Caseation occurring in Lymphatic Glands, or in other parts; to gray Consolidations, and other Phthinoplasms previously existing—It has yet to prove that they may be produced by common wounds in the integuments, as in the ex- periments of Drs. Sanderson and Fox—But in these cases of natural production of tubercle, as in the experiments, some predisposition or co-operating cause, is necessary—This may be either defective vitality of'the sarcophytes, or some additional corrupting influence in the body or in the air—Parallel cases of Pyicmia and Acute Tuberculosis__The latter promoted by Heat, Damp, and Foul Air; Inflammatory and Chronic Phthisis more by Cold. Other causes of constitutional weak- ness favor the development of Tubercles, and when in excess may CONTENTS. XV suffice to originate them in their acute form, exhibiting characters almost malignant—Gray Tubercles then soft, plump, and without fibre or stroma to circumscribe them—Influence of Climate and Altitude on different forms of Consumptive Disease,......98 CHAPTER XV. FAMILY PREDISPOSITION AND CERTAIN OTHER CAUSES OF CONSUMPTION. By Dr. C Theodore Williams. Causes general and local—Family Predisposition—Consumption proved to be hereditary—Opinions of Niemeyer, Virchow, and Waldenburg— Family Predisposition explained—Hereditary Tuberculosis in sheep, cattle, guinea-pigs—Offspring of Gouty, Syphilitic, Asthmatic, and Aged Parents often Consumptive—Prevalence of Family Predisposi- tion—Evidence of Louis, Copland, Cotton, Fuller, Pollock, Briquet, and the Author—Its more frequent occurrence among Females than Males —Paternal and Maternal Transmission—Influence of Age on attack— Private and Hospital Practice—Influence on Symptoms—Cases—Influ- ence on duration—Relations affected—Age at Death—Conclusions— Other Causes of Consumption—Impure Air, and Improper Food—Con- tinued Fevers—Scarlatina and Measles—Cessation of Discharges—Un- favorable Confinements, and Over-lactation—Mental Depression—Damp —Buchanan and Bowditch's Researches—Dusty Occupations—Con- sumption not Infectious,..........107 CHAPTER XVI. HAEMOPTYSIS AND THE HEMORRHAGIC VARIETY OF CONSUMPTION. By Dr. C. Theodore Williams. Hasmoptysis—Its Significance—View of Louis, Laennee, Andral, Watson— Niemeyer's Explanation of large Hasmoptysis—His Comparison of Bronchial Hemorrhage with Epistaxis inappropriate—Differences in the Bronchia1! and Nasal • Tracts—Niemeyer's Views of the Relation of Hasmoptysis to Phthisis discussed—Origin of Phthisis from Haemoptysis unproved and improbable—Author's experience—Hemorrhage of early Phthisis explained by Fatty Degeneration of Vessels—Of later stages, by Pulmonary Aneurism—Varieties and Pathology of latter—Hasmop- tysis from Congestion—Influence of Age and Sex on Hasmoptysis—In- fluence of Stage—Illustrative Cases—Influence of Form of Disease— Hemorrhagic Phthisis; its Characteristic Symptoms and Exciting Causes—Examples—Effects of Hasmoptysis in Phthisis; general and local Pneumonia—When and why set up—Results—Illustrative Cases —Influence of Hasmoptysis on Duration of Life, ..... 127 xvi CONTENTS. CHAPTER XVII. OUTLINE OF PHYSICAL SIGNS OF VARIETIES AND STAOES OF PULMONARY CONSUMPTION. By Dr. Williams. page Signs of Phthisis originating in Bronchitis—Of Breath-sounds and Crepita- tion—Signs of partial Consolidation affecting Percussion; Tubular Sounds; Expiration and Voice—Situation of Signs—Signs of Softening and Excavation replace signs of Constriction—Signs of Pneumonia passing into Phthisis—Explanation of Loud Tubular Sounds of Hepati- zation—Give place to Gurgling and Cavernous Sounds—Signs of Abscess —Signs of Phthinoplasms after Pneumonia—Signs of Contraction and Dwindling, with those of Emphysema—Signs of Congestion passing into Phthisis, or into Emphysema—Signs of Miliary Tubercles, scattered and clustered—True explanation of Wavy Respiration, and its value as a sign of Phthisis—Subclavian Arterial Murmur—Signs of Caseation and Excavation—Signs of Miliary Tubercle more scattered ; from in- fecting tendency—Signs of Extension of Disease—Corruption—Signs of Cure and Arrest of Phthisis—Complete—Partial—Residuary Lesions and Signs—Contraction and Emphysema—Calcareous Expectoration after Obsolescence,...........148 CHAPTER XVIII. ABSTRACTS OF CASES ILLUSTRATING THE NATURE, VARIETIES, AND TREATMENT OF PULMONARY CONSUMPTION. Large number of Cases—Grounds of Selection—Division into Groups—First group, Phthisis originating in Inflammation—Acute and Chronic— Pneumonia and Pleurisy—Fibroid and Caseating—Indurations and Excavations—27 Cases...........156 CHAPTER XIX. abstracts of cases, etc.,—continued. Asthmatic Phthisis — Usually originating in Inflammation — Arrested Phthisis passing into Asthma—Asthma passing into Phthisis—8 Cases, 177 CHAPTER XX. abstracts of cases, etc.,—continued. Scrofulous Pneumonia and Acute Tuberculosis ; grouped together as repre- senting the most rapid forms of Phthisis: but Scrofulous Pneumonia arrested in 3 out of 7 cases—Acute Tuberculosis—8 cases, all fatal, one in 21 days—Several from purulent infection, ...... 183 CHAPTER XXI. abstracts of cases, etc.,—continued. Scrofulous Phthisis from Infection through Lymphatics, connected with CONTENTS. xvii Glandular Scrofula, Fistula, Abscess, Purulent Otorrhcea, &c, 12 Cases ; generally arrested several years—Fatal Dyspnoea from Caseous Bronchial (Hands—Empyema threatening Phthisis ; Recovery, .... 195 CHAPTER XXII. abstracts of cases, etc.,—continued. Chronic Phthisis and Chronic Tuberculosis—Anatomical difference between Acute and Chronic Tubercle; Chronic more limited and local, therefore more tractable—Of First Stage 6 Cases, arrested and cured—Of Second Stage 5 Cases, arrested and cured—Of Third Stage 25 cases, retarded, arrested, or cured : surviving for periods varying from 3 to 27 years, . 202 CHAPTER XXIII. abstracts of cases, etc.,—continued. Miscellaneous Cases—Utero-Gestation in Phthisis—Disease arrested 12 years ; healthy child born : death 4 years after from Dropsy, &c.— Phthisis retarded 10 years ; three living and two dead children born— Phthisis during Pregnancy: death after Childbirth—Phthisis arrested before marriage; relapse after second Childbirth: arrested again; and two more children—Phthisis after injury to chest; 2 cases—Pneumo- thorax: 4 cases; all recovered—Phthisis with Heart Disease: recovery —Caseous Pneumonia arrested : uric acid nephralgia, eczema, and cal- careous expectoration after—Syphilis and Phthisis : recovery—Senile Phthisis—Phthisis from Inflammation: Chronic Bronchitis for 30 years after ; death at 84 from Hasmoptysis,.......225 CHAPTER XXIV. THE DURATION OF PULMONARY CONSUMPTION. By Dr. C. Theodore Williams. Estimates of Portal, Laennee, Andral, Louis, and Bayle compared with those of the Brompton Hospital, Fuller, and Pollock—Differences ex- plained by Class of Patients and Mode of Treatment—Author's Thou- sand Cases selected from wealthy Classes—Ground of Selection explained —Method of Tabulation of Cases—Sex—Age of Attack—Family Pre- disposition—Origin and First Symptoms—Cases of Inflammatory ori- gin ; their Proportion and Course of Symptoms—Hasmoptysis—State of Lungs at first Visit as evidenced by Physical Signs—Classification by Stages adopted, with Restrictions—Majority of Patients in First Stage, and consequent favorable Prognosis—Mortality in each Stage—State of Lungs at last Visit—Classification into "Healthy," "Improved," "About the Same," and " Worse;" and Percentage of each—Relative Liability of Lungs to Attack, Excavation, and Extension of Disease- Number of Deaths—Causes—Long Duration—Living Patients more numerous, and with higher average Duration—Present State described b xviii CONTENTS. PAGE as "Well," "Tolerably well," and " Invalid "—Large Proportion of First Two Classes—Hopeful Prognosis—Causes of Long Duration—In- fluence of Age and Sex on Duration—Among Females Duration shorter, Age of Attack earlier, and Age at Death younger than among Males— Great Age reached by some Patients—Relation of Age of Attack to Du- ration— Prolonging Effect of Inflammatory Origin—Pneumonic, Plcuro- pneumonic, and Bronchitic—Duration of Pathological Varieties of Con- sumption difficult to determine—Diagnosis of Tuberculosis and Caseous Phthisis obscure, .......-••• ^"° CHAPTER XXV. TREATMENT OF PULMONARY CONSUMPTION.—SUMMARY VIEW. By Dr. Williams. Author's Retrospect of Forty Years—Discovers a Great Improvement in the Results of Treatment, chiefly due to the introduction of Cod-Liver Oil and the Tonic Plan—Duration of Life in Phthisis quadrupled— Modern Treatment chiefly Sustaining and Tonic; but not excluding moderate Antiphlogistic Measures, where required ; soon returning to Tonics and Oil—Mode, of Action of Oil—Summary of Directions and Cautions concerning its use—Necessity of enforcing its continued use— Adjuvant Remedies—Iodine—Ilypophosphites—Sulphurous Acid—In- halations—Mineral Waters in Consumption—Mountain Cure—Air and Climate,.............256 CHAPTER XXVI. TREATMENT OF PULMONARY CONSUMPTION. Treatment of Forms and Varieties—Acute and Chronic not Synonymous with Inflammatory and .Non-Inflammatory—May be Acute from rapid- ity of Decay, as well as from Inflammation—Decided Antiphlogistic measures chiefly required for Sthenic Inflammation—In other cases lim- ited measures—Blisters very useful: their management—Croton Oil— Opium, and other Sedatives—Treatment of Asthenic Inflammation by Stimulants and Tonics—Cautions—Treatment of Subacute and Chronic Inflammations; Iodine; Counter-irritants—Rest and Quiet—Conser- vation of Strength,.....'...... 266 CHAPTER XXVII. TREATMENT OF PULMONARY CONSUMPTION.—ANTIPHTHISICAL MEASURES. Objects of Antiphthisical Treatment to sustain Vitality of Bioplasm and counteract Decay—Remedies, Medicinal, Dietetic, and Hygienic__Of Medicinal, Cod-Liver Oil the chief—Its beneficial effects—Mode of Ac- tion, as an Oil, on the Bioplasm and on the concrete Sarcophvtes; soft- ening exudates and promoting resolution—To be effectual must be "-iven largely and constantly; to act on Phthinoplasms and counteract Decline CONTENTS. xix which may exist before or after Phthinoplasms—Notice of other Oils and Fats—Pancreatic Emulsion—Reasons for preferring pure Cod-Liver Oil—Mode of preparing it—Sources—Modes and Times of Exhibition— Cautions—Tonic Medicines : best combined with the Oil—Mineral Acids —Nitric—Sulphuric—Phosphoric—Sulphurous—Hypophosphites—Bit- , ters and other Tonics—Prescriptions—Doses to be few—Antiseptics— Inhalations—Arsenic,..........272 CHAPTER XXVIII. TREATMENT OF PULMONARY CONSUMPTION.—PALLIATIVE MEASURES. By Dr. C. Theodore Williams. Palliative Treatment useful, but subordinate to Antiphthisical—Treatment of the Varieties of Cough by Sedatives and mild Expectorants—Cough Mixtures, Linctus, Lozenges—Time and form of Administration—Ob- jections to their use—Pain in the Chest, how caused and how relieved— Plasters and Liniments—Treatment of Hasmoptysis—Styptics acting on the Blood—Gallic Acid—Tannic Acid—Acetate of Lead : Dose and Method of Elimination—Turpentine—Perchloride of Iron—Styptics acting on the Bloodvessels—Digitalis—Ergot of Rye—External Treat- ment by Cupping and Blisters—Restrictions in Diet and use of Ice— Treatment of Night Sweats—Niemeyer's Conclusions—Tonics—Acid Sponging—Sulphuric and Gallic Acids—Quinine and Iron—Success of Oxide of Zinc—Treatment of Diarrhosa and its varieties—Bismuth— Logwood—Sulphate of Copper—Combination of Astringents with Opi- ates—Opiate Enemata—Tannic Acid—Acetate of Lead—External Ap- plications—Constipation—Importance of counteracting it by Diet or mild Aperients—Treatment of Bed-Sores—Prevention and Healing measures—Treatment of Laryngeal Symptoms—Blistering—Inhalations —Internal applications to the Larynx,.......287 CHAPTER XXIX. TREATMENT OF PULMONARY CONSUMPTION.—DIETETIC AND HYGIENIC MEASURES. By Dr. C. Theodore Williams. Effects of good Diet on Consumptive Patients—Object of Diet—Importance of Meat—Exemption of Butchers from Consumption—Raw Meat: when useful—Blood Drinking—Vegetables and Fruit—Objections to Pastry, Pickles, Salad, &c.—Cautions as to the use of Fatty and Oily Food—Bread and Farinaceous Articles—Liquid Nourishment—Stimu- lants—Mode of Administration and Uses—Varieties, and Rules for their Selection—Brandy and Rum best combined with Food—Cooling Drinks —Clothing—Best material for under-clothing—Warm Wraps—Exer- cise—Its benefits—Active Exercise : its objects and varieties—Rowing— Swimming—Gymnastics—Walking—Passive exercise: its varieties— Carriage—Sailing: their effects—Riding: its great advantages—Habi- tation—Soil—Site—Locality and Shelter—Temperature—Ventilation and Drainage,............295 CONTENTS. CHAPTER XXX. TREATMENT OF PULMONARY CONSUMPTION.—CLIMATE. By Dr. C. Theodore Williams. munity of Localities from Consumption not assignable to any one Con- dition of Life—Objections to High Altitude Theory—Kirghis, Ice- landers and Faroese—Objections to " Koumiss " Theory—Twofold Ori- gin of Consumption—Influences originating Inflammatory Attacks— Septic Influences—Nature of the Disease dependent on its Causation— Knowledge of Countries where each class prevails: a guide to Climatic Treatment—Objects of Change of Climate—Division of Climates into Marine and Inland—Marine: their stimulating and equable qualities— Caution as to Seaport Towns—Cool and moist British Coast Stations- Dry Climate of Mediterranean Basin—Warm and moist Madeira group —Inland Climates: their great diversity—Division into three groups— Calm and Soft—Dry and Warm—Climates of elevated regions—Marine Climates suitable for Consumption arising from Inflammation—Choice dependent on degree of irritability of system—Inland localities best fit- ted for the most irritable variety—Climate of elevated regions indicated for Consumption of Septic Origin—Restrictions—Residence at high altitudes important as a Preventive measure—Ordinary Chronic Con- sumption best treated by warm stimulating climate in winter, and cool bracing climate in summer—Importance of Exercise—Inland Climates of North America—Sea Voyages : advantages and disadvantages—Cau- tions—Certain Cases of Consumption unfit for Change of Climate— Practice of sending Patients in advanced Consumption abroad con- demned,............. 302 ON PULMONARY CONSUMPTION. CHAPTER I. Definitions—Illustrations of degrees—Galloping Consumption—Acute Tu- berculosis—Scrofulous Pneumonia—More chronic and limited forms— Progress of the disease—Power of Medicine—Unity but not uniformity of Phthisis. The disease, too well known to the public, as well as to the medical profession, as Pulmonary Consumption, is character- ized by the symptoms, persistent cough, expectoration of opaque matter, sometimes of blood; a progressive loss of flesh, breath, and strength; often hectic fever, night sweats, and diarrhoea; and the common tendency of the disease is to a wasting of the body and a decline of its powers, down to its termination in death. Pathologically considered, pulmonary consumption is charac- terized by certain changes in the -textures of the lungs, con- sisting chiefly of consolidations, granular or diffused, which irritate their functions and clog their structures, and which proceed to further changes, of degeneration, disintegration. and excavation of some parts, and of induration and contraction of others—all tending to a disorganization of the lungs, and a wasting away of the flesh and blood of the body. It is this tendency to degeneration and destruction, which stamps the consuming character of the disease; and the more strongly this tendency is manifested, the more irresistible and rapid will it be in its fatal course. In certain cases the disease is so acute and extensive as to carry oft' the patient in a few weeks or months. In others it is more limited and slow, and may not destroy life for five, ten, twenty, or more years. In the former cases, medicine has little or no control over the disease; decay and death invade the frame so overwhelmingly, that there is neither sufficient power in nature to resist them, nor time for art to aid that power. One of the most vital 3 34 PULMONARY CONSUMPTION—DEGREES AND FORMS. organs of the body becomes suddenly invaded by a disease, changing its structure, obstructing its functions, and spreading through it the seeds of further decay, which not only in the organ itself, but by the blood and lymphatics, diffuse its de- structive influence through the whole sj'stem. Let us briefly sketch the two most terrible forms of the disease. A man of middle age is attacked with fever, with pungent heat of the body, cough, viscid expectoration, extreme oppres- sion, and overwhelming weakness, resembling that of continued fever; and the likeness sometimes appears also in the coated or dry brown tongue, sordes on the teeth, and occasional de- lirium. The vesicular breath-sound is superseded everywhere by bronchial rhonchi and mixed crepitation. On percussion, the chest is dull nowhere, but less clear in the posterior than in the front parts. This case might be supposed to be one of universal capillary bronchitis, with general pulmonary con- gestion. So it is; but this is not all. In spite of blisters and other remedies, the breathing remains short and difficult; the pulse becomes more rapid and feeble; the lips, cheeks, and nails become livid; clammy sweats break out, and the patient dies in the third or fourth week from his first attack. The lungs are found congested, and the bronchi loaded with viscid mucus; but more than this, innumerable miliary tubercles are scattered throughout the pulmonary tissue, and these are the obvious cause of the intractability of the case. They break out simultaneously, like the eruption of an exanthem, and by their numbers and bulk induce such an amount of obstruction and congestion in the lungs, as to destroy life before there is time for any considerable degeneration or softening to take place. This acute tuberculosis is the worst and most surely and rapidly fatal form of consumption. The second form of acute consumption begins with pneumonia in one or both lungs. The patient, generally a young subject, is of consumptive family, and may have previously had couch and occasional haemoptysis. The fever attendant on the inflam- mation may not be very high at first, and the expectoration by no means so viscid and rusty, nor the crepitation so fine and even, as in simple inflammation of the lungs. But the symptoms are more persistent. The pulse and respiration remain fre- quent. The heat of the body, particularly of the chest continues remarkably high, almost burning the ear of the auscultator as he examines the back. But this intense heat is alternated with occasional chills and profuse sweats at night. The cough continues distressing, and the expectoration becomes opaque, purulent, and clotty; the flesh wastes, and the strength ebbs away; and if the appetite does not return, the prooress of ACUTE TUBERCULOSIS — SCROFULOUS PNEUMONIA. 35 consumption and decay is rapid. Auscultation reveals the steps of the destructive process in the lung. The affected part, or the whole side, or part of both sides, becomes dull on percus- sion, only varied with the cracked-pot note from the gurgling within ; the loud tubular sounds are replaced by coarse crepi- tation, in parts amounting to gurgling; and the diffused bron- chophony is modified into detached islands of voice, loud and pectoriloquous, or into the snuffling or whispering sounds equally characteristic of a cavity. This form of galloping con- sumption may also prove fatal in a few weeks ; and the lungs are found after death in a state of consolidation little more dense than the hepatization of pneumonia, but their red is mottled with gray and yellow patches of tuberculous or aplastic matter, and excavated in various parts into numerous small cavities, communicating with the bronchial tubes, and containing more or less of the same compound matter which was expectorated during life, consisting of mucus, pus, degenerating epithelium, and exudation-matter, with disintegrated fragments of lung- tissue. This form of sicute phthisis, although generally rapidly fatal, is not universally so When not too extensive, it may sometimes be arrested and brought to a chronic state; and the chance of this result will very much depend on the recovery of the appetite, and the power of the stomach to bear strong nutriment, tonics, and, above all, cod-liver oil. And in a large majority of the cases of consumption the de- structive element is still less extensive and less active, and its progress is much more slow; and we have both time and means to resist its inroads and to fortify the system against its opera- tion to a greater or less extent. In the greater number of in- stances the disease begins with the symptoms of common cold, often referred to the throat as much as to the chest; and there is, in truth, more or less of bronchial irritation and inflamma- tion attendant on the development of the disease, and recurring with renewed intensity at the time of its increased activity. Often the disorder is mistaken for a common cold, until either its remarkable persistence, or the occurrence of haemoptysis, of night sweats, of loss of flesh, or of some other uncommon 8}Tmptoni, gives intimation of its more serious nature. Then it is found that, in addition to the signs of bronchial catarrh, there are some of the signs of consolidation of the lungs, generally near an apex; slight dulness or raised tone of the stroke-sound at or below a clavicle, or at or above a scapula; a tubular charac- ter in the breath-sound and voice ; an undue intensity or dura- tion of the sounds of expiration, or a weakness or absolute obstruction of the inspiration ; and sometimes the various slight degrees of crepitus substituted for the proper breath-sound; and various other signs which it is unnecessary here to detail. 36 PULMONARY CONSUMPTION—DEGREES AND FOR.A These signs, however, are the indications of incipient pulmonary consumption—that is, of a disease which tends, sooner or later, to injure and destroy the structure of the lung, and to deteri- orate and waste the flesh and blood of the whole body. And the progress of this work of injury and destruction is marked by signs of increased density and diminished motion of parts of the lungs; by more of the moist crepitus, from augmented hu- midity, in and around the consolidations; and eventually by signs of excavation at one or more points, which announce the removal of the diseased tissue. The progress of this disease may vary infinitely in time and in extent. The more extensive the mischief, generally the more rapid will be its progress, which goes on in the worst cases, uninterrupted by any check or pause, attended by the distressing train of symptoms—harassing cough, opaque clotty expectoration, increasing shortness of breath, burning fever alternated with profuse sweats and chills, rapid loss of flesh and strength and color, sometimes diarrhoea, and aphthous mouth; and terminates in death in a few months. But in other cases, and these are by far the most common, the destructive lesions are less extensive, and their progress is more slow and intermittent, and often seems in great degree to depend on occasional attacks from cold or other external causes, in the absence of which the disease may be quiescent or station- ary, and may not destroy life for years. Powerless as medicine is in the overwhelming and rapid types of the disease, it has yet considerable influence over these milder forms; and the following pages will give some evidence that under careful treatment life may be prolonged for many years in comfort and usefulness, and in not very few cases the disease is so permanently arrested, that it may be called cured. It maj- well be questioned whether a disease which presents such striking differences in form, intensity, and result, can be truly one and the same disease; and there seems to be a grow- ing disposition among modern pathologists to supersede the comprehensive terms consumption and tubercle by others more specifically applicable to definite forms of the disease. But while I fully participate in the objections to include all forms of phthisis under the head of tubercle, and have long insisted on the origin of many cases in inflammation, I still maintain that all the varieties of phthisical lesion are identified by their com- mon consumptive nature; and the following pages will supply numerous proofs that all are characterized by a tendency to de- generation and decay. It will be shown that all are due to the presence of various kinds of phthinoplasm,1 a withering or decay- i I divu, have found it necessary to coin this word, phthinoplasm (from 6diu or " I waste or decay "—whence also " phthisis "—and Tr/ldc^a), to give'ex- PULMONARY CONSUMPTION. 37 ing modification of the proper plasma or formative material of the body; and although for clinical purposes it is useful to note their differences, and group them accordingly, yet we hold it to be most important, in relation to pathology and treatment, to consider them as varieties of one common malady,—pulmonary consumption. CHAPTER II. pathology of pulmonary consumption. Pathology of Pulmonary Consumption—Views of Laennee criticized, and compared with those of Andral, Cruveilhier, Alison, and Abercrombie —Original Conclusions of the Author—Consumption produced by de- fective Vitality and Organization of the Plasma resulting from In- flammation or Malnutrition. The term "pulmonary consumption" was restricted b}rLaen- nee to the wasting disease produced by the presence and prog- ress of tubercles in the lungs. These tubercles he described as existing in the form of gray granulations, or miliary tuber- x cles (of Bayle), yellow tubercles, and tuberculous infiltration, J- cc(s\' k which might be either grav or yellow. But he held that the ( yellow is only a more advanced stage of the gray, and that the yellow tubercle tends to change further from the crude hardj/~£u~v^ state "to that of softening and ultimate excavation. He entirely D ^^4,\ denied the inflammatory origin of tubercles; and in classing %» r them among "accidental productions" he associated them with^^ cancer and other formations, which have been subsequently ^tfKv/- denominated growths, although he was well aware of the generic difference between them in regard to both structure and history. These views of Laennee, characterizing pulmonary consump- tion as an essentially tuberculous disease, and repudiating the previously prevalent notion, that it might arise from inflamma- tion, were adopted by Louis, and by most writers iu this toun- try, with very little qualification. But they were by no means so implicitly accepted by the contemporary pathologists of France. Broussais, true to his system, traced phthisis to varieties of in- flammation, and propounded the notion that tubercles are the result of chronic inflammation of the lymphatics of the lungs. Being personally acquainted with the strong antagonistic feeling entertained by Laennee towards Broussais, I have little doubt pression to one of the leading ideas of this book, and to avoid the common use of the word tubercle, which is quite inapplicable to many kinds of degenerative formation which cause pulmonary consumption. I trust that the utility of the term will reconcile the reader to its novelty. 38 PATHOLOGY OF CONSUMPTION. that the former was biassed in his views, and framed them in opposition to those of his rival. Another eminent pathologist of that school, Andral, not less remarkable for his powers of observation than for his sound and impartial judgment, was also led to differ from the exclusive views of Laennee, and recognized inflammation as a primary agent in much of the pathology of pulmonary consumption ; and he even sought to trace miliary tubercles to an inflammation of individual vesicles of the lung. Cruveilhier also maintained the inflammatory origin of tubercles, and thought that he had produced them artificially in living animals by injecting quicksilver into the bronchial tubes. But although it may" be admitted that what is called yellow tubercle may be developed in both the modes thus indicated by Andral and Cruveilhier, yet the same cannot be said of miliary tuber- cles, the ^general.uniformity of which, in size, shape, ancl_sub-_ stance, gives them a character quite distinct from that of inflam- "niatory "products. 'The diffused consolidations, which Laennee called infiltrated tubercle, were soon proved to be of inflammatory origin, a re-, suit, in fact, of ^chronic pneumonia; and as these often form a large par t~oTtTie lesions in phthisical lungs, the exclusive opin- ions of Laennee have long ago undergone modification. One of the earliest critics of the peculiar views of Laennee on the origin of tubercles, was my revered teacher, the late Profes- sor Alison, of Edinburgh, one of the most careful observers and soundest reasoners of his day. In a series of papers read before the Medico-Chirurgical Society of Edinburgh during the years 1822, 1823, and 1824, he brought forward a number of cases and statistical facts to prove that tubercles and other lesions met wi_thjin_thj§ lungs.of .consumptive patients may originate in in- flammation. I quote one sentence: "I have also" been led"to BelieTe that it is not merely, as Laennee states, a possibility, but a real and frequent occurrence, that inflammation, acute or chronic (to which 1 wotfTcTadJ, and febrile action), howeverpro- auced7becomes in certain constitutionsThe occasion~oFThe de- velopment of tubercles; and the facts, which seem to me decis- ive on this point, I propose to lay before the Society." (" Trans. of Med.-Chir. Society of Edinburgh," 1824, p. 408.) In the same volume, p. 682, is a remarkable communication from another eminent physician of that time, Dr. Abercrombie "On the Nature and Origin of Tubercular Diseases." The views ex- pressed in this short paper are so important, and have so apt a bearing on recent researches on tubercle, that I am induced to give their substance in a note.1 i After alluding to the complex character of the tubercular masses met with in the lungs, and the consequent difficulty of tracing their nature and progress he mentions the tuberculous disease in the mesenteric and lymphatic glands "as \ VIEWS OF ALISON AND ABERCROMBIE. 39 These papers of Drs. Alison and Abercrombie appeared dur- ing the period of my study in Edinburgh; and I was the more interested in them as some of the cases described by Dr. Alison were under my care in the New Town Dispensary during the years 1823 and 1824. It was not to be wondered at, therefore, when I became a pupil of Laennee in 1825, that, much as I ad- mired and profited by the clinical sagacity and skill of the dis- coverer of auscultation, I did not accept much of his pathology; and from that time to the present, in all my writings and lec- tures, 1 have consistently repudiated his opinions on pulmonary consumption and tubercle as unsatisfactory and unsound.1 strictly analogous in its nature, and as exhibiting more simply and distinctly its states and stages. He traces the change from simple enlargement (hyperplasia) to increased firmness, and paleness, until it assumes a kind of semitran^parency, and a texture approaching to that of soft cartilage. Then appear opaque white spots (caseation), which seems to be the last step in these changes, and strictly analogous to the white tubercle of the lungs. In the most advanced stage, the opaque white matter is most abundant; and this afterwards softens and degener- ates into the soft cheesy matter, or ill-conditioned suppuration. From the effect of boiling water on the simply enlarged glands, he concludes that the enlarge- ment is due to an accession of albuminous matter, first soft, but subsequently becoming concrete, and the mass becomes less vascular and less organized; and this albumen increases in proportion to the advance of the disease from simple enlargement to gray consolidation and opaque transmutation. Mesenteric or lymphatic glands, in their natural state, contain hardly an}' albumen, and are almost entirely dissolved in boiling water. When simply enlarged, about five- sixths are dissolved, the remaining sixth presenting the properties of coagulate albumen. Glands in the advanced state of semitransparent consolidation lose one-fourth by boiling, three-fourths remaining in the state of firm albuminous coagulum ; and the white opaque tubercular matter loses still less by boiling, and, when small portions are detached from other structures, they seem to consist al- most entirely of coagulated albumen. "There seems, then, to be some ground for the conjecture that this deposition of albumen is the origin of tubercular dis- ease. It is in the mesenteric and lymphatic glands that we have the best oppor- tunity of marking its progress; but betwixt the various stages of disease in them and the various forms of tubercular disease in the lungs, there is the most close and remarkable analogy. In the bronchial glands we observe the same forms of disease, and according to Portal and other writers of the first authority, glands similar to these exist in very groat numbers throughout the whole structure of the lungs, being found at every division of the bronchia?, however minute. If this be the case, they must pervade every part of the pulmonary sub- stance in such numbers as would readily account for the usual appearances of tu- bercular lungs, on the supposition that this disease is seated in this glandular structure. For even the larger glands which we find at the bifurcation of the trachea are very small bodies in their natural healthy state; while in the state of tubercular disease, they may acquire the magnitude of eggs, or even a still larger size. I do not, however, contend that tubercular disease is necessarily confined to a glandular structure. On the contrary, there seems every reason to believe that the peculiar deposition which constitutes it may take place from every tissue of the body ; in some cases slowly and gradually, in others as the re- sult of a low inflammatory action of a peculiarly unhealthy character." 1 " Much as Laennee has done in elucidating the history of phthisis pulmonalis, his opinions on tubercles and other diseased products have always appeared to me artificial and unsatisfactory. Tubercles, according to this author an acciden- tal tissue, are produced—or, according to some of his expressions, spring up—in a healthy tissue without any aid of the vessels of the part, are changed, from & 40 PATHOLOGY OF CONSUMPTION. Adopting, with some modifications, the general opinions of Alison and Andral, I was led by observation and reflection to conclude that the lesions constituting pulmonary consumption originate in either some form of inflammation, or a perverted nutrition, of the textures of the lungs, all tending to further degradation or degeneration, and consequent decay and destruc- tion of the affected parts. In scrofulous constitutions, whether hereditary or acquired, these results might follow any form of inflammation, acute or chronic, membranous or parenchyma- tous, the products of the inflammation being yellow tuberculous (caseous), tending to softening and irregular suppuration or ulceration, and infecting the system through the blood, break- ing out in the form of miliary tubercles in other parts, with or without inflammation. But consumption may arise also in those previously healthy, fromvarious chronic inflammations of tdie lungs, either following acute attacks 'itnpeTTectly cured,, or arising from the long operation of excising causes, such as the "Kabitual inhalation of irritating dust of stone, metal, &c, or pro- longed exposure to cold and damp. The prevalent idea to which my study of consumptive dis- eases led me, as expressed in my first little work in 1828, and grayish semitransparent to an opaque yellowish white color, and pass from a state of cartilaginous hardness, through intermediate gradations, into that of imperfect liquidity: and all this by a mechanism perfectly unknown, and in a manner entirely unexplained. It is too, in my opinion, without sufficient rea- son that he identifies the granulations of Bayle with the yellow tubercle—bodies quite different in their physical character—only because the one is generally in time converted into the other. As well might cartilage be called bone, or in- flamed cellular tissue a stage of pus."—Rational Exposition of the Physical Signs of the Diseases of the Lungs and Pleura, p. 154. By Charles J. B. Williams. M D (1828.) I introduce this quotation to disprove assertions recently made by several writers, German and English, that the views of Laennee on tubercle have been generally adopted, and only called in question by Dr. T. Addison in this country, and more fully by German pathologists during the last ten years. My views on this subject were not unknown in Germany, for the little work above quoted was translated into German more than thirty years ago, and passed through several editions, having been used, as I have been told, as a text-book at some of the medical schools in that country. Another early writer in this country, Dr. W. Stokes, also long ago antici- pated the Germans in their opposition to the opinions of Laennee, and advanced views on the inflammatory origin of phthisis, in many points similar to those held in this volume. The titles by which Dr. Stokes designates the varieties of phthisis will sufficiently show this: "1. Acute inflammatory tuberculization of the lung without suppuration. 2 Acute suppurative tuberculization. 3. Chronic progressive tubercle, with signs of local and general irritation; pulmonary ulceration. 4. Chronic 'progressive ulceration succeeding to an unresolved pneumonia. 5. Tuberculous ulceration succeeding to chronic bronchitis. 6. Tubercle consequent on the absorption of an empyema."—On the Diagnosis and Treatment of Diseases of the Chest 1837 p. 414. Allowing for difference in nomenclature, rendered necessary bv ad- vances in pathological science, several of these varieties correspond with those described in this work. FURTHER RESEARCHES ON TUBERCLE, ETC. 41 in several subsequent editions, was that the consolidations of the lung characteristic of phthisis, instead of being, as Laennee main- tained, " accidental productions " or " heterologous growths" (like cancer), are really merely degraded""modificationsi"of the common nutrition of the tissues of the lung, often, but not always, produced by inflammation ; and that their disposition to further change and decay is owing to their defective vitality and organization. The cause of this degradation is to be re- ferred to the low or chronic type of the inflammation producing them, or to a depraved state of the blood from which they are formed. Thus, in a previously healthy subject, consumptive disease can arise only from inflammation of a low type, or rendered chronic by inefficient treatment, or by the prolonged or re- peated operation of its exciting cause. The result is cacoplastie consolidation, of low organization, red or gray, which tends to undergo the further degradation into opaque and still more dis- organized matter (caseous or yellow tuberculous). But in a scrofulous subject, the cacoplastie or degenerating tendency may have been already manifest in enlargement and caseation of the lymphatic glands, or in the spontaneous forma- tion of indolent abscesses or ulcers; and in such a subject, any inflammation of the lung, however acute, may end in consump- tive destruction, through the imperfectly organized (aplastic), and therefore decaying, nature of its products, which go under the designation of caseous or yellow tubercle. In a person of this constitution also, the gray consolidation, diffused and granu- lar,1 may arise in the lungs without further cause than casual congestions or catarrhs, and sometimes without even these. It would take up too much of our space to trace this subject through all the handlings which it has received from various observers and commentators during the forty years which have elapsed since the above stated views were published; but so much light has been obtained from certain lines of research, that it will be necessary to give a brief account of the best ascertained facts concerning them, which may be ranged under these three heads: On the nature and changes of tubercle and kin- i " The constant form and shape that these miliary granulations present be- come another matter of inquiry, and it seems probable that they are some ele- mentary part of the lungs in a state of chronic inflammation. Broussais con- ceives them to be the lymphatic glands, whilst Andral considers them as the individual vesicles, or single terminations of the bronchi."—Rational Exposition, &c, 1828, p. 157. The question which I thus proposed so long ago has only recently been answered by the sagacious and careful investigations of Drs. Burdon Sanderson and Wilson Fox, who have pretty well proved that these granula- tions are hypertrophied portions of the adenoid or lymphatic glandular tissue, which is a normal constituent of the lung and other organs—in a measure thus verifying the conjecture of Broussais, and that independently expressed by Dr. Abercrombie in the passage before quoted. 42 PATHOLOGY OF CONSUMPTION. dred matters, which will lead to the subject of Caseation, or Fatty degeneration of tissues, and, in conclusion, to the Artificial produc- tion of tubercle by inoculation, suppuration. In serous and fibrous membranes, on the other hand, suppuration is a rarer result, because the vessels are few, and the effused corpuscles (sarcophytes) placed less within their influence."—" Principles of Medicine," 3d ed., p. 364. Referring to the above work for the further explanation and substantiation of this view, I would now add that mature re- flection and modern research have not shaken my belief in its ^-v correctness. Recent observations have given a clearer insight into the vital properties of the plasma and its representative sarcophytes, and have supplied more definite facts in the process of histogenesis; but the chemistry of the inflammatory process has not made similar advances, and has been too little con- sidered by the most modern writers. It is a subject that re- quires further experimental investigation ; but in the meantime I propose this view as consistent with our present knowledge concerning the chief varieties of abnormal nutrition. The rapid increase of the germinal matter or sarcophytes in inflammation is the result of that combination of increased flow of blood to the part, with obstruction to its passage throno-h it, which characterizes inflammation. The sarcophytes, thus supplied with abundance of pabulum, increase and multiply rapidly; and under the exciting influence of the oxygenating arterial currents, and of the heat evoked by it,thTs multiplying germinal matter displays all its lively properties of motion and migration, through the coats of the obstructed vessels, into the surrounding textures, where it exerts its digestive and'assimila- tive powers, which are communicated also to the o-erminal matter already existing in the cells ofjhe connective and other tissues; and if the inflammatory orgasm "(determination of blood, with obstruction) continues, the multiplying, dio-estino- and oxidating process goes on until the whole massts converted into pus, in vyhich the sarcophytes have become loose cells with liquid tritoxide of protein within and without. Such is the result in complete^suppuration, or abscess; in which the somatic SALUTARY RESULTS OF SUPPURATION. 69 life and integrity of the part is sacrificed to the molecular life and chemical action, ending in destruction of the tissues. This process of suppuration, although thus destructive to the part, and often producing other mischievous results, is never- theless one salutary for the body; being Nature's mode of re- moving a part so much injured by disease as to be incapable of living, and therefore liable to a much worse kind of decay, by putrefaction. In their active proliferation and power of assimi- lation, pus-globules evince the vital attributes of germinal matter, which resist the common chemical tendencies to putre- factive decomposition. But if by its own solvent and penetra- tive action, pus does not make its way to the surface, to be discharged outwardly, it after a time becomes inert; the cells collapse and form a curdy or cheesy putrid age, closely resembling in aspect and chemical composition, the softened cheesy matter of lymphatic glands ami yellow tuhej'cle. As in these instances, this change is accompanied by a considerable increase of fajtty matter; and it has long been noticed that the matter of old ab- scesses abounds in fatty globules. So the latter end of chronic abscesses is a closer approximation to the end of tubercle and sucli aplastic matters, involving the parts affectedTn a destruction more gradual £han that caused by suppuration and gangrene. ~ ButTfierehire many situations in which the formation of pus does not involve the destruction of tissue. Inflammation of mucous membranes causes an abundant formation and shedding of epithelium and mucus-cells, which after a time present all the characters of pus-globules; and the free discharge of these e may terminate the inflammation. This is the common course of catarrhal inflammations. And further, where the inflamma- tion is deeper, involving the submucous tissues, and even the connective tissue and parenchyma, so long as the sarcophytes, proceeding from the bloodvessels and proliferating in the tissues, retain their vital properties of motion and migration, they may likewise escape to the surface and be thrown off; and thus the products of bronchitis and pneumonia may be cleared away by free mucous*and purulent expectoration. But if the sarcophytes are deficient in these subtle properties of migration, and prem- aturely form granular cells (" formed matter," Beale), which cannot escape, but choke up the tissues, then is produced the red and gray hepatization, which if the inflammation continue, may pass on to the state of purulent infiltration, or may other- wise remain solid, as in caseous pneumonia, and other caco- plastie consolidations of the lungs, subject to the usual processes of fatty softening and decay. One or other of these evil results is to be feared, when, after the active stage of pulmonary in- flammation, the pulse continues frequenfTthe heat keeps high, and the physical signs of obstruction and consolidation of the 70 PATHOLOGY OF CONSUMPTION. lung persist, with perhaps increasing liquidity and coarseness of the crepitation in parts.1 On the other hand, a favorable issue i Such cases as the following are uncommon, but they teach us not to condemn all such as hopeless : . Case 2.—A married lady, aged 44, of consumptive family, was attacked in Dec , 1869, with double pleuro-pneumonia. I had attended her in a slighter attack on the right side, two years previously. Two-thirds of the left lung, and the lower third"of the right were now involved ; and in spite of blistering and other treatment, the disease went on to hepatization, with dulness and large tubular sounds on both sides, but on the left, extending through nearly the whole lung. The strong vocal vibration showed that there was no liquid in the pleura. The orthopnoea was distressing, and aggravated by a very sick stomach, which rendered the exhibition of food and medicine very difficult. In the third week from the beginning of the attack there was no amendment. Pulse 120. Jleat, above 100°. Sweats and purulent expectoration followed, with great loss of flesh ; and the increased liquidity of the crepitus in parts of the left lung seemed to threaten softening and excavation. Just then a boil in the left axilla, which followed the blistering, began to assume large dimensions, and in a few days a large abscess formed, and being opened by Mr. Squire, of Orchard Street, dis- charged a large quantity of healthy pus. From this time the stomach recovered its tone; food and stimulants, and cod-liver oil and tonics, were well borne; the pulse and temperature fell, and the chest symptoms subsided. But the most re- markable change was in the rapid restoration of the lung to a nearly healthy state, the chest sounding much clearer, the vesicular respiration returning, and the only sign of disease remaining was some dulness and a little crepitus at the left base. The abscess continued to discharge for six weeks, but the general health has since continued good, without cough, with increased flesh, and with on'y some remaining shortness of breath. This lady is now (June, 1871) stout and well, except some shortness of breath. The sudden subsidence of the lung disease on the occurrence of the large abscess externally, is strongly suggestive of a translation of the sarcophytes—by some way or other—perhaps by some migratory process more direct than through the bloodvessels. Case 3.—Mr. ----, set. 45. March 3, 1866 (seen with Dr. Humby).—Strong and active, and in constant habit of lecturing to large assemblies. A fortnight ago, after a. chill, had a rigor, followed by pain in chest, cough and rusty ex- pectoration, with signs of consolidation of left lung (lower two-thirds). To-day there is less dulness, but large liquid crepitus, impaired breath, and bronchial rhon- chi in lower half of left lung. Cough violent; sputa mucopurulent. Profuse sweats. Is taking Dover's powder, and has been blistered. Nitric acid, calumbo, and glycerine three times daily. Morphia linctus at night. 10th.—Was better till two days ago ; after talking on business, the cough has become more violent; with much purulent expectoration; the pulse weaker and more frequent; and there is great failure of strength and appetite. Has wasted much. Clammy sweats Dulness, with large tubular sounds and gurgling at and below left scapula ; coarse crepitation, and tubular pounds are heard now above right scapula also. To take cod-liver oil, with nitric acid, strychnia, and columbo ; back to be painted with iodine. Wine and nutriment increased March 22d.—After a few more doubtful days, began to amend: taking more food, and cough and expectoration moderating, especially in the last week Pulse reduced to 80. Perspirations have ceased. Less dulness and more vesicular sound in left lung; loud bronchophony at and within left scapula ; right lung clear. April 5th.—Convalescent; rapidly regaining flesh and strength ; cough slight- expectoration mucous. ' Dulness and tubular sounds much diminished, and a rough vesicular sound in left lung. ' 1871.—In two months resumed his lectures, and has been strong and active ever since. FAVORABLE SUPPURATION — SYMPTOMS. 71 may be expected, for the present at least, when there is a re- duction of the frequency of the pulse and heat of the body : when the cough either subsides, or becomes looser and accom- panied by easier and sometimes more copious expectorating of opaque matter, abounding in corpuscles, more or less of the pus- cell character, but presenting considerable variety in size and form. The occurrence of this expectoration is by no means constant, for in many cases, especially in the young, pneumonia subsides without cough or expectoration, the inflammatory pro- ducts being dispersed by absorption. When it does occur, it gives us some insight into the changes of these products which accompany their dispersion ; and in the bland inadhesive quality of the sputa, with a diminution of the viscid and saline con- stituents, and an increase of the granules and fat, we can trace a resemblance to the process of fatty degeneration and disin- tegration of larger deposits; only in the latter case, the lung- tissue is involved in the decay, whereas in the case under con- sideration the matter expectorated contains the exudates only, and shows no fragment of the lung-tissue under the microscope. The resolution and dispersion of the inflammatory consolida- For about a week both general symptoms and physical signs seemed to announce breaking up of the lung ; but this happilv was averted. Case 4. — Mrs.----, set. 30. April 29th, 1868 (under Mr. Theoph. Taylor).— Without any previous ill-health except menstrual irregularity, after a chill, ten days ago, was attacked by vomiting and sharp pain of right side. At first the pain was supposed to be from gall-stones, as there was absence of bile in the feces, but cough followed, with catch in breath, rusty expectoration, scanty, dark urine (slightly albuminous), and hot skin. Dulness in whole right chest; most in lower half (which is tender on percussion), with crepitation in several parts; fine in axilla, near sternum, and above scapula; tubular sounds atand above scapula. The case (obviously pneumonia), was treated with effervescing saline with nitre, calomel, and morphia at night, and repeated blisters. It went on to complete hepatization of the lung, which at the end of the second week showed no signs of resolution, the dulness being still extensive, with large tubular sounds, and no crepitus or breath in the whole side. In a few days the ex- pectoration became purulent, and coarse gurgling crepitus was heard in the large tubes. The pulse was still 120, and the weakness and perspirations increasing, although wine and liquid nutriment had been freely supplied. The patient had a strong prejudice against cod-iiver oil, and it was only after'much persuasion that she was induced to take it, which she did without difficulty in a mixture of nitric acid and orange infusion. The improvement in the general symptoms was striking, the pulse coming down in frequene}-, the sweats ceasing, the cough and expectoration moderating, and the appetite increased. The chief change in the physical signs was in the diminution of the liquidity of the large crepitation ; but the large snuffling bronchophony, simulating pectoriloquy, at and above the scapula, and the persisting intense dulness over a great part of the right lung, made it for a long time doubtful whether it would recover its normal state. The flesh, and in some degree the strength, were restored several months before the breath and the healthy sounds of the lung. In the spring of 1869, a year after the attack, an examination was made, and there was onlyslight dulness and deficiency of motioyi of the right chest, and a gene- ral vesicular breathing less soft and uniform than on the left side. There has been no recurrence of pulmonary symptoms since (1871). 72 PATHOLOGY OF CONSUMPTION. tion may be complete, leaving no trace behind ; or it may be partial, sufficient to remove present danger of destructive sup- puration, or of caseation, but leaving patches of consolidation; and these, if not gradually dispersed by the improved circula- tion and respiration of restored health, may prove sources of future irritation and obstruction, and become the nuclei of re- current disease. The signs of these remnants of consolidation are commonly patches of dulness, with weaker or partially ob- structed breath-sound, sometimes with roughness or slight remaining crepitus in the affected part. But a very common sign of remaining disease is a tubular sound, often loud, above one or both scapulae, most frequently the right; and this comes on sooner or later, even when the lower lobes of the lungs alone have been previously the seat of disease. I believe this sign to arise from enlargement of the bronchial glands, which, pressing on the lung, conduct the sound of the tracheal breath and voice through it. I have had few opportunities of__verifying this by examination after death, as patients rarely die at ..this stage; but it is almost proved by the seat and nature of the bronchial sound, and the fact that it seldom supersedes the vesicular sound of the spot; and if it affects the stroke-sound, it is by adding somewhat of a tubular note, rather than deadening it. I notice these observations here because, if my inference is correct, it throws light on the pathology, in showing the share which the lymphatic system has in the subsidence, as well as in the devel- opment, of this class of diseases; the corresponding lymphatic glands swelling as the reabsorbed matter passes through them. It is rare to find the bronchial glands free from disease in chronic tubercle of the lung; and I have long been in the habit of pointing to this in the dead-house, as one of the proofs of absorption of tubercle. InJ;hese chronic cases, the_ matter ,, ^found in the glands is commonly old, being cheesy or calca- reous; but the examples I have cited above are recent, and show how these glands may be first affected. After the preceding analysis of consumptive diseases of the lungs, we shall be able to construct a table, with comments, presenting a synthetic view of the inflammatory and tubercu- lous lesions of the lungs which are met with in the consumptive. This mayserve as a key to explain the varieties, contrasts, and complications in the morbid appearances, and the very o-reat diversity in the symptoms, signs, course, and duration of the malady in differeut cases. As strictly bearing on this subject I quote the following propositions, to which I was led more than' thirty years ago, and which I venture to believe are now receiv- ing their detailed demonstration : " Lymph, pus, and tubercle are the same albuminous matter and differ from each other in mechanical condition and suscep- GRADATIONS OF LYMPH, PUS, AND TUBERCLE. IS tibility of organization, rather than in their chemical nature. .....We can readily perceive that these different prop- erties, although possessed by matter chemically the same, and from the same source, must lead to all that variety of results which we know to follow, respectively, organizable, purulent, and (yellow) tuberculous deposits. But the characters of these matters are not always distinct; lymph is not always equally organizable, nor perfectly free from the greenish color and dis- integrating globularity of pus, nor even from the lifeless curdy particles of (yellow) tubercles; and tuberculous matter often contains flakes or fibres of imperfect lymph. The diffused tu- berculation or infiltration of the lung from inflammation gen- erally presents a matter in this transition state. It is neither good organizable lymph, nor is it wholly unorganized tubercle; and the albuminous (curdy) effusions on serous and mucous sur- faces not unfrequently present such an intermediate state that it is difficult to determine to which class they most belong. L//»)p/i, pus, and tubercle pass by imperceptible gradations into each other. The history of the intermediate products has yet to be more fully studied; and it is a subject of immense importance, for they probably constitute those forms of phthisical lesions which it is most within the power of medicine to control.'1 In accordance with the view here given, it maybe stated that, although the protoplasm, from changes in which all these mor- bid products proceed, does take the distinct forms defined in the following table, and in different examples, one or other of these forms may so predominate as to distinguish the disease into characteristic groups, yet most cases present less marked distinctions, and comprise a mixed history of various propor- tions of lymph, pus, and gray and yellow consolidations, in the varying course of the consumptive malady. 1 Pathology and Diagnosis of Diseases of the Chest, 4th ed., 1840, p. 166. Tabular View of Elements of Consumptive Diseases, and their results. I. Hyperplasms from blood- vessels in- flamed, or congested. in lymphat- ic system, ( Liquid Fibrin. Sarcophytes. 1. Liquid Fibrin. 2. Sarcophytes, or germi- nal matter. Ditto. Ditto. 3. Albumen; mucus; epi- thelium and other cells andgranules; red blood- corpuscles, &c. II. Hyperplasms j. Sarcophytes and trabec- ula in glands 2. Sarcophytes in minute adenoid tissue of lungs, &c. 3. Sarcophytes in leukae- mia. Condition. Healthy or euplastic. Healthy and active. Unhealthy or cacoplastie. Unhealthy. A. Active, with over-oxi- dation by arterial blood. B. Proliferating, but con- crete and inactive. C. Inactive and aplastic. Combined with the above, Multiplied and increased. Multiplied and concrete. Multiplied, with deficiency of red corpuscles in the blood. Products. Fibrils in connective tissues. Tissue cells and nuclei. Fibroid or scar tissue. Pus-cells, with liquid trit- oxide of protein; pro- liferating and assimila- ting other tissues into pus. Red, pale or gray indura- a tions of lung and other j b. tissues. Caseous hepatization. a, \b. ind partaking of their changes Ulterior results. Well organized ; or reabsorbed. Well organized; or reabsorbed.) a. Dense, tough, and contracting. b. Degeneration and caseation. Discharging from free mem- brane. Suppurating into abscess, and discharging. Imperfectly suppurating and caseating. Withering and cornefaction. Decay by caseation and soften- ing. Early softeningand excavation. Obsolescence and calcification. and results. Enlarged and indurated glands. Miliary tubercles. Suppuration, caseation, calcifica- tion. Caseation and softening, calcifica- tion, obsolescence. Soft swellings of lymph tis- Occasional suppuration or casea- sues in glands, spleen, j tion. &c. | Atrophy of other tissues. CONSUMPTIVE DISEASES. 75 CHAPTER VIII. CLINICAL AND PATHOLOGICAL VARIETIES OF CONSUMPTIVE DISEASES, EUPLASTIC AND CACOPLASTIC. Phthinoplasms, or elements of Consumptive disease—Their origin and re- sults—Divided into those of the bloodvessels and those of the lymphatic system—Clinical and pathological varieties of Consumptive diseases, euplastic and cacoplastie—Of inflammatory Phthinoplasms ; the fibroid is the highest, tending to contract, and endure long without decay— But it dwindles, and is attended with evidences of wasting—Effects of fibroid in the lung ; scars ; dilated bronchi; emphysema. The preceding table will supply a key to explain the leading varieties of consumptive disease with which clinical experience makes us familiar, by referring them to the predominance of one or other of the elements here specified. The first two on the list, representing the most healthy hy- perplasms produced by inflammation, do not in themselves tend to induce consumptive disease. They are supposed to occur in otherwise healthy subjects; and, although they are morbid in their superfluity, yet they have in themselves either sufficient vitality to assimilate them to the affected tissue, or sufficient vitality and divisibility to be removed by reabsorption. But what begins as healthy inflammation may become deteriorated through mistreatment or neglect, or other unfavorable circum- stances, or bj- the repeated application of the exciting cause; and then some of the more unhealthy results follow ; and so the healthy hyperplasms may be combined with, or turned into cacoplastie or aplastic products. The converse takes place more rarely. A person previously unhealthy recovers health; and then an accidental inflammation may produce euplastic results, to be well-organized or dispersed without any evil con- sequences. Unhealthy inflammations evolve two classes of hyperplasms, with less or more of a degenerative or consumptive tendenc}': (1) the fibroid, and (2) the corpuscular, each of which has several remarkable varieties. 1. Fibroid hyperplasms are probably in part formed from the fibrilhe of the fibrin exuded from inflamed vessels; possibly also by hypertrophy of pre-existing connective tissue. A great part of the tough consolidations produced in the lung by pro- longed subacute or chronic inflammation consists of a fibrous material, which assumes the form of irregular connective tissue. 76 PATHOLOGY OF CONSUMPTION. They may owe their origin to the variety of pulmonary inflam- mation which I long ago1 distinguished as the interstitial kind, and leading to a non-granular form of hepatization. To this varietv, without recognizing its cause, Laennee gave the term of carnification. It occurs hi" pleuro-pneumonia when the pres- sure of the pleural fluid on the lung restricts the plastic effusion to the interstitial texture, without any granular formations in the air-cells. This is the most common origin of extensive fibroid disease of the lung; and its nature is evident in the ac- companying proofs of previous inflammation—the general adhe- sions (often of the same tough character) of the pulmonary and costal pleura of the affected'lung. But there is also, probably, a peculiarly fibrinous state of the blood, which Eokitansky calls a fibrinous eras is, in certain cases, rendering the products of in- flammation more fibrinous than usual, and with smaller propor- tion of the corpuscular element; and tending, therefore, to produce more fibroid or contractile tissues, and less of the puru- lent and opaque curdy deposits which originate in the corpus- cles or sarcophytes. In whatever way fibroid disease of the lung may have origi- nated, its ultimate tendency is either to contract and condense the textures in which it is formed, or to degenerate and disinte- grate into cheesy matter. The remarkably different effect of this condensation and contraction, according to its seat, has already been pointed out. When affecting the upper parts and root of the lungs, it contracts and constricts the large bronchi, causing an asthmatic difficulty of inspiration and expiration, and an emphysematous distension of the lower and peripheral vesic- ular texture. When, on the other hand, the condensation and contraction affects the lower lobes and obliterates the peripheral air-cells, the bronchi become generally dilated by the pressure of the inspired air within their walls, as it cannot penetrate to the cells beyond. This is the explanation which I originally gave of the dilatation of the bronchi which follows contractile pleuro-pneumonia, and which was subsequently ascribed by Corrigan and his followers to a new tissue called cirrhosis, to which was imputed the paradoxical power of dilating the bronchi by contracting around them ! But it is obvious that the dilating power is the pressure of the air in inspiration, which, failing to penetrate beyond the tubes, is exerted in distending them. The contractile property of the fibroid tissue is manifest in the shrinking of the lung, and in the drawing towards it of the walls of the chest, the heart, and the opposite luno-5 to occupy its place. Thus, when the left lung is affected, in addition to the collapse of the ribs, the heart is drawn upwards, and may 1 Cyclopaedia of Medicine, Article " Pneumonia," 1833. EFFECTS OF CONTRACTILE PHTHINOPLASMS. 77 be felt with its apex beating at or above the fourth rib, and its body in contact with the ribs to the third costal cartilage; and the right lung may reach to the left of the sternum above. When the right lung is contracted, besides the flattening of the walls of the chest, the heart is drawn over to the right of the sternum, with its apex beating between the fourth and fifth costal cartilages, with the left lung sounding clear above it. So, likewise, other adjacent organs, the stomach and the liver, may be drawn up into the chest by the contractions of the lungs above them; and the upper and posterior walls of the chest may show depressions or flattenings from the same cause. This contractile disease of the lung, consequent on inflamma- tion, although an evidence of cacoplasis and degeneration, does not in all cases end in decay or consumption. In some in- stances, especially in young subjects, it may give way to a gradual re-expansion of the affected lung, and a restoration to the normal state. [Cases will be given afterwards.] Yet fibroid disease may properly be grouped among the varieties of phthisis; both because in most instances it is attended with symptoms of decline, and shows a tendency to degenerate further by its own caseation, and by the production of miliary tubercles in other parts of the lung; and also because in other varieties of phthisis, already tuberculous or caseous, inflammation of the lungs com- monly produces more or less of this fibroid tissue in the more healthy parts of the decaying lung. It is, in fact, a modification of this which constitutes the scar tissue around and between tuber- cles and their vomicae, and which tends, by its condensation and contraction, to pucker up and cobble together the wounds and breaches of the more destructive decay. In almost a 11 of the more chronic kinds of phthisis there are proofs of the~presence and operation of this contrac_tiJeJ:is8ue during life, in flattening or hollowing ofcor responding parts~oTThe chest-walls, or in the signs of partial emphysema in the adjoining portions of lung; and after death, in puckered scars on the surface and in the substance of the lung, around cavities or remains of caseous or tuberculous matters. In the more rapid forms of consumption there is neither time Tior"material for the formation "of this fibroid scar tissue. "The exudations and deposits are corpuscu- lar, more destitute of vitality, and therefore aplastic; passing speedily into disintegration and decay. BuJ^ in chronic cases, there is an attempt to limit and hedge in the work of destruc- tion ; and although this is done by a cacoplastie material, and in a clumsy "and "irregular manner, it may be looked on as* a proof that nature is capable of exerting some resistance to the consuming malady. In such"cases the clinical history of the malady will show the svmptoms and signs of partial emphysema and bronchitis, iu 78 PATHOLOGY OF CONSUMPTION. addition to those of phthisis. Occurring, as tuberculous lesions commonly do, mostly near the apex and root of the lungs, the puckering and contraction of the scar tissue around them may shorten and narrow some of the chief bronchial tubes, with the effect of causing more rhonchi and wheezy prolonged breathing instead of tubular, and more emphysematous stroke-sound in patches, instead of the general dulness of consolidation. We \ were before led to this same conclusion, that chronic cases of /consumption frequently assume more or less of an asthmatic • character, which h^s some tendency to divert the disorder from i the substance of the lungs to the bronchial surface. "But to complete the history of these fibroid productions, and to prove their connection with phthisis, w.e have to point to the other ulterior, results mentioned in the table; they are them- selves liable to degeneration and caseation. In most cases of confirmed phthisis, even of the chronic kind, sooner or later there conies a break up—a failure of the vital powers and a sudden increase and prevalence of the work ofdecay._ It may be occasioned by any weakening or greatly disordering influ- ence—an exhausting hemorrhage or diarrhoea; a harassing in- flammation; any cause of severe mental depression or bodily weakness; or the decay may be gradual and progressive. But the change is manifest'in the increasing weakness, pallor, ema- ciation, and colliquative sweats; in the occasional hard cough and wheezy breathing giving way to constant loose expectora- tion and panting breathlessness, the sputa being copious, opaque', and heavy; in the substitution of more moist and cavernous sounds in the breathing for the bronchial or wheezing rhonchi which existed before. Then come increasing weakness of cir- culation, oedema and lividity, and the end is not far off. In the lungs of these genuine victims of chronic consumption are found the evidences of decay, not only in the old cavities spreading, and tubercles softening and forming new, but also in the opaque spots of caseation mottling the fibroid masses, and proving their degeneration; and in the numerous plump and soft (therefore newly-formed) miliary tubercles scattered through the less dis- eased parts of the lung. These are the signs and seeds of decay spreading and invading both the healthy tissues, and the frail barriers which nature had raised against it. VARIETIES OF CONSUMPTIVE DISEASE. 79 CHAPTER IX. CLINICAL AND PATHOLOGICAL VARIETIES OF CONSUMPTIVE disease—continued. Inflammatory Phthinoplasms—Corpuscular, from change in the Sarco- phytes—Suppuration, if healthy, not Phthisical, but unhealthy often so ; and also often part of the Consumptive process—Purulent Phthisis —Causes. But although we thus find the fibrous element of hyperplasms amenable to the law of degeneration and decay, it is in the cor- puscular element, the sarcophytes or bioplasts, that wTe can more commonly and constantly trace its workings. These, which in their healthy and vigorous state, are so lively in their moving, self-nutrient, assimilating, organizing, and prolifera- ting powers—in their unhealthy and enfeebled condition fail in these manifestations of vitality, and form a material more or less perishable and prone to decay, spreading degeneration and dilapidation in the adjoining tissues. It will be an interesting subject for further investigation to trace the operation of this bioplasm in the more normal varia- tions from healthy nutrition in mere determination of blood to a part, and in simple membranous inflammation, soon termin- ating in increased secretion, resolution, and the dispersion of its products; and still further to observe it working in adhesive inflammation, and in the healing of the simplest wounds by " first intention." In all these operations the bioplasm exer- cises its full vital properties, and the result is a living structure abiding and conforming to the nature and habits of the tissue of the part. This is all euplasia (healthy healing), hardly differ- ing from normal nutrition, and tending to no decay. But when inflammation becomes intense, or endures long, the hyperplasia exceeds the bounds of euplasia, and the bioplasm suffers in its vital properties, and tends to form products more or less prone to disorder and decay; in other words (as I ex- pressed them forty years ago), the results of the inflammation are less vital and less susceptible of lasting organization, and constitute a material producing further disorder, and sooner or later falling into decay. We are now able to define more pre- cisely the kind and form of these degraded products of the plastic process, and some at least of the particulars in which they differ from each other, and from the healthy sarcophyte 80 PATHOLOGY OF CONSUMPTION. or bioplast, which is the representation of healthy nutrition. For in declaring the corpuscles of the fibrinous exudations of inflammation, pus-cells, and gray and yellow tubercles to be only modifications of the same sarcophytes, which are known as the pale corpuscle of the blood and the lymph-globule of the lymphatic system, I only express what all the most recent and most careful observations have concurred to establish.1 In the remarks preceding the table, and in the table itself (p. 74), an attempt has been made to explain the nature of these variations from the healthy sarcophyte; the truth of this explanation has to be tested by further investigation. In the meantime, a brief further consideration of these elementary variations will supply an intelligible clue to the diverse forms and phases which we meet with in consumptive diseases, and may help us better to understand their nature. The first morbid variety of the sarcophyte presented in the table is the pus-cell, which, although still lively and proliferat- ing, is distinguished by its solvent and disintegrating power. This is undoubtedly a frequent element of consumptive disease; for there is more or less of suppuration or ulceration, mixed up with the advancing work of phthisical destruction in the lungs and other parts of the body. But the formation of healthy pus in suppuration and abscess, although consuming and destroying tissues, does not carry with it the progressive habit of destruc- tion, such as we find in true consumptive disease. On the con- trary, suppuration tends to rid the body of the destroj-ed matter; and under the protective and repairing power of the healthy and active sarcophj-tes and tissue-cells of the empty abscess-walls, the breach is repaired and the part is healed. Healthy suppu- ration, therefore, has no tendency to produce consumption; and I can cite numerous cases of abscess of the lung ending in com- plete and comparatively speedy recovery. It is far different in scrofulous abscess, or in any kind of sup- puration in unhealthy subjects. Not only is the pus in these instances imperfectly formed, and mixed with flakes and curdy matter, which render the suppuration incomplete and the abscess cold and chronic, and as likely to caseate as to discharge, but the surrounding consolidation is formed of cacoplastie material tending either to contract or to caseate, according to its decree of degeneracy, and perhaps, too, according to the predominance of the fibroid or of the corpuscular constituents. These results must be referred to defective vitality of the sarcophytes, which i In Dr. Burdon-Sanderson's interesting lectures on Experimental Pathology in the Medical Times and Gazette of the present year, and in his able essay on the Process of Inflammation in Holmes's System of Surgery, the reader will find an admirable summary of the most recent researches which have been made on this and kindred subjects. PYJE.MIA AND TUBERCULOSIS. 81 instead of actively completing the processes of clearing, resolu- tion, or suppuration, choke up the textures with an obstructing and decaying matter, which involves them in continued disorder and consumption. Undoubtedly, also, suppuration and ulceration are largelv concerned as secondary results of the softening and breaking up of tubercles and other cacoplastie consolidations of the lung. Where there is intervening healthy tissue with sufficient circu- lation, inflammation may be excited, and go on to the more complete formation of pus and partial abscess; and often in phthisical lungs little abscesses containing chiefly pus may be found between the tuberculous cavities. The common, and sometimes abundant, presence of pus in the expectoration of the consumptive might be supposed to be another proof in point, but it must be admitted with some reserve, as much of this often proceeds from the bronchial membrane. Still, this is part of the general process of consumption ; and where the larynx is also affected with ulceration, we have exemplified another form of the disease—laryngeal phthisis. There is another relation, which the formation of pus bears to consumptive diseases, which must not be overlooked. The outbreak of pulmonary consumption, even in its most destructive forms—acute tuberculosis and scrofulous pneumonia—has, in some instances, been preceded by the existence of an abscess or purulent wound in some other part of the body. The most com- mon case is that offistula in ano, but I have known the sequence after abscess in the jaw, in the cervical glands, in the inguinal glands, and lumbar abscess, and not always in cases distinctly scrofulous.1 The sudden healing of old ulcers, and of the sup- purating wounds of setons and issues, is often quoted by authors as a cause of pulmonary consumption; but it is not clear that the cessation of the discharge may not be due to the morbid change in the lungs having already begun. Compared with the artificial production of tubercle in animals, which we shall hereafter notice, it appears as likely that the presence of pus in an}' part, whether by production or inoculation, may have a deteriorating influence on the sarcophytes of the blood and lymphatics, as that the cessation of suppuration should have a similar effect. But it is quite rational—and, perhaps, the safest view—to admit both influences in different cases. A comparatively healthy subject may, under some unknown con- ditions, get his blood contaminated by the occurrence of sup- puration in any part of the body. A scrofulous subject, whose blood always abounds in sarcophytes of low vitality, which have been habitually drained off by a suppurating wound, is likely 1 Examples will be given in the abstracts of cases. 6 82 PATHOLOGY OF CONSUMPTION. to suffer from their accumulation and mischievous effects in other parts, if this wound be suddenly healed. In the latter case, the decaying material, which was escaping from the body, is retained. In the former case, a deteriorating or decaying influence set up in a part is communicated to the contents of the lymphatics or bloodvessels, and results in a degeneration of sarcophytes into pus-cells or concrete adenoid corpuscles; and thus, under certain unknown conditions, a suppurating wound may produce pyaemia or tuberculosis—[ say unknown conditions, for the sequence is rare compared with the very common pro- cess of local suppuration; but as the occurrence of pyaemia seems to be promoted by close habitations, foul air, and con- centration of animal effluvia, so it may probably be found that similar influences, associated with damp soil and malnutrition, favor the production of tuberculosis as a result of the deteriora- ting influence of a local suppuration on the living sarcophytes. The zymotic character of these developments of pyaemia and tuberculosis may be further argued from the increasing evidence which we have of the preventive and salutary influence of anti- septics, and, above all, of the pure dry air of a healthy locality; or, better still, of a high mountain. This subject will claim our attention again under the head of Treatment. CHAPTER X. VARIETIES OF CONSUMPTIVE DISEASE; INFLAMMATORY phthinoplasms—continued. Eed and gray Indurations of the lung ; consist of multiplied concrete Sar- cophytes, with more fibroid, tending to contract and wither ; with less fibroid, tending more to caseate and'excavate—Varieties and Results- Obsolescence and Calcification. Leaving the suppurative element of consumption, we now come to that which consists in the sarcophytes becoming con- crete and comparatively inactive, although they retain at first their proliferating powers, so that they multiply into numerous cells, which stuff and condense the containing tissue. This in the pulmonary texture, forms a consolidation, at first red and of moderate firmness and consistency; but as the multiplying cells supersede the bloodvessels and their contents, the solid becomes harder and of a light buff color, which may be rendered more or less gray^ by the black pulmonary matter which is not re- moved. This consolidation may occur in small spots or iu RED AND GRAY PHTHINOPLASMS. 83 lobules, or may extend to one or more lobes. The latter more diffused variety commonly arises from pneumonia or pleuro- pneumonia of a subacute or chronic type, and occurs chiefly in the lower and middle lobes; whilst the lobular or'more limited variety may originate in phlegmonous bronchitis, and affect the upper lobes in preference. It is this last kind of consolidation which is induced in persons habitually exposed to cold and damp, or to the inhalation of an atmosphere containing dust of an irri- tating nature, as in the occupation of stone-masons, coal-miners, dry-grinders, feather-cleaners, and millers. The cold in the one case, and the dust in the others, excites bronchial inflammation, which, on continued operation of its cause, gets deeper and deeper, affecting first the bronchial membrane, then the con- nective tissues underneath, and eventually the pulmonary tex- ture of individual bronchial bunches. As the inflammation penetrates deeper, the hyperplasm which it produces is less readily thrown off. The sarcophytes thrown out by inflamed mucous membrane pass off in form of mucus and pus-cells and epithelium; but those in the deeper tissues are retained in a concrete form, and by accumulation constitute the consolidations of the pulmonary texture. This latter result is favored by any constitutional cause lowering the vitality of the sarcophytes, such as scrofula, syphilis, irregular living, and other influences which degrade the standard of nutrition. The different forms and varieties of red and light or gray in- duration of the lung-texture thus induced, correspond with the carnification and gray tubercular infiltration, chronic hepatiza- tion, red and gray, of Laennee and Andral, and with the albu- minous pneumonic solidification of Dr. T. Addison; the iron- gray induration of the last author beiug a more chronic form of the same lesion. In those varieties resulting from the inhala- tion of dust, the presence of particles of the dust may add an- other anatomical character; and in the case of coal dust, the very striking one of completely blackening the consolidations. Without dwelling further on their details, we go on to notice the ulterior results to which they tend, as mentioned in the table (p. 74)—a withering and coruefaction, and decay by case- ation and softening. It has been before mentioned that red consolidation in time becomes pale from the multiplication of its constituent cells superseding the bloodvessels and their colored contents; and subsequently gray by accumulation of black pulmonary matter; and if the consolidation endures in its low vitality, without going into caseation and decay, it uudergoes more or less of a wither- in o- or dwindling process, somewhat like the contraction and hardening of the fibroid or scar-tissue; but being much more corpuscular than fibrous there is less shrinking and more drying 84 PATHOLOGY OF CONSUMPTION. I up of the material, so that it becomes more leathery or horny in substance, and of darker hue, from the increase and approxima- tion of the black pigmental matter of the lungs. The gray con- solidation thus withers and darkens with age, and passes into a state of obsolescence not liable to further change. This result, it" //^e^.to^ahirge extent, is not very common, and occurs chiefly m old Objects, and renders them less liable to more destructive and .. :\ generally chronic. But limited specimens of this gray wither- ing of old consolidations, without any scar or remnant of yellow (tubercle, are not uncommonly found at or near the summits of the lungs in persons who die of other diseases, and may be con- sidered evidence of pluthinoplastic deposits arrested in their earlier stage. But the more common tendency of the chronic consolidations of the lung-tissues is to caseation and softening, which we now identify with fatty degeneration and disintegration, and which was mysteriously characterized by Laennee as a new stage or change from the infiltrated gray tubercle to the yellow crude and softened tubercle. That the diffused gray induration of the lung is of inflammatory origin was generally concluded, in op- position to Laennec's views, by many of his contemporaries, and this view was adopted and extended by Dr. T. Addison, who very ably traced the inflammatory origin of several varieties of solidification of the lung, distinct from tubercle, and yet leading to the same consumptive decay.1 He described these consolida- tions, produced by inflammation, as persisting for a time, and then either becoming more indurated, or being hollowed into cavities resembling those of tuberculous phthisis, yet sometimes quite distinct from them; in other cases combined with them and affecting their course. He specifies the three kinds of in- flammatory consolidation: the uniform albuminous, the granu- lar, and the iron-gray induration. The albuminous and the iron- gray correspond with the pale and gray indurations which I have been in the habit of designating cacoplastie, and form the varieties of chronic induration which have just been described. The granular induration is that state of lung-tissue correspond- ing with granular hepatization, more aplastic, and tending to break down soon, and to form cavities. It appears to me that the albuminous and gray indurations are only different phases of the same change at different periods and in different subjects; the albuminous pale consolidation affecting younger subjects and at an earlier stage; and the gray being the result of longer du- ration and at an older age. But all these consolidations are produced by sarcophytes 1 Collection of the Writings of Dr. T. Addison, New Sydenham Soc. 1868. INFLAMMATORY PHTHINOPLASMS. 85 multiplying and becoming concrete in the lung-tissue, with more or less tendency to disintegration and decay in the way of fatty degeneration and softening. The least tendency to this change is in the more uniform hyaloid and fibroid indurations, which have been recently noticed in their converse disposition to chroniccontraction and withering. The greatest disposition to Tin? destructive change is manifested in opaque consolida- tions, commonly more or less granular on section; and under the microscope showing a great crowd of corpuscles or granular cells, in which fat-globules already show themselves in consid- erable numbers, portending the organic instability of the mate- rial and its proclivity to break up and decay. If with this we contrast the character of euplastic matter, as manifest in the sar- cophytes or bioplasts of a healing process or of a healthy inflam- mation—all transparent, gelatinous, teeming with vital prop- erties of motion and formative and nutrient power—we can form some conception of the different tendencies of the two products; the one bringing new life and living material to a work of reparation, the other clogging the tissues with opaque, sluggish, inorganizable corpuscles, either lifeless or of the weakest vitality, and doomed to speedy dissolution and decay. Let us bear in mind also how these cacoplastie products of in- flammation injure the nutrient power of the textures in which they are crowded. Compressing the bloodvessels, they deprive the nuclei or bioplasts of the tissue-cells of their pabulum from the blood, these consequently starve and waste, and soon partake of the decay of the encroaching material; and all break down together into a caseous mass, which softens and makes its way into the bronchi for expulsion. CHAPTER XI. VARIETIES OF CONSUMPTIVE DISEASE. INFLAMMATORY phthinoplasms—continued. Caseous Hepatization—Sarcophytes lifeless—Scrofulous Pneumonia—Soon softening and excavated, or drying and calcifying—Infecting, or en- cysted. The advanced or caseous stage of the pulmonary indurations, noticed in the last chapter, is in some cases presented from the first in wrhat may be called the aplastic or caseous consolidation of the lung, the direct result of acute scrofulous pneumonia. The effused matter is at first in a curdy opaque condition, without signs of plastic activity or capacity in its constituent elements, 86 PATHOLOGY OF CONSUMPTION. which are numerous granules, irregular cells, and their frag- ments, so loosely cohering together that they form only a soft cheesy mass, choking up the proper tissues, and speedily run- ning into fatty decay and partial suppuration. This caseous consolidation, being not circumscribed bj' induration, may ex- tend to a large part of a lobe, a whole lobe, or more; but some- times it is confined to lobules, not extending through the interlobular divisions. A variety of it seems to have its seat in the bronchial tubes and alveolar texture ; and it has been stated that the effused matter consists chiefly of epithelium; but this is of rare occurrence, and does not warrant the assertion which has been made, that all cheesy deposits are to be referred to "catarrhal pneumonia." In all probability, any acute form of pneumonia or broncho-pneumonia in a scrofulous subject may end in caseous consolidation, and thus produce an acute phthisis or " galloping consumption ;" and we here have occasion to refer its rapidly destructive tendency to the lifeless and aplastic nature of its products, and their consequent proneness to early decay. But caseous consolidation may be so limited that although it destroys the part, yet it may not extend to other parts of the lung or infect the system at large. Clinical instances of this may have occurred in those cases in which after an attack of inflammation signs of excavation become evident in conjunc- tion with the expectoration of opaque matter; after which the cavity contracts, the wound heals, and the patient recovers. More common is the necroscopic evidence met with in the bodies of those, who, after having recovered from an attack of inflammation, have died of some other disease; and there is found a cavity, lined with adventitious membrane, either empty or containing cheesy matter. If old, this exhibits more or less of the calcareous transformation, or calcification, a change to which all effete animal matter retained in the body is subject in time.1 This calcareous matter is chiefly phosphate of lime, and 1 Case 5.—Miss F. M., set 28; brother and sister died of phthisis. In 1839 was attended by Dr. W. for cough, with opaque expectoration, which lasted several months, with considerable loss of flesh. Slight partial dulness- harsh and tubular breathing were found at the summits of both lungs, most of the left, where there had been occasional pain. Under the use of iodide of po- tassium and sarsaparilla, with external counter-irritation, the cough abated and flesh and strength were pretty well restored. _ In 1841 a serious abdominal disease came on, attended with pain and indura- tion of a considerable extent of the small intestines and colon, ending in ulcera- tion and perforation of the ileum, and death. This was diagnosed to be carci- nomatous disease; and so it proved on examination after death, that a scirrhous growth had spread between the coats of the intestines to a great extent causino- both stricture and ulceration in several parts. It is unnecessary to dwell on this part of the case, which is cited in reference to the arrested disease of the CASEATION AND CALCIFICATION. 87 may be either the mineral ash or residue of the deposit after the animal matter has been dissolved or absorbed away; or it may be the result of a chemical concretion from the pervading fluids, like urinary calculi. In all these cases of partial casea- tion of the lung from inflammation the aplastic matter is hedged in by a plastic process in the surrounding texture, which forms a membrane or cyst, and the softened caseous matter may Both pleurae were partially adherent, especially at the summits of the lungs. At the apex of the left lung was a thick fibrocartilaginous patch, with puckering of the lung-tissue around its edge ; and underneath was a mass of opaque yellow and partly calcified tubercle, not completely filling a cavity, which was lined by a dense membrane forming a cyst around the caseous matter. On the right apex there was also some puckering of the pleura, with thin opaque patches, and slight condensation of tissue underneath. When cut into these were dark gray in color, with several minute cavities of size of hemp-seeds. There were no other tubercles in the lungs, but several small calcareous nodules near the roots. These may be considered the residue of tubercle, perhaps superseded and rendered innocuous by the revulsive influence of the more malignant disease in the abdomen. Case 6.—A brewer's clerk, age 25. First seen September 13, 1847. A year and a half ago had syphilis, and was treated by mercury for three months. Eight months ago an eruption appeared on the skin, followed by cough, slight at first, but afterwards becoming violent, with purulent expectoration, and lately accompanied by sweats, and loss of flesh, strength, and breath. Marked dulness below left clavicle, extending to mammary region; gurgling and crepitation around. Loud tubular sounds within and above right scapula. Ordered oil; and counter-irritation with iodine liniment. May 24, 1848.—Has taken oil regularly all the winter, and has quite recovered flesh and strength. Cough slight, with scanty opaque morning expectoration. Still dulness in upper left chest, with dry cavernous sounds above and belov: clavicle; but no crepitation; vesicular sound faintly heard in lower chest; less tubular sounds in right lung. September, 1850.—Quite well, and taking active exercise. Dulness much diminishing; some tubular sounds in upper left chest, front and back. No cavernous sounds, but breathing harsh. December 26, 1856.—Heard from Dr Carlill that this patient had just died suddenly of peritonitis from intestinal perforation. He had been apparently well, and actively engaged in business, till ten days before his death ; subject only to occasional attacks of headache and costiveness. After walking a mile he was seized with sudden and severe pain in the abdomen, with collapse and other symptoms of perforation, and died in two days. A post-mortem examination was made by Dr. (now Sir W.) Jenner. The abdominal walls were found to be covered with fat an inch thick. The ileum just above the ccecum was perforated by ulcers of tuberculous character, of which there were several. Both lungs were strongly adherent at their apices, especially the left; and in both cretaceous matter was found ; in the right in tubercles, varying in size from a pin's,head to a pea; but in the left lung there was a large mass of the same material, which quite filled an ancient cavity at the summit of the lung. This patient had been free from chest symptoms for eight years. This case is less remarkable for the duration of life after recovery from the third stage of consumption, than for the completeness of the cure of the chest symptom's, and for the demonstration it afforded after death (from another cause) of the arrest of the tuberculous disease which had made rapid strides eight years before. The phthinoplasm at the left apex must have been long in a caseous state, before it petrified, without giving rise to fresh tubercles ; and those which formed at last in the intestines, and were the cause of death, are rather to be ascribed to constitutional causes than to the influence of the obsolete phthinoplasm. PATHOLOGY OF CONSUMPTION. either be discharged through an opening into the bronchi, or be- ing retained, it becomes obsolete and may petrify. Small cheesy or calcareous bodies, commonly but not always encysted, are so frequently found in the lungs of adult and old persons who die of other diseases, that they may be taken as proof that there is nothing specific or peculiar in their nature, but that they are among the common lesions of nutrition, which are injurious by their extent rather than by their kind. A reference to the table will show that caseation and calcification is a result in which most of the phthinoplasms may end and become obsolete. The frequent occurrence of caseation to a limited extent, without any evil effects, sufficiently sets aside the notion, recently pro- pounded in Germany by Buhl and others, that acute tubercu- losis is always produced' by infection from caseous matter. CHAPTER XII. VARIETIES OF CONSUMPTION FROM INFLAMMATORY EXUDATION__ continued. Varieties distinguished by expectoration—Catarrhal, albuminous, and hemorrhagic—Catarrh may precede or follow Phthisis—Peribronchial and fibroid variety—Albuminous, mucopurulent, and pellicular- Hemorrhagic. Although in all inflammatory consolidations of the luno- leading to consumption, the sarcophytes and fibrin constitute the basis or essential element, there are other contingent mat- ters belonging to the hyperplasms which give a variety to the course of the disease and to the character of the consolidation. These are noticed in the second column of the table (p. 74), as a third class of morbid elements, including albumen, mucus epithelium, and other cells and granules, red corpuscles, &c.' These are thrown out in various proportions during the inflam- mation of the lungs and bronchial tubes, and may be studied in the expectoration, where they are often blended with the con- solidating materials, and partake of their changes and results It is chiefly, however, in the expectorated matter that these con- tingent products are seen; and an examination of this, in dif- ferent cases, suggests three chief varieties which may be con nected with phthisis, under the terms catarrhal, albuminous and hemorrhagic. By the catarrhal variety I would designate those forms of in flammatory phthisis preceded or attended by mucous secretion CATARRHAL AND ALBUMINOUS S9 from the bronchial membrane, with an unusual amount of cough and expectoration. There is more or less of bronchitis in all cases of phthisis; but in some, the early history is completely that of bronchial catarrh ; and the affection of the lung becomes apparent only through the persistence of the disease, and the additional physical signs and constitutional symptoms. In some cases the bronchial inflammation precedes the lung affection, and eventually induces it by penetrating deeper, in the manner already described. In others, the consolidation of the lung is evident from the beginning, but is attended with bronchial in- flammation or bronchial flux to an unusual extent. This occurs especially in connection with the fibroid or cacoplastie consoli- dation of the lung. The expectoration is often abundant, with various degrees of frothiness and viscidity, and contains chiefly water, with saline matter and more or less hyaline mucus, and numerous epithelial cells, ciliated and pavement, from the bronchial membrane. To these at times may be added pus-cells in various proportions, giving the expectoration the mucopurulent character, which in- creases with the occurrence of any suppurating or softening process in the lung. Sometimes this opaque appearance of the expectoration is attended with a diminution of the bronchial irritation. In other instances, it brings no mitigation, and only adds to the weakness and emaciation. In fact, these catarrhal varieties of phthisis are often more distressing than those of more rapid and unresisted decay. The harassing cough, ex- hausting expectoration, and oppressive dyspnoea, are most pain- ful, and are sometimes very little controlled by treatment. Under the head of albuminous expectoration of inflammatory phthisis, I would include that containing albumen, either unco- agulated or coagulated. The expectoration in the first stage of pneumonia, and in bronchitis attended with much pulmonary congestion, contains a considerable amount of liquid albumen, which may be coagulated by heat and acids. This was noticed long since by Drs. Brett and Bird, and may be considered the result of the exudation of serum from the over-distended blood- vessels. In the advanced stages of inflammation, the sputa be- come opaque, either from pus-cells multiplying, or from the albumen coagulating into a curdy matter. In some cases the albumen coagulates as secreted, forming opaque films or flakes; and where these occur to a large amount, they unite to form the pellicular or croupous matter, which may take the forms of the bronchial tubes, ramiform, or arborescent. When thus tough and consistent, they probably contain also fibrin and sar- cophytes, being like the false membranes thrown out on serous surfaces; but in the looser a.nd more curdy varieties, these exu- dations have a nearer resemblance to the albumen or casein 90 PATHOLOGY OF CONSUMPTION. coagulated from eggs or milk. In the expectoration of certain phthisical patients, this curdy or shreddy matter predominates so much as to constitute a variety; and it probably proceeds from a croupous or albuminous exudation from the parts of the bronchial membrane contiguous to cavities, rather than from the cavities themselves. The hemorrhagic variety of phthisis is that in which, more or less constantly blood appears in the expectoration. As this subject will be noticed in a special chapter, we need not dwell on it here further than to point out its connection with the first stage of pneumonia, in which the sputa are tinged with haemo- globin, often altered; and the common persistence of red cor- puscles iu their entire state in certain other varieties of phthisi- cal sputa in connection with scurvy and purpura. In all these different cases, the haemoglobin, like the other matters, may be superseded by the pus formation or caseation. The abundance of this hgeraatin is the cause of the dark brown or green color of phthisical sputa sometimes brought up before death. The coloring matter exuded by the moribund congestion is even then undergoing conversion. CHAPTER XIII. varieties of consumption—continued. Phthinoplasms of the lymphatic system—Production of Tubercle by inocu- lation—Observation of Laennee—Experiments of Villemin, Andrew Clark, Sanderson, and Fox—Analysis of results—Causes of success and failure considered—the most infecting matters either phthinoplastic or septic—Local effects of inoculation—Lymphatic or adenoid system first infected—then organs—Observations of Drs. Sanderson and ^Y. Fox —Infection aided by septic influences in the body or in the air. We have now gone through the consumptive elements which originate from the sanguiferous system—the phthinoplasms from inflamed or congested bloodvessels. We have next to notice those which have their origin and chief seat in the lym- phatic system—that remarkable supplementary apparatus which is at once the feeder and the scavenger of the flesb and blood of the body. We have already, at some length, endeavored to trace the origin of disease in the lymphatic glands and other portions of the so-called adenoid tissue to a change in their most vital and characteristic element—tbe germinal*matter or sarcophytes. And to enable us to understand how this change may be brought about independently of inflammation, we now artificial tuberculization. 91 have to bring to our aid the subject of infection, and the modern discoveries on the artificial production of tubercle. The idea of the possibility of producing tubercle fry inocula- tion originated with Laennee. I have several times heard him relate what happened to himself twenty years before ; how that, in opening some vertebras affected with tubercle, the fore-finger of his left hand was slightly scratched by the saw. The next day a little redness appeared, and there formed gradually after, a little swelling under the skin, of the size of a large cherry- stone. In eight days the skin opened at the scratch, and there appeared a yellowish compact body, exactly like crude yellow tubercle. After cauterizing it with butter of antimony, which gave hardly any pain, he gently squeezed out the contents, which, being softened by the liquid caustic, exactly resembled/i softened tubercle. After repeating the cauterization to the'; remaining little cyst, the wound healed, without further incon- > venience. I may remark that Laennee died of phthisis; and during the~year~before his death, wheiTl attended his clinique, although full of vivacity and intelligence, he had the wasted aspect of one in advanced disease. The subject seems to have received no further attention till about seven years ago, when M. Villemin, led by various con- siderations to suspect the infectious nature of tubercle, per- formed experiments on animals to determine whether it could be produced by inoculation. The matter of tubercle, gray and yellow, was inserted under the skin of rabbits and guinea-pigs; and in the course of from two to six months the animals were killed, when tubercles, both gray ancryelTow, were found in the lungs, liver, spleen, lymphatic glands, peritoneum, and other parts, the yellow being most manifest in the animals that lived longest. These experiments have been repeated and varied by many competent observers in France, England, and Ger- many, and with a concordance of results so general, that no doubt can be entertained of the fact that gray tubercles, in all respects resembling those spontaneouslj7 occurring in the human subject, affecting the same structures, and liable to the same changes, may be artificially produced in certain animals by the insertion of tuberculous matter in any form under the skin. This result seemed at first to countenance M. Villemin's idea that tubercle depended on a specific poison, the infection, of whicli was communicated from one animal to another. But as experiments were multiplied and varied, it was found that the subcutaneous introduction of not tubercle only, but of other matters, as pus, putrid muscle, and diseased liver, from non- tuberculous subjects, was equally followed by the production of tubercles in several organs. This was first announced by Dr. -t*fiy, fas Aft-//r^f /teV ^^^'^ ° V%W& fa- -/" <. ^/ ')w* 'a fa/*e^*A f f^ * ^ *i^(\\»^4\ ^C^Zaw^ Ay^-6- A^/Ci^ y>c*^ ,'//_, /l^-w^* 7- 92 PATHOLOGY OF CONSUMPTION. Andrew Clark,1 and confirmed, subsequently, by Drs. Burdon- Sanderson2 and Wilson Fox.3 Further, it was proved by both 'the last experimenters that, without any inocculating matter at ; all, the introduction of a mesh of clean cotton thread, as a seton, 'into the skin of a guinea-pig, was followed by the production of itubercles in the lungs and other organs. Dr. Fox has given a tabular view of the results of his experiments, and from this we will give extracts, from which some estimate may be formed of what agents prove most efficient in producing artificial tubercle. Of 8'inoculations with tubercle, 6 succeeded, 2 failed. Of 11 inoculations with various pneumonic products (red pneumonia in tuberculous patient, gray infiltration, "scrofu- lous,'-* yellow, cheesy, and chronic), all succeeded. Two inoculations with sthenic pneumonia failed.^ Four inoculations with sputa of chronic bronchitis and acute pneumonia failed. Of 2 inoculations with phthisical sputa, 1 succeeded, 1 failed. Of 17 inoculations with pus from various sources, 7 suc- ceeded: comprising, 1 each from injury to knee, suppurating bone, and lumbar abscess; 3 out of 5, of foul pus; 1 out of 2, from scrofulous bone. Of 11 inoculations from acute inflammations, 4 were success- ful, 2 being from pygemic abscess of spleen; 1 out of 2 from unaffected part of same spleen; and 1 out of 2 from slough}7 wound. Of 9 inoculations from matters from " chronic inflammations, &c," 6 succeeded: 2 of gelatinous inflammation of knee; 3 of lardaceous liver; and 1 of cirrhosis of kidney. //n*X£/* ^ -^ cases of reinoculation from tuberculated animals all Col'^£~ were successful. {UMl^U-y-s-J-- Four cases inoculated with vaccine matter succeeded. ' Of 5, with putrid muscle, 4 succeeded. Of 4 tried with seton, 1 succeeded. Of 3, with cotton thread, 1 was successful. Of 10 trials with matter from syphilis, typhoid intestine, and cancer, all failed. In these trials, we find that the materials most efficient in producing artificial tubercle were those from low pneumonia, pysemic abscess, gelatinous inflammation of knee, lardaceous liver, reinoculation from artificially tuberculated animals, and vaccine matter. Less constantly successful were human tuber- cle, phthisical sputa, foul pus, putrid muscle, and cotton thread and seton ; whilst no results were obtained from material from acute sthenic pneumonia, pneumonic and bronchitic sputa, 1 Med. Times and Gazette, 1867. 2 Tenth Report of the Medical Officers of the Privy Council, p. 150 (1868b 3 The Artificial Production of Tubercle in the Lower Animals (18681. pUc ilct/fyC: vuu„ u^-d*-^ iZ^ l,s^/ia*'^1'^j ARTIFICIAL TUBERCULIZATION. 93 healthy abscess, diphtheria, various inflammations in rabbit, syphilis, typhoid intestine, and cancer. Whatever be the influence which determines the production of tubercle, that Jtis_ nothing specific in the materials which succeed in producing it is obvious from'"their varied nature— tuberculous and non-tuberculous, animal products and mechan- ical injuries. But it is impossible to avoid seeing the close analogy which this process bears to suppuration. When Air. Simon's experiments on the production of tubercle in the rabbit were discussed at the Pathological Society in the spring of 1867, my opinion was asked whether the experiments did not prove the specific nature of tubercle. My reply was in the negative; aiicl that I believed "it would be found that tuberculization bore more analogy to suppuration; and that acute tuberculosis had its parallel in pyaemia. But it is not healthy pus, or other sthenic inflammatory products, which surely produce tuberculosis, but the pus of pyaemia, foul pus, putrid muscle, and such septic matters as must be injurious to the vitality of the bioplasm; these have the same effect as tubercle itself, and the kindred forms of deteriorated bioplasm found in chronic condensations and caseations of the lung, lardaceous liver, &c. The occasional production of tubercles from more healthy materials, and from the wound of a seton, must be referred to some additional septic influence accidentally acquired, and giving a foulness to the material or to the wound; and here we can perceive how atmospheric hygienic agencies may operate, as in acute suppuration infecting the blood by pyaemia, so in chronic injuries infecting the lymph and blood with tubercle. On this point the following observations of Dr. Bunion-Sander- son are very important, and call for further investigation. " With reference to the traumatic origin of tuberculosis in the guinea-pig, another possibility claims consideration, namely, that of the influence of the air and of the organisms which it contains. It has not yet been proved that injuries which are of such a nature that air is completely excluded from contact with the injured part are capable of originating a tuberculous pro- cess. The following experimental results seem, indeed to sug- gest that they may not be so. Setons, steeped in carbolic acid, were inserted in tenguinea-pigs, on September 24, 1868, each animal receiving*twd. At the same time, extensive fractures of both scapula? were produced in five others, care being taken not to injure the integument. No tuberculosis or other disease of internal organs has resulted in either case."1 Before noticing some of the details of the process of artificial i " Further Eeport on the Inoculability and Development of Tubercle," Eleventh Keport of the Medical Officer of the Privy Council, 1869, p. 92. 94 PATHOLOGY OF CONSUMPTION. tuberculization, I must again advert to the subject of the very different degree of susceptibility shown by different animals. Rabbits and guinea-pigs have been generally selected as afford- ing the most frequent results, and therefore must be considered to be somehow predisposed to artificial tuberculization, although Dr. Sanderson declares "that they are not liable to the natural disease. Attempts made to produce tuTjei'cTe'in other aninials "^dogs," cats, goats, sheep, and birds—have rarely succeeded. Again, Dr. Fox has remarked that tuberculization succeeds better with guinea-pigs than with rabbits; and ascribes Al. VTl1emTh";rs" repeated failures with other materials than tubercle to his using the latter animals. In several of these experiments the rabbits died of pyaemia, before there wTas time to produce the more chronic result, tuberculization; and in others, a local suppuration occurred, without being followed by any appear- ance of tubercle in the organs. In others, there was a slight appearance of pus, often offensive and becoming cheesy, and this was more generally followed by tuberculization. Drs. Sanderson and Fox have given the most complete and minute descriptions of the process of artificial tuberculization in the guinea-pig, and these should be carefully studied. We can here give only a brief abstract of the principal points, chiefly relating to the primary local effects, and to those in the lymphatic glands and the lungs. The most common result of the introduction of the matter under the skin is the formation of masses of cheesy matter, which are dry and friable (" de'bris of fattily degenerated ma- terial ") and often eucapsuled. But in addition to these are small granulations, varying in size from that of a poppy-seed to that of a hemp-seed, irregularly scattered in the subcutaneous tissue. These masses, sometimes transparent throughout, sometimes opaque in the centre, present to the naked eye and under the microscope a striking resemblance to the changed lymphatic glands. In their denser and more central parts they consist of nuclei imbedded in a homogeneous tissue; in their less dense parts a fibrillated tissue which forms bands or trabecule, be- tween which the cells lie, the whole forming a structure which has the strongest resemblance to the elementary composition of a lymphatic gland. Throughout the granulations many of the cells and also of the nuclei are seen in various stages of fatty degeneration.1 Dr. Sanderson also describes the local effect of the inocula- tion in the guinea-pig to consist in the production of small sub- cutaneous knots, which at first appear to be'composed of round cells, like lymph-corpuscles (sarcophytes). At a later period 1 Dr. Wilson Fox, op. cit., p. 8. RESULTS OF INOCULATION. 95 these cells are inclosed in a meshwork of fibres, thicker and coarser than the reticulum of a healthy lymphatic gland, but so exactly " resembling that of a gland enlarged and hardened by disease, that the two are indistinguishable under the micro- scope." According to Dr. Sanderson, " the first step in the dissemin- ation of tubercle consists in its being absorbed primarily by the lymphatics (which convey it to the lymphatic glands of which they are tributaries), and secondarily by the veins. Having thus entered the systemic circulation, it is distributed universally by the arteries. The serous membranes seem, however, by preference to appropriate it, and from them it extends by con- tiguity to the superficial parts of the organs which they cover."1 Of lymphatic glands, those supplied from the inoculated part may soon become enlarged and congested, with such an enor- mous multiplication of corpuscles as to impair the consistence of the gland, and sometimes to run into suppuration. When more slowly affected, they enlarge, harden, and caseate. The enlargement is chiefly from multiplication of cells, the indura- tion partly from the same cause (why not from their hardening also?), and partly from the rapid growth of their fibrous reticu- lum, or trabecular stroma. The caseation is from fatty decay and disintegration of the indurated mass. The internal lymphatic glands are affected in consequence of secondary production of disease in the organs from which they receive their afferent lymphatics. Their change is also chronic, and tends never to suppuration, but to enlargement, induration and caseation, referable to the same increased cell formation with fibrous degeneration, and eventual fatty or calcareous ne- crobiosis. Very similar changes affect the spleen, the structure of which bears a close analogy to that of lymphatic glands. In Dr. Fox's observations, tjiejungs were affected with tuber- cle_mfifty-n_ine cases out of sixty-four—the same proportion as in those invading the spleen. The following is an abridgment of his description: "The chief state I have to describe consists in the lungs being permeated more or less thickly by scattered granulations, varying in size from a millet-seed to a hemp-seed." Some are hardly visible specks, and all gradations can be found between the smaller and the larger. Generally they are scat- tered, but sometimes confluent in groups; even in the larger groups there is evidence that they have been originally com- posed of distinct granulations. The granulations do not project much from the cut surface, and they blend more or less inti- mately with the surrounding pulmonary tissue, from which they tear with difficulty. They are firm, and all marked by a pecu- 1 Loc. cit., p. 117. 96 PATHOLOGY OF CONSUMPTION. liar semi-transparent, hyaline, cartilaginous-looking margin, and a cheesy centre, which is sometimes soft in the larger ones, and when evacuated leaves a cavity. Some of the smallest are semi-transparent throughout. They are more common on the pleural surface than deep in the lung, but are distributed pretty equally through the lobes. Sometimes when there is a group of these granulations clustered together, an appearance Is presented, which is also occasionally seen in the human lung, of a fibrous network running between the granules, as if the intervening tissue was becoming fibrous. In addition to this there is a general induration of the lung-tissue, affecting in a variable degree the whole organ. Signs of pneumonia and of general infiltration, independent of the granulations, are exceed- ingly rare. The microscopic examination of these growths in the lungs presents the following features: There are three main points in which they appear to originate,—around the bronchi, around the bloodvessels, and in the lung-tissue unconnected with either. Around the bronchi, they seem to extend from little masses of a lymphatic character (adenoid tissue), which normally exist in the bronchial sheath, and are also stated by Kolliker to " exist in the human lung. These granulations around the bronchi consist of masses of cells ^gbj^th to ao^th of an inch in diam- eter, mostly round; but sometimes, when densely packed, showing nothing but nuclei." "In the perivascular sheath of the pulmonary arteries, the growth is nothing more than an accumulation of the cells lining the perivascular canal. The growth may extend for a considerable distance in length along both peribronchial and perivascular sheaths, and from both these sources of origin a rapid extension ensues into the sur- rounding walls of the alveoli and smaller bronchi. A thicken- ing of these is thus produced apparently by a double mode of growth,—by a rapid development of fusiform cells at the mar- gins, clusters of which are seen passing among the capillaries, and by an increase of rounder cells, which are seen nearer the centre of the new formation ; coincidently with this °rowth a change of great importance occurs in the neighboring capilla- ries of the lungs; their nuclei enlarge, and the vessels otherwise apparently unchanged, contain no blood—that is to say, no injection will pass into them; and yet their outline is 'still marked by lines of nuclei. This obstruction of the capillaries takes place through very much wider areas than the space ap- parently occupied by the tubercle. So also with the thickening of the walls of the alveoli. Around the gray granulations and for a space of three or four times their area* there is a circum- ference of thickening affecting the walls of both the alveoli and the smaller bronchi. This appearance is more distinct in the COMPOSITION OF ARTIFICIAL TUBERCLES. 97 guinea-pig than in many specimens of tubercle in the human lung; but it can sometimes be distinctly seen in the latter, and is a fact of great pathological importance, explaining the in- crease of density and loss of elasticity in the lung, which occurs in the early stage of tuberculosis, and which cannot be satisfac- torily accounted for by the mere presence of the gray granula- tions."1 In his second paper, Dr. Sanderson confirms his conclusion that the tubercles and consolidations artificially produced in the various organs of animals consist essentially in overgrowth and [nduration of the adenoid tissue naturally exis'ting in various parts of the textures; but as regards the semitransparent and iron-gray nodules in the lungs, that they comprise also an accu- mulation of the bodies commonly found in the alveoli, and which have been generally but erroneously considered epithe- lial. These alveolar cells are nucleated bodies consisting of a soljd_enyelope,.oTtransparent substance collected round a more refractive central part, and contain pigment and other^granules. The true alveolar epithelium cells are much smaller, and are very difficult to demonstrate; but those in the terminal bronchi can be made evident by nitrate of silver, and appear as oval plates, with spherical nuclei about half their width. " In ani- mals killed at an early stage of tuberculosis, that is to say about four weeks after inoculation, no change is observed except that the peribronchial adenoid pulp is increased, or in other words, that true miliary granulations are formed in the neighborhood of the terminal bronchioles." Subsequently the alveolar cells become multiplied, and, filling the alveoli, complete the mass of iron-gray nodules. " Whether the choking up of the air-cells is merely a mechanical result of the accumulation of adventi- tious matter around the bronchioles, or of a catarrhal process, there can," Dr. Sanderson thinks, " be little doubt that the granulation stands to the block of lobular pneumonia in the relation of cause to effect, and that when a kernel of adenoid pulp occupies the centre of a nodule, the fact signifies that the nodule originated from it."2 Dr. Wilson Fox also denies the epithelial character of the alveolar corpuscles, and, as a true disciple of Virchow, consid- ers them to be derived from the connective tissue. It is not necessary for our object to enter into the details of the process of artificial tuberculization in other organs. Suffice it to say that they correspond in character with those in the lung, having their origin and chief seat in the adenoid tissue, naturally existing in membranes or textures^ appear firsf as "a" 1 Dr. AYibon Fox, op. cit., p. 10-12. 8 Dr. Burdon-Sanderson, 11th lb-port, &c, p. 115. 98 PATHOLOGY OF CONSUMPTION. rapid multiplication of lymph-cells or corpuscles, with a fibrous network, all of which'increase and harden, and^ eventually caseate and break up by fatty degeneration and disintegration, with variations in course and concomitants, according to the structure and functions of the parts. The perfect resemblance of tubercle thus artificially produced to human miliary tubercle, in seat, general distribution, in- trinsic structure, and in course and effects, removes all doubt as to their identity. But as regards their modes of origin, and comparative power of affecting different animals or species, there may be yet a great difference; and we must be cautious, therefore", before we apply all the facts of an artificial tubercu- losis to the spontaneous occurrence of tubercle in man. The closest analogy lies with those cases of tubercle which are of constitutional nature, not arising from a visceral inflammation or any local cause, nor affecting one organ in particular, but scattered through several in the form of miliary granulations, and having their origin in the circulating lymph or blood. We comprehend them, therefore, under the second division of the Table of Elements of Consumptive Disease (p. 74). CHAPTER XIV. GENERAL CONCLUSIONS ON ARTIFICIAL TUBERCULIZATION OF ANIMALS, AND ON THE CAUSATION OF PHTHISIS IN MAN. Nature and Conditions of Infection—Causation of Phthisis—Specific or Common Septic ?—Parallel between Experimental and Clinical Origin of Tubercles — Predisposition necessary — Defective Vitality of Sar- cophytes, and corrupting Influences in the Air—Analogy between Py- .semia and Acute Tuberculosis—The latter developed by Heat and Damp —Inflammatory and Chronic Phthisis produced more by Cold—The former more diffusive, the latter more circumscribed—Influence of Cli- mate and Altitude on different forms of Consumptive Diseases. AVe may sum up the chief facts of the process of the produc- tion of tubercle by inoculation in the following conclusions: 1. With regard to the material necessary for inoculation, it is no^aaecific form of tubercle^ jior even tubercle at all; for some non-tuberc'uTbus'matters are equail}7 successful, and, in a minor degree, matters formed in an open wound in the same aiiimaC- But those materials are most sure to pr6d¥cTTii^eT?Ti^vliich either resemble it in its tendency to decay, or show a septic character, as foul pus, putrid muscle, carious bone, and the like. On the other hand, healthy pus or other product of acute in- CHANNELS OF INFECTION. 99 flammation, has no effect; and although a seton or other open wound sometimes produces tubercles, yet setons dressed with.au antiseptic, and wounds secluded from the septic influence of the air, have no such result. 2. The local effect of successful inoculation is not active in- flammation, suppuration, or sloughing, for these always prevent the tuberculization ; but either low inflammation, slowly pro- ducing a slight abscess, often offensive or cheesy; or the direct formation of little nodules at the point of inoculation, consisting of adenoid indurations, and which may be considered a primary tuberculization. And what are these but sarcophytes or bio- plasts, proliferating and hardening in their fibrous network, and tending to early death and decay by caseation ? 3. The next effect is found in the lymphatic glands supplied by the absorbents proceeding from the seat of inoculation. These are enlarged, indurated, and soon become cheesy in points, but never suppurate (in the guinea-pig), even where there may have been partial suppuration in the primary wound. Most natural is it that the lymphatics should convey injured sarcophytes (lymph-corpuscles) to their usual receptacles, and with them that deteriorating influence on the myriads of sar- cophytes contained therein, which take on the same degenerative course of rapid proliferation and induration, ending in early decay. 4. After the lymphatic glands, various organs and membranes of the body become invaded by the indurations, chiefly in the granular form of gray tubercles, but some, as the liver, in larger masses. But in all forms and sites the careful examinations of Drs. Sanderson and Fox have detected the same structure, that of the adenoid or lymphatic glandular tissue, hypertrophied and indurated by multiplication of corpuscles and fibrous reticulum ; tending to obstruct and irritate the natural structures, and to infect them with their own degeneration and decay. The chan- nel of dispersion may be both the lymphatics and bloodvessels, communicating, as they do, not only through the thoracic duct, but more directly in the spleen, and probably also in the lym- phatic glands, in which the blood and lymph-corpuscles are either intermingled or brought into close proximity. And thus the infection of"the system becomes complete. It remains yet a question open for further inquiry, what is the influence in the inoculating matter or open wound which appears thus to affect the vitality of the sarcophytes in the part, and make them proliferate in a concrete perishable form, and communicate a like tendency to other sarcophytes in the adenoid tissue of the body through which they circulate ? From its in- fective power it would appear to be of a zymotic nature (what- ever that may be, whether a chemical catalytic force or an 100 PATHOLOGY OF CONSUMPTION. ^organic spore or germ). And the notion has been propounded " \ >iev^u recently by Dr. Madden, of Torquay, and Dr. AV\ Budd, Aj^J->r"^ of Bristol, that tubercles are the result of a specific poison, like (va^ lscarlatina, typhoid fever, and other zymotic diseases. We are, /perhaps, as yet hardly in a position to accept or to reject this [notion, for there are many facts for and against it, which we I cannot afford space to consider at length; but at present it seems \to me more probable that the influence which causes tubercle is something more common than a specific poison—something more analogous to putrefactive matter, which may proceed from various materials, and even from the decomposition of a part of ' X the body itself. It may, indeed, be said that putrefaction and VJ\)1 Jother kinds of decomposition are promoted, if not produced, by the presence of vibriones, bacteria, and other septic organisms; hut if so, it is in the way of common corruption, and not through any specific agency engendering or engendered by disease. If I am correct in my inference that tubercles arise from a degraded vitality and concrete state of the sarcophytes, whereby they lose their mobility and plasticity, although they retain their prolifer- v .v ating power, it can be easily conceived that, without assuming V the existence of any specific poison, various noxious agencies \ J r JL may be capable of so injuring them. The observation of Alax ^Schultze has been already noticed, that heat above 104° Fahr. is sufficient to stop the movements of the sarcophytes and make them harden. It may be a question how far this power of heat is concerned in developing tubercles in exanthematons fevers, especially measles and scarlatina, which are not unfrequently followed by tuberculosis. This power of heat to injure the sar- cophytes may also have some share in the difficult healing of wounds from burns and scalds, and in the very cacoplastie char- acter of the scars which they leave behind them. But both eruptive fevers and burns have other effects besides this direct operation of temperature; and it is easy to perceive that foul- ness or tendency to corruption of any kind may similarly injure the vital properties of the bioplasm, and degrade its constituent corpuscles to the condition of tubercle. And if we revert to the miscellaneous matters found capable of producing tubercle by inoculation (for example, in Dr. Fox's experiments, tubercle ; red, gray, and cheesy pneumonic matter; foul pus; pysemic pus; lardaceous liver; putrid muscle; vac- cine matter; and, less successfully, seton wounds, &c), we find further proof that the cause seems to be some common corrupt- ing influence, rather than any specific poison. Again, w7e must not lose sight of the different susceptibility to the morbific operation of this cause in different individuals and still more in different species of animals. In most carniv- orous and herbivorous animals, inoculation commonly produces ANALOGIES IN PRODUCTION OF TUBERCLE. 101 mere inflammation and suppuration, and very rarely tubercles. In rabbits, inflammation and suppuration are as commonly ex- cited as tubercle, and often prevent the production of tubercle. In guinea-pigs, on the other hand, suppuration is rare, and tuberculization is the comnion result."" In Their indisposition to suppuratipj^ birds and reptiles, in which Air. GrnlTverdoubtedthat true pus isever.produced. This must depend on a natural difference in the sarcophytes of these respective classes of animals, and suggests the probability of similar variations between different individuals of those animals capable of both suppuration and tuberculization. We are now in a position to consider the spontaneous occur- rence of miliary tubercles in the human subject, and the light which it may derive from the above experiments. The gray miliary tubercle of Laennee, of size varying from a millet-seed to a hemp-seed, remarkable for almost cartilaginous hardness and some degree of translucency, occurring scattered through the pulmonary tissue or gathered into groups, which in relation to the bronchioles resemble little bunches of berries, is the pro- duction which most distinctly characterizes the tuberculous form of pulmonary consumption. Laennee noticed that these little bodies tend to become opaque and to soften, just as dif- fused consolidations do, and, therefore, he included all, granular and diffused, under the common term tubercle, which presents the different conditions of gray, crude yellow, mature, and soft- ened, as successive stages of the same accidental production. Whilst, with Laennee, we acknowledge the identity of the granular and diffused consolidations in their composition and changes to the opaque and softened states, we reject his notion that they are accidental or heterologous growths like those of cancer, following special laws of their own; and we adopt the much simpler and more obvious view that they are only results of the degradation of the ordinary material and process of his-, , togeuesis or textural nutrition, and that their changes are noj other than the successive steps of decay, the natural conseJ quence of gradual declension of life and organization. S,w^-With regard to the diffused consolidations of the lung in phthisis, we found reasons for regarding them as the results of ■inflammation, and have endeavored to trace them from the ob- served operation of that process in its different varieties. Alili- ary tubercles may probably also sometimes originate in inflam- matory irritation ; for example, when they break out during the febrile stage of an exanthem, measles or scarlatina, from the febrile poison acting as an irritant, in points of the pulmo- nary tissue, as it does outwardly in the eruption in the skin. Probably we may also refer a certain number of cases of miliary \ tubercle to prolonged or repeated bronchial inflammation, under 10-2 PATHOLOGY OF CONSUMPTION. circumstances, which deteriorate the blood plasma, such as poor living, damp air, and close habitations. But in the greater number of instances miliary tubercles seem to arise independently of inflammation, by a spontaneous dissemination through the lungs and other textures, as if scat- tered by means of the bloodvessels or lymphatics. These are the cases that are so precisely imitated by the experiments of artificial' tuberculization that we can hardly avoid the conclusion that the process is similar in the two cases. Let us trace the analogous cases of tubercle spontaneously arising from infecting causes in the body. 1. We are abundantly taught by clinical experience that miliary tubercles form in the lung after various kinds of un- healthy local suppurations: for example, after scrofulous suppura- tion of the cervical and other lymphatic glands; after abscesses and unhealthy wounds connected with diseased bones; after fistula in ano ; after ulceration of the intestines from typhoid fever; and after empyema and pyoperitonitis. 2. Miliary tuber- cles form in the lungs and other organs also after caseation taking place in the lungs ; in the bronchial, cervical or other lymphatic glands; in the liver, kidneys, spleen, or serous cavities. (Buhl and other German writers have taken too partial a view in limiting the paternity of miliary tubercles to this cause.) 3. Miliary tubercles form also in consequence of the presence of various consolidations in the lung or other organs when these consolidations have a decaying tendency. Thus various chronic in- durations of the lung (among which may be included pre-existing miliary tubercles), lardaceous liver, granular kidneys, and dis- integrating fibrinous emboli in bloodvessels, may become causes of new miliary tubercles. 4. And lastly, we learn from Drs. Sanderson's and Fox's experiments that common wounds in the integuments, such as that of a seton or issue, may, in rare cases, determine the production of miliary tubercles in the internal organs. But as in the experiments, so in the natural development of disease, it is not in every case that tubercles are produced from their supposed causes. If all kinds of animals are included, in- oculation with the most potent materials, such as tubercle itself or the matter of pyaemia, had no effect in many instances, and in others caused suppuration and not tubercle. Even in guinea- pigs, which these experiments prove to be naturally disposed to tubercle, the effect was not certain when matters less allied to. tubercle, or less foul, were used; and no result was obtained from healthy pus or other products of healthy inflammation. So in clinical experience we find many instances of the presence of even scrofulous suppuration, of caseation, of chronic indura- tions of organs, including tubercle, without any further spreading % DEFECTIVE VITALITY—SEPTIC ACTION. 103 or infecting the body; and quite exceptional are the cases of a common wound or healthy suppuration being followed by in- ternal tuberculization. There must, therefore, be some co-operating cause which renders inoculation in the one case, and the products of disease in the other, effective in producing tubercles. In the absence of any direct evidence on this point, we may be guided by cer- tain facts and analogies to the inference that this co-operative cause may exist in the body of the subject, or in the atmosphere, or in both. AVhere the sarcophytes in the blood and lymph are deficient in vitality, although abundant in quantity, they are more easily injured in their plastic powers by any noxious influ- ence which may affect them ; and, proliferating in concrete masses in their adenoid receptacles, form the little tumors, prone to decay, which are called tubercles. On the contrary, where the bioplasm is vigorous and not redundant, it may resist the operation of these noxious influences, and maintain the blood and the lymph in their proper condition for nourishing and invigorating the tissues of the body. The air, too, may convey subtle influences or organisms with septic properties, injurious to life and tending to promote decay; and these may co-operate with the disordering action of any morbid matter previously existing in the body, or introduced into it by inocu- lation. Take the parallel case of pyaemia, or hospital fever. AVounds and suppurating sores of all kinds have little tendency to infect the system, so long as cleanliness and free ventilation carry off decomposing matters, and supply abundance of pure air for the active performance of the processes of respiration and sanguification ; but in close habitations, with an atmosphere tainted with foul effluvia, every sore becomes both an inlet and a source of poison, which is spread by proliferating and septic pus-cells throughout the body. This is a rapid and more acute form of caehaemia. That inducing tuberculosis is more chronic; probably arising from a less potent septic power in connection with humidity of air, and operating on a less active bioplasm, it palsies and coagulates the lymphatic sarcophytes, which, ag- gregating in little nodules, form spots of degenerating and decaying matter in scattered points of the adenoid tissue of the lungs and other organs. And here we are led to a position from which we may per-i ceive that the local cause of tubercle by inoculation, or by pre- vious existence of either tubercle or some other degenerating matter in the body, is not indispensable. The septic or deteri- orating influence of impure air and bad blood may itself be enough to degrade the bioplasm, and engender tubercle, without any additional exciting cause; and thus may arise the constitu- tional form of pulmonary consumption. Nor are impure and u 104 PATHOLOGY OF CONSUMPTION. damp air and septicaemia the only causes of constitutional phthisis. Insufficient or improper food, bad digestion, malas- similation, venereal excesses, exhausting discharges, and perhaps the secondary effects of febrile poisons, diabetes, and uraemia, have been noticed as antecedents of phthisis—often enough to entitle them to be considered as causes; and it is quite intelli- gible that they may so injuriously affect the bioplasm as to give parts of it a spontaneous tendency to degeneration and decay. To these must be added family proclivity or hereditary disposi- tion to tubercle. This is regarded more commonly as a predis- posing cause, requiring some additional influence, as an exciting cause, to bring it into operation. But some families seem doomed to be cut off by tuberculous disease, which sometimes arises without any obvious exciting cause; and thus tuberculous meningitis in infancy, mesenteric disease in childhood, and pul- monary tubercles in adolescence, attack the members of these families at certain ages, who so fall victims to an inbred decay. Happily, such cases are much more rare than they are reported to have been formerly; and it may be hoped that timely pre- ventive measures, hygienic and medicinal, may still further succeed in averting these untimely tragedies. It is these spontaneous or sporadic cases of acute tubercu- losis which sometimes present characters almost malignant, as if from the presence of poison in the system. Extreme prostra- tion of bodily and mental powers ; very frequent pulse ; con- stant pungent heat of the body, often rising five or six degrees above the natural standard; depraved secretions; furred tongue, and sometimes sordes on teeth and lips; occasional low deli- rium ; and rapid wasting of the body—mark the acute tubercu- lous fever, in addition to the cough, dyspnoea, and other pul- monary symptoms, and the signs of suffocative bronchitis in all parts of the lung, often masking those of the numerous tubercles scattered through them. Such cases may prove fatal in from two to six weeks, by suffocation or exhaustion, often before there is time for the tubercles to go on to softening and exca- vation. The miliary tubercles found in these acute cases are remark- able for their general dispersion over all parts of the lung, not as in the chronic disease, chiefly confined to upper lobes or parts; and also for their plumpness and comparative softness; so that, although they feel as solid granules in the lung-texture, they can be crushed by firm pressure, and have not the cartilagi- nous hardness of older tubercles. They consist almost entirely of aggregations of sarcophytes multiplied in poiuts of the ade- , noid tissue, with little of the fibrous stroma which time would jform around them, and which gives the greater hardness to : 1 older tubercles. It may be the soft looseness of these morbid ACUTE TUBERCULOSIS. 105 sarcophytes which favors their dispersion and multiplication in these acute cases, even to infecting the whole blood with matter prone to decay. In chronic tubercle, on the contrary, the V ; decaying material is hedged around by tough connective tissue, \ : which limits its dispersion, and in a measure protects the j system. AVe can hardly fail to see here an analogy with the I erysipelatous and phlegmonous modes of pus formation, another phase of sarcophytic history. If we turn to the external circumstances in which this consti- tutional form of tubercle occurs, we shall find that, besides damp and foul air, a high temperature seems to favor its pro- duction, and in this respect it contrasts with the inflammatory forms of consumptive disease. The latter prevail especially in cold seasons and climates; but consumption is frequent also in hot climates, and often assumes the acute or febrile form, with less marked cough and other pulmonary symptoms. M. Guil-i bert goes so far as to assert that phthisis increases in frequency , from the poles to the equator, and from the highest mountains to the sea-shore. This assertion seems to have been founded _ chiefly on observations on the South American continent, where the prevalence of the disease in the low, hot plains of Peru and Brazil contrasts strongly with its almost absence in the high table land of Peru and Bolivia, which rises ten thousand feet and upwards above the level of the sea. The climate at this height within the tropics, is much as that of the temperate countries of Europe; and, considering the general prevalence of phthisis in the latter, we must refer the exemption of the mountainous regions rather to their elevation than to Their low temperature^" Since the late Dr. Archibald Smith first called attention to the preventive and curative influence of high altitudes on phthisis, his statements have been corroborated by several ob- servers. In Lima, and other of the lower towns of Peru, pul- monary consumption is very prevalent, and it has long been the practice to send invalids" up the Andes, to altitudes of from 8000 to 10,000 feet, and with most beneficial results. Dr. Guilbert gives similar accounts of the efficacy of the high places of Bolivia, and Dr. Jourdanet of the high plateau of Mexico, in preventing and curing phthisis. In Europe also the greater immunity of high Alpine inhabitants from phthisis has been observed by Lombard, Brehmer, Kiichenmeister, and others; and in this country, Dr. Hermann Weber has directed the attention of the profession to the subject in reference to the causation and treatment of phthisis. The general result of recent statistical observations is that pulmonary consumption is most common in damp, low situa- tions, and those liable to great transitions of temperature, in all 106 PATHOLOGY OF CONSUMPTION. climates; that it is of less frequent occurrence in dry places, even although very cold; and that it is still more rare at great altitudes, varying from 10,000 feet in the torrid zone down to 2000 feet in the cooler temperate regions. These facts render it most probable that the causation of con- sumption is twofold : one class comprising the influences which 1 excite and keep up inflammatory affections of the chest, which end in cacoplastie products, such as transitions of temperature, and prolonged operation of cold and damp; the other class includes septic agencies, which tend to blight or corrupt por- tions of the bioplasm of the blood or of the lymphatics, and thereby to sow the seeds of decay: these comprise combined warmth and humidity, foul air, bad nourishment, depraving habits or diseases, and the like. And when these two classes of causes co-operate, the effect is more certain; for example, when a person, with bioplasm deteriorated by a foul atmos- phere, or by enervating heat, is exposed to a chill, or where the subject of an inflammatory attack is confined in a room tainted with impurities, or deprived of the invigorating influences of pure air, light, and proper food. It thus becomes manifest that whether we are considering; the intimate nature and causation of consumptive disease, or are seeking for means to prevent or cure it, we must duly keep in view all the elements concerned in its production, and give, full consideration to the variations which these may occasion in individual eases. This subject will require reconsideration under the head of Treatment: when I hope to prove that the view here taken of the nature and causes of pulmonary con- sumption will receive new confirmation from the facts best ascertained with regard to its prevention and cure. CAUSES OF CONSUMPTION. 107 CHAPTER XV. FAMILY PREDISPOSITION AND CERTAIN OTHER CAUSES OF CONSUMPTION. By Dr. C. Tueodoke Williams. Causes, general and local—Family Predisposition—Consumption proved to be hereditary—Opinions of Xiemeyer, Virchow, and W aid en burg— Family Predisposition explained—Hereditary Tuberculosis in Sheep, Cattle, and Guinea-pigs—Offspring of Gouty, Syphilitic, Aged, and Asthmatic Parents often Consumptive—Prevalence of Family Predis- position—Evidence of Louis, Copland, Cotton, Fuller, Pollock, Briquet, and the Author—Its more frequent occurrence among Females than Males—Paternal and Maternal Transmission—Influence on age of Attack—Private and Hospital Practice—Influence on Symptoms— Cases-Influence on Duration—Relations affected—Age at Death— Conclusions—Other Causes of Consumption—Impure Air and Improper Food—Continued Fevers—Scarlatina and Measles—Cessation of Dis- charges—Unfavorable Confinements and over-lactation—Mental De- pression—Damp—Buchanan and Bowditch's Researches—Dusty Occu- pations—Consumption not infectious. Some of the causes of consumption have been glanced at in the preceding chapters in their pathological relations: in this we propose to discuss some of the more important ones which have not yet been considered. Looking at the subject broadly, the causes may be classed as follows, as: 1. General causes, which, by their weakening influence on the constitution generally, predispose to consumption: such are family predisposition, want of pure air and good food, continued fevers, scarlatina, measles, cessation of discharges, miscarriages, bad confinements, and over-lactation, mental depression, dampness of habitation. 2. Local causes, the effects of which are limited at first to the lungs, but may at a later date extend to the system. These are: attacks of bronchitis, hooping-cough, and croup; attacks of pleurisy and pneumonia; attacks of asthma; trades and occu- pations giving rise to a dusty or gritty atmosphere; injuries. Such are the principal causes of pulmonary consumption; and they may act either as predisposing or exciting causes of the disease. Insufficient food and severe fevers, by impover- ishing the blood, and interfering with the nutrition of the body, may predispose to consumption. On the other hand, in a case of well-marked family predisposition, they may excite the hith- 108 CAUSES of consumption. erto latent malady. Some of the local causes may act as directly exciting causes, by giving rise to irritation and a low form of inflammation, the products of which would tend to disintegra- tion. Family predisposition has by general consent held a very prominent place, but the value of its influence in the causation of phthisis has been modified of late years by the fuller recog- nition of other causes which had been to some extent over- looked—such as damp, inflammatory attacks, &c. These and other direct sources of phthisis must exercise in our calculations a depreciatory influence on the amount we assign to hereditary transmission, and numerous cases of this disease which have hitherto been held to originate in a consumptive ancestry, will now be traced to a nearer and more direct cause. Nevertheless, no small number of cases owe their origin to hereditary predis- position and to no other cause, though it is not always easy to demonstrate their hereditary character. Its exact value as a predisposing agent, its mode of transmission, the varieties of the disease in which its influence is most apparent, all these and other points of interest are by no means settled questions, but still open to further inquiry. One of the most striking proofs of the hereditary character of phthisis is the presence of tubercles, often demonstrated in the lungs of a foetus or of a young infant1 of consumptive parents; another, though less striking one, is to be found in instances where a consumptive and healthy person marry, and the children become consumptive; but, on the death of the affected parent, the sound one marries again and the offspring of the second marriage is healthy. Niemeyer admits that the tendency to consumption is inherited only if the parents were consumptive at the time of begetting the offspring. "But it is not," he says, "the malady which causes inheritance, but the weakness and vulnerability of con- stitution, which had already laid the foundation of the consump- tion in the parents, or which had arisen in them in consequence of that disease."2 Waldenburg3 denies the direct hereditariness 1 "Waldenburg and Yirchow deny this as regards miliary tubercle. "We would draw their attention and that of our readers to the following passage in Sir Charles Scudamore's work on Pulmonary Consumption, p. 55: " I examined the body of an infant which died of extreme emaciation at the age of four months, the mother having been in the last stage of tubercular phthisis when she gave birth to it. I never witnessed so remarkable and extensive a display of tuber- cles, both miliary and of a larger size, the former semitransparent, the latter gray in color. The lungs on each side, both upper and lower lobes, the liver and spleen, the mesentery and peritoneum, were universally studded with tubercles." The italics are our own, but the description needs no comment. 2 Text-Book of Practical Medicine, vol. i, p. 213. 3 Die Tuberculose die Lungenschwindsucht und Scrofulose, p. 524. "Waldenburg cites an instance of six brothers and sisters, who, when they first FAMILY PREDISPOSITION. 109 of consumption by means of a specific contagion, and only allows, in any case, the transmission of the phthisical habitus and innate disposition of the parents to phthisis. Both these authors, re- garding tuberculosis as a secondary product, and never a primary one, hold that tubercular consumption can never be directly in- herited, but that the caseous deposits from which it arises may be produced by the scrofulous or phthisical habitus. We propose to consider some of the principal features of the subject, and to give, as concisely as possible, the conclusions which our researches and those of others warrant us in adopting; and first, we would explain why we prefix as the heading, " family predisposition," instead of " hereditary predisposition"" As it was our object to w7ork on a broad basis, it was thought desirable to estimate indirect as well as direct influence, and for this purpose the existence of consumption was noted in uncles, aunts, brothers, and sisters, as well as in parents and grand- parents, the principle being to accept as instances of disease in the family all those derivahle from a common stock. Several phthisical uncles and auuts throw a suspicion of consumptive taint on the grandparents, while several brothers and sisters thus affected would lead us to suspect, though not necessarily to conclude, that the parents' health was not quite sound. It may, however, be objected, that the fact of several of the same generation being affected may be explained by a local cause; for instance, a healthy married couple may take up their residence on a clay soil, and their children born and hred in this unhealthy locality may be attacked one after another with con- sumption. In this instance it would be clearly incorrect to at- tribute the disease to family predisposition, as the origin is probably endemic; but Ave must bear in mind, that this objection applies, to some extent, in nearly all cases of family predisposi- tion, as when the son of a consumptive father is attacked with the disease, it is often difficult to say for a certainty that the son's disease is hereditary and has not been acquired, especially if, as may be the case, his brothers are quite exempt. We must therefore take into consideration all degrees of came under his notice, were strong and blooming, but five out of the six died of phthisis between the ages of 24 and 34, the disease beginning in many of them with haemoptysis. The father died of a different complaint, and the mother, up to the age of *53, enjoyed uncommonly good health, being quite free from any symptoms of consumption. She was then suddenly attacked with haemoptysis, and expired the same day, her death being subsequent to the commencement of the disease in the children. "Waldenburg says the children's ill-health could not be traced to endemic causes, as they had lived in different localities, and sepa- rated from each other, and had been brought up under favorable circumstances. He concludes, " This is a very remarkable instance where the mother, without having phthisis herself, had the disposition to consumption, and transmitted it to the children, who died of phthisis." 110 CAUSES OF CONSUMPTION. family predisposition, and try to estimate each at its proper worth. It may be remarked in passing, that man is not the only ani- mal cursed with hereditary consumptive disease. Delafond states that a phthisical ram in a flock of merinoes transmitted his disease to sixteen or twenty of his progeny. Dr. Sanderson told me that at the great cattle-breeding establishment at Lyons, the offspring of a Scotch bull whose lungs were found to be stuffed with" tubercle, after his death, were also infected with the disease, and several of the guinea-pigs who were tubercu- lized in the late experiments have produced tuberculous off- spring. We must not overlook the fact, that it is not necessary for parents to have consumptive disease in order to produce phthisi- cal offspring. The children of very aged parents, of syphilitic, gouty, or asthmatic1 parents, or of those whose constitutions have been greatly weakened by drink, sexual indulgence, or other debilitating causes, are prone to phthisis. We cannot agree with Niemeyer, that these parents are as liable as con- sumptive parents to beget children who come into the world with a predisposition to consumption ; on the contrary, the pro- clivity is present to a far less extent than those in whom family predisposition is strongly marked. The extent in which hereditary predisposition exists among cases of phthisis, is a subject on which authorities differ; but these differences, as Dr. Fuller remarks, are attributable to the various degrees of relationship included. The 1010 cases of the Brompton Hospital Report, included only parents, and gave an average of 24.4 per cent. Dr. Fuller's 385 cases embraced grandparents, uncles and aunts, and furnished 59 per cent. Dr. Cotton's 1000 cases included parents, brothers and sisters, giving 36.7 per cent., and Dr. Pollock's 1200 similarly esti- mated, showed 30 per cent. Dr. Copland gives 47 per cent., but does not state his number of cases or the list of relations included. Louis, Briquet, and Rufz base their calculations on so small a number of patients, as hardly to furnish fair evidence, but, as far as it goes, it is contirmatorv of the above estimates. 1 The tendency of asthmatic parents to produce phthisical children is hardly sufficiently recognized. Among my out-patients at Brompton I found many instances, and our tables include several cases. The reason of this probably is, that many cases of asthma were at their com- mencement cases of limited phthisis, which have been arrested. In the course of this process induration at the root of the lung has taken place, causing con- traction of the bronchi, and giving rise to asthmatic symptoms. (See p. 58.) The children of these patients, if phthisical at all, are generally more decidedly so than the parents. FAMILY PREDISPOSITION. Ill Onr 1000 cases give 484 instances, the particulars of which may here be seen : 10 had grandparents affected. 43 " father affected. 67 " mother affected. 10 '' both parents affected. 48 " uncles and aunts affected. 72 " father's or mother's family affected (particulars unknown). 224 " brothers and sisters affected. 10 " cousins affected. 484 Where more than one relation was affected, as was the case in 60 of these patients, it has been the rule not to make a double entry, but to record the nearest relative of the preceding generation: e.g., "mother and brother" affected is entered under " mother," " father and sister" under "father," and so on. The greater number of duplicates occurred in those of the same generation as, brothers, sisters, and cousins. Our percentage of family predisposition was 48.4, but, as will be seen by the above table, the number of purely hereditary cases, that is, with parents alone affected, was only 12 per cent., thus differing greatly from the percentages of Drs. Cotton1 and Fuller,2 and of the first Brompton Hospital Report, which was about 25. The only explanation we can offer of the discrepancy, is a difference in the class of the patients from which our statis- tics are taken, and of those on which the above authorities found their estimate. Their calculations were based on hospital practice (except Dr. Fuller's, which included some private pa- tients) : ours are based entirely on private practice. Great pains were taken by Dr. Williams to arrive at an ac- curate result. The patients were all closely questioned as to their dead and living relations. In many instances, the exist- ence of consumption iu the family was at first denied; but after cross-questioning, not only was its existence admitted, but un- doubted cases of death from that disease were traced among their relatives. On the whole, we think that an average of 12 per cent, for direct hereditary predisposition, and of 48 per cent, for family predisposition, are not unfair estimates for the upper classes, and that the average of the above authorities is probably cor- rect for the lower classes; and we think it also likely that our smaller percentage in a class which, from its wealth, is able to banish many of the most fertile causes of phthisis, gives a more just estimate of the influence that hereditary predisposition, un- aided by poverty and exposure to divers pernicious influences, exercises on the causation of phthisis. Having discussed the i 24.1. 2 25.7. 112 CAUSES OF CONSUMPTION. prevalence of family predisposition, we now proceed to consider the following questions regarding its transmission. First, the influence of sex. (1.) Family predisposition is much more common among women than among men. This was clearly proved, as far as hereditary influence is concerned, by the first Brompton Hospital Report, which showed that, in this particular, the relative pro- portions of the sexes were as two to one. Our own cases of family predisposition show similar, though as might be expected from the wider list of relations included, less striking evidence. 57 per cent, of the females, and only 43 per cent, of the males were thus affected. The more common occurrence of this fea- ture among females than among males is to be accounted for on the ground that the sedentary and less invigorating life of the former offers less opposition to the development of the seeds of the malady; whereas the more vigorous and active life of a man tends to fortify a naturally delicate frame, and render the predisposition inert. Again, where the sons of phthisical fathers lead very sedentary lives, how very common it is for them to be attacked with consumption at an early age, and often of an acute description ! This observation thus confirms what has been sug- gested with regard to the hereditary prevalence among females. (2.) The transmission of phthisis is more common through the mother than through the father. Mr. Ancell1 states that, as far as limited statistics go, the evidence on this point is strong. We are glad to be able to confirm this statement from our own statistics, which in 1000 cases, record sixty-seven consumptive mothers against forty-three consumptive fathers. Mr. Ancell justly remarks: "Regarding it (phthisis) as a disease of the blood this result might have been predicated, since there is only one period at which the father's influence could be'exercised, viz., that of conception; whereas the influence of the mother is exercised at that period, and also through uterine gestation." (3.) Fathers transmit more frequently to sons, and mothers to daughters, than the converse. This important fact was first established by the first Brompton Hospital Reports, and having been amply confirmed by numerous competent observers, may now be said to be matter of everyday experience. How does family predisposition influence age in consumption? This is a very important question, bearing intimately on the prognosis of the disease, and deserves a fuller discussion than we have time or space for. Our researches2 have, we trust cleared up some of the mystery in which the connection of ao-e and family predisposition was enveloped. We have demon- 1 A Treatise on Tuberculosis, p. 385. 2 " On the Duration of Phthisis, and certain Conditions which Influence it " Medico-Chir. Trans., vol. liv. ' PARENTAL TRANSMISSION. 113 strated clearly that the chief influence which family predisposi- tion exercises is on the age at which the patient is likely to be attacked. It hurries the onset of the disease. This conclusion was arrived at by careful investigation of the age at which the 1000 private cases were attacked. This having been ascertained, we pursued a similar inquiry with regard to tliose affected with family pre- disposition; and lastly, with reference to those who were free from it, as far as could be ascertained at the time of their being under observation, that is to say, who up to the last date had had no relatives affected with phthisis. The result is shown in the following tables: Average age of attack in total males,..... " " females, .... Average age of attack in males free from Family \ Predisposition,............j Average age of attack in females free from Family 1 Predisposition,............j Average age of attack in males affected with 1 Family Predisposition,.........j Average age of attack in females affected with 1 Family Predisposition,.........} Average age of attack. No. of Cases. 29.47 26.06 025 375 30.03 355 28.05 181 27.07 270 21.51 214 Tins table shows that the average age of attack in the num- ber affected with family predisposition of both sexes, was earlier than the average age of attack in the whole number by 2% years in the males, and by 4J years in the females. There is also shown that it was earlier than that of those free from family predisposition by 3 years among the males, and by 6| among the females. This is very striking; but remembering that these statistics were of the upper classes only, and might only apply to certain circumstances connected with them, I determined to pursue the same inquiry among the lower classes, and for this purpose I had recourse to my Brompton note-books. Among 400 out- patients, the result was as follows : Average age of attack. No. of Cases. Average age of attack in males free from Family \ Average age of attack in females free from Family j 32.01 28.47 24.64 24.00 100 100 100 100 Average age of attack in males affected with 1 Average age of attack in females affected Avith \ 114 CAUSES OF CONSUMPTION. The figures confirm the former results as regards the age of attack being rendered earlier by family predisposition, but the relative influence on the two sexes differs greatly from what we found among the richer classes. In the out-patients' class, the age of attack was about the same for males and females, the males being attacked earlier than among the rich—the females later. The age of attack in those free from family predisposi- tion was for both sexes considerably later, and the influence in the male sex greater than in the female—a result exactly oppo- site to that obtained among the upper classes. This remarkable influence of family predisposition in hurrying the onset of the disease does not seem to have attracted much attention, and the only authority I can find who seems to have noticed it is M. Briquet,1 who, in the smaller number of 95 cases of consump- tion, arrived at the conclusion that "hereditary tuberculosis develops itself in the form of phthisis at an earlier period of life than the disease does when acquired. In 89 of the cases with the history of hereditary transmission, 26 became phthisical before 30 years of age; while of 56 cases born of perfectly healthy parents, 31 did not become phthisical until after 30." M. Briquet's cases were rather too few to afford strong evi- dence, and he makes no attempt to separate the sexes, and trace the influence in each sex; but we have little doubt that his ob- servations, as far as they went, were correct, and that the fact "that family predisposition hurries the onset of phthisis," as ascertained by his and our own researches, is one not to be dis- puted. Let us now consider whether the presence of family predispo- sition exercises any decided influence over the type of phthisis. Have cases with family predisposition any distinguishing fea- tures? We must confess that it is hard to trace any feature which cannot also be found in other cases of consumption. In many instances, great transparency of skin, with veins clearly visible, and a delicacy of outline, is noticeable; in others, marked want of development, or else distortion of the thorax; in many, glandular enlargements come on at an early age. These and other features are to be found, often strongly marked, in heredi- tary cases; but they are not invariably present, and, on the other hand, they are to be seen occasionally in non-hereditary cases. We are afraid we cannot point to one distinguishing point of hereditary phthisis. Dr. Pollock remarks that in acute cases of phthisis the influence of hereditary predisposition is undoubted, and he says that of 179 cases, only 34 could positively state that there was no family taint either parental or remote. 1 " Kecherches Statistiques sur l'Histoire de la Phthisie." (Kevue Medicale INSTANCES OF FAMILY PREDISPOSITION. 115 We subjoin a few well-marked instances of hereditary origin, some of which were attacked early and some later in life. We think they will be found instructive, as showing that the strongest hereditary taint does not hinder the beneficial effect of remedies, if persevered with. Cask 7.—A lady, aged 34, first consulted Dr. "Williams, June 20, 1850. Had lost her father and mother, and ten brothers and sisters, from consump- tion, and had herself been always liable to cough, and had one constantly since December. Three years previously she had haemoptysis, amounting to a tablespoonful. At the time of her visit the expectoration was streaked with blood. She had lost much flesh and strength, and complained of pain in her chest: catamenia irregular and deficient. Dulness and tubular sounds in the upper part of both sides of chest, most marked on the rigid, where there was crepitation.—Ordered cod-liver oil in a mixture of hydrocyanic and phosphoric acids, with infusion of calumbo and orange ; counter-irritation with acetum eantharidis ; and a linctus containing morphia. May 21, 18UO.—Greatly improved under the above treatment, and has grown stout. lias hardly any cough or expectoration, but lately suffers from oppression of breathing and frequent boils.—Ordered oil in a mixture of chlorate of potash, nitric acid, and glycerine. July 30, 1801.—Continued to improve till the winter, when had inflam- mation of the lung ; and since the attack the expectoration has been some- times gritty and sometimes fetid. Is still stout and strong, but breath short. Has taken oil regularly, combined with strychnia. Dulness, tubular sounds in ujgier left back and riyht front. April 19, 1S06.—Has always wintered in Cornwall, and out a great deal in the open air ; but lately stomach weak, and has not been taking much oil. Has lost much flesh ; but cough and expectoration are less than during last winter, when they increased, and there was some haemoptysis. Suffers from piles. Dulness, laryc tubular sounds in upper right chest.—To take oil, with phosphoric acid and hypophosphite of soda. An electuary of sulphate and bitartrate of potash. October 1, 1870.—Returned to Cornwall, and improved again so much that for the last two years has taken no oil. Last February took cold, and cough again returned, and has been troublesome since, with frequent sick- ness. In July went to North "Wales, there caught fresh cold, and has been very ill ever since, with sickness, pyrosis, disgust at food, and great loss of flesh and strength. Urine pale and copious ; sp. gr. 1010 ; no albumen. A number of red scaly spots on skin. Cough, and opaque expectoration. Dulness and tubular sounds in both upper regions. Collapse under left clav- icle, with defective breath. Crrjntus in lower half of right lung. Heard of her death in December, about 12£ years after her first marked symptoms. Case 8.—A young gentleman, aged 16, whose mother and sister had died of phthisis," saw "Dr. Williams, August 28,18o5. He had had repeated haemoptysis since Christinas, sometimes amounting to an ounce, and also cough, with some loss of flesh, and lately pain in right shoulder. Dulness anil tubular sounds above right scapula.—Oil ordered, with sulphuric acid, and infusion of roses, &c, and acetum eantharidis liniment. September 20, 18">(j.—Wintered at Hastings, aud improved in flesh, strength, and health. Oil has been taken steadily, except for about three weeks, when it was omitted, and he lost flesh. Haemoptysis has occurred several times, generally after some exertion, and once amounted to £vi. Dulness, tubular and obstructive sounds in upper right chest, with subcrcpitus. October 9, 1S.V7.—Was ailing in May. but now better and free from 116 CAUSES OF CONSUMPTION. cough. In last month has suffered from lowness of spirits, sleeplessness, and confused head. Chest clearer, but still some tubular sounds, with obscure breathing in upper rigid chest. January 11, 1859.— Sleeplessness gradually improved, and spent spring at home ; but, after three months in the Regent's Park, cough increased, and haemoptysis came on to the amount of 5 ii. Some dulness and tubular sounds in upper right r I test, crepitation sounds above scapula. July 11.—Went soon after to-.Madeira, and rode out a great deal. Lost cough", and ascended the Peak of Teneriffe. Now strong, ruddy, and able to walk six miles. October 16, 1801.—Last two vears have been spent in London. Has been free from cough and haemoptysis, and his condition has been good, but breath short. Oil has been taken regularly for nearly two years. Still loud crepitation, left front and right back, with dulness and tubular sounds above rit/ht scapula. September 7, 1803.—Had been studying at Cambridge for a year, when had haemoptysis, iiii, after bathing; and pain in right chest. After Easter, 1863, nursed bis father (who died of Bright's disease), and had haemoptysis to ^ii daily, for a week in July ; has left off oil and is taking cream, and is much reduced in strength, though not in bulk. Much dul- ness, and obstructive sounds in upper right back. Tubular sounds both upper sides of chest. April 8, 1864.—At St. Leonards ; wonderfully improved in flesh, color, strength, and breath. AValks fourteen miles at a time. Oil in sulphuric acid has been taken all the winter. October 4, 1864.—Improved at Tunbridge Wells, and was able to walk ten miles briskly : physical signs became drier. Then returned to keep terms at Cambridge. Remained well till on a visit to Liverpool, had haem- optysis to amount of ,$iv. In February, 1865, was sent to Madeira, and gained strength, 7 lbs. in weight, being much out riding ; then spent sum- mer in Hants ; and returned to Madeira in following winter, there remained till April, when had fever and congestion of the lungs. Since then weaker, with more cough and expectoration, and often chills and heats, and has some expectoration, sometimes opaque, sometimes calcareous. Tubular and crepitation sounds in both backs, most in the right. October 15, 1867. —Remained at St. Leonards till February, then went to Mentone till May, and gained 8 lbs.; improving also in strength and appe- tite. Had been taking oil, .^vi once a day. In warm weather improved in weight, strength, and breath, but worse lately. More crepitating and ob- structive sounds in left front and right back. Case 9,—Miss F., aged 24, consulted Dr. Williams, September 17, 1857. She had lost her mother, two brothers, and one sister from consumption, and had herself suffered from cough for lh year, accompanied by expectora- tion sometimes streaked with blood. Catamenia had been absent for three months, and she had lost flesh, strength, and breath. Extensive dulness, obstruction, and croaky sounds in upper left chest. Pectoriloquy below clav- icle. Tubular sounds upper right chest. Oil ordered in tonic, and use of acetum eantharidis. October 31st.—Under these means has much improved in flesh, strength, and appetite. Cavernous croak below left clavicle; more breath below. September 20,1858.—Continued better, taking oil till May, when omitted it for two months, and lost flesh and strength. Then resumed it for two months, and has improved, but has not yet regained the loss. Cavernous sounds in upper left chest, tubular and crepitating sounds upper right. March 29, 1859.—Heard that she had been better till last two months when she has had more weakness and sickness. No catamenia since May'. Case 10.—Miss T..., aged 21, whose mother had died from consumption, CASES OF FAMILY PREDISPOSITION. 117 was seen by Dr. Williams, August 26, 1857. From the age of 14 to 16 had been delicate, and taking cod-liver oil. Often subject to cough in the last three winters ; now one since March, with yellow expectoratiou, and lately a little blood. Has been losing flesh and strength. Collapse, dulness. tubular sounds in left front and back. Bronchocele 6 months.—Oil ordered, with tonic. March 29, 1864.—Took oil, and improved very much, having cough only in winter ; but now has one lasting since Christmas, with yellow expectora- tion, breath shorter. Oil has been discontinued on account of sickness, and no tonic taken. Dulness, tubular sounds and crepitation, in upper left chest, loose crepitation upper right. Case 11.—Miss V., aged 10, who had lost her mother and sister from consumption, was seen by Dr. Williams, March 22, 1859. Had cough and cold in December, which has continued, though to a slight extent, ever since, with opaque expectoration, and yesterday some blood. Breath short. Dulness, large tubular sounds, and gurgle in upper right chest, front and back. Oil ordered in tonic of phosphoric and hydrocyanic acids, with calumba and orange tinctures, the use of acetum eantharidis liniment, and a mor- phia linctus. June 10, 1860.—Taken oil, &c, and much better. Last summer had measles; cough was violent for three weeks, but subsided under the use of oil, and has remained moderate since. Wintered at Cannes, and out much. Still decided dulness, and marked tracheal sounds in upper right chest. After measles, coarse crepitation there and below. October 16, 18(52.—Well, and free from cough till a month ago, when it was violent for two weeks, and subsided under oil and iodine paint. Now has no cough or expectoration. Hard dulness at and above right scapula, with loud tubular sounds. Back rounded. 1871.—Not seen since ; but heard of as tolerably well, having passed a winter at Mentone. Case 12.—Mr. N., aged 42, consulted Dr. Williams, July 31, 1860. He had lost his father, mother, and a brother from consumption, and had been subject to cough for the last seven years. Two years ago he had haemop- tysis to ,^ii and breath has been shorter ever since. Cough has been constant for the last nine months, and haemoptysis to amount of Sss., has occurred once. Has taken oil regularly (-ss. ter die) for nine months. Dulness and tubular sounds in upper right chest. Tubular sounds above left scapula.—Oil was ordered with phosphoric acid and tinctures of calumbo and orange; counter-irritation with acetum eantharidis, and a morphia linctus. April 5, 1867.—Has kept pretty well and stout, but breath has always been short, and he has cough with opaque expectoration, which has been less in last winter, but patient is hoarse. No oil taken last year. Still dulness upper right, tubular sounds above scapula. Subcrcpitus and weak breath below.—Ordered oil, with nux vomica, phosphoric acid and quassia. June 8, 1868.—Tolerably well, but always has slight cough, and some haemoptysis occurred last spring; oil taken last winter. Sputa opaque and tinged with blood. Some didness at and above left clavicle with tubular sounds, but breath weaker above right scapula; crepitation down left front. Here the strong family predisposition did not tell till comaratively late in life, and did not prevent the remedies used from having a beneficial effect. The patient has been about eight years under observation, and the disease seems to have diminished in right lung, though some increase has taken place in the left. Case 13.—Mr. R., aged 17, whose father had died of consumption, saAv 118 CAUSES OF CONSUMPTION. Dr. Williams, Mav 7. 1857. For three years he had had swelling and dis- charge from the cervical glands, and cough off and on for two years ; lately has had cough for six weeks, accompanied in last fortnight by pain in the side, and short breath. The scrofulous sores in the neck are still discharg- ing. Oil taken till two months ago. Dulness, obstructed breath, and much crepitation in front of left chest, mostly in upper portion and above the clavicle. Some dulness above right scapula. Oil ordered in nitric acid and tincture of orange : a liniment of strong tincture of iodine. April 13, 1804.—Took oil, and states that he got quite well in six months, and then omitted oil, except an occasional dose. Throughout last winter has had cough and expectoration, and three times brought up blood to the amount of ,55ii. Has lost much flesh and strength. Dulness, cavernous sounds in upper half left chest, with obstruction sounds below. What effect has family predisposition on the duration of phthisis? Is the duration curtailed by it? Do patients thus affected die earlier than other consumptive patients? These questions are of considerable importance in the prognosis of the disease; and we have attempted to answer them in the fol- lowing statistical results, extracted from our tables: Average Duration from the Commencement of the Disease in 198 Deaths. Yrs. Mths. No. of Cases. Average duration of cases affected with Family) Average duration of cases free from Family Pre- \ Average duration of total number of deaths, . . 7—5.8 7-10.9 7-8.7 87 111 198 Here it is shown that the average duration among the 87 deaths of those affected with family predisposition was 7 years 5.8 months, an average not greatly differing from that of the eases free from this influence, or again from that of the total deaths. A difference of only a few months is noticeable, and does not indicate that family predisposition exercised any de- cided influence in shortening the duration of the disease. The evidence of 397 living cases of family predisposition sup- ports the same conclusion; for among these the average dura- tion already reached was 7 years 11 months; that of all the cases free from predisposing taint being 8 years 1\ months, and of the total living 8 years 2 months. It would seem, therefore, that family predisposition, without reference to sex, exercises but a slight influence over the dura- tion of phthisis. Does it influence the duration of the disease in one sex more than another? PREDISPOSITION INFLUENCING DURATION. 119 We have seen that the age of attack is influenced differently in the sexes, and also that phthisical females live a shorter time than phthisical males; and the following question should now be solved: Is the duration of the disease shorter among phthis- ical females affected with family predisposition than in others not so affected? This maybe seen by a glance at the table below : Relative Duration of Disease in the two Sexes in Family Predis- position. No. of Cases. Dead. No. of Cases. 216 181 Living. Males,. . . Females, . . Total, . . 54 33 Yrs. Mos. 8 — 2 6—7.3 Total, . Yrs. Mos. 8—2.7 7—6.7 87 397 The inspection of this table will show that the sexes are equally influenced as to the duration of the disease, aud that family predisposition exercises no particular influence—a con- clusion which contrasts with that arrived at with reference to the age of attack; and is entirely at variance with the old views of hereditary phthisis being more rapidly fatal than acquired phthisis. To this conclusion it might be replied, by those who still believe in the curtailing influence of hereditary taint, Perhaps family predisposition, as a whole, does not influence the duration of phthisis, but do not some of its various degrees do so? We had hoped to answer this point satisfactorily, but, unfortunately, lack of materials prevents our doing it completely. Such in- formation as our cases afford is to be found in the following table: Dead. No. Living. No. Total. Grandparents affected, Average. Yrs. Mos. *16—7.00 2 Average. Yrs. Mos. *10—6.62 8 10 Father " *7—5.28 7 7—9.25 36 43 Mother '' 8—3.54 11 7-10.75 56 67 Both parents " 1 *6—9.11 9 10 Brothers and sisters affected 7—6.02 44 8—2.24 180 224 Uncles and aunts " *12—6.00 4 7—6.18 44 48 * Numbers too small to yield fair average. 120 CAUSES OF CONSUMPTION. The evidence here furnished is chiefly of a negative kind, and must be viewed as proving that some forms of predisposition do not curtail the duration of the disease, and not as demon- strating what influence other forms may have on it. We see in 11 deaths where the mothers were consumptive the duration was S\ years, that 56 living patients similarly situated had lived 7 years lOf months. Among these few cases maternal influence had no effect in curtailing the duration, which in the 11 deaths was rather higher than ordinarily. In the case of brothers and sisters, where the numbers warrant our speaking more decidedly, what do we find? In 44 deaths, the duration was 7 years 6J months, slightly below the whole average of deaths; while of 180 living cases in this category the mean duration was 8 years 2^ months, about the same as the common average. Here again family predis- position seems to have exercised little or no influence. The other numbers are too small to furnish even negative evidence. Our last point to consider is the age which these patients affected with family predisposition live to. Do they die earlier than other consumptive cases? The grounds for determining this question have been already to some extent settled; the age of attack and the duration in these cases having been ascertained, and therefore the following result was easily arrived at: No. of Deaths. Average age reached by males free from Family \ Average age reached by males affected with \ Average age reached by females free from Family \ Average age reached by females affected with \ 41.51 35.29 34.92 30.74 65 54 46 33 Family predisposition, therefore, though it does not materially curtail the duration of the disease, has considerable influence in shortening the duration of life, such limitation amounting in males to more than six years and in females to not quite five years. But we must remember to assign this cutting short of the span of life to its proper cause—not to hereditary phthisis being more virulent and rapid in its progress, for that idea has been disproved—but to the fact that those who come of a con- sumptive stock are liable to be attacked earlier than others whose families are free from taint. Our conclusions on the subject may be briefly summed up: 1. Family predisposition occurs more commonly anion a-? and exercises a more decided influence on, females than males; and the former have a greater power of transmission than the latter. TYPHOID AND OTHER FEVERS. 121 2. Fathers transmit more frequently to sons, and mothers to daughters, than the converse. 3. Family predisposition does not directly shorten the duration of the disease. 4. It precipitates the onset of the disease, and thus shortens the duration of life. We have entered thus fully into the relation which family predisposition bears to phthisis, because we believe the subject has hitherto been considered as rather obscure, and not because we think the other causes of phthisis less important. But the action of these is better recognized, and therefore needs but a passing mention. Impure air and improper food are well-known general causes of consumption. Among the lower classes, in crowded cities, evidence of their effects is only too common. Of 3214 men who became inmates of the Brompton Hospital in ten years, 1812 (more than half) had indoor employments. Among my own out-patients, the numbers of those who ply their trade in close, ill-ventilated rooms, and during long hours, are very great: clerks, compositors, tailors, shoemakers, among men; and milliners, dressmakers, among women, are attacked at an early age. Want of proper food acts by impoverishing the blood and lymph, whether the fault lies in the quality or quantity of food. If healthy pabulum be not supplied for nutrition of tissue, it is impossible for it to retain its normal standard; it starves, and the pabulum not good enough for the tissue will go to form morbid material. Instances of this predisposing cause can be seen in the poorly-fed children who attend at the Brompton Hospital, and in whom a very slight exciting cause brings on the consumptive disease. Typhus and Typhoid Fecers.—Of these, typhus is the least pow- erful cause, though it exercises some influence; but man}' cases of consumption are to be traced to an attack of typhoid or py- thogenic fever. Dr. Murchison says, " An attack of pythogenic fever is often followed by tubercular deposit in the lungs." And again, " In my experience, acute tuberculosis of the lungs is a far more common complication or sequela of p}7thogenic fever than of typhus, and it is intelligible why this is the case, when we recollect the more protracted duration of the former malady, and the greater emaciation it entails. Louis records four fatal cases of pythogenic fever, in which the lungs were found studded with recent tubercles. Bartlett also observes, that consumption is a common sequela of this fever in America."1 1 Treatise on Continued Fevers, p. 503. 122 CAUSES OF CONSUMPTION. It is worthy of notice, that the organs so commonly affected in typhoid fever—viz., the solitary glands, Beyer's patches, and the mesenteric glands—are also frequently the seat of tubercu- lar disease. The wasting, too, which accompanies both these diseases seems to be connected with a disordered state of the lymphatic system, particularly of the lacteals. We know that the organs attacked by typhoid fever and the intestinal forms of consumption are portions of the lymphatic system, and the recent researches of Sanderson1 and Wilson Fox2 have shown in some of the pulmonary lesions in artificial tuberculosis, too, that the lymphatics are the seat of the disease, and that the principal morbid changes take place in and around them. Scarlatina and measles are very common causes of consump- tion, chiefly in children. Acting generally, they exhaust the patient, and leave him an easy prey to the first exciting cause fKthat comes. Acting locally on the lungs, by their sequelae, I bronchitis, and inflammation, they embarrass them with con- [ solidations more or less prone to caseation. (See pp. 101, 104.) I* The cessation of habitual discharges, as those from fistulas in ano and old ulcers, will sometimes give rise to symptoms of con- | sumption, which often diminish on the discharge being re-estab- llished. In fistula this is so marked, that many physicians 1 refuse to sanction, and many surgeons to perform, operations |for fistula on patients who have shown evidence of consumptive ; '• disease of the lungs. Miscarriages, bad confinements, and ocer lactation, are fertile causes of phthisis among the poor, chiefly through the great exhaustion consequent on them; but we must not overlook, in the case of the two former, the highly fibrinous state of the blood, which predisposes to the production of material of a phthino-plastic kind. Mental depression.—Some doubts have been expressed by au- thors as to this exerting any influence in the causation of con- sumption. When mental depression arises from any great loss, whether of relatives, friends, or property, it is often followed by irregular habits. Food is not taken regularly, nor in sufficient quantity; and, on the other hand, stimulants are often taken too freely. In these cases, it is doubtful whether we ouo-ht to assign as the cause the mental depression, or the irregular living accompanying it. Laennee gives an interesting instance of the effect of mental depression. "I had under my own eyes," says he, "during a period of ten years, a striking example of the effect of the depressing passions in producino- phthisis, in the case of a religious association of women of recent founda^ tion, and which never obtained from the ecclesiastical authorities any other than a provisional toleration, on account of the extreme severity of its 1 Op. cit. 2 Op. cit. MENTAL DEPRESSION—DAMP. 123 rules. The diet of these persons was certainly very austere, yet it was by no means beyond what nature could bear ; but the ascetic spirit which reg- ulated their minds was such as to give rise to consequences no less serious than surprising. X«»t only was the attention of these women habitually fixed on the most terrible truths of religion, but it was the constant prac- tice to try them by every kind of contrariety and opposition, in order to bring them, as soon as possible, to an entire renouncement of their own I proper will. The consequences of this discipline were the same in all: after beintr one or two months in the establishment, the catamenia became suppressed, and in the course of one or two months thereafter phthisis de- clared itself! .... During the ten years that I was physician of this association, I witnessed its entire renovation two or three different times ; owing to the successive loss of all its members, with the exception of a small number, consisting chiefly of the superior, the grate-keeper, and the sisters who had charge of the garden, kitchen, and infirmary. It will be observed that these individuals were those who had the most constant dis- tractions from their religious tasks, and that they also went out pretty- often into the city on business connected with the establishment."1 Damp.—A damp atmosphere may be generated either by moisture brought to the locality through the prevalence of cer- tain winds, or by the impermeable nature of the soil underly- ing it, causing the accumulation of moisture on the surface. Whether a damp atmosphere generated in the first-mentioned way gives rise to consumption, there is as yet no decided proof; but of its origin in the last-mentioned way, viz., from a damp soil, the investigations of Drs. Buchanan and Bowditch leave no room to doubt. Dr. Buchanan was appointed by the Privy Council to investigate the effects on the public health produced by the improvements lately made in the drainage, water-suppl}7, &c, of certain towns. He found, with regard to phthisis mortal- ity, that its diminution or non-diminution depended on whether the sanitary improvements of the place had or had not included any considerable drying of the soil. In fifteen large towns where a diminution had taken place after the improvements, the death-rates from phthisis had fallen some 11 to 20 per cent.; in others, 20 to 30 per cent.; and others again, 30 to 49 per cent.; and in many towns this diminution of deaths from phthisis formed the principal sanitary amendment. " This," as Mr. Simon2 says, " is extremely interesting and significant, when it is rememhered that works of sewerage by which the drying of the soil is effected must always precede, and do indeed some- times precede by 37ears, the accomplishment of other objects— house-drainage, abolition of cesspools, and so forth—on which the cessation of various other diseases is dependent." These results naturally directed attention to the influence of the soil in the distribution of consumption, and led Dr. Bu- chanan to institute a farther inquiry on this point. By a care- 1 Diseases of the Chest, Sir John Forbes's translation, p. 334. 2 Keport of the Medical Officer of the Privy Council for 1867. 124 CAUSES OF CONSUMPTION. ful comparison of the geological formations of the registration districts of the counties of Surrey, Kent, and Sussex with the death-rates from phthisis in these districts, and by an elimina- tion of all probable chances of error, he arrived at the impor- tant conclusion, that wetness of soil is a cause of phthisis to the popu- lation Iking on it. This conclusion was supported by the evidence of the Registrar-General of Scotland with regard to that country ; and by that of Dr. Bowditch of Boston, U. S. A., who in 1862 had drawn attention to the inequality of the distribution of phthisis in the state of Massachusetts, and to the connection of this inequality with differences of moisture of soil. He cited the written statements of medical men resident in 183 towns, which tended to prove the existence of a law in the development of consumption in Massachusetts, that dampness of the soil of any township or locality is intimately connected, and probably as cause and effect, with the prevalence of consumption in that township or locality; and he also adduced particular instances as demonstrating that even some houses may become the foci of consumption, when others but slightly removed from them, but on a drier soil, almost wholly escape. The following in- stance of this law came under my notice, one of the family being for some years under my care. The rector of a parish in Essex resides on a clay soil, and has a large pond immediately in the neighborhood of his rectory. He and his wife have always enjoyed good health, and there is no hereditarydisease traceable, either in his own family or his wife's. Of their twelve children, eight were born at the rectory, and four in a neighboring parish ; but all spent childhood and youth at their father's house. The eldest, if alive, would now be 36; the youngest is 19. Six have died; four of consumption, one of scrofulous disease of the spine, and one of whooping cough at the age of 5. Of the six alive, three are healthy, one is deli- cate, but I have not heard from what cause; two have scrofu- lous disease of the spine. The three healthy ones have spent but little time at home since they have grown up, and one spends much time in travelling. So that out of twelve children, there are no less than four cases of consumption, and three of scrofula. This seems to me a fair instance of phthisis arising from en- demic causes; the social position of the family, who are rich, precluding many other causes, which we have been discussing, from entering into consideration. We may therefore conclude that dampness of soil is an undoubted cause of consumption; and in our preventive treatment of the disease we should aim at either the draiuage of the soil, or removal of the inhabitants to a drier locality. ENDEMIC CAUSES. 125 Of the local causes of consumption, the most important have already been considered, and it only remains for us to notice: Trades and occupations giving rise to a dusty or gritty atmosphere. —A life pursued in an atmosphere abounding in small particles of flint, or iron, or coal, or cotton, or flax, or straw, as is the case with stonemasons, potters, fork-grinders, needle-grinders, cotton- carders, and chaff-cutters, is shown by Dr. Greenhowand others to be a short one; and the cause of death was generally found to be tubercular phthisis, induced by constant inhalation of the irri- tating particles. These have been detected chemically and microscopically in the lungs. They seem to set up irritation in the larger bronchi, causing thickening; and also in the lung- tissue, causing induration and consolidation. It was at first doubted whether these lesions were tuberculous; but the pres- ence of both gray and yellow tubercle, and the tendency of the consolidations to soften and form cavities, sufficiently demon- strate their consumptive nature. Dr. Greeuhow calculated that 45,000 deaths occurred from these causes in England and Wales; and he clearly showed that the whole of this mortality was preventible by the introduction of better methods of venti- lation and working. Since his reports, Acts of Parliament have been passed which, if carried out, ought totally to abolish this cause of phthisis; and it is to be hoped that ere long we may no longer be able to number " dusty occupations " among our causes of consumption. It may be well, before closing this chapter, to allude to the position occupied by consumption with reference to infection—a subject of very great importance to the community. The idea of the disease being infectious is an old one, and has always held its ground in Italy. Recently in this country it has been supported by Dr. William Budd,1 who holds that tubercle is a true zymotic disease in the same sense as typhoid, scarlet, and typhus fevers, never originating spontaneously, but perpetuated according to the law of continuous succession; and that the tuberculous matter itself is, or includes, the specific morbid matter of the disease, and constitutes the material by which phthisis is propagated from one person to another and dissem- inated through society. Among the grounds on which Dr. Budd supports this theory, are (1), the prevalence of both zy- motic fevers and phthisis in very crowded communities, and in prisons, convents, and barracks; (2), the geographical distribu- tion of phthisis in past and present times, and its great fatality in countries which when first discovered by Europeans were known to be entirely free from it; (3), instances in which there was evidence to show that the disease was communicated from one person to another. 1 Lancet, October, 1867. 12(3 CAUSES OF CONSUMPTION. As regards the first ground, it may be observed that the coincidence of the diseases may be explained by the coexistence of common causes, independent of infection, such as impure air and water, bad food, &c.; and as to the second statement, if it be well authenticated, it is hardly fair to overlook the change in the habits of natives which contact with Europeans generally entails. This change, as we know well, is generally for the worse; and to a more domesticated life and the abuse of spirit- uous liquors, much may be ascribed, which Dr. Budd would assign to infection. With reference to the third reason, we must admit that recent experiments on the artificial inoculation of tubercle has given a fresh aspect to the subject of the conta- gion of phthisis, and have rendered it possible that the caseous and purulent material might infect those brought into close con- tact with consumptive patients. The instances of a wife of a consumptive husband, and the sister of a consumptive woman, who had been sleeping with, or attending closely on her, being attacked with the disease, are those which most readily occur to the mind; but we must remember that the close confinement which occurs in these cases must be taken into account; and moreover, if the above experiments point to a possible inocula- tion from tuberculous material, they point also to the same re- sult arising from the inoculation of various other noxious mat- ters, as pus, putrid matter, &c. (See p. 99.) We see, therefore, that if phthisis can be engendered in this manner, it does not arise from any specific poison, but it can be produced in the dissecting-room, or in the surgical wards, as well as, and prob- ably better, than in a hospital for consumption. Dr. Cotton1 justly remarks: "If Dr. Budd's views be correct, this (the Brompton) hospital, as well as every like institution, must be nothing more nor less than a pest-house, and must afford sad and repeated proofs of its banefulness." Now, what do facts say on this subject? The statistics2 of the Brompton Hospital, as furnished by Dr. Cotton and Mr. Virtue Edwards, directly negative any idea of infection. The occurrence of phthisis among the physicians, resident medical officers, chaplains, ma- trons, secretaries, nurses, porters, and servants, and others closely connected with the hospital since its foundation in 1846, has been very rare, and the deaths very few. One assistant physician and one clinical assistant (a member of a consumptive family) have died, and three more of the clinical assistants are said to be consumptive, out of a total of between sixty and seventy. Of the numerous nurses and servants who have been or are connected with the institution, only one nurse and one servant have died of phthisis; and in each case the disease 1 Lancet, November, 1867. « Lancet. HEMOPTYSIS. 127 seems to have been contracted after they left the service of the hospital. None of the chaplains, matrons, secretaries, or porters have been attacked, and the last-mentioned, be it remembered, have to remove the dead from the wards, and subsequently from the dead-house. Two dispensers have died of consump- tion, but in the case of one it was doubtful if he had the disease when attached to the institution. This is surely a small mor- tality from phthisis in twenty-one years! Dr. Cotton says that his experience of one of the largest metropolitan hospitals during the same period, as regards the frequency of phthisis among its official staff, is decidedly in favor of the Hospital for Consumption. He states: "In the same number of years, I have known, at the former institution, one physician, one sur- geon, one chaplain, two house-surgeons, and four or five former dressers or clinical assistants, succumb to this fatal disorder." We need hardly add that a comparison of the number of cases of phthisis among the Brompton staff with the number occurring from zymotic fever among the staff of any fever hospital, will at once annihilate any hypothesis of similar contagion.1 CHAPTER XVI. H/EMOPTYSIS AND THE HEMORRHAGIC VARIETY OF CONSUMPTION. By Dr. 0. Theodore Williams. Haemoptysis—Its significance—Views of Louis, Laennee, Andral, Watson —Niemeyer's Explanation of large Haemoptysis—His Comparison of Bronchial Hemorrhage with Epistaxis inappropriate—Differences in the Bronchial and Nasal Tracts—Niemeyer's Views of the Relation of Haemoptysis to Phthisis discussed—Origin of Phthisis from Haemopty- sis improbable and unproved—Author's Experience—Hemorrhage of Early Phthisis explained by Fatty Degeneration of Vessels-Of later Stages by Pulmonary Aneurism—Varieties and Pathology of latter— Haemoptysis from Congestion—Influence of Age and Sex in Haemoptysis —Influence of Stage—Illustrative Cases—Influence of Form of Disease —Hemorrhagic Phthisis—Its characteristic Symptoms and exciting Causes—Examples—Effects of Haemoptysis in Phthisis—General and local Pneumonia—When and why set up—Itesults—Illustrative Cases —Influence of Haemopt}sis on Duration of Life. So many cases of phthisis are accompanied by haemoptysis in 1 Although I concur in the opinion that we have no evidence that pulmonary consumption is infectious, like small-pox, scarlatina, or typhus, or that it depends on a specific poison, yet I think that both reason and experience indicate that a noxious influence may pass from a patient in advanced consumption to a healthy person in close communication, and may produce the same disease; just as foul pus or putrid muscle will produce tubercles in an inoculated animal. (See chap. xiv.) I therefore always recommend such patients to sleep alone, and to use measures for increasing the purity of the air.—C. J. B. W. 128 HEMOPTYSIS OF CONSUMPTION7. some part or another of their course, most commonly in the early stages, that spitting of blood, or " bursting a bloodvessel," as it is popularly called, has long been considered by the public, and to some extent by the profession, as an indication of con- sumption. The connection of haemoptysis and phthisis, though simple in the stages of softening and excavation, is by no means always so in the early stages of the disease, and especially in cases where large haemoptysis takes place, and but slight if any physical signs are detected at the time of its occurrence. Here the existence of consumptive disease is often denied; and when at a later date it develops itself more clearly, its cause is referred by some writers to the blood effused into the bronchi during haemoptysis, which is considered to have given rise to inflam- mation and destruction of the lung-substance. We propose in this chapter to examine the views held by various writers on the relation of haemoptysis to phthisis, and to state the conclu- sions which our own experience has led us to adopt on the subject. What then do authorities say as to the significance of haemop- tysis? Louis states, that excluding cases of amenorrhea and mechanical injuries to the chest, he did not find a single instance of haemoptysis among 1200 cases, unconnected with tuberculous disease of the lung. Laennee holds much the same opinion; and Andral states, that of persons who have had haemoptysis, one-fifth have not tubercles in the lungs; but he does not state whether any cardiac or other lesion existed to account for the hemorrhage. Sir Thomas Watson1 says: " If a person spits blood who has received no injury to the chest, in whom the uterine functions are healthy and right, and who has no disease of the heart, the odds that there are tubercles in the lungs of that person are fearfully high." On the other hand, Niemeyer, after stating that bronchial hemorrhage is the " most frequent cause of haemoptysis, ex- plains that it proceeds from rupture of the capillaries, caused either by over-distension, or else by a morbid delicacy of the walls—a result of perverted nutrition."2 He remarks very justly, that "trifling capillary hemorrhage, such as occur in bronchial catarrh, violent irritation of air-passages, and in the circulatory disorders attending organic disease of the heart, proceed from the first of these causes, but that in most hemor- rhages in which large quantities of blood are poured into bron- chi to be ejected by haemoptysis, they are due to the latter condition." It is much to be regretted that Niemeyer uses such 1 Practice of Physic, vol. ii, 200. 2 Text-book of Practical Medicine, vol. i, p. 141. Although we cannot sub- scribe to all Niemeyer's views, we deeply lament the loss which Clinical Medi- cine has sustained in the recent death of so careful and accomplished an observer niemeyer's VIEWS. 129 vague terms as "morbid delicacy" of walls of vessels; but as far as we understand him in regarding the vascular walls as the seat of disease, and their fragility the cause of large haemoptysis, we agree with him. Why he should assign such hemorrhage to the bronchial trunks and capillaries, we are at a loss to un- derstand, as he gives no fact to support his statement, and we know that as jet simple bronchial hemorrhage has never been demonstrated by post-mortem examination. The comparison with the large hemorrhage from the nasal mucous membrane, which occurs in profuse epistaxis, does not hold good, as may be shown by structural differences in the two tracts. The Schnei- derian membrane in parts, as on the septum nasi and over the spongy bones, is very thick, partly through the presence of glands, but chiefly, as Todd and Bowman1 say, "from the pres- ence of ample and capacious submucous plexuses of both arteries and veins, of which the latter are by far the more large and tortuous. These serve to explain the tendency of hemorrhage in case of general or local plethora." The bronchial mucous membrane, though undoubtedlj- vascular, cannot be said to pre- sent in its structure any explanation of copious hemorrhage like that of the nasal tract. Nieme3'er2 sums up his views on the relation of haemoptysis to phthisis in the following paragraphs: "1. Bronchial hemorrhage occurs oftener than is generally believed in persons who are not consumptive at the time of the bleeding, and who never become so. " 2. Copious bronchial hemorrhage frequently precedes con- sumption, there being, however, no relation of cause and effect between the hemorrhage and pulmonary disease. Here both events spring from the same source—from a common predispo- sition on the part of the patient, both to consumption and bleeding. " 3. Bronchial bleeding may precede the development of con- sumption as its cause, the hemorrhage leading to chronic in- flammation and destruction of the lung. "4. Hemorrhage from the bronchi occurs in the course of established consumption more frequently than it precedes it. It sometimes, although rarely, appears when the disease is yet latent. " 5. When bronchial hemorrhage takes place during the course of consumption, it may accelerate the fatal issue of the disease by causing chronic destructive inflammation." With regard to the first class, Niemeyer states that haemop- tysis occurs, though rarely, in young persons in blooming health and of vigorous constitution, and that there is absolutely no ex- i Physiological Anatomy, vol. ii, p. 3. 2 Op. cit., p. 144. 9 130 HEMOPTYSIS OF CONSUMPTION. planation of the disorder, which is often followed by such sad re- sults. Here we question the facts, both of the hemorrhage being really bronchial, for the reasons we have given above, and of the health of these persons being really sound. In few such cases have we failed to find signs of disease, limited, it is true, and generally confined to the interscapular regions of the chest. Niemeyer admits that exceptional instances occur in which tubercles and inflammatory processes form in the lungs in a manner so latent that no tokens of disease are manifested by the individual affected, until he is suddenly attacked by a fit of hemorrhage; but he denies that this is the case in the great majority of instances where the first attack of haemoptysis has not been preceded by cough, dyspnea, or other sign of pulmo- nary disorder. How he distinguishes between these two classes, or on what grounds he supposed that they are separate classes does not appear; but he continues, "That bronchial hemorrhage is by no meaus so rare an event where there is no grave disease of the lungs, is shown, moreover, by the tolerably numerous eases in which persons, after suffering one or more attacks of pneumorrhagia, regain their health completely, and indeed often live to an advanced age, and after death present no discoverable traces of extinct tuberculosis in their lungs." Unfortunately, none of these " tolerably numerous cases " is given to support this statement, which can hardly, therefore, be considered to be supported by satisfactory evidence. Our own experience is exactly the reverse, and we have generally been able to detect signs of disease during life, in the lungs of all those patients who have had extensive hemop- tysis, unconnected with heart disease, injury to the chest, or disorder of the menstruation. Niemeyer also finds " a strong tendency to profuse capillary hemorrhage from the bronchi in young persons between fifteen and twenty-five, whose parents have died of consumption, and who have suffered in infancy from rickets or scrofula, have often bled at the nose, and grown rapidly tall." He is tempted to refer the remarkable frequency to a deficiency of vital material which has beeu immoderately expended in the maladies of childhood or in the process of growth, and therefore does not leave sufficient to maintain the normal nutrition of the capillary walls. He remarks that this does not explain why the seat of the hemorrhage should be, first in the nose, and secondly in the bronchi, ,&c. Now we would ask our readers, could a case for probable consumptive origin of haemoptysis be more clearly made out than it is here by Niemeyer himself? The family history, predisposing influences and diseases, and structural fea- tures are complete. Some exciting cause, like catarrh, only is w.auting to determine the outbreak of disease in the luno- and OBJECTIONS TO NIEMEYER'S VIEWS. 131 those patients will run the course of phthisis. We do not wish to state absolutely that haemoptysis does arise in these cases from tubercular disease, but that the fragile state of the vessels is connected with consumptive disease we entertain no doubt. Again, Niemeyer seems to forget that there is a common ten- dency in childhood to coryza and epistaxis which may continue in youth, if disease in the vessels of the lung do not cause a diversion. We are quite ready to confirm the accuracy of Nie- meyer's fifth paragraph, and can cite many cases illustrating the destructive effects on the lung, of large hemorrhage during the progress of phthisis, ^uch inflammation and consequent de- struction of the pulmonary tissue is more likely to occur at the base of the lungs to which the blood gravitates than at the apex, and in our own cases it has always been found there. We notice, however, that in one of Niemeyer's cases (Dr. N.)1 and also in one of his translators, Dr. Baiimler's,2 the physical signs gave evidence of disease of the apex of one lung. This is surely a strong argument against a hemorrhagic origin for the disease; for we know no reason why the blood effused from the bronchial mucous membrane should be exempted from the laws of gravity, directing it to the lower portions of the lung, and should flow upwards towards the apex, the portion of all others, it may be remembered, most prone to tubercular attack. Whether the presence of the coagula in the bronchi is the cause of the inflammator}7 changes is open to question. It does not appear why blood coagula should irritate more than mucus or croupous matter, which cause collapse of the lung and not inflammation ; but it is probable that in these cases of pneumo- nia after hemorrhage, some laceration or congestion of the lung has taken place, and in this way is started the inflammatory process which, in a consumptive person, tends more decidedly to destruction of tissue than in a healthy subject. With regard to paragraph three, where the doctrine of devel- opment of phthisis from hemoptysis is laid down, we are en- tirely at issue with Niemeyer, who says, " Unbiased and careful observation of patients, who, without warning, and often in the midst of exuberant health, have been attacked by pneumorrha- gia or hemoptysis, and who, without rallying, have perished in a few months of a phthisis florida, or 'galloping consumption,' has taught me that such patients scarcely ever succumb to a pulmonary tuberculosis in its stricter sense, but that they usu- ally die of a form of consumption as yet but little thought of, and of which bronchial hemorrhage is the immediate cause." We must confess we have never in the course of practice, or in consulting the extensive records at our disposal, met with a 1 Lecture on Phthisis, p. 36. 2 Clinical Transactions, vol. ii, p. 86. 132 HEMOPTYSIS OF CONSUMPTION. case of phthisis florida arising from simple hemoptysis, though many instances of large hemoptysis, accompanying very limited induration, have come under our notice, and one ended in death, with pyemic symptoms. We have also known men with- out the symptoms of lung disease bring up quantities of blood and recover, without permanent cough ; these patients were generally middle-aged, and often had arcus senilis, from which we are inclined to think that fatty degeneration may have been present in some of the pulmonary vessels, as well as in the cornea, and thus have caused their brittleness and rupture. As recovery is the rule in these cases, an opportunity seldom occurs of investigating the state of the vessels after death. If the hemoptysis leave no congestion or injury to the lung, we have generally found it give relief to previouslj- existing oppression or cough; but in cases where the physical signs of consolida- tion and breaking down, and not merely of bronchial plugging, exist, there follow increased cough and fever, and the lung passes rapidly through its career of destruction. Again, looking at Niemeyer's view from the aspect of probability, if persons have been really in exuberant health, without any previous dis- ease of the lungs or of their vessels, why should they, without warning, suddenly spit up quantities of blood and go into rapid consumption, when really healthy persons may be subjected to all sorts of violent exertion without such results? Having discussed Niemeyer's views, we will state that our experience of many thousand cases has led us to conclude, that hemoptysis to the extent of more than a drachm, in a person, free from the hemorrhagic diathesis, from cancerous disease of the lung,1 injury of the chest, disease of the heart, and from dis- order of the uterus—is indicative of a fragile state of the vessels of the lungs, closely connected with, and generally arising out of, consumptive disease of these organs. What are the changes which have been traced in the bloodvessels to account for their great fragility? Two causes have at present been observed, but in a disease which embraces, as phthisis does, various forms of degeneration of tissue, it is probable that others will in time be discovered. First, fatty degeneration has been demonstrated, by Dr. Rad- eliffe Hall, to exist in the small bloodvessels. In a series of careful observations " On the varieties and metamorphoses of tubercle," well illustrated with plates, to which the reader is referred,3 Dr. Hall records having detected fatty degeneration of the bloodvessels in phthisis in four instances, "near to but not mixed up with tubercle in one; within gray tubercles on i Two cases of fatal haemoptysis from cancer of the lung are related, by Dr. Theophilus Thompson, in Pathological Transactions, vols, vii and viii. ' 2 British and Foreign Medico-Chirurgical Review, April-October 1855. ANEURISM OF PULMONARY ARTERY. 133 the inclosed wall of an air-vesicle in one; in the wall of a large cavity in two." Alluding to the case where the vessel was connected with gray tubercle, he states that it was studded with dim granules and oil dots of various sizes, and that the patient had suffered from copious and repeated hemoptysis two years before his death. Dr. Hall remarks, "Considering how many cases of phthisis spring into noticeable activity coincidently with an attack of hemoptysis, the patient so commonly declaring that his chest was strong, and his health good, until suddenly he broke a bloodvessel, this fact of fatty degeneration of blood- vessels, where no inflammation exists, at the earliest stage, the highest form of tubercle, while as yet it occasions neither pain nor organic irritation of the lung—'is valuable and explanatory." It appears then that this source of hemoptysis may exist in all stages of the disease; but while in the second and third stages larger hemorrhage may be accounted for in other ways, it seems to furnish the only explanation for profuse hemoptysis in the first stage, and especially in those eases of slight consolidation of the lung, where the general health of the patient is appar- ently good. In some of these we have noticed the existence of the arcus senilis, and thence surmised the nature of the dis- ease. In patients with the bloodvessels of the lung rendered brittle, any great strain may cause a rupture, as it takes place in the cerebral vessels when similarly affected, there causing apoplexy. In lungs extensively consolidated, the obliteration of many of the vessels causes an increase of pressure on those which remain open, thus facilitating the rupture. Secondly, aneurism of the hranches of the pulmonary artery is perhaps the best ascertained cause of fatal hemoptysis in phthisis. The changes which the vessels undergo to arrive at this condition, have of late years received considerable atten- tion from pathologists, and great light lias been thrown on the various steps of the process. We believe that Dr. Peacock,1 and Mr. Fearn, of Derby, were the first to record instances of pulmonary aneurism in this country. Rokitansky gave an excellent account of it in his "Patholog- ical Anatomy;" and of late years numerous cases have been de- scribed by Drs. Cotton,2 Quain,3 Moxon,4 Douglas Powell,5 and others. Dr. Rasmiissen,6 of Norway, has treated very fully of the modes of formation and bursting in these vascular expan- sions, as exemplified by nine cases, carefully investigated by himself. From the accounts of the above-mentioned observers, 1 London and Edinburgh Monthly Journal, 1843, p. 383. 2 Lancet, 1841. 3 Vol. iv, p. 117. 4 Medical Times and Gazette, Jan 13, and Oct. 20r 1866. 6 Path Trans., vols, xvii, xviii, xxii. 6 Dobell's Keports, for 1869. 134 HEMOPTYSIS OF CONSUMPTION. and from several cases we have witnessed ourselves, the course of events appears to run thus: When the processes of softening and excavation are going on in the lungs, branches of the pul- monary artery are laid bare, and are to be occasionally seen, as yet nndilated, in the walls of cavities in phthisical patients who die from other causes than pulmonary hemorrhage. This state of the vessels, if there is much obstruction to circulation in the lungs, does not last long; either a rupture takes place, as oc- curred in one of Dr. Powell's cases, or the want of support causes the vascular wall to dilate on the side towards the cavity, and a protuberance, varying in size and shape according to that of the unsupported portion of vessel, takes place. The slightest form of aneurism is that denominated ectasia, by Dr. Rasmiissen, where the vessel touches the cavity for only a limited extent, and a small oblong dilatation is formed, due partly to the ex- pansion of the bore of the vessel, and partly to the wall growing thicker. The bursting takes place on the boundaries between the vessel and the wall of the cavity, and the point of the lid always lies in the direction of the blood current. A very good example of ectasias was recorded by Dr. Quain, where in one cavity two small branches of the pulmonary artery exhibited several varicose dilatations, one of which had burst, causing fatal hemoptysis. The other form of aneurism is sacculated, and varies in size from a pea to a small orange, being sometimes large enough to nearly fill a small cavity; a larger amount of the vessel is exposed than in the ectasias, and the pouch contains sometimes clots of blood, sometimes laminated fibrin; the per- foration, according to Dr. Rasmiissen, being found on the most protruding portion of the dilatation. Several aneurisms or ec- tasias are sometimes found in the same lung, though their pres- ence is always confined to cavities. The cause of the formation of these aneurisms does not always lie in any general diseased condition of the pulmonary vessels, for these, except at the points of dilatation, have been hitherto found to be healthy, but it owes its existence principally to the want of support of the ' wall of the vessel turned towards the cavity, and partly to heightened intervascular pressure, from a strong tendency of blood to fill the vacuum caused by the contraction of the lung, especially about the cavities, and also from the obliteration of so many branches of the pulmonary artery. That pulmonary aneurism is a very common cause of fatal hemoptysis in phthisis is proved by Dr. R. D. Powell's table of 15 cases of fatal hemop- tysis occurring at the Brompton Hospital in the last few years, in all of which cavities of various sizes existed. In all but two, a ruptured vessel was discovered; in one there was rupture without dilatation of a vessel; and in 12 ruptured aneurisms were found. The hemoptysis from this source is frequently INFLUENCE OF SEX AND AGE. 135 fatal, although the first attack is not necessarily so, for in eight of the Brompton Hospital cases, there had been copious hemop- tysis on more than one occasion, previously to the attack which terminated life. Having thus pointed out the pathology of large hemoptysis in phthisis, we may state that the expectoration of small quantities of blood is probably due to congestion or in- flammation of one or other of the two systems of vessels exist- ing in the lung, similar to what occurs in heart disease or in pneumonia. For such slight oozings of blood it is not necessary that there should be any rupture of vessels, as it has been as- certained that the red corpuscles can, like the white corpuscles, migrate through the vascular walls and pass into the surround- ing tissues, but it is extremely improbable that any considerable hemorrhage can take place in this way. It will be useful now to consider certain other points con- nected with hemoptysis, such as (1.) The influence that age and sex exercises on its occurrence. (2.) The stage and form of the disease in which it is most marked. (3.) What effect it exerts locally and generally on the course of the disease—what complications it gives rise to. (4.) Whether or not it curtails the duration of life. The influence of sex, according to the first Brompton Report,1 is very trifling, the females showing excess over the males of only 3 per cent. In 1000 cases tabulated from private practice, the majority of whom have been under observation for many years, we arrived at a different result. The total number of cases of hemoptysis in both sexes was 569, or about 57 per cent.; but among the males the percentage was 63, and among the females 47, giving an excess to the males of 16 per cent. Again, in 283 cases where the amount of blood expectorated at any one time exceeded an ounce, the liability of males was still more marked. Large hemorrhage was found to occur in 34.76 per cent, of the males, and in only 17.67 per cent, of the females, this greater liability of males to spit blood in large quantities being amply confirmed by Dr. Pollock and the second Brompton Report. Age cannot be said to exercise a very marked influence, ex- cept that, according to the first Brompton Report, in the case of females, hemoptysis occurred more frequently under 35 years of age than between 35 and 70. The influence of the stage of the disease is of much greater account; and here the first Report demonstrated, from observa- tions on 696 cases, that hemoptysis is more frequent (as 3 to 1) before softening than after that process has taken place. Our 1 P. 28. 136 HAEMOPTYSIS OF CONSUMPTION. own observations amply confirm this; and with a view of car- rying these investigations farther, we have classified our 286 cases of profuse hemoptysis into stages, annexing the number of deaths from this cause to each stage: Stage. No. of Cases. Deaths. Percentage. 1st, 187 26 13.95 2d, 65 16 24.61 3d, 31 21 67.74 283 63 The figures demonstrate most convincingly the significance of large hemoptysis in the third stage of phthisis, and its com- parative slighter importance in the first stage; but a few cases to illustrate these points may not prove unacceptable. The first three are instances of hemoptysis in the third stage. Case 14.—Sarah B., a single woman, aged 26. was admitted into the Brompton Hospital, under the care of Dr. Quain, Nov. 21, 1870. She had lost a brother and sister from consumption, but gave no history of illness previous to two months before admission, when she was attacked with cough, streaky expectoration, followed by great wasting, feveryshness, and night-sweats. "When seen, her cough was constant, with muco-purulent expectoration, and she had some dyspnoea. Tongue furred ; bowels active ; appetite good; catamenia regular till last period, but scanty, now absent about two weeks. Pulse 120. On examination of the chest, cavernous gurgle was audible over right side of chest, front and back, and some crepitation over the left side. A few days later I saw this patient, and, in Dr. (plain's absence, had charge of the case. She became worse, losing flesh, in spite of taking oil and nourishment, and about January 12, was attacked with haemoptysis, which was checked by styptics, but recurred again on 16th, and she brought up large quantities, i. c, more than a pint at a time, for several days, the hemorrhage being only slightly influenced by treatment. She died sud- denly on the 21st, after bringing up a large quantity of blood. The tem- perature during the last few days other life, was, according to Mr. Giflard, the clinical assistant's, observations, as follows : January 17, 18, 19, " 20, On post-mortem examination by Dr. K. Douglas Powell,' the left lung appeared highly emphysematous. The right was firmly adherent at its base, and the pleura thickened and gelatinous. The base of the lung was consolidated, and contained a cavity, projecting into which was the pulmo- nary aneurism which gave rise to the fatal hemorrhage. The aneurism was situated on a vessel which originally crossed the cavity, and at the time of death projected into it about an inch, having, at this point, broken across in the progress of the disease. The arterial channel was preserved Morning. Evening. 99.3 102 99 101.2 99 100 99 1 I am indebted for some of the notes of the post-mortem examination to Dr Powell. INFLUENCE OF STAGE. 137 to the end of the truncated vessel, where it was dilated into a bulbous ex- tremity. One side of this channel was formed by the brittle degenerated wall of the vessel, and presented a longitudinal rod-shaped deposit of lymph, the opposite side being made up of a considerable thickness of laminated coagula, tilling up the sac of an aneurismal dilatation. Another cavity was found in the upper portion of the lung containing clots of blood, and an aneurismal dilatation of a small pulmonary vessel which had burst. In this case the rapid breaking down of the lung-tissue had led to the dilatation of the vessel from loss of support and degeneration; but it is curious that the same process should have taken place in two cavities at nearly the same time. Case 15.—A young gentleman, aged 15, was seen by Dr. "Williams, in consultation with Mr. AY. Jones, on May 5,1853. Had suffered from cough for six months, and during the last month from pain in the left shoulder, and considerable loss of flesh and strength. Dulness, and crepitation, fine and coarse, in upper left chest.—Ordered oil, acid tonic, and counter-irrita- tion. November 28.—Vastly improved, and has gained 14 lbs. "Walks eight miles, and for the last three months has been shooting in the country. Dulness and tubular sounds in upper left chest as low as third rib.—Ordered oil in sulphuric acid tonic. May 17, 1854.—Wintered well, with only slight cough and expectoration and .short breath. Has been riding a good deal, and a week ago Mas caught in the rain, and rode home in wet clothes. Has since had pain in the left side, with night-sweats, and diarrhoea. Increase of dulness and moist coarse crepitation in upper left chest.—Ordered a blister, and mercurial and chalk powder, with effervescing saline ; afterwards to return to oil, which had been discontinued for six months. August 9.—Has been taking oil in the country, and is improved ; but has cough and yellowish expectoration, occasionally tinged with blood. Liquid car emulous sounds below left clavicle. The patient continued better; but in September, after having been out shooting for five hours, was attacked with haemoptysis to the amount of two pints. This recurred again and again, and he died in a week. On examination after death there were found only a few miliary tubercles at the apex of the left lung, and a cavity of the size of a walnut, lined with a thick membrane, deficient at one point, where the hemorrhage had come from. The rest of the lung was congested. The right lung was healthy. But for his imprudent exertion, this patient would probably have avoided this fatal haemoptysis, and might have completely recovered. Case 16.—Kobert S., set. 34, brewer's drayman, admitted into University College Hospital, under Dr. AA^illiams, May 30,1840. Stout-built. Tn habit of drinking much porter. Has had cough six months, but no illness till last February, in bed brought up, without cough or vomiting, a large quantity of blood. He was bled, and, after taking medicines some days, returned to work. A week ago, while stooping, again brought up a quantity of blood. Was again bled, and took medicine ; but has brought up considerable quantities daily—to-day nearly a pint, frothy and florid. Breath very short; pulse, hard and frequent; skin, hot; face, flushed. Has not lost flesh till the last week. Bowels open. No sleep for three nights. Flattening below left clavicle, dulness and cavernous sounds, with gurgling, above left scapula. 'Some dulness and tubular sounds below right clavicle. AY as bled to twenty-four ounces, which made him faintish. Three grains acet. lead, three times a day. May 31.—Continues spitting large quantities of blood, with much cough. Pulse 104, jerking; skin, hot and dry. 138 HEMOPTYSIS OF CONSUMPTION. June 2.—At 3 a.m. suddenly threw up blood copiously, and died in a few minutes. Post mortem, 12 hours.—Body little emaciated. Blood generally fluid. External jugulars distended with it. Left lung adherent by dense membrane at posterior part of apex, and in separating it a cavity was torn open of size of lien's egg, containing frothy blood, and a few dark clots, one of which partially plugged an opening into a large bloodvessel. Walls of cavity irregular, with broken gray matter, and several large veins containing fluid blood. Anterior part of lung pretty health}-, but a few gray solid masses below the cavity, and a few tubercles scattered through both lungs. A larger mass at the right apex, in some points opaque and softening, in others, intersected by dense bands. Bron- chi contained much frothy blood and bloody mucus. Bronchial glands much enlarged, with pinkish and gray deposit. Bloodvessels of the lung very large : the veins more than double the size of their accompanying bronchi. Heart rather large, without increased thickness of walls. Aorta somewhat dilated. Kidneys large and much congested. Liver very much enlarged, rather pale; substance fragile. Although considerable disease must have existed before the hemorrhage, it had not attracted much attention. There was no material loss of flesh, and he continued his work, and probably his habit of drinking freely of porter. This filled the bloodvessels, and led to the hemorrhage^ which in the post mortem was traced to ruptured vessels. The following is an example of hemoptysis occurring during the second stage : Case 17.—A medical man, aged 45, was seen by Dr. Williams, June 2, 1863. He had been long in India, where he had suffered from fever and dysentery ; and during last winter a cough had come on, which had often been hard. In the last few days he had brought up a quantity (according to his own account pints) of blood. Dulness, obstruction, and crepitation sounds in upper right chest, crepitation being coarse in parts. Under doses of bitartrate of potash and gallic acid, followed by occasional draughts of sulphate of magnesia and sulphuric acid, the haemoptysis was checked, and the cough lessened, but the hemorrhage recurred several times. September 29,1865.—AVintered at Bournemouth, but was confined to the house, and had haemoptysis to the amount of several ounces several times. Cough troublesome, and expectoration increased, but patient is by no means thin, and looks well. Dulness and crepitation in upper right chest, most marked in the front SubcrepUus and tubular sounds audible above left scapula. This patient died in the spring of 1868, having lived nearly 6£ years after his first symptoms. The following is a good example of hemoptysis accompany- ing the first stage, in which the patient remained well for many years, though eventually excavation of the lung took place: C>SE 18-~A geTntlem^n;0aSed JT6> of strong, large frame, consulted Dr. AA ilhams first on June 19, 18o0. Had been in good health, with no cou^h • but after much exertion in May he expectorated half a pint of blood and yesterday about the same quantity. Had been bled and leeched on the right chest with diminution of the dulness ; signs of congestion were found in the right lung. Pulse quiet; no cough ; bowels confined.—Ordered ^allic and nitric acids, and digitalis ; an aperient of sulphate of magnesia "with sulphuric acid. ° EXAMPLES. 139 June 24.—Hemorrhage returned slightly next day. but not since. Dul- ness and tubular sounds in tlie upper right front and back.—A blister to the scapula ; nitric and hydrocyanic acid mixture. July 2(1.—No return of hemorrhage ; cough slight. Has taken cod-liver oil with acid mixture a fortnight. Less dulness, but still large tubular expi- ration in the upper right front and back. September 26.—At Norwood. Taking oil, &c, regularly. Much im- proved in flesh and strength. Cough and expectoration slight. Dulness and tubular expiration less marked. June 21, 1851.—AYintered in Madeira. AY ell, but frequent colds from damp weather. Continued oil and acids till the last three months. Breath harsh and loud below right clavicle; little dulness and less tubular somids in right back. September 25, 1852.—Has continued well. November 24, 1853.—Passed last winter with only one attack of cold and cough, when the sputa were discolored. Has been pretty well since, but has had an occasional feeling of oppression in the right lung, and three weeks ago, after much exertion of voice, brought up four ounces of blood, and some on the following days, when it was checked by gallic acid. Still much cough and wheezing. Urine scanty, red, and turbid. General wheezing rhonchi in right lung; little didness or tubular sounds.—Ordered iodide of potassium, carbonate of potash, squills, stramonium, and liquorice, and a croton-oil liniment. Under this treatment he soon got the better of this illness, and continued in good health, except occasional attacks of the same kind ; more wheezy and asthmatic than phthisical. He continued active in business, and often gave lectures and spoke at public meetings, although warned against doing so. February 13, 1863.—Three months before had coughed up four ounces of blood, and about the same quantity three days ago. Breath had been shorter since, with more expectoration. Feels the cold more, but voice and muscular strength good. Urine often thick.—Dulness and- tubular sound at and above right scapula; moist crepitus and mucous rlionchus above and, below.—To take oil, with sulphuric acid, calumba, &c. ; saline at night. June 18.—Several times haemoptysis this year ; now about half an ounce daily, five days. Physical signs the same. December 27,1864.—Haemoptysis recurred every two or three weeks till August, when he went to Bournemouth ; none since. Has regained some flesh and strength. More extensive dulness, obstruction, and coarse crepitus over greater part of right lung; cavernous sounds in scapular region ; dulness and loud bronchophony now also at and above left scapula. These signs have been increasing during the last twelve months, with more constant cough, copious opaque flocculent expectoration, rjulse 100, and loss of flesh and strength. A few months later the cavernous sound in the right lung became am- phoric, with signs of increase in the left also. In the autumn of 1865 he went to Madeira, and died on the voyage back, early in 1866. From 1853 to 1863 the disease was so much arrested that he resumed active habits, and ceased to regard himself an invalid. The disease in con- sequence recommenced its activity, and ran its destructive course. While hemoptysis may accompany all stages of consumption, and may vary considerably in amount, it may also be entirely absent throughout the whole course of the disease. In the acute forms, and particularly in acute tuberculosis, hemoptysis rarely occurs, and the relief in the more chronic varieties of the malady often derived from a copious hemorrhage has led some physi- 140 HEMOPTYSIS OF CONSUMPTION. cians to think that the sreat congestion noticeable in acute cases might be relieved by local or general bloodletting. Whilst the most rapid cases of phthisis are nearly free from hemoptysis, there is a class of patients already alluded to in whom the amount of the disease is small, and large and repeated hemorrhage the principal feature. We described a few of these cases three years ago under the term of the hemorrhagic variety of consumption,1 and it is no small satisfaction to us that so careful an observer as Dr. Peacock also recognized in them a separate class, which he calls "the haemoptysical variety,"2 and he gives an excellent description of its chief features. As far as we ourselves have observed, the symptoms are as follows: The patient may have had a slight cough for some time, or shown signs of failing health, but very often this is not the case, and he may be in apparently fair health, when he is suddenly attacked with hemoptysis, generally of a profuse character, lasting often many days, and causing much reduction in flesh and strength. Cough and expectoration follow, and a careful examination of the chest detects only slight physical signs, and these in the supra or interscapular regions, or else beneath the clavicle. The patient gradually improves, and will sometimes recover his strength and lose his cough before the hemoptysis recurs, which it is pretty sure to do sooner or later. The period before its recurrence may vary from days to years, and with it, to a great extent, the prospect of ultimate recovery, as the fre- quently recurring attacks considerably weaken the patient and soon usher in the train of symptoms usually attendant on active consumptive disease. The cough becomes persistent, the ex- pectoration inuco-purulent, when not sanguinolent, wasting and night-sweats appear, and the physical signs which first evidenced slight consolidation, and later the same in a greater degree, now show softening and excavation. This is, however, rare, for the changes in the lung are generally limited to increase in the amount of consolidation, and what appeared at first rather ob- scure and was even denied, now becomes unmistakable. The blood brought up is generally florid, but occasionally dark in color, and partially coagulated; the amount varies greatly, but it is usually large, and in one case under observation amounted to seven quarts at a time. But the quantity expectorated is no measure of the danger resulting to the patient, as in this form of the disease a large amount of blood may be brought up without fatal, or even pernicious results. Our 1000 tabulated cases furnish 72 instances of this form of phthisis, of whom 60 were males and 12 females, a proportion of 5 to 1 of the former to the latter, which forms a contrast to 1 Lancet, June, 1868. « gt. Thomas's Hospital Keports, 1870. CASES OF RECOVERY. 141 the proportionate numbers of the two sexes in all forms of con- sumption, which was as 2 to 1. Thus we see that males are far more liable than females to the hemorrhagic form of phthisis, and this for a reason that will presently appear. The patients were attacked rather later in life than tie generality of con- sumptives. The average age of attack for the males being 30 and for the females 27. Family predisposition was not usually present, appearing in only 25 instances, and perhaps this may account for the later age of attack. In 42 cases the hemoptysis was preceded for a shorter or longer time by cough, but in the rest hemorrhage was the first symptom. In 45 no exciting cause was recorded. In 27 an explanation was to be found either (1) in the patient having been subjected to some great bodily exer- tion, as preaching, lecturing, acting on the stage, rowing, climb- ing, or running; or (2) in his having been inhaling an atmos- phere either mechanically or chemically irritating to the lungs, as that of a laboratory or workshop; or (3) in his having been exposed to decidedly depressing conditions, as chills from getting wet through, great mental worry, fasting, too close application to a sedentary occupation, severe attacks of certain lowering diseases, as dysentery, measles, and syphilis, the latter being in one case followed by mercurialization. We see, therefore, that in a large number of these cases the attack of hemoptysis did not occur, without, as Dr. Peacock expresses it, some more or less decided exciting cause, and it is probable that had great attention been paid to this point in the history, an exciting cause would have been traced in many more cases. Of the 72 instances of hemorrhagic phthisis, we subjoin a few examples: Case 19.—A clergyman, aged 34, first consulted Dr. Williams on July 17, 1848. After hard duty fourteen months ago he had haemoptysis to the amount of two ounces, and in smaller quantity a week or two afterwards. Was much reduced by treatment, and wintered in Madeira with great bene- fit, and was well enough to ascend the Peak of Teneriff'e without difficulty about six weeks ago ; but has had cold and cough ever since. Dulness and tubular expiration in upper right chest. Bronchophony and mucous rhonchus below right clavicle.—Ordered iodide of potassium and carbonate of potash, and a croton-oil liniment. In August he had haemoptysis in church at Brighton to the amount of an ounce and a half, which ceased under acetate of lead with a daily aperi- ent draught. After this he took oil, and got much better. July 18, 1849.—A Yell till last few weeks, when he had temporary cough. July 9, 1852.—AYas well and doing double duty till a year ago, when he caught severe cold, and had haemoptysis to the amount of three ounces ; for which he was leeched and much lowered. Has lost much flesh and strength, has night-sweats, and expectoration has become yellow. Dulness and loud tubular sounds in the left mammary region.—Ordered oil in tonic of nitric and hydrocyanic acids, with tinctures of hop and orange. July 22.—Had haemoptysis (four ounces), yielding to treatment as before. In 1854 he went to Madeira, and passed a second winter with benefit. Married in 1856. 142 HAEMOPTYSIS OF CONSUMPTION. March, 1868.—Heard that he was quite well, with a family of six children. Mav, 1871.—Continues well. Since last visit he has had two or three attacks of haemoptysis, and some years ago severe bronchitis and congestion of the lungs. At present he is in excellent health, doing parish duty, which he has not omitted for more than two months at a time for the last twelve years. Upwards of twenty-four years have elapsed since this patient's first symptoms. Case 20.—A clergyman, aged 42, first consulted Dr. Williams on Aug. 15, 1850. Nine months ago, after over-exertion, he lost his voice, and had cough, accompanied by some wasting and failure of strength, but continued to take three services every Sunday all the winter. After more exertion a month ago, for four days his morning expectoration was streaked with blood. Slight dulness; moist crepitation, with slight tubular sounds below left clavicle, more marked above; slight dulness and tubular voice in right inter- scapular region.—Ordered oil in a tonic of nitric and hydrocyanic acids, with the tinctures of hop and orange, and a liniment of acetum eantharidis. September 16.—Much improved, under the oil, in flesh, strength, and breath, and able to walk fast and up-hill. Came from Hastings to-day, and after much talking, on lying down at night, expectorated blood to the amount of two ounces, with irritating cough. Is in too much tremor from fear to bear examination; pulse 90. Ordered gallic acid, with syrup of poppy, followed by an aperient draught of sulphate of magnesia and sul- phuric acid. 21.—No return of hemorrhage ; dulness, with crepitus above left scapula. 30. —Haemoptysis to a pint and a half in last two days, and cough still troublesome. Ordered a blister and a morphia linctus, together with the gallic acid. April 17, 1851.—Has wintered at Hastings, taking oil regularly, and gradually recovered from a state of great weakness ; moderate cough and only slight expectoration. Has so much improved that now he can walk for five or six hours daily. Physical signs diminished. May 4, 1854.—Has taken oil regularly, and been quite well all the win- ter, without cough or expectoration; but has lately had neuralgia of the eye and occasional flushes of blood to the head ; urine thick, with lithates ; very little dulness or tubular sounds, but breath obscure above left scaptula, and whiffy in left scapular region; tubercular voice above right scapmla.—Or- dered oil in nitric acid and tincture of orange, and an occasional effervescing saline. January 21, 1858.—Has done duty well since. Only occasional cough, but always some mucous expectoration. Is strong and active, although of late has been much worried by a lawsuit. Signs diminished. May 18, 1860.—Active and well till a month ago, when cough returned, with opaque expectoration, which has since improved. Still some dulness and tubular breath in both scapular regions, chiefly in left, and in left front. September 26, 1866.—Wonderfully well, and generally does duty. Cough and expectoration very slight. Weighs twelve stone—heavier than ever? This patient was alive and well in January, 1871, more than twenty years after his first visit, and more than twenty-one since his first symp- toms ; and for the last thirteen years has done duty regularly. Case 21.—A gentleman, aged 32, consulted Dr. Williams, Aug. 9, 1854. Two years ago he had haemoptysis to the amount of half a pint, and after- wards every three months he continued to bring up a smaller amount, till June, when he states, that in five days he brought up 14 pints ! He'has had a bad cough for the last month, and has lost much flesh. Bowels costive. Dulness, deficient breath, and tubular sound in upper right back. Ob- structed breath and crepitation below. Tubular sounds above left scapula. remarkable case. 143 Oil was ordered in a mixture of sulphuric, gallic, and hydrocyanic acids, with tinctures of hop and orange. Also, for a time, a morning aperient draught of sulphate of magnesia and sulphuric acid. Counter-irritation with a cantharides liniment. November 9.—Has gained much flesh and strength, and only once had haemoptysis, amounting to 3Hi. Tubular sounds above right scapula, breath still obscure below, and mucous croak on deep breath. December, 1867.—Heard that he got quite well, except that his breath has continued rather short. Only lately has had more cough and expecto- ration. The subjoined case is remarkable on account of two brothers being affected with the same course of symptoms. Case 22.—Mr. M---, aged 21, Oct. 9, 1835.—Paternal aunt died of haemoptysis. Three years ago several times spit blood, and had since cough, with }7ellow expectoration, and short breath. Has taken oil in winter, and not lost much flesh Decided tubular sounds above both scapulce, most left; where is also slight crepitus. Breath and percussion generally good.-—To take oil, with phospho- ric acid and quinine. January 8, 1866.—Suffering from a cold and increased cough in the last month ; and now from sickness and oppressed breathing. More dulness, with crepitus, in upper right, most front. Effervescing saline with opiate, and blistering with acetum cantharid. June 18, 1866.—Since February has been at Torquay, taking the oil and tonic regularly ;. and has much improved in strength; cough slight, but expectoration is still yellow, and breath short. Breath sound still weak in right chest, with crepitus and tubular sounds above. Breath puerile in left lung. May 30, 1867.—Last November was laid up with abscess of the rectum, which healed in a month ; but left him weak ; and being shut up all winter at home, he has lost much strength. Cough, however, is much better. Tubular sounds still above right scapula, and croaky crepitus below clavicle. Breath pretty clear elsewhere. May, 1869.—Took oil with tonic steadily, and very much improved ; spent next winter abroad ; and finding himself so much better he remained last winter at home, attending to business, without suffering, till the middle of April, when, after exertion, he brought up a large quantity of blood, and sank in three weeks. A brother was attacked in 1866 with similar symptoms and signs, and expectorated large quantities of blood repeatedly, requiring gallic acid in full doses. He has been more careful of himself, has implicitly followed his instructions, and has been restored to health, unbroken when last heard of, 1870. Case 23.—An officer in the army, aged 20, was first seen by Dr. Williams, March 12, 1860, and gave the following history : He had been subject to cough in winter, but otherwise enjoyed good health till the previous Sep- tember, when he had a chancre, followed in December by sore throat, and an eruption on the legs. Four weeks ago cough came on, and a week later he had haemoptysis to the amount of three drachms. Feels much weakened. Slight dulness; tubular sounds in upper part of right chest. Oil was ordered in a tonic of nitric acid ; iodide of potassium and tincture of orange, and a night draught of iodide of potassium and bicarbonate of potash. June 8.—Has been at Pau since. The cough is better ; but he has had occasional haemoptysis to the amount of a drachm ; and he still has syphil- itic eruption and pains. Submaxillary glands swollen. 144 HEMOPTYSIS OF CONSUMPTION. November 12.—Has been living in Ireland, and was better till he caught cold in the camp, and fresh cough came on, with increased expectoration. and occasional haemoptysis to the amount of several ounces. Dulness ami tubular breath and voice above right scapula. Crepitation and obstruction sounds in the upper third of left chest. To continue oil in acid tonic, and winter at Torquay. September 18, "1801.—Wintered well at Torquay till April, when he brought up 4 ounces of blood, and continued spitting some blood for 10 days. He remained well till 18 days ago, when haemoptysis recurred to the amount of 4 ounces, and he discovered he had recent syphilitic symptoms. Dulness and deficient breathing, and, some croaky sounds in upper left chest. July, 1862.—Wintered in Madeira, and remained well, and married there ; but after some exertion he brought up an ounce of blood, and some slight amount since. There is still dulness, with rough breath in upper left chest, harsh behirul. Dulness increased above right scapula. October 2, 18(53.—Passed winter travelling in Italy, Sicily, Spain, and Egypt, with little cough, and only hemorrhage to amount of half an ounce. Took oil pretty regularly. In the summer went to Turkey and Malta, and enjoyed the heat. Still dulness above right scapula, and croak on deep breath. December 28, 1804.—Was last winter at Bonchurch, and able to walk twelve miles a day, and lost cough. Lately has been in Edinburgh, and tolerably well, except occasional colds and pain in the side. Oil omitted from May till November. Weak breath, and some friction-sounds in left ber portions of both lungs—most in the left, where slight crepitus. January 6, 1870.—Has been pretty well, except occasional colds and cough; and once had haemoptysis, a drachm, which relieved cough; and again later half an ounce. Has suffered chiefly lately from enlarged tonsils. Weak breath and whiffy sounds audible in upper left lump June, 1870.—In the spring following had an attack of diphtheria, followed by pneumonia of right lung ; but recovered well with tonics and oil, and is now stronger than before the attack. Only tubular sounds and harsh breath- ing at left apex. The lung affection in this case probably originated from syphilis, traces of which were perceptible in several parts of its course. Case 24.—A gentleman, aged 35, was seen by Dr. Williams, June 20, 1S62. He had lived freely, but had been fairly well, and only suffered from occasional giddiness before the end of November, when he was wetted and chilled. Haemoptysis came on, and in ten days he brought up three pints, and was much reduced. Three months before the attack he had a cough, which gradually di- minished, but had not quite disappeared, and was accompanied by yellow expectoration. At present his breath is good, and he is free from cough, and has been taking cod-liver oil and gaining flesh. Slight dulness; tubular voice and breath in left interscapidar region, and to a less degree below the spine of right scapula. January 17, 1866.—Remained quite well, except in November, 1863, after fifty-four miles hunting, brought up gvi of blood, for which was bled, and soon recovered. At present has no cough or short breath. Physical sio-ns —still bronchophony can be detected at and above the left scapula. GENERAL and local effects. 145 Let us now consider the effects of hasmoptysis, both general and local, on the course of phthisis, and the complications it gives rise to. We know that a very profuse attack may cause immediate death by exhaustion, as in some of the cases already given, or by suffocation ; or it may prove fatal in a short period through the supervention of pyaemia, as in the very remarkable instance we give further on. These, however, exceptionally severe cases of hasmoptysis are of rare occurrence, and proba- bly not greatly to be influenced by treatment; but it will be useful to notice the effects on the system generally, and on the lung locally, of moderate hemorrhage. To many patients its occurrence seems beneficial rather than otherwise, for the con- gestion is thus relieved, and the system not materially weakened by the loss of blood. The effusion of blood into the smallest bronchi and air-cells does not necessarily cause any general irri- tation ; for after hasmoptysis the presence of blood in the air- vessels may often be detected by physical signs; but these may disappear in a few hours or days, and no results follow. On the other hand, in some instances its presence irritates the lung considerably, giving rise to bronchitis, and even catarrhal pneu- monia, A rise takes place in the temperature; and sometimes while the haemoptysis is going on, the pulse becomes more fre- quent, the breathing more rapid, and the cough more trouble- some. Crepitation is heard in the lower lobes of one or both lungs, intermingled with a good deal of sibilant rhonchus, and the case becomes one of pneumonia. Fresh consolidation of the lung may even arise in this way, but according to our ex- perience it is seldom permanent, being reabsorbed. Why the effusion of blood into the smaller bronchi should be in some cases followed by bronchitis and pneumonia, and should give rise to no symptoms whatever in others, it is difficult to say, but we are inclined to ascribe the inflammatory consequences to a previous congestion, not sufficiently relieved by the hemorrhage, rather than to the mechanical irritation caused by the blood- clots in the bronchi, which is the cause assigned by Niemeyer. The occurrence of hemorrhage is generally preceded by violent exertion, sudden change of temperature, or something which produces pulmonary congestion. If the hemorrhage removes this congestion, no inflammation follows; but if not, the injury of the ruptured vessels, and the reaction after the hemorrhage or its cause, may convert the congestion into inflammation; hence the bronchitis and pneumonia. It may still be admitted that clots of blood plugging the bronchi add to the congestion of the lobules supplied by them, by depriving them of the air necessary for free circulation. The first case given below, illustrates well some of the bad effects of ha?mopytsis, pneumonia being set up by it. In the 10 146 HEMOPTYSIS OF CONSUMPTION. second case, the general effects were more marked, the patient dying of pyaemia. Case 25.—A French valet, aged 34, was seen by Dr. Theodore Williams. January 28, 1871. He stated that six years ago, whilst waiting on a gentle- man, he had brought up some ounces of blood, and that since that time he had had two attacks, one two years ago, in which only a slight amount was expectorated, and the other three months ago, when he brought up a pint. He had been subject to cough off and on, and has lost some flesh since the second attack two years ago, but was never laid up or discontinued his work till two days ago, when he was again attacked with haemoptysis, and brought up a pint; and to-day about an ounce. Is now expectorating bloody mu- cus. Pulse 68 ; temperature 97.8 ; respiration normal. Has gained flesh in the last three months through taking cod-iiver oil. Deficiency of expan- sion and tubular sounds in upper part of right front chest. Some bronchoph- ony above the scapula. The patient continued to spit up blood for a week, the amount at a time varying from a teaspoonful to upwards of a pint; various styptics were used, and generally checked the flow of blood, but if omitted, the hemorrhage re- turned. There was no rise of temperature or pulse, but the breathing became slightly more hurried, and the cough worse. On February 6 the physical signs were dulness, tubular sounds in upper right chest, some crepitation audible in mammary region. Harsh tubular sounds scattered orer both lungs. He improved on tonics and cod-liver oil for ten days, but on February 16 got excited about the war taking place in his country, and copious hemor- rhage came on. Bowels^ costive. Cough very troublesome. Temperature 99.8 ; pulse 80. Ergot of rye and a blister were ordered. 17th.—Blister rose well, and cough better. No more haemoptysis has occurred. Bowels still costive ; pulse 90 ; temperature 101.2. Crepitation audible in lower right lung. 18th.—Bowels freely open with medicine. Patient very irritable, and has wandered much in his mind, and has had some slight return of the hemorrhage. Pulse 92 ; temperature 99.2 ; respiration 30. 19th.—\Yorse. Aspect blanched ; breathing embarrassed. Crepitation audible in lower left lung as well as in right. Pulse 108 ; temperature 101.6 ; respiration 32. A blister was applied to the left side. 20th.—Blister rose well, and patient was relieved as to breathing and cough ; but, after severe fit of coughing, slight haemoptysis came on, and now cough and other symptoms are worse. Pulse 108 ; temperature 101.2 ; res- piration 36. Ordered oil again. 22d.—Slight haemoptysis, and cough has increased. Pulse 100 ; tempera- ture 101.1 ; respiration 28. March 3d.—Patient was very restless, cough very troublesome, and breath very short till a few days ago, when he expectorated largely of thick mucopurulent matter and some frothy mucus, and since then his aspect is much brighter. Crepitation in hirer left chest. Bhonchus and crepitation (scattered) over whole right side. Quinine, in two-grain doses twice a day, was ordered to be combined with the oil, and patient took it for two days, and then refused to take any more. 6th.—Worse ; much paler; tongue, which has been generally slightly furred, is now glossy and red. Pulse 120; temperature 100; respiration 32. Ordered sulphurous acid with tincture of orange, to be taken with the oil. 9th.—Aspect much brighter; tongue cleaner and moister; appetite im- proved ; and patient gets up for some hours in the day. Couch only at night and in the morning, and expectoration frothy. Crepitation in right lung has diminished. Pulse 100 ; temperature 99.2 ; respiration 28. 28th.—Has steadily improved in the last three weeks, and gaining in flesh INFLUENCE ON DURATION. 147 and strength. Oil and sulphurous acid have been taken the whole time. Breath remains short. Some dulness above the right scapula, loith increased vocal fremitus, and slight crepitation in the upper front; some crepitation at the posterior base of both lungs. Harsh tubular expiration throughout the left lung. Pulse 96 ; temperature 98.1;'respiration 28. Ordered oil, with di- luted nitro-hydrochloric acid. April 21st.—Now walks about, though finds breath rather short, Cough only in fits. Has taken oil regularly. Pulse 80 ; temperature 98.4 ; respi- ration 24. In right chest slight dulness and crepitation to third rib. Some scattered, crepitus behind. In left chest crepitation has quite disappeared, bid harsh tubular sounds arc audible in parts. In this case haemoptysis occurred several times without giving rise to any inflammatory symptoms ; but at length after an attack, pneumonia was set up, which was happily ended in resolution. The following is a remarkable instance of hasmoptysis ending in fatal suppuration. Case 26.—A nobleman, aged 48, of a gouty family, first consulted Dr. Williams, July 18, 1855. He had suffered from gout more or less for years, and in order to escape the attacks he had been to the West Indies, and two winters ago to Italy. In the following spring he passed blood by the bowels, and in the summer had haemoptysis to an ounce, which continued to a less degree in spite of cupping and leeching, but was stopped by gallic acid. Passed the last winter well, and free from cough, in Egypt, until chilled by a ride to Damascus ; and in May, while in Paris, brought up an ounce and a half of blood. Cough returned and increased on reaching Lon- don in June. Slight ditlness, slightly louder breath, with some tubular sound in upper left back. More tubular voice and obscure breath in upper right.— Ordered oil in tonic of nitrfc and hydrocyanic acids, with tinctures of hop and orange, and counter-irritation. August 2d.—Takes the oil well, and with benefit. Dulness and tubular sounds, mostly in upper back, with slight crepitation. October 5th.—Two months ago, after feeling much better and attending quarter sessions, had a cold ; and a few days later slight haemoptysis, and a sensation of weight at the sternum. Gallic acid and acetate of lead were given. On the 2d and 3d of October, without effort, he spouted up alto- gether two quarts of blood, and became very faint. Yesterday and to-day (Oct. 5th) he brought up only a few ounces. A draught of infusion of roses and sulphuric acid, with morphia, was given every four hours. Bowels not open for three days. Patient almost free from cough. Pulse 90. Breath clear and puerile in left front; much obstruction, with obscure crepitation in right front. Too weak to bear examination in the back.—Ordered an aperient draught of sulphate of magnesia and sulphuric acid, and a mixture of gallic and sulphuric acids, &c. The patient continued in an extremely weak state, with frequent pulse and respiration, hot skin, and low fever ; expec- torating bloody pus in increasing quantities. A few days later symptoms of pyaania came on ; tongue became dry and brown ; pulse very rapid and running. Slight delirium ensued, and the patient died within a week. What influence does the occurrence of hasmoptysis exercise on the duration of phthisis? Does it tend to curtail it? Re- liable information on this important, point will be acceptable to both physician and patient, affording fair grounds of prognosis to the one and holding out comforting hopes to the other. Our 1000 tabulated cases include 63 fatal ones, where the patients 148 PHYSICAL SIGNS OP CONSUMPTION. had hasmoptysis of an ounce and upwards on one or more occa- sions. Among these the average duration was 7 years 6 months; an average only differing by a few months from that of the total deaths. ^Again, in 220 living cases of similarly extensive haem- optysis, the average was 8 years 3.23 months—about the same as that of the living cases"generally. These facts certainly do not indicate that hemoptysis exercises any curtailing influence over phthisis viewed as a whole. When, however, we classify the deaths according to the stages the patients were in when the hemorrhage took place, we perceive the significance which at- taches to the state of lung at the time of its occurrence: Average Duration. Stage. No. of Deaths. Yrs. Mths. 1 26 9 2.11 2 16 7 4.62 3 21 7 1.42 We here see that hasmoptysis occurring in the second or third stages is more likely to curtail the duration of the disease than in the first; and in the first, as in phthisical cases gen- erally, it is comparatively unimportant. CHAPTER XVII. OUTLINE OF PHYSICAL SIGNS OF VARIETIES AND STAGES OF PULMONARY CONSUMPTION. Signs of Phthisis originating in Bronchitis—Of Pneumonia passing into Phthisis—Suppuration—Signs of Congestion leading to Phthisis or Eiuphysema—Signs of miliary Tubercles—Signs of increasing Disease —Softening—Excavation—Corruption—Signs of Cure, and Arrest of Consumption—Complete—Partial—Residuary Lesions and Signs—Cal- careous Expectoration. There has been so much said on the pathology and clinical history of consumptive diseases, that we cannot afford space for a complete separate description of their signs and symptoms. It must suffice to sketch the most common and remarkable physical signs which attend the development and progress of phthisis in its chief varieties. When a common cough or bronchial cold turns to consump- tion, there will generally be an increase of the signs of bron- chitis in particular spots, especially in the upper portions of the lungs. Below a clavicle, or at or above a scapula, a persistent sonorous or sibilant rhonchus, or still more any degree of crep- itus, is suspicious; and the more so, if these sigus'are confined to these parts. In general capillary bronchitis there is also BRONCHITIS passing INTO PHTHISIS. 149 crepitus; but, then, it is more in the lower than in the upper regions. All fine crepitus may be taken as a sign of the paren- chyma being either congested or inflamed; and the finer, the sharper, and closer to the ear—the more purely vesicular, like the crepitation of pneumonia. But the crepitus of early phthisis is not like this; it is more subcrepitant, crumpling, or mere roughening, of inspiratory sound, and often accompanies the expiratory, which the crepitation of pneumonia never does. The natural vesicular breath-sound is impaired, or superseded, by the crepitation, except when it is so slight as only to roughen it. Fine crepitus, with or instead of the breath-sound, signifies some intermitting or vibrating obstruction to the entry of air into the lung-tissue, such as may be produced by swelling and increased secretion of the bronchioles and air-cells. ]N"ow, wherever these sounds of crepitating obstruction are heard, it may be inferred that some plastic or histotrophic change is going on—sarcophytes are at work, proliferating and migrating, whether for euplastic or for phthinoplastic results; therefore does the sign at its first'appearance demand attention. Soon other signs follow, indicating the partial consolidation of the lung. The sound on percussion becomes duller, very slightly it may be at first, but still perceptible on careful ma- nipulation, and on comparison of the two sides of the chest. Then may come also the tubular sounds, usually inaudible through the ill-conducting lung-texture, but now transmitted through its becoming more solid. These are hardly distinct where and whilst the crepitation prevails; but as this dimin- ishes with increased obstruction, in situations overlying consid- erable bronchi, below the clavicle, above, within, and at the scapulas, and in the axillary and middle dorsal regions, the sound of air passing into and out of the tubes is heard, having more or less of a whiffing or sharper blowing quality, which contrasts well with the soft diffused character of vesicular breath-sound. Often too, lint not always, the morbid sound differs in an increase in loudness and duration of the expiratory sound, which is hardly audible in natural breath. This is not one and the same thing as tubular breath-sound, for although this commonly includes it, yet expiration is sometimes long and loud, without being tubular. It would take too much space to discuss and explain the whole of this subject; and it may be stated that, besides the ordinary loud expiration of tubular breath-sound, transmitted from the large tubes, expiration may be made audible and prolonged by any resistance to the escape of air through the small tubes, short of producing a rhonchus or wheeze (which is a totally different sound), and such a resist- ance may be caused by tubercles or other solids outside these tubes. 'i>o likewise the expiratory part of tubular breath-sound 150 PHYSICAL SIGNS OF CONSUMPTION. is increased in intensity, by partial obstructions in the large bronchi, as at the root of the lungs, from pressure of enlarged bronchial glands ; in the trachea, from goitre or aneurism ; in the larynx, from constricted glottis; and even in the throat, by en- larged tonsils. Exaggerated tubular sounds of this kind may sometimes b.e heard through every part of the lungs, where there is no disease, but then may readily be traced back to their source. Excluding such extreme cases, tubular sounds near the root of the lung/especially the right, heard above and within the scap- ulae, are among the earliest and most common signs of disease in the lungs; and it is rare to find a case with mischief in other parts of the lung of any duration, without this becoming mani- fest. But I have before explained that it may arise from an enlargement of the bronchial glands, without involving the lung-tissue; and whilst we recognize its significance, as proving an infection of part of the lymphatic system, we must not accept it as an indication of the consolidation reaching into the lung, without the additional evidence of dulness on percussion, bron- chophony, or impaired, or crepitating vesicular sound in the part. Bronchophony, or tubular voice, does not always accompany tubular breath-sound. It generally requires more consolidation to transmit it, and a greater freedom of the tubes from constric- tion and secretion. It is most heard in vicinity of large tubes, like tubular breath; and its combination with this forms the snuffling or whispering bronchophony so ominous under a clav- icle, or above a scapula. Over smaller tubes it has often a reedy quality, as in the mammary and subscapular regions. If phthisical tendency prevails, soon signs of softening and excavation follow, in increase of crepitation in one or more spots, looser and coarser, or of more croaking character, gener- ally with diminished breath-sound, and small crepitation around. These spots, soon becoming cavities, form little islands of cav- ernous voice and breath-sound, first mixed with coarse crepitus or gurgling; afterwards more croaky and dry, with the charac- teristic pectoriloquy, and the occasional concomitant, cracked- pot, or chinking percussion. When the cavities become large, the souffle voilee, or cavernous puff with the cough ; the am- phoric resonance or metallic tinkling, which I long a^o ex- plained as an echo from the walls of the cavity, give decisive information of the ravages of the consuming disease in the lung. Thus, in bronchitis passing into phthisis, there is a gradual transition of the signs of the former into those of the latter. In the variety when the phthinoplasms are peribronchial, there is a longer persistence of bronchial rhonchi, sonorous, sibilant, and mucous, giving the disease a wheezy or asthmatic charac- PNEUMONIA PASSING INTO PHTHISIS. 151 ter, until softening ensues and cavities form, which relieve the constrictions. Acute pneumonia passing into phthisis, from the hepatization being a plastic or of cheesy nature, is marked by the persistent dulness ami by the same loud1 tubular sounds, and other signs of consolidation giving place to coarse liquid crackling or gur- gling, commonly in the central or superior portions of the lung, and the signs of one large or of several small cavities soon fol- low7, to announce the rapid destruction in this form of galloping consumption. The signs of suppuration of the lung, or abscess ending in phthisis, are those of one or more cavities forming and extend- ing; and of tubercles or other phthinoplasms forming in other parts—such as crepitus, dulness, and tubular sounds at or near the apex of the opposite lung, which may have been previously sound. The more common mode in which pneumonia or pleuropneu- monia terminates in phthisis, is through the chronic consolida- tion, which they leave behind them, instead of dispersing, be- coming phthinoplasms—that is, degenerating into fibroid and caseous matter, the one dwindling and contracting—the other softening and disintegrating—the affected tissues of the lung. The course of these phthinoplasms is marked by the signs of extensive dulness, absence of vesicular breath-sound and motion, and exaggeration of tubular sounds of breath and voice, persist- ing for months or even years; the collapse and tight dull sound of the walls of the chest of the contracting portions; the irregu- ar and sometimes cracked or chinking dulness over the parts undergoing caseation and excavation, which also yield their 1 The remarkable loudness of the tubular sounds of a completely hepatized unsj has not to my knowledge been satisfactorily explained. The "consonance " of Skoda is not applicable, inasmuch as it would require a certain relation be- tween the sound of the voice and the size of the tube, as in the case of the recip- rocating notes of tubes or chords. But I believe the true explanation to lie in the fact that, whereas the lungs are naturally constructed to destroy the vocal sound by the tubes ending in a spongy texture, which thoroughly damps or chokes all sonorous vibration—no sooner is this spongy tissue made solid than the tubes become reflecting cavities, capable of reverberating the voice with all the loudness which it has in the trachea, and the vocal vibrations are not only heard, but may be felt by the hand applied over the part. Thus the voice is not only better conducted, as supposed by Laennee, but it is also greatly intensified, by the solidification of the lung. There is yet another acoustic effect developed in the tubes of a consolidated lung, which explains the loudness and almost musical tone of its tubular breath-sound. Naturally the air passes to and fro in the tubes and air-cells, and although its passage causes the breath-sound, and any accidental rhonchus in the tubes, yet this prevents any longitudinal vibrations in the whole tube. But when the tubes are stopped at their vesicular end by consolidation, the air breathed no longer passes through them, but passing across their open ends, in its way to and from the still pervious lung, it may cause a hollow whistling sound like that produced by blowing across the open mouth of a panpipe. The same principles are applicable to some sounds heard in cavities in the lungs. 152 PHYSICAL SIGNS OF CONSUMPTION. signs of crepitation and gradually increasing cavernous sounds; whilst, in other portions" of the lung, the breath-sound may be puerile, or mixed with crackling, from emphysematous over- distension, which is also seen in the protrusion of the intercostal or supraclavicular spaces on coughing. These and other varia- tions in the signs of post-inflammatory phthisis have been al- ready noticed, and will be found exemplified in the related cases, therefore it is unnecessary to enter into further details here. There is another mode in which phthinoplasms, both con- tractile and caseating, may form and induce consumption, with- out any distinct inflammatory attack; without pain or fever; with little cough and expectoration; but generally with short- ness of breath and weakness. A peculiar crumpling crepitus invades a considerable portion of one or both lungs, superseding the breath-sound in the part—in some cases gradually inducing dulness and tubular sounds; in others becoming mixed with wheezing rhonchi and the clear stroke-sound of emphysema. The primary condition seems to be one of congestion rather than inflammation—hence the absence of active symptoms, and the slow rate at which phthisical processes follow. In fact, they sometimes do not follow; but that portion of the lung becomes partially emphysematous, and the tendency to further deposit is thereby restrained. This is a common result of those long- continued congestions at the base of the lungs, resulting from organic diseases of the heart and liver. But, as in predisposed individuals inflammation may develop the disease, so continued or extreme congestion in the same subjects may produce a simi- lar result. The crumpling crepitus and impaired breath-sound may be caused by congestion alone; but this does not continue without altering the nutrition further in one way or another: if chiefly around the tubes, producing vesicular emphysema, with its wheezing breath-sounds and clear stroke-sound ; if in the al- veoli—dulness, and tubular sounds, added to the crepitus, which eventually passes into cavernous sounds, audible in one or sev- eral parts of the lung-texture thus invaded by the phthinoplasms. Spontaneous miliary tubercles, scattered through the lung, without preceding inflammation, are sometimes hardly indi- cated by physical signs. When numerous, as in acute tubercu- losis, they excite more or less general bronchitis; and the at- tendant sibilant, sonorous, and mucous rhonchi obscure the special signs of the tubercles, until the increasing obstruction and density of the lung become apparent from interrupted breath in parts, with patches of irregular dulness on percussion. These signs, together with the persistent high temperature—ranging from F. 100° to 105°,—and the rapidly increasing weakness, WAVY RESPIRATION EXPLAINED. 153 wasting, and oppression, soon declare this frightful form of the disease. But when the miliary tubercles are few and scattered, they may produce no signs. An increase of numbers, and, still more, their accumulating in a particular spot, will cause a roughness in the breath-sound and a prolongation of the expira- tory sound over them. So, likewise, the clustering together of even a few miliary tubercles may, perchance, slightly deaden the sound on percussion in a spot, and transmit more of the voice and heart-sounds than is to be heard in other parts. Our lamented colleague, the late Dr. Theophilus Thompson, and others, have laid much stress on the wavy or jer/.'ing respira- tion (respiration saccadee, entre-coupee) as an early sign of phthisis; but no one seems to have traced it to its true cause. It is noth- ing more than the respirator}7 sound modified or divided by the successive pulsations of the heart. These, on the left side espe- cially, slightly impede the passage of air in part of the lung, and thus give its sound a jerking or interrupted character. The presence of tubercles in the lung increases this effect by transmitting the heart's pressure further, and by narrowing the area of the passing air. Hence, too, this kind of respiration is observed most in females, with a narrow chest, and a palpitating heart; and in such I have frequently heard the wavy breathing, without any evidence of the existence of disease of the lung at all. With this understanding of the true nature of the sign, we can better estimate its value as indicative of disease in the lung. The same remark may be applied to the subclavian arterial murmur which was mentioned by Dr. Stokes as a sign of incip- ient phthisis. It is caused by pressure of the apex of the lung on the artery, and although such pressure is more readily pro- duced when the lung is partially condensed, yet it does occur in some subjects without any disease of the lung. With the advance of the tubercles to caseation and the infec- tion of new parts of the lung, the various degrees of crepitus, click, and croak become developed, and are the more striking in lymphatic or infected tuberculosis, from not being preceded by the rhonchi or crepitus of inflammation. And the signs which follow—increased dulness, tubular sounds, cavernous croak and gurgle, pectoriloquy, hollow puff or souffle with cough, &c— commonly have a more remarkable character of isolation in this than in the inflammatory form, where the dis- ease is more diffused. But it must be kept in view that the gray tubercle represents the infective type of the disease, and that even where the first phthinoplasin'has begun in inflammation, the subsequent spread of the disease will be" through the lymphatic or adenoid system, 154 PHYSICAL SIGNS OF CONSUMPTION. in the form of gray miliary tubercles. It is this which establishes the identity of consumptive diseases, which not only have all the degenerative and wasting character, but they all tend sooner oHater to infect the lymphatic system, and break out in the tu- bercular form. We have, therefore, to watch for the signs of these in parts hitherto untouched, especially at the summits and roots of the lungs, and in the bronchial and other lymphatic glands. And so" long as we find these signs wanting, we have ground for hope that the disease has not assumed its most con- stitutional and destructive form, and is still limited to the part already invaded. The consumptive disease may be known to be in an active or increasing state, when there is more obstruction to the breath- sound, crepitating or complete; when the dulness becomes more marked and extensive ; when tubular sounds are hollower or louder, or are mixed with a bubbling or moist coarse crepi- tus, and these signs are further enlarged into the gurgling, churning noises of softening phthinoplasms and enlarging cavi- ties. And the increasing size of the cavities may be judged by the sound of their hollow: when small or moderate, and com- municating with the bronchi, forming islands full of voice or blowing breath-sound close to the ear or stethoscope applied to the chest; when large, giving less loudness of pectoriloquy, but the more mysterious reverberations of amphoric blowing or metallic tinkling, which add a peculiar sepulchral tone to the sound. As we do not profess to give a complete history of consump- tive disease in its worst as well as in its more tractable form, it is not necessary to dwell on the symptoms which mark this last stage of deca}T. They indicate not only rapid degeneration and waste, but often corruption and decomposition, in which septic parasites, vibrios, bacteria,and aphthous fungi,lend their destruc- tive aid. Thus yOLoi^ passes into .—Breath and cough much relieved. Pulse 104, sharp. February K.—Further relieved by blister, &c. Pulse 84 ; urine more copious. February 18.—Continued better, with little complaint of breath or cough. Pulse 8o. Gums sore from calomel. Less dulness and more breath heard in right chest, with loud friction-sound. February 27.—Breath has been getting shorter, and cough more trouble- some, although he has been again blistered. Pulse 84. More dulness in right chest, and loud, leather-creak at the side. May 2.—Condition gradually become worse. Breath and cough always troublesome ; only temporarily relieved by repeated blistering, &c. Pulse risen to 90. Expectoration now mucopurulent, sometimes rusty. June 20.—Occasional sweats, and diarrhoea. Pulse, 100. Losing flesh rapidly. Sputa viscid, purulent, sometimes streaked. Dulness of right chest increased; and- noiv cavernous sounds heard above left mammilla. Throat became aphthous, and died July 5. Sect in 34 horis post mortem. Uody much emaciated. Right pleura at posterior contained a pint of turbid serum. Both pleurse strong adherent to upper, front, and back walls of chest, and in many parts thickened by red, tough false membrane, thickest on right side, be- hind and laterally. Right lung large, dense to the feel, scarcely at all crepitant. On cutting into "it the substance is found pervaded by solid matter in gray opaque masses of roundish shape, from size of walnut to that of cherry-stone ; these in many points presented opaque yellowish specks ; and in some parts small cavities ; these were chiefly in upper part of lung; towards the base the lung was more generally red and tough. The same appearances to less extent in left lung ; the lower lobe most" free ; with dilated marginal air- cells. At apex of left lung was a cavity of size of hen's egg; the walls composed of dense tissue, "studded with soft yellow tubercle ; superiorly quite thin, consisting chiefly of pleura, which was quarter of an inch thick at this spot. Bronchial glands enlarged and soft. Pericardium contains ,'>ii vellow serum. Heart pale, large, and flabby, containing fluid blood, staining lining membrane ; mitral valve thickened at free margins, by dense deposit under serous lining ; attachments of aortic valves also thickened, and a little cor- rugated. 160 CASES of consumption Several patches of ulceration, with raised edges, in mucous membrane of colon and rectum ; no increased redness. Mesenteric glands slightly en- larged in several parts. Liver large ; substance fragile. Case 29.—Phthisis after Pleuro-pneumonia. Anne S., aged 42 ; admitted January 5, 1844. Tall, and has been very stout till the last four years. Has not been well fed in the last year. No serious illness till eighteen months ago, when she had severe pain in the side which was called inflammation of the liver. Was ill for many weeks, and was bled, cupped, and blistered. There was tickling of throat, but not much cough till some time after, and it became much worse in November ; lately with much opaque expectoration, and diarrhoea, and has become very weak and thin. No return of catamenia since November. Pulse frequent; skin cool. Fxtensive dulness in right chest, with loud cavernous sounds in upper regions, front and back. Loud, puerile breath in left lung. Pills, with \ grain sulphate of copper, opium, and creasote, three times a day, moderated the diarrhoea, but the cough became worse. Pyroxylic spirit was tried, but discontinued, as the purging returned, and continued till her death, which was preceded by an aphthous state of the mouth and inability to take food. The diagnosis given was extensive excavation and consolidation of right lung. Partial tubercles in left lung; tuberculous ulceration of intestines. Died February ">. Body much emaciated. Five ounces turbid serum in left pleura, which posteriorly was patched with red and granular lymph. A few clusters of tubercles in the upper lobe of left lung, and some miliary granulations scat- tered below. Posterior parts of left lung red and congested, but lower part of upper lobe in state of soft gray consolidation, with a few small cavities. The right lung was generally and firmly adherent by dense cartilaginous deposit, which extended also between the lobes. The whole right lung was in a state of dense gray consolidation, speckled with yellow spots, and the upper lobes riddled with numerous cavities, freely communicating. Liver healthy, but small; weighed 21b. 8oz. Several tuberculous ulcers in the ileum, and much inflammatory redness through the small and large intes- tines. Be marks.—In all probability this phthisis originated in the attack of pleuro-pneumonia which began the fatal illness, and ended in general con- solidation of the right lung, the universal adhesions and dense thickening of the pleura between the lobes proving its inflammatory origin. Subse° quently this lung caseated and softened, and miliary tubercles formed in the other lung. Case BO.—Chronic Pleurisy. Phthisis. John B., aged 37 ; admitted July 26, 1844. Tailor. In good health till twelve months ago, after frequent exposure and often getting wet had cough and pains in limbs, with much weakness. AVas out-patient of a hospital, with some relief; but in last two months has suffered with short breath, pain of right side, and temporary swelling of the legs. He also expectorated a quantity of dark stuff". Has lost much flesh, orthopncea; urine very scanty ; mouth aphthous. Chest movements imperfect, especially over right side, which is altogether dull, except above the second rib', where stroke is tubu- lar, and breath and voice sounds are tubular, and also above the scapula. Xo vesicular sound, but cegophony also below scapula. In left back breath puerile and stroke clear, but some dulness and tubular sound with coarse crepitus be- low clavicle. Friction-sound in left hirer lateral and dorsal regions. Heart Xnisheel to below the mammilla. Liver reaches to umbilicus. A blister was applied, and he was given blue pill, squill, and digitalis, with decoction of Iceland moss, acetate potass., and borax,' ter die. ' ORIGINATING IN INFLAMMATION. 161 July 27.—Breath not better; urine still scanty, albuminous, specific gravity, 1019. Less friction-sound in left back. Pills omitted, and 4 grains calomel and i grain hydrochlorate morphia given at bed-time. No relief followed, and he died on the 29th. Scetio 2 horis post mortem.—There were 10 pints of purulent serum in right pleura, with flakes of curdy lymph floating in it. liight lung com- pressed against mediastinum and spine, and middle dorsal ribs. Much tough opaque lymph over the surface of the lung in granules and in patches. On inflating the lung it became partly expanded, but was chiefly bound down by the deposits on the pleura. Texture of the lung flaccid. dry, dark purplish in color, sinking in water ; several small tubercles scat- tered through it, and a cluster of tubercles near the root, all dark gray col- ored and gritty—some near surface paler. Left lung covered with recent false membrane, forming a series of rough ridges of granular texture. Sev- eral gray tubercles in this lung, chiefly in upper lobe. Lower lobe heavy and congested. Yellow cheesy matter in bronchial glands. Weight of lungs: left, 21b. 9oz. ; right, 10oz. Pericardium strongly adherent to whole heart; adhesions dense, especially over right ventricle. Heart, with pericardium, weighed 14 oz. 1 aver weight, 3 lb. 2 oz. Some granular irregu- larity of surface, with predominance of pale matter, and texture coarse. A few white tubercles scattered through it. Both kidneys much congested ; texture soft: on surface of right one cyst and one white tubercle ; weight, 5^ oz. ; left, 5 oz. A few pale tubercles in spleen. Case 31.—Chronic Pneumonia.. Phthisis. Mary D., aged .77, admitted January 27, 1843; married, one child. Generally good health till winter 1840, when she had a severe cold, followed by cough and loss of flesh and strength. Lost cough in summer, but did not recover her strength ; and in the following winter the cough returned, and has continued ever since with increasing expectoration, shortness of breath, and loss of flesh. Much worse in last six months ; often suffering from severe spasms of the stomach and chest, and failure of appetite. Pro- fuse night-sweats. Pulse 100. Sputa copious, in separate opaque clots. Dulness on pereussitm in both upper regions, most under right davic'e, where gurgling and cavernous breath. Ordered mixture diluted nitric acid, tincture of henbane and hop, three times a day. February 4.—Cough easier, but the expectoration very purulent, and weakness increases. Wine and full diet. Two grains sulph. quinine to be added to each dose of mixture. 7th.—Getting weaker. Expectorates with difficulty darker matter. Pulse thready, irregular. Dozes much, and is incoherent. With more wine there was some rallying, but she gradually sank, and died on the 18th. Sectio US horis post mortem ; body much emaciated. Right lung exten- sively and firmly adherent at apex by very tough old false membranes ; slighter and more recent adhesions posteriorly; middle and lower lobes covered by opaque rugous membrane, in parts shreddy and hardly organ- ized. At posterior part of apex was a cavity, size of hen's egg ; its walls little more than the thickened corrugated pleura ; it contained purulent and curdy matter: its internal walls very red, pretty smooth, with shreds of opaque lymph. The middle and posterior portions of this lung were firmly consolidated, and dark red on section, with mottled gray and opaque yellow7 patches. Another small empty cavity in the anterior of upper lobe. An- terior portions of middle and lower lobes were pale, distended with air, and very flaccid and thin to touch, with general dilatation of air-cells. Left lung partially adherent at apex, in which also was a cavity, rather smaller than that in right lung, containing in a little opaque liquid and quite loose, 11 162 CHRONIC pneumonia. an irregular calcareous nodule of the size of a horse-bean. Texture below this cavity much puckered, indurated, and mottled with perfectly black nodules for an inch downwards. A few clusters of very hard miliary tuber- cles were scattered through lower lobe of this lung; but the greater part Was light, very pale, porous, and flaccid, with generally dilated air-cells (flaccid emphysema). Liver and kidneys small, and somewhat granular in parts. Case 32.—Chronic Pleuro-pneumonia. Fibroid Phthisis. A barrister, aged 45 ; March 18, 1843. Always delicate, with bilious tendencies. Has been more ailing since losing his wife in consumption last autumn. In November in Cheshire, and after getting chilled, he had what was called rheumatic influenza. On return to town he found his breath short, and perceived that he was breathing with one side only. He con- sulted several physicians, and got almost as many different opinions ; and was blistered and physicked in various ways without much benefit. He persisted, however, in going to chambers till the last three weeks, when the breathing has become much shorter, with dry cough and rapid loss of flesh. Pulse 100, easily quickened ; tongue furred. Urine scanty, high-colored. Left chest quite dull ami rather contracted in lower two-thirds, and without breath-sound or motion; upper third clear on percussion, with loud harsh breath; loose crepitus in mammary region. Bight chest dull in hirer half, without breath or voice; above, loud reedy vocal resonance. Heart pulsation felt in epigastrium. Liver dulness extended, with tenderness. May 12.—After treatment with repeated blisters, and at first mercurial diuretic, and subsequently iodide potass, and sarza., great improvement took place in comfort and strength, although he is still wasting and the breath continues short. No cough. Signs on the left side unchanged. On the right there is less dulness, and some breath-sound with crepitus down to the lower third, and less bron- chophony above. He afterwards went to Sandgate, where his strength further improved; but the breath remained very short, with a little cough. The medical attendant then concluded that there was a cavity in the left lung. He died October 2, after a few days' illness with sickness, slight jaundice, and delirium. On examination both pleurse were found firmly adherent at diaphragm, and anterior and upper walls. Several ounces of serum in lower and pos- Tterior part of both pleurae. Lower and posterior parts of both lungs (but most left) in a state of* tough, red consolidation, or carnification0; with crepitant tissue only on anterior surface. No trace of tubercle or cavity in either lung. Liver much congested and enlarged. Gall-bladder contained a quantity of very dark bile. Case 33.—Chronic Peripneumonia. Fibroid Phthisis. A proetor in Doctors' Commons, ret. 39, February 18, 184.">. Sedentary and much occupied in writing ; but lives well. In last two years breath has been getting shorter, with slight cough, worse in winter. Losino- flesh and strength ; but face red with acne. Thinks he strained himseFf two years ago by running, which brought on severe pain in chest. Lately pain m right hypochondrmm. Pulse quiet. Urine, scanty, dark. Dulness with wheezing in upper third right back; crepitus with weak breath-sound at both bases. Under regulated diet, diminished stimulants, and a course of iodide potass with carbonate potass, and sarza., and occasional mercurial aperient con- siderable improvement took place; but the breath was still short andcreui- .tus still in the back. l fibroid phthisis. 163 July 31.—A week ago, after exposure to cold, a pain came on in the right side, which has been only partially relieved by a mercurial dose. Is chilly and feels ill. Cnpitus increased in both lower dorsal regions, which now are dull. Liver large and tender. C. C. lat. dextro, ad 5viij. Pil. Hydrarg. scillae et digitalis, bis die. Haustus sennas o. m. September 9.—Was relieved of the pain, and afterwards improved on a mixture of nitric acid, taraxacum, and chiretta. Lately pain in right side has returned, with loss of flesh and breath. Dulness, with contraction, in right interscapular region, and in both lower dorsal, with crepitus. April, 1840.—Has had several attacks of low inflammation, affecting suc- cessively both lungs, with cough, mucopurulent expectoration, and much loss of flesh and strength. Has been repeatedly blistered, and had blue pill, squill, and digitalis, which gave temporary relief. In June some improve- ment took place, under iodide potass, and nitric acid three weeks. Increased dulness and contraction with crepitus in lower half of right lung, and lower third of left. In 1847 he moved to Brighton, and gradually declined, with the ordinary symptoms of consumption, constant cough, and opaque expectoration, and progressive loss of flesh, strength, and breath. More than usual oedema preceded his death, which took place at the end of 1848. His usual attendant, Mr. Ridout, informed me that, on examination after death, both lungs were found universally and firmly adherent, and their lower lobes in a state of dense, tough, reddish-gray consolidation. No cavities or tubercles. These two cases are remarkable exceptions to the general degenerating tendency of phthinoplasms. The fibroid induration persisted without either caseation or tubercular formation. But the wasting process was still there, the deca}7ing matter passing off in the purulent expectoration. Case 34.—Fibroid Phthisis after Pleurisy. Cavities. Mrs. M., aged 20, seen October 18, 1842. Two and a half years ago she had pleurisy of left side ; since then has had slight cough, and breath has been short. In last year has had several recurrence's of pain and cough, and is now much worse, after exposure to cold outside a coach three weeks ago. The cough is suffocating, with copious purulent expectoration, sweats, and extreme dyspnoea. Moist cavernous sounds under both clavicles. Extended dulness in region of liver. The patient died the same night. On post-mortem examination the left lung was found to be closely adherent to the back and side of the chest- wall. It was much shrunk, nearly the whole front being occupied by the heart. Texture of left lung was of dark color, and very dense, writh a few cavities. Right lung not condensed, but with several tubercles and cavi- ties, chiefly in upper lobe. Liver large and fatty, floating in w7ater. Case 35.—Phthisis after Pneumonia. Mr. O, aged 30, February 12, 185G. Four years ago had inflammation of the right lung, and ever since has had cough, with yellow expectoration, and lost much flesh and strength. Taken oil for two years. Dulness; de- ficient and obstructed breath-sounds throughout the right chest. Large tubular 'sounds and crepitation in upper portions. To continue the oil, with a tonic of nitric acid, hop, &c, and occasionally use acetum lyttae. January 25, 18(17. Has taken oil on and off ever since, but always in the winter. Is wonderfully improved in all respects, but never quite free from cough with expectoration, which has lately been worse, and accompanied by pain in the right side. Bowels costive. Suffers from piles. Has several times expectorated calcareous matter. Dulness and tubular sounds above 161 PLEURISY ENDING IN PHTHISIS. both scapula'; no crepitus, and chest clear elsewhere.—To continue oil and acid : senna confection with sulphate of potass. March 29, 1870.- Pretty well, and attending to business. Flesh and strength good ; but always some cough with yellow expectoration, and purulent coryza. Sometimes bilious, and liver now tender.—Dulness, and whiffy inspiration and long expiration at and, below right scapula.— To take a blue pill occasionally, and the oil once daily. Case 3(5.—Pleurisy ending in Phthisis. Master II., aged 10, June 2(5, 18(>3.—Delicate, but pretty well till, a fort- night ago, fainted at church ; after which slight pain of chest, and cough, but not laid up till last two days with increasing shortness of breath and swelling of left breast. Whole left side quite dull and motionless. Dulness extends to right of sternum and spine, and heart displaced to rigid of sternum. Intercostal spaces bulge, especially near left mammilla. A mixture of citrate and nitrate of potass was prescribed, but arrangements were made for tap- ping the chest next day. On the morrow, however, the dyspnoea was less, and the swelling less prominent; so a blister was applied, and the saline continued. He gradually recovered, the fluid dispersing, and weak breath- sound and resonance returning to the left side ; but considerable dulness and contraction remained in August. Cod-oil with tonic, iodine tincture externally, and country air were prescribed. This treatment was carefully pursued, and in 18(55 he was considered quite well, having nearly outgrown the contraction of the left chest, which was, however, still apparent. August 3, 1807.—Has been well, and is now at Harrow. Three weeks ago caught cold, and has since had pain in left side, wheezing, and cough. Looks ill. Pulse 100. Dcp'cient motion and percussion, and rrnetky rhonchi through left lung.—To resume the oil and have iodine painted. February 17, 18(59.—Improved and lost cough soon. Has been pretty well since, but grows fast, and requires care. In the last three weeks has again had cough and short breath, and appetite has been failing. Dulness and tubular sounds nmo at and, above rigid scapula.—Left lung more free. June 26, 18(59.—Improved with constant treatment and care ; but there is still some cough, and lately a little blood has appeared in the expectora- tion. Bowels not free ; and he has been taking quinine pills as well as the oil and mixture. Dulness and tubular sounds at right scapula, rhonchi at left.—Oil to be taken with phosphoric acid and hypophosphite of soda. Bowels to be care- fully regulated, and iodine regularly used. July 29. 1SG9.— Much better, cough gone, and signs diminished,.—Con- tinue same. November 2, 1869.—Continued better till return to Harrow, when cou^h again, with pain in chest and increasing weakness. To go to Ventnor.° Croaky crepitus at and above left scapula. Tubular sounds above right. April 18, 1870.—At Yentnor, taking oil, &c, and better till January 7. had severe cold, cough became worse, and spit 2 oz. of blood ; since expec- toration opaque, appetite bad, bowels costive.—Oil has been left off three weeks, and he has taken iron. Much dulness and croaky obstruction through left lung; tubular or carern- ous in upper part.—To resume oil, with phosphoric acid and strychnia mix- ture. Bowels to be kept regular. Tinct. iodine to be regularly applied. June 7, 1871.—Continued pretty well during the summer, and in Decem- ber went to Madeira, and, as advised, steadily persevered with the oil and tonic, and rode regularly up the hills ; so he 'kept fairly well. On voyage home, a fortnight ago, encountered cold winds, and cough much increased FIBROID PHTHISIS, WITH CAVITY. 165 with yellow expectoration. Left chest rather contracted. Heart beats at fifth rib. Moderate dulness. and crumpling suhcrcpitus through left lung. No cavernous sounds, but tubular above scapula. Case 37.—Fibroid Phthisis, trith cavity, arrested 15 years. Emphysema. A merchant, aged 45, first consulted Dr. AVilliams July 13, 1855. Was well till eight months ago, when he caught a severe cold, with cough and yellow expectoration, which have continued, with much loss of flesh, and lately with very short breath. Took oil in the winter, but soon sickened of it. Extreme didness on left side of chest, mostly in upper front, where there are large tul>ulue somids, and some liquid rhonchus, almost gurgUug. Less dulness behind, but tubular sounds and mucous rhonchus.—Ordered oil in a tonic of nitric and hydrocyanic acids and strychnia, and counter-irritation with acetum eantharidis. April 111, 1856.—Wintered at Hastings, and very much improved under the above treatment. Now walks six miles. Still marked hard dulness and obstructed breath in left front; but voice less tubular. Coarse crepitation in parts. November 28, 185(>.—Passed summer well, but six weeks ago brought up half a pint of blood, and was largely leeched. Has taken oil regularly, except during six weeks, and is quite stout. Breath still short. Cougli has increased in last ten days. Physical signs the same, except the addition of loud tubular breath above right scapula.—To continue oil, but in tonic of nitric and hydrocyanic acids, with iodide of potassium and tincture of orange. April 28, 1857.—Continues well, and fatter than ever. Breath short, but walks six miles. Just now has headache and increase of cough. December 7, 1859.—Passed last winter at Hull, and pretty well; but breath short, and had morning expectoration. No oil for one year. Has lately had more cough and slight haemoptysis. Dulness, cavernous croak and voice in upper left chest. February 21, 1S('>1.—Has taken oil, but wras shut up at Hull all the win- ter. Lost"flesh, and lately appetite and strength. Cough increased, and occasionally streaked expectoration. More caveoious sounds in upper left, front and back.—Ordered strychnia, with oil. March 29, 1862.—At Hull through the winter, and not confined to the house; but breath shorter, and losing flesh since August. Three weeks ago had pain in left side, increase of cou<|h and expectoration, which was / more opaque. Symptoms relieved by blisters, and patient has resumed the oil and strychnia"since. Large tubular sounds and crepitation in upper left front and back. Cavernous sounds below clavicle. March 24, 1864.—Again recovered, and has been generally well. Has little cough, but breath very short. Weighs twelve stone. Attends to business. No oil for one year. Less dulness, no cavernous sounds, but breath weak and subcrepitant. Tubular voice, and little breath at ami within lift scapula. Large tubular sounds above right scapula.—Ordered nitric acid, tincture of nux vomica, and glycerine. March 7, 1865.—Fatter, and pretty well; but breath always short. Six weeks ago had hemiplegia of left side, and confused state of mind ; but, after leeching and blistering, was relieved. Moderate dulness, crepitation, and croaky sounds over whole left chest. Xo large tubular sounds, except above rii/ht scapula. June 1, 18(56.—Pretty well; but lately palpitation, and pain in left arm. Breath-sounds feebly audible throwjhout left lung, only tubular in back. April 15, 1868.— Was pretty well; but during last year breath has be- come shorter, and palpitation has increased. Has little cough, with only transparent expectoration. No oil for two years and a half, and has spent 166 CHRONIC INDURATION. the last winter at Hull. More dulness in left front, and upper back, and large tubular or cavernous sounds above left scapula and immediately below left clavicle; dulness and obstruction sounds in lower part of left lung, with some sibilus; more tubular sounds in upper right cliest. HcarVs apex drawn up, and beating at left mammilla; action weak. March 4, 1869.—Wintered at Hull pretty well, with little cough, but breath very short on exertion, and some palpitation. Still molerate dulness and defective breath and, motion throughout left chest, but no cavernous sounds, and tubular only at and above scapula. Heart-sound and impulse, high and feeble.—To take three drops of liquor arsenicalis and two grains of hypo- phosphite of soda in a gentian and glycerine mixture, twice a day. February 26,1870.—Improved much in strength, and somewhat in breath during the summer, complaining only of his breath. Lately has suffered from fluttering at heart. Four months ago, for three days, had difficulty of articulation, but it passed off; only he complains of his memory failing. Lately closely confined to the house, and has indigestion, and become paler. Urine high-colored and scanty. Physical signs much the same. Liver rather full and tender.—To take iodide of potassium and digitalis, with tincture of calumba, and a few mercurial pills. May 26, 1870.—Health and appetite better ; but breath very short, and urine becomes scanty when he leaves off medicine. About three months later the legs began to swell; and he died suddenly in a faint. The remarkable degree of dulness in the left chest found on first examin- ation makes it probable that the disease was inflammatory, causing a hard cacoplastie deposit. This was afterwards partly softened and excavated, and partly absorbed and contracted. The general inference from several examinations (some of which for want of space have not been given) was, that emphysematous dilatation of the air-cells took place in the consolidated front of the left lung, rendering the stroke-sound more clear, whilst the breath and voice were obscured ; but the signs of old cavity and consolida- tion were still heard in the scapular region. In the last two years the lung disease was stationary, and there was neither cough nor expectoration ; but the heart showed signs of weakness, and death is to be referred to this cause. Post-mortem examination not permitted. More than fifteen years elapsed since the first attack. Case 38.— Chronic Induration after Inflammation. A builder, aged 37, first consulted Dr. W. January 13, 1842. Has lost a child from tuberculous disease of the lung. Twenty years ago had inflam- mation of the chest, for which he was bled, and was very ill for six months. Remained very weak till two years after, when he went to Arentnor, where he improved sufficiently to resume his occupation, but was always short- breathed, with more or less cough. Five years ago, after much exertion was attacked with pain in the chest and dyspnoea, lasting six weeks and has had cough every winter since. Symptoms w7orse since September'after exposure, with loss of strength and flesh. Dulness under both clavicles; de- ficient breath under left; and bronchophony, almost amounting to pectoriloquii under humeral end of right da ride. Expectoration scanty, sometimes tinned with blood. Ordered iodide of potassium, sarsaparilla, and liquor potassa? • also counter-irritation. ' December, 1842.—Much improved in flesh and strength ; little or no couch • dulness diminished ; tubular sounds almost gone. ' June, 1845 -Heard from Dr. Martin that he was quite well, and busy at work in the Isle ol AVight. J Well and active in 1869, twenty-seven years after his first visit, and fortu- seven after his first attack of inflammation of the chest. It is by no means clear that the disease in this case ever assumed a de- INDURATION AND CAVITIES. 167 cidedly tuberculous character; but it may be considered one of phthinoplastic deposit resulting from inflammation, and capable of degenerating. It is a significant fact that one of his children has died of tubercles in the lungs. Case 39.—Fibroid after Inflammation. A gentleman, aged 32, who had lost a brother and sister from consump- tion, first consulted Dr. W. January 25, 1855, and stated that a year ago he suffered from pleurisy of the left side, and since that time from weakness and short breath. No cough or expectoration, but lately had pain below the left clavicle. Extreme dulness over the whole of the left side of chest, with only weak breath in upper portion; expiration and voice tubular; heart close to chest-wall, and felt over a large space. Arcus senilis well marked ; urine scanty. Has taken cod-liver oil, but it purges.—Ordered oil combined with tannic acid and infusion of orange ; iodide liniment to be rubbed on chest. Ma}- 23.—Oil agreed well. Much improved in flesh, but still weak ; urine still thick ; appetite bad. Left side a little less dull, but no more breath-sound or motion. To take iodide of potassium, liquor potassse, and sarsaparilla. August 13.—Has been at Ems, where the waters proved strongly diuretic. Breath and strength improved, but has now slight cough. Still dulness, although less, and weak breath in left chest. May 6, 1856.—Continues pretty well; but often pain in left chest, and urine turbid, unless when taking the iodide and potass mixture, which has been continued at times. Some further diminution of dulness, and slight return of breath-sound, chiefly in upper parts. October 23.—Pretty well, till five weeks ago, large boils appeared on the cheek and throat. Chest continues to improve. Ordered chlorate of potass, with nitric acid and quinine. March 17, 1857.—No more boils, but lately is thinner and w7eaker. Still defective breath and dulness in lower left chest. To take oil in quinine mix- ture. June 4.—Better in flesh and breath ; also in chest sounds. October 14.—Lately has slight cough and more pains in chest. Has lost flesh. No oil or medicine lately. April 21, 1858.—Well through winter, but in last two weeks cough and yellow expectoration. Signs the same. Oil and acid tonic to be resumed. July 14.—Took oil and tonic six weeks, and lost cough. In last month large boil on neck, now discharging. To take syrup of iodide of iron, tinc- ture of calumba, and glycerine. March 5, 1859.—Passed winter pretty well, but continues thin. In last week cough and expectoration. Breath still weak, and limited motion in lower chest, but sound on percussion clearer. In left scapular region stroke- sound is tubular. This patient has not been seen since 1861, when he was reported to be well and improving in breath, and may be presumed to have recovered. Case 40.—Phthisis after Inflammation.—Post mortem. A lady, aged 35, was first seen December 14, 1841. Had three children and four miscarriages. Had suffered from phlegmasia dolens, mammary abscess, and other' puerperal complaints. Twelve years ago had right pleurisy ; and ever since breath has been short, with some cough. Suffered lately from pain and tightness of the chest. Occasional haemoptysis to the amount of several ounces. Has been often bled for the tightness of the % chest, and with much relief; but has lately become very pale and weak. Cough has increased, and is occasionally accompanied with profuse muco- purulent expectoration and night-sweats ; aphonia ; pulse 120. Dulness 168 PHTHISIS AFTER INFLAMMATION. throughout right chest, csjiccicdly in the lowest parts, where there is litlh mo- tion. Tubular breath in middle, front, and back. Cavernous sounds in lower back. Sub-rcjiitus under left clavicle; breathing puerile below, throughout lift chest. Heart beating under sternum. Liver enlarged. — Ordered iodide of iron with tincture of hops, and aconite ointment for neuralgic pain. March 8, 1842.—In the country, and improved in breath and color, but lost flesh, and in last few days had pain and oedema of left leg. Cough better, with expectoration more mucous and slightly tinged with blood. Breath and voice loudly amjihoric in lower rigid back; obscurely vesicular above, but shortened. Bight front very resonant, witlt loud cough and tubular breath. Tubular sounds under left clavicle. Dyspnoea and weakness in- creased, with extensive oedema in both legs up to the abdomen ; and she died on June 11. On post-mortem examination the left lung was found to contain scattered gray tubercles in the upper lobe, and a small cavity, with broken-down walls, at apex, where the lung was adherent to the chest. The right lung was adherent on all sides, except in front; adhesions being tough and firm, especially that connecting the lung to the diaphragm. The tissue of the lower lobe was solid, tough, and of a dark gray color ; the bronchi greatly dilated, even to their ends. In the posterior portion was a well-lined cavity, of the size of a large egg, containing purulent fluid and communi- cating by three round openings with dilated bronchi ; a smaller cavity at the base of this lobe. The middle lobe was very emphysematous and flaccid in front, but consolidated behind, and contained nodules of gray tubercle. In the upper lobe was a cavity of the size of an orange, with gray irregular walls, containing broken-down tubercle. The rest of the lung was in a state of gray consolidation, which in some parts had become yellow and softened. The large bronchi were very red. In this case the contractile consolidation of the lung, resulting from in- flammation twelve years before, eventually went into tuberculous degenera- tion. This case occurred before the use of cod-liver oil was well'known and ma}- be contrasted with the following examples. Case -11.—Fibroid after Inflammation.—Eeconry. A gentleman, aged 43, was seen by Dr. ATilliams for the first time on May 1, 1855. Had been closely confined to business, but pretty well till February, 1855, when he was chilled, and a few days afterwards attacked with cough, shortness of breath, and then with severe pain in the loins and lower chest, and inability to lie on the left side. Expectoration has nearly ceased, but cough continues ; breath is very short, and he looks miserably thin and pale, yet he is engaged to be married very shortly. The urine contains much brown sediment. Left side generally contracted, hard, and dull; no breath-sounds audible in lower regions, but some below the clavicle; large tubular sounds and strong vocal vibration in middle regions; heart drawn up above fifth rib to the left. Has been taking citrate of iron and qui- nine.—Ordered oil in a tonic of nitric and hydrocyanic acids, with tinctures of hop and orange. An effervescing saline'to be taken at night, and tinc- ture of iodine to be applied to the chest. July 7.—Has been taking oil three times a day, with acid and quinine, and is much improved in flesh and strength. Is'free from cough, and ex- pectorates but little; but still has pain in the left side. PlFi/siml .S;7/».s slightly better, but still great contraction and duhtess of this sidj.—Ordered to take oil, with iodide of potassium, and to continue counter-irritation. December 29.—Was married in the middle of July, and has continued to improve, taking oil rlgularly, and gaining much in flesh, strength, and breath. Has had slight cough during the last ten days. Phgsical signs about the same. FIBROID. — CAVITY AFTER PLEURISY. 169 May 26, 1850.—Had cold and cough for some weeks in the winter, and expectoration has continued since. Flesh and strength good, and breath better, though still short. Still dulness and collapse in lift side of chest, but more vesicular breath in upper portion. October 23. 1862.—Has been quite well, and has three children. Had lost cough, but breath remains short on exertion. Lately, at Scarborough, got chilled, and cough has returned, with yellow expectoration, and furred tougue. Still defective motion and breath in left chest; obscure in back and siS, when he was carried off by an attack when Dr. AY. was out of town. The case probably originated in abscess at the base of the right lung, the deep position of which prevented its being emptied and healed, and favored 174 PHTHISIS AFTER INFLAMMATION. the continual accumulation of offensive decomposing matter. In such cases the fingers become clubbed more than in ordinary phthisis. Case 49.—Purulent Phthisis after Inflammation.—Recovery. Mr.---, aged 30, florid.—September 4, 1841. AVas sent to Dr. AY. for an opinion as to prognosis. Three years ago had inflammation of the chest, and last spring two years was sent by Sir J. Clark to Ventnor, where he was very ill, expectorating large quantities of matter and blood. He was leeched and kept very low, and was said to have much disease of the lungs. Returned to London in a very weak state, and was sent for the next winter to Madeira. Not improving there, in June he went on to Brazil, where he improved rapidly, and returned in May apparently well, and has continued so ever since. Breath and strength good. Deficient breath, in upper right front, and tubular sounds. Slight dulness at and below left clavicle. February 22, 1845.—Continues well. Signs the same. ' October 20, 1845.—Been generally quite well, except occasional headache and indigestion. Physical signs the same, but slighter ; prognosis favorable. Alive and well in 1868, twenty-seven years from first illness. Case 50.—Bronchitis and Induration of Lung.—Recovery. Mr. B., aged 50—December 10, 1862. Brother and sister died of phthi- sis. Twelve months ago had cold and cough, which has continued more or less ever since, with loss of taste and smell, much snuffling, coryza, and transparent expectoration. Urine often thick. Much given to field sports ; cautioned thereon. Only bronchial rhonchi in various parts. Iodide and car- bonate potass., squill, hemlock, and liquorice mixture. May 28, 1863.—Living in Yorkshire, he has not abstained from his usual amusements. Therefore he has had cough all the winter, and two months ago had inflammation of the lung, with pain in right chest, low fever, and some gout after. Had profuse sweats, and was much reduced in flesh and strength ; but has since taken oil and improved. Still cough and yellow expectoration. Didness and deficient breath in upper half of right lung. Tubular sounds above scapula.—To continue oil, with nitric acid mixture. October 10.—Much improved in flesh and strength, but still has cough, with opaque mucopurulent expectoration. Now a fresh cold, with coryza, and deafness. Still dulness, obstruction and tubular sounds at and above right scapula. Tubular also within left scapula.—Continue oil and tonic, aud winter at Hyeres. July 14, 1864.—Except an increase of cough in December from a fresh cold, has done well at Hyeres ; having been much in the open air, gained much flesh and strength, and has hardly any cough or expectoration. Taken oil regularly. Still dulness and tubular sounds as before, but with more vesicular breath. March 24, 1865.—Passed the winter in Yorkshire, and has occasionally hunted. Breath much better ; strength good ; but he is not free from cough and expectoration. Dulness and tubular sounds diminished. July 2, 1868.—Has remained at home since, moderately joining in field sports, and is much improved in general health, and now weighs thirteen stone. But he is rarely free from cough ; has a fresh cold during the last two months. Often retches in the morning. Urine thick, and other symp- toms of gout. Some tubular sound remains in upper right, but no dulness or obstruction.—To take a course of effervescent salines, and afterwards tonic and oil. June 7,1871.—Has continued well in general health, and active as usual • but suffers from cold, and has generally coryza and bronchial cou"h.' INDURATION AND CAVITY. 175 Urine often thick and red. Breath short on exertion. Sibilant rhonchi in jiarts. Little tubular sound. To go to Ems. The chronicity and degenerating tendency of the lung consolidations during twelve years threatened to end in phthisis, but appear to have been arrested by treatment and change of climate. Case 51.—Phthisis after Inflammation.—Recovery. A young lady, aged 13 ; first seen May 9, 1848. Two maternal aunts had died of phthisis. AYas well till three months ago, when she had in- flammation of the right lung, with severe pain in back, cough, and expec- toration, and was reduced to a state of great weakness and emaciation. Had since been taking iron and much animal food, and improved in strength, but not in flesh, and the cough and short breath are very distress- ing, with high fever at night. Dulness in right chest, especially in lower half posteriorly. Loud tubular sounds with peculiar piping sibilus in lower part; tubular without sibilus above. Dulness and tubular respiration in left scapula. AYas ordered cod-liver oil in acid tonic twice daily ; an effervescent opiate at night; and iodine liniment. The state of this patient had been pronounced hopeless by an eminent London physician ; yet in a fortnight she was free from cough and fever, and so rapidly regained flesh and strength that she was considered well, and was not seen by Dr. AV. till September 15, 1849, when she had become very anaanic in the previous six weeks, having only once menstruated. The right lung had recovered, its permeability in the lower parts, but there were still dulness and tubular sounds in the scapular region. January 7, 1852.—Under long-continued use of iodide of iron regained color and strength, and catamenia returned, but tardily, and had to con- tinue iron, sometimes with oil, several years. Had no return of cough, became quite well, and has been married several years ; 1870. Case 52.—Induration and Cavity after Inflammation.—Recovery. A young gentleman, aged 14, first seen by Dr. AY. on August 3, 1843. Three years had inflammation of the chest, for which the patient was bled five times and otherwise severely treated, and suffered much from faintness and palpitation for several months afterwards. A similar attack occurred half a year later ; and since then he has had occasional cough, which dur- ing the last six months has become constant, and is accompanied by abundant green expectoration, sometimes fetid. Did lose much flesh and strength ; but he has lately regained them, and his color is good. Dulness and dejii-ient motion in upper rigid front. Tubular sounds and loud mucous or sonorous rhonchus in the mammary region on deep breath. Some dulness and obscurity of breath in upper left. Right side three-quarters of an inch larger in circumference than left.—Ordered iodide of potassium and sarsapa- rilla, with an iodine liniment, also a linctus containing stramonium. September 15.—Expectoration diminished, and now opaque white, not fetid. Flesh and strength good, and face blooming. Less rhonchus, but pectoriloepuy below right clavicle. Tubular breath below left clavicle.—Ordered a tonic of iiitro-hydrochloric acid and sarsaparilla. To winter in Madeira. July 1, 1845.—Lost cough and expectoration soon after his arrival in Madeira, and has remained well since, except short breath and occasional epistaxis. Collapse and dulness in right upper chest; loud tubular sounds below the clavicle; breath free on left side.— Ordered aMiniment of camphor and cantharides. October 13, 1846.—AYintered again in Madeira without cough, except for about a month. AYell grown and active, but thinner. Still collapse of 17G PHTHISIS AFTER INFLAMMATION. upper right chest, with tubular sounds, but more vesicular breath. Lift side mewes more slowly and fully than tlie right. April 21, 1849*.—Has wintered successively in Arentnor, Devonshire, and Oxford well. AYalks several miles, and breath improved. Has only occa- sional cough, with copious expectoration. Some dulness with in right scapu la, and marked tubular sounds below rigid clavicle; but vesicular sounds audible everywhere, with fair motion of the chest. Tjgur intercostal sjniees protrude on cough (partia'l emphysema). Took oil afterwards, got quite well, and has required no advice since. Was heard of as quite well in 1864—twenty-one years after the first visit, and twenty-three after the first attack of inflammation of the chest. Case 53.—Induration of Lung after Empyema.—Recovery. Mr. K., set. 37, April 11,1864.—Had a slight cough since croup in child- hood, but was in good health till 14 years ago, when he had right pleurisy, followed by empyema and very offensive expectoration. A deep incision was made in right dorsal region of chest, and half a pint of very fetid pus was discharged, after which the cough and expectoration ceased. The wound discharged for several months. The side contracted considerably, the ribs being drawn together, and he was restored to fair health, lie married (has now eight children) and lived an easy country life, but was never quite free from cough. Four years ago he took the command of a A'olunteer Corps, after which had more cough, and breath was shorter. He paid no attention to these symptoms till they increased, with some pain and expectoration and considerable loss of flesh, then he took oil and iron, and used counter-irritation. Defective motion of right chest, most lower half, dulness only on deep percussion. Breath-sound weak, esj>icially below: above right scapula, stroke clearer than on left (emphysema).—To take oil in nitric acid mixture, and use croton oil liniment on the side. October 11th.—Much improved in flesh, breath, and strength. Still cough and morning expectoration, chiefly mucus, with opaque streaks. Still defective and irregular breath in right lung, chiefly below. Tubular sounds at and within left scapula. December 2d.—Continued better till last Aveek, more cough and expecto- ration. More obstruction in right lower lobe. To go to Pau. May 29, 1865.—Not much out at Pau on account of weather. Has still cough and expectoration, and short breath. Took Cauteret's waters three weeks. Has lost 14 lb. in weight. Signs not altered.—To resume oil and tonic. Saline at night. October 5.—Much improved, and has gained 14 lb. Cough and expecto- ration much diminished, he thinks by the application of turpentine to his mustaches. Sounds of right lung dearer. 1871.—Favorable reports. No examination. Case 54.—Gangrenous Abscess of Lung.—Recovery. Mr. H., a3t. 56, consulted Dr. AYilliams January 21, 1844.—He had been well, except being subject to winter cough, and five months ago had broken his leg and clavicle. Mas chilled at the end of November, and attacked with cough, rusty sputa, and feverish symptoms, for which he was largely bled, with considerable relief, but is now extremely weak, and oppressed. The expectoration became opaque and offensive, "and is now abundant, amounting to from six to eight ounces a day. Cough violent, especially so when the expectoration is most fetid. Pulse 70. Dulness throughout right lung, most marked in the hirer portions, where coarse crepitation and, friction- sounds are heard. Tubular sounds in upper portion.—Whs ordered quinine in dilute nitro-hydrochloric acid, good living, and wine. ASTHMA PASSING INTO PHTHISIS. 177 April 10. 184").—Cough and expectoration gradually diminished in three weeks, and the patient improved in flesh and strength. Only occasional stitches of pain in right side. Dulness, obscure breathing, and slight sub- crcpitus through right chest, dulness being most marked at apex. \Yas ordered a mixture of nitric acid, iodide of potassium, and sarsaparilla, twice a day, and a blister to right side. May 1.—Ouite well. Sounds in right lung almost natured. 1871.—Has enjoyed good health ever since, and is now a hale old man of eighty-three. CHAPTER XIX. ASTHMATIC PHTHISIS. Usually originating in Inflammation—Arrested Phthisis passing into Asthma—Asthma passing into Phthisis. Most of the following cases may be considered of inflamma- tory origin, the original attacks being either in the bronchi, or near the roots of the lungs, so as specially to affect these tubes. Therefore, they have presented symptoms and signs of bronchial dyspnoea, with wheezing and convulsive cough. Thfir pathol- ogy has been noticed at pp. 58, 76, and 82. The first of the group show a declining tendency from asthma to consumption, the decay of the latter loosening the bonds of the former. In the last cases, on the other hand, the converse change has taken place, consumptive lesions being healed by a contractile process which has produced asthma—that is, constriction of the bronchi and dilatation of the air-cells. Some of these features may be traced in many of the histories of the other longer cases. Case 55.—Asthma}xissing into Phthisis. A young gentleman, aged 17, consulted Dr. Williams July 6, 1860. He stated that one of" his uncles on his mother's side was asthmatic, and that he himself had been subject for the last two years to attacks of asthmatic bronchitis. His breath had become permanently short for six months, and in the last two he had attacks of difficult breathing every night. Loud wheezy prolonged breathing in both sides of chest. Percussion clear.—A mix- ture of stramonium, squill, iodide of potassium, and carbonate of potash, was ordered to be taken twice a day, and a compound assafcetida pill com- bined with extract of stramonium, to be taken at night. July 20, 1865.—AYas much relieved, but had frequent recurrence of dysp- noea till last September, when the cough increased and the wheezing dimin- ished. Expectoration scanty and tinged with blood, and yellow only when patient has fresh cold. Obstruction sounds and wheezing all on r the chest, but no dulness or tubular sounds.—Oil was ordered in nitric acid and quinine, and an inhalation of creasote, chloroform, and conium, to be used at night. October 28.—Has gained flesh and strength, but cough is troublesome 12 178 ASTHMATIC PHTHISIS. and convulsive.—A mixture, containing iodide of potassium, conium, poppy, and squills was prescribed. February 8.—Living at Hastings, and much better. Has gained 11 lbs. Lost cough in December till last few days, when it returned. Physical siejns the same. October 8.—AYent to Torquay in March, when cough diminished, but be- came worse on patient leaving off oil, to which he returned in May, and again improved. Lately cough bad, and some pain in upper right chest, where coarse crepitation and tubular sounds are audible above the scapula.— Ordered syrup of hypophosphite of iron with glycerine and infusion of quassia ; and tincture of iodine to be painted on the chest. June 29, 1867.—Passed the winter at St. Leonards and Ventnor, taking oil and iron regularly, and gained flesh and color ; but lately pale and cough tight. Has had several asthmatic attacks, and breath is very short. Coarse crepitation and tubular sounds above right scapula; dry whiffy sounds above the left scapula. Sputa of two kinds : some opaque, yellow, and heavy, the rest frothy and transparent.—Ordered to continue taking oil, with iron and strychnia. October 19.—The cough and tight breathing became worse after taking the iron, and so nitric acid and quassia were substituted, and a pill of Indian hemp and stramonium given at night. Patient found that the asthma was worst when at Ascot, better at St. John's AYood, but best at Croydon, where he has been seven weeks, and gained strength, but not flesh. Large croaky crepitation sounds in upper left chest. This patient was alive in the autumn of 1868, suffering much from asthma and convulsive cough. The largeness of the crackling and croaky sounds at the left apex, to- gether witff the opaque purulent character of part of the expectoration, ren- dered it probable that small cavities had formed between the emphysematous portions of the lung. The cough and occasional fits of dyspnoea were asth- matic, but the emaciation and aspect of the patient were consumptive. Case 56.—Asthma passing into Phthisis. A gentleman, aged 48. August 7, 1860. He had been subject for seven years to attacks of bronchial asthma, which were much relieved by iodide of potassium and stramonium, prescribed by Dr. Williams in 1856, but they recurred this summer more severely, and were accompanied by more opaque expectoration than usual. Tubular sounds are heard above the right scapula o,nd whiffy sounds below. Marked arcus senilis.—A mixture of iodide of potassium, squills, and stramonium, nux vomica, and glycerine, was pre- scribed. June, 1861.—Has had several attacks : one in April, which was severe, but was much relieved by medicines, and he has been free since. May 20, 1862.—AYintered well at Hyeres, with fewer asthmatic attacks ; but in April had haemoptysis amounting to .pi, which recurred on the jour- ney home. Tubular sounds and crepitation in upp>er portions of both sides of chest. Was ordered cod-liver oil in a tonic of phosphoric acid, calumba, and orange. September 29, 1862.— Taken oil well, and has gained flesh. Expectora- tion streaked with blood. Crepitation still in upper right chest. May, 1863.—AYintered well at Cannes, having only two attacks of asthma, which were relieved by taking stramonium pills and burning nitre-paper. Has taken no oil for three months. Dry tubular sounds in upper ri°-ht chest; no wheeze.—To repeat oil, with nux vomica tonic. October 17, 1864.—AYintered in Italy, and was well till June, when out fishing, caught cold, and inflammation of the lungs followed, with bloody sputa, and worse cough ever since. Lost 12 lbs. Loud tubular sounds and .some wheeze.in right upper diest: some wheeze in upper left. ASTHMATIC BRONCHITIS TENDING TO PHTHISIS. 179 May, 1865.—Improved, gaining flesh, and partially losing cough ; but went late to Hyeres, and had severe cold and cough for two months. Had lately haemoptysis amounting to ^iij. Dulness; tubular sounds in upper right chest; slight crepitation in upper left.—Ordered oil in a tonic of sul- phuric acid and calumba. April 6,1866.—Wintered at Torquay and Yentnor. Always cough, with increased yellow expectoration. Has suffered little from asthma, and has lost flesh and strength. November 25,1869.—Has remained in England the last two winters and was well till fresh cold last May, but improved in the summer. In October was chilled, and has ever since had bad cough, opaque expectoration, short breath, and great loss of flesh. No asthmatic symptoms. Dry cavernous sounds above right scapula, dulness and tubular above left. Deficient motion, crepitation, and obstruction-sounds in left front.—To continue oil with phos- phoric acid and calumba. Not seen since ; death reported in 1870. Case 57.—Asthma verging into Phthisis. A clergyman, aged 45.—First consulted Dr. AYilliams January 8, 1861. He had been subject to eczema from childhood, and to asthma till he was 25, when he visited Corfu. Since then he had only occasional attacks ; but last May a severe one occurred. He has not been well since. Neverthe- less, continued active in his duties till six weeks ago, when he was laid up with cough, rusty expectoration, fever, and pain in right side of chest. Lately, the cough has ceased, but the patient is losing flesh and strength. Patches have appeared again on his arms for the last nine months. Dul- ness and tubular sounels in upper part of right chest, chiefly above scapula. Slight bronchophony above left scapula.—AY as ordered oil, with mixture con- taining iodide of potassium ; stramonium at night, in case of asthma re- turning. June 22, 1862.—Has been to Madeira ; and improved for six weeks. Then had severe asthma for one month; then returned to England, and has been improving under stramonium and oil. Lately has been taking beer and wine, and has had long sittings in Convocation, and the eczema is increased. Arsenic solution in gentian mixture was prescribed September 20, 1866.—Has been much better in skin and breath, suffering rarely, and attacks slight, till last January, when he had an attack of cough, with fever, which was treated by stimulants. Since then the cough has been very bad, with purulent expectoration and night-sweats. A great loss of flesh. Increased dulness, and large tubular sounds in upper right chest. Some obstruction-sounds in upper left, in addition to the usucd bronchial rhonchi. Under oil and hypophosphite of soda and phosphoric acid he improved much in flesh and strength, and the cough and expectoration abated. July, 1867.—AVintered at Cannes, and continued to improve. Has lately increased in weight one stone. In the last fortnight has had fresh cold ; cough moderate. Strength good, and regularly does duty. Expectoration still purulent. Physical signs greatly improved. February 27, 1869.—Spent the following winter at Cannes, and was quite well, able to be much in the open air ; but no medicines were taken. In the spring, however, the legs became cedematous (no albumen in urine), and remained so more or less up to the present time. In October cough came on, with copious expectoration, first bloody, since very thick and opaque, accompanied by feverish symptoms and much loss of flesh, but the patient has been better lately. No albumen can be detected in the urine. More dulness, and large tubular or cavernous sounds in right upper chest, chiefly be- low clavicle. Breath not clear at left apex. Dry whiffy emphysematous breath- ing below. To resume oil, with phosphoric acid and strychnia, and paint the chest with tincture of iodine. August 9, 1870.—Improved much again during the summer, gaining 180 ASTHMATIC PHTHISIS. weight and strength, and losing oedema. Remained at home during winter, being quite equal to public duties. In the last month some return of cough, with opaque expectoration, streaked with blood. Patches of eczema have also appeared. Had left off medicine for several months. Dulness in upper right diminished, but occasional click with the tubular sounds. Oil and tonic to be resumed. August 14 1871.—Pretty well through Inst winter; but always opaque expectoration and dulness in upper right. Has lately lost a daughter, aged 15, from acute tuberculosis. Case 58.—Asthmatic Bronchitis passing into Phthisis. A widow lady, aged 35, April 17, 1865.—Last autumn bad severe cold and cough, with much oppressive dyspnoea, and not quite free since, although exerting her voice much in public recitations and teaching elocution. A fortnight ago had a fresh cold, and since has suffered much from oppressed breathing, cough, and purulent expectoration. No fever now. Loud sibilant and mucous rhonchi in every part, but some breath-sound and clear stroke-sound throughout. Mixture of bromid. potass., squill, conium, and hop ; acetum canthar. lin. May 12, 1865.—Symptoms gradually abated, but still some cough, opaque expectoration, and short breath. Has lost flesh. Rhonchi have cleared up in most parts, but at and, above riglxUscipula there is coarse crepitation. To take oil with mixture of phosphoric acid, calumba, and nux vomica. February 22, 18(i6.—Improved much in every respect during summer, but never quite lost cough and expectoration, nor the crepitus at right apex. In November had fresh cold, with symptoms of bronchitis, as before; expectoration being purulent or opaque. Improved under similar treatment, but confined to the house. Has taken salines during attack, and oil and tonic in intervals, and so regains flesh and strength. 1871.—In 1868 married again ; and has since lived in the country, subject to the attacks in the winter as before. In one, haemoptysis to the amount of a tablespoonful occurred daily for a week. In more recent examinations, the coarse crepitus, with tubular breath and voice, has continued in the right suprascapular region; and the same signs to a less degree on the left side, but without distinct dulness. Some emphysematous clearness and bulging were manifest in the dorsal regions. Decided tendency to wasting is manifest during and after each attack ; but this, and the copious opaque expectora- tion, have been controlled by steady perseverance wflth oil and tonics. Case 59.—Emphysema. Contractile Disease of root and apex. H. K., aged 54, admitted to U. C. Hospital, January 3d, 1846. A pot- man at a public house. In last fourteen years had suffered from colds and cough from exposure, and has had pretty constant short breath since, in- creasing much of late years, and has several times sought relief in hospitals. Always much worse in winter, and his present attack came on in November, with cough and dyspnoea, greatly disturbing his rest. Expectoration for- merly very viscid, and sometimes rusty and partly opaque. Often pains of chest, worse on left side. On admission, extreme dyspnoea, dusky skin, cold extremities, frequent violent fits of cough. Pulse frequent, hard, and sometimes irregular. Tongue much furred. Dulness in upper right, most at sternal end of clavicle. Percussion clear in, lower dorsed regions. Breath very wheezy, with prolonged, expiration. Inspiration obscure, with submucous rhonchus below right clavicle. Same signs, but less, on left side'. Blister, mixt. of ipecac, squill, and stramonium ordered. No relief followed, and he died on the 6th. Sectio 6 horis post mortem. Emaciation moderate. On opening chest, anterior surface of both lungs presented a remarkable puffy appearance of emphysema, with numerous cells projecting beneath the SUPPURATIVE BRONCHITIS. 181 pleura, of various sizes, from a pin's head to small pea. Left lung, weight 16 oz. Volume large, with dilated cells in every part, especiall}7 at margins, which were very thin and flaccid. A large cell, of the size of a marble, pn ejected from the root. A small consolidation at apex, with a deep dimpled depression on the surface, to which a tough old membrane adhered. Right lung weighed 14^ oz. Several old pleural adhesions. Upper lobe covered with tough opaque false membrane, thickest at apex, with one small patch of consolidation of lung-texture to depth of half an inch, quite gray and opaque. A tough opaque membrane also covered much of the middle lobe, and similar opaque tissue appeared around the bloodvessels and bronchi near the root. The texture of the lung generally showed general dilatation of the air-cells, and only here and there small gritty solid black particles of consolidation. The lower lobe, like that of the left lung, was in extreme state of atrophied emphysema, at the margins feeling like a single thin mem- brane, which contrasted remarkably with the texture near the root, which was much more dense and resisting. Bronchial mucous membrane very red, and circular fibres very conspicuous. AY alls of large bronchi near root much thickened. Heart weighed 12^ oz.; an oblique valvular opening of foramen ovale. On the liver were many patches of deposit, and marked depressions on its surface, corresponding with the ribs which had pressed against it. Texture adhered firmly to capsule. There were other evidences of granular induration, with increase of fat-globules ; weight 31bs. Kidneys also had adherent capsules, and much fine granular matter in the tubules. This case illustrates the origin of general emphysema of the lungs from contractile consolidation at their roots. Case 60.—Phthisis arrested. Asthma long after. A gentleman, aged 58, whose brother was phthisical, saw Dr. AYilliams, July 28, 1858. lie stated that in 1832 he had bad a cough and expec- torated blood and calcareous matter ; he was considered consumptive, was ordered to Madeira. He returned much improved, and gradually recov- ered, being able to lead an active life, and even to hunt. He remained free from cough till the last four or five years, and then it recurred in fits of some violence, occasionally causing stupor; and last winter he had a convulsive cough, with long back draught, and wheezy breath and expectoration, referred to the left lung. Pretty stout and strong, and is actively engaged in heavy business. Arcus senilis. Some dulness and tubular sounds ivith prolonged wheeze in left upper front and right beak. Emphysematous clearness below.—AVas ordered a mixture of iodide of potas- sium, bicarbonate of potash with squills, stramonium, and hops, and to winter in a warm climate. May 7, 1859.—AYas unable to go away for his health or to diminish his business, and has become weaker and his breathing more oppressive ; but his cough is less. Stroke-sound clear, but more obstruction and wheezy sounds audible in several parts of the lung, especially the left. Case 61.—Suppurative Bronchitis and Emphysema originating in Inflammation. Mr. N., aged 34, December 31, 1848.—Eighteen years ago had severe in- flammation of the lungs, from which he slowly recovered ; but in the fol- lowing year had an attack of haemoptysis (several ounces) ; and this recurred" several winters, followed by cough and purulent expectoration, lasting from six to twelve, weeks, leaving him pretty well during the sum- mer. J las spent several winters in the south of Europe with benefit. The last two have been passed at home, and there have been several attacks. hist ing six or seven weeks. During the last summer was in AYales, able to walk several miles and to climb mountains. A fortnight ago Mas attacked 182 ASTHMATIC PHTHISIS. with rigors and oppression, and coughed up a quantity of dark blood, and has been suffering from cough and dyspniea ever since. Expectoration now purulent. Is much alarmed by his physician telling him that it was from an abscess in the lung. Pulse 120. Skin cool. Urine clear. Lips rather livid. Sweats at night. Is taking bark in the day and half a grain of morphia every night. No appetite. Chest distorted by spjinal curvature; anterior iqqjer regions project, stroke-sound clear, with harsh puerile breath- sound; irregular dulness and loud tubular sounds at and eibove both scapula', with coarse crepitus below, with lessening breath-sound downwards; only ob- scure short clicks at left base, which is rather duller than the right. The chest was freely blistered with acetum eantharidis; a mixture of nitric acid and decoction of Iceland moss with tincture of hop, given three times a day; and a weak opium linctus for the cough at night. The cough, expectora- tion, and dyspnoea soon diminished, and the appetite returned. Cod-liver oil was then given in an acid tonic, and in six weeks the patient was free from the attack, and had nearly recovered his usual state. The crepitus and obstruction had cleared from the greater part of the right lung; leaving still some at the base and the lower third of the left lung; breath- sound above harsh, and either tubular or cavernous at and above both scajiulir. Notes have not been kept of the subsequent history, wdiich ended in death about 1863, but this is the summary : He gained considerably in health and strength during the intervals of the attacks, but having always slight cough and opaque expectoration, and being wheezy on exertion. The at- tacks came on generally two or three times during the winter, sometimes with symptoms of bronchitis and coryza, and sometimes with oppression, pulmonary congestion, and sometimes haemoptysis ; but all with dyspnoea, lividity and cough ending in profuse purulent expectoration ; and then the tight wheezy obstruiiion in the lungs was replaced, by cexirse liquid crepitation. A colliquative stage of great wasting and weakness followed ; but this was successfully combated for several years by generous diet and the sustaining measures. Eventually the lungs became more emphysematous, and the dyspnoea more permanent, and death was preceded by anasarca. This case, originating in inflammatory consolidation, may be considered as occupying an intermediate position between consumption and asthma. Case 62.—Phthisis going into Asthma. Mr. T., aged 35 ; May 7, 1842.—Six years ago spit a little blood, which much alarmed him, being very nervous ; but no other symptom occurred till two months ago, when he again coughed up blood, and slight cough has continued since, with opaque expectoration in mornings. Pulse 84, jerking. Breath shorter, and has lost some flesh. Some irregular dulness in upper regions of both sides, in right interscapular and left subclavian. Bronchophony, almost pectoriloquy, below right clavicle.—Nitric acid and sar- saparilla. Iodine liniment. Dec. 14.—Cough and expectoration has been slight. General health im- proved ; but now more cough, disturbing sleep. Still dulness with cavernous sounds in rigid subclavian and mammary regions; below, tubular expiration. April 17, 1843.—AYintered at Hastings. Cough moderate. In the last few days has been expectorating blood. Breath-sound weak below left clavi- cle. Still loud cavernous expiration below right clavicle. September 20th.—Has remained in the neighborhood of town, much in open air, taking the acid and sarza. No cough or hemorrhage. Sounds only tubular below right clavicle. April, 1844.—Has wintered in Italy. Free from chest symptoms, hut weak. Same signs. November 1, 1845.—Has continued well till a few days a<'o, whenhavino- caught cold he spit some dark blood, without cough. Stilt a little dulness CASEOUS PNEUMONIA. 183 and tubular sound in upiper right. Expires 180 cubic inches. Height 5 feet 9j inches. 1860.—Lived in Italy for some years, and subsequently in the A\rest of England ; generally in good health, but breath rather short, and subject to occasional attacks of asthmatic bronchitis, from one of which he was now suffering. No obvious dulness or tubular sound, only wheezy breathing in upper part of chest. From the imperfect notes kept of this case, it can hardly be decided whether there was a cavity or merely consolidation of the apex ; but, in either case, the original lesion seems to have disappeared, and left a some- what emphysematous state of that portion of the lung, with asthmatic rather than consumptive tendency. CHAPTER XX. CASES OF SCROFULOUS PNEUMONIA AND ACUTE TUBERCULOSIS. Scrofulous Pneumonia—Acute or chronic—Acute cases ' two fatal, with post mortem—Acute Cases arrested, five—Acute Tuberculosis—"Rapid Phthisis—Six fatal Cases with post-mortem—Origin from various Causes—Caseous Glands—Abscess—Measles combined with Tubercu- lous Arachnitis—Post-mortem Characters of Acute Tubercle. The following group, which might be easily enlarged, include those cases of acute phthisis in which the disease has been so much localized as to resemble those of inflammation more than those of scattered tubercle. But they have proceeded so rap- idly to excavation, and so early declared their phthisical char- acter, that their place seems to belong to consumption rather than to common inflammation; and this corresponds with the designation, Scrofulous or Caseous Pneumonia described in Chapter XL Their acute and very consumptive character approximates them to those of Acute Tuberculosis which follow ; but the dis- seminated and adenoid distribution of the miliary tubercles in the latter strongly marks them as a distinct variety of con- sumptive disease. Case 63.—Phthisis. Acute Caseous Pneumonia. S. N., aged 18 ; admitted into University College Hospital, November 23,1839. Cellarman. Always weakly. In last six months overworked in wine-cellars, damp and draughty, and kept up at night at the bar. Three weeks ago became suddenly weak, with loss of appetite, thirst, and violent cough, and mucous expectoration. Ten days ago came on pain of left side. and been since confined to bed. lias lost much flesh and strength. Ex- pectoration was streaked ; now viscid and opaque. Pulse 84; respiration 27. Urine high-colored. Dulness in upper left, most front. Cracked pot- stroke under clavicle, and loud tubular sounds. Breath-sound bronchial, with some dulness in left back, except the base, winch is quite dull, emd azyophony is 184 CASEOUS PNEUMONIA. heard in mid-region. Breath puerile in right lung.—18 leeches to the right chest, calomel, James's powder, and opium every night. Senna draught in morning; nitrate and tartrate of potass., in camphor mixture, three times a day. November 26.—Much relieved in breathing and pain, especially since blister on the 23d. Still much cough and expectoration, but less viscid, and no blood. Pulse 120. Less dulness in left back, and more breath- sounds. December 5.—In last week cough relieved by eruption on side, produced by tartar emetic ointment. Left front of chest still dull and collapsed. Pulse 96. December 17.—Cough easier; but weakness increasing.—Ordered iod. potass, in infus. cascarilbe. December 24.—Cough increased, with rusty sputa, and pains on both sides, with increasing weakness. More crepitus and dulness in posterior re- gions.—Ordered antimony and henbane mixture, instead of cascarilla, &c. December 31.—Has been better in every respect, and feels stronger. Cough and expectoration diminished, but the latter still rusty. Squills substituted for antimony. January 14.—In last few dajs more cough, rusty expectoration, and in- creasing weakness. Loud amphoric breathing, pectoriloquy, and gurgling in left front. Pulse 120. Occasional night-sweats. Continued to get weaker, with harassing cough and copious yellowish clotty expectoration, and died on March 11. Examination 48 hours after death.—Great emaciation. Left pleura firmly adherent throughout. A large cavity in anterior part of left lung capable of holding half a pint of fluid. Its anterior walls were little more than the adherent pleurae ; in other parts the surface was irregular, with some bands stretching across, and contained mueo-purulent matter. The upper and posterior part of this lung was in a state of gray consolidation, here and there mottled, and with small excavations communicating with the large cavity. The base of the lung was firmly adherent to the diaphragm by a large mass of organized lymph, which contained in its interior opaque patches of yellowish-white color, some tough and some softened (yellow tubercle). Right lung in first stage of pneumonia, with several patches of yellow tubercle, some crude, some soft. No adhesions in right pleura. Mesenteric glands much enlarged in parts, with patches of crude yellow tubercle. Mucous membrane of larynx and trachea rough,, red, and par- tially thickened with numerous isolated pits, apparently ulcerated follicles ; and several were found also in the bronchi of the left lung. Case 64.—Phthisis. Acute Caseous Pneumonia. Fred. R., aged 38, tailor, admitted March 20, 1840. In good health till last five months, when he was out of employment and living badly. He then began to cough, and soon to expectorate, and lose flesh and strength. A fortnight ago the cough became much worse, and he brought up about a tablespoonful of blood, which has recurred nearly every mornin^. There is also pain in left side; thirst and increasing weakness. Pulse frequent. Whole left side more or less dull, and with crepitus superseding breath-sound. Crepitation also in upper right. AYas cupped ten ounces, and ordered tart. antimony. April 2, 1840.—Pain and cough better. Vomited several times after medicine. Sweats at night. Pulse 108. Ipecac, wine and tinct. camph. co. substituted for tartar emetic. April 7, 1840.—Cough has again become severe, and breath more tight. Has been blistered and again put on antimonial treatment. Left side'dull (except at apex), with mixed crepitus and bronchophony. Dulness and coarse crepitus at rigid apex. ACUTE PHTHISIS ARRESTED. 185 April 21, 1840.—Has continued to get worse in spite of all remedies; breath very short, cough urgent, and now the sputa have become partially rusty. Pulse 120. Veins much distended. Distress great. To be bled to six ounces. Ammonia and wine. Some relief from the bleeding, but weakness increased, with inability to expectorate. Died on the 25th. Percussing the chest below the left clavicle elicited the cracked-pot sound, which could be traced to the mouth of the subject, showing that it was caused by the succussion in the cavity communicated to the air in the trachea. Both lungs adherent to the ribs and diaphragm, most firmly posteriorly and below ; but some recent lymph was found at left base. In the sub- stance of both lungs were consolidations of various sizes—those in the left pervading many lobules, and of the density of liver; some small as miliary tubercles, harder than the others. Parts of the general consolidation were yellow opaque, and softened at points. At the summit of the left lung was a cavity of the size of a small orange, and some smaller ones below. At the summit of the right lung were several solid gray masses, with small yellow patches of softening in some. The lung-tissue between the masses was generally red and congested, and in parts hepatized. Bronchial mem- brane generally much injected. Many dilated air-cells in marginal lobes. The consolidations of the lungs in this case presented every gradation between recent acute hepatization and the gray nodules commonly called tubercular, and the change to the opaque state (caseation) was seen in parts of both. The case is an example of acute phthisis arising from inflammation de- graded by malnutrition. Case 65.—Scrofulous Pneumonia. Cavity. Death from Hmnoptysis. Mr. J. Ar., aged 28, April 9,1867. —A brother had haemoptysis. Devoted to tropical horticulture; has travelled in Australia and China. Cervical glands occasionally swollen. In the end of February caught severe cold with cough, which has been increasing with tinged expectoration, pain in the left chest, high fever, and extreme weakness and wasting. Pulse 120 ; skin hot, 104°. Dulness, deficient breath, crepitation on deep breath, in whole left, except apex. Reedy bronchophony in mammary and scapular regions. Blister to left side ; nitric acid, calumba, and glycerine morning and mid- day ; effervescing saline with opiate, evening and night. May 31.—Fever, hard cough, and viscid expectoration continued a fort- night, requiring repeated blistering and continued saline. Then expectora- tion became purulent, cough looser, and temperature lowered. Cod-liver oil was then added to the morning doses, and improvement soon followed. Cavernous sounds in mammary region. Some breath above. October 15.—Has steadily continued the oil with phosphoric acid and hypophosphite of soda ; quinine and iron being added at times. Fever and sweats have long since subsided; the cough and expectoration are much moderated ; appetite is good ; 10lbs. have been gained in,weight, and he can walk a mile. Dulness and collapse of left front, with croaky cavernous sounds, most marked in mammary region. Modende dulness and subcrepi- tus with obscure breath posteriorly and above. Tubular sounels above right sea) ad a. June 2, 186S.—AYintered at Hyeres. Able to be much in the open air, and steadily improving the whole time, taking oil with phosphoric acid and hypophosphite of soda, and sometimes quinine. AYeight has increased from 9 st. 9 lbs. in October, to 10 st. 7 lbs. in April. Cough and expectora- tion gradually diminished ; and have been trifling in last three months. Collapse and dulness with cavernous sounds in left front, most marked at 186 SCROFULOUS PNEUMONIA. 3r7, 4th, and oth ribs. Clearer, with a little breath above and in ujiper dorsal regjon ; more dull anil obstructed below. I'ubular still in upper right. "September 23, 1868.—Quite well \through summer, except shortness of breath and slight cough with opaque expectoration. Cavernous sounds are rather high.er up, and heard in the scapular region also, but less. Heart drawn up above an inch. Rather less obstruction in lower dorsal region. Mav 5, 1869.—Again wintered at Hyeres, regularly taking oil and acid hypophosphite. AYeight has risen to list, lib., and has walked four or five miles daily. June 25th.—On his return home he attended to business in nursery grounds and hothouses, and lived more freely, and at end of May coughed up 6 oz. of blood, and less for three days, with pain in right side, fever and viscid expectoration. Fine crepitation in lower two-thirds right lung. After a blister and a few days with antimonial saline, this attack of pneumonia subsided, leaving him" weak, with loss of 13 lbs. weight. Xoiv breath pretty clear through right lung, but large tubular sounds above right scapula. Cav- ernous sounds on left side are still further drawn upwards and backwards, and the heart occupies the front up to the third rib. August 25.—Has gradually improved, having lost all pain and hardness of cough, and has regained some strength and flesh. Signs in lift chest much the same. There has been some crepitus at right apex, but that is no longer heard. Is bilious, and requires occasional omission of oil, and a dose of blue pill, &c. October 11.—Has been distressed, and called into exertion by the death of his father. More cough, expectoration, and weakness. Has required blistering with acetum eantharidis. More crepitus in left lung, but no exten- sion of cavity. May 31, 1870.—Wintered again at Hyeres, taking oil with strychnia and phosphoric acid and hypophosphite mixture ; and has gradually improved, gaining twelve pounds in weight, and some breath and strength, but not up to the point of this time last year. Dulness and, collapse of left front as be- fore, but the cavernous sounds are more croaky and, mufjled. A little crepitus also above right scapula.—Still occasionally bilious, as now. Treatment accordingly. August 1.—Has had a slight recurrence of hemorrhage, the bowels being confined at the time. Since has frequently taken acid sulphate of magnesia in mornings, and has improved, and breath and cough are better. More breath-sound, at left apex. Cavernous sounds croaky and, dry in scapular region. Crumpling crepitus below. Xo crepitus at right apex, but heart- sounds arc loud there. In the following week, during Dr. AYilliams\s absence from town, hemor- rhage came on, became profuse, and death followed in two days. This case at first appeared to be a hopeless one of galloping consumption, and was pronounced to be so by a physician who had been consulted. The great and continued improvement afterwards was very remarkable, and might have been more permanent, but for the patient's too early return to active business and his subsequent heavy trial. Although at first the dis- ease appeared to be scrofulous pneumonia, the subsequent affection of the apex of the righj lung was probably tuberculous. Case 66.—Scrofulous Pneumonia. Cavity. Arrested. Mr. F. AY., aged 24, January 14, 1867.—Mother scrofulous. Is reported to have been quite well till October, when he caught a severe cold, followed by pain in left side, cough, and expectoration, which lately has become very clotty and opaque. Has lost much flesh and become extremely weak, with fever and profuse sweats at night; much annoyed with piles. Pulse 110. Dulness and, obstructed breath through whole left chest. Large tubular sounds and coarse crepitation in mammary region, and less above. Tubular SCROFULOUS PNEUMONIA ARRESTED. 187 sounds above right scapula.—To take oil with phosphoric acid and strychnia. To paint with the tincture of iodine. Morphia linctus at night. July 12.—Has vastly improved in all respects. Gained 21 lbs. in weight. Has long lost fever and sweats. Cough and expectoration moderate. In last two months quinine has been added to tonic. Still much dulness and obstruction in left chest; but no crepitation. Dry cavernous sounds in left mammary region. Tubular above. October 10.—Except a bilious attack, requiring a few doses of aperient and the suspension of the oil, &c., for a week, improvement has been con- stant. Gained 8 lbs. more. Has lately suffered from bleeding piles. Cav- ernous sounds in left front and upper back. Breath still obstructed below.— To take electuary of senna with sulphate and bitart. potass. Continue oil and tonic. March 30, 1868.—Has wintered at Hyeres, and generally well, having been regularly out for exercise. Had gained 8 lbs. up to January. Then suffered from piles, and left off the oil for five weeks, and lost 9 lbs. in weight. Now has a fistula. Cough and expectoration still, but moderate. Mudi less didness and obstruction in left side. Cavernous sounds obscurely heard in mammary and subclavian regions. More tubular above scapula, with weak breath below. June 30.—More cough, expectoration, and tightness of breath since in- creased exertion and exposure in an excursion to Germany. Signs much the same. October 13.—Has been well and active, and gained 6 lbs. Cough ceased for three weeks in August. Fistula still open. Cavernous sounds heard only on deep breath, which causes a " squash," and some crepitus posteriorly. Taken oil once daily. April 24, 1869.—At Hyeres, and out all the winter, though often wet. Gained lj lbs. and much strength. No cough, except in mornings, with a little dirty expectoration. Fistula has discharged more, till touched with caustic. Obscure, jtectoriloquy with croak on deep breath in upper left. Par- tial obstruction and dulness below. Tubular sounels above right scapula, but ivith good vesicular breath-sound. (Enlarged bronchial gland.) September 23, 1869.—Has been well and active in his business (builder), till six weeks ago ; caught cold and has had more cough and expectoration, which is now quite yellow. Has lost 3 lbs. Signs much the same. March 31, 1870.—AYintered well at Hyeres, although a bad season. Has taken three tablespoonfuls of oil with tonic once daily. Gained only 1^ lbs. Xo material change in signs. xAugust 6, 1870.—Continues well; about the same in flesh ; but stronger and in active business. Pulse 72. Little cough or expectoration. Cavity smaller, and with only crumpling crepitus around. This case had all the aspect of acute phthisis from scrofulous pneumonia, until arrested by treatment. The fistula had probably a salutary influ- ence. Case 67.—Scrofulous Pneumonia. Cavity. Arrested. A medical man, aged 30, whose paternal aunt had died of consumption, saw Dr. AYilliams on October 14, 1859. In 1856 he had a bad attack of scarlatina, and has not been strong since, but remained in laborious prac- tice till March, 1858, when he was attacked with severe pneumonia of the right side, followed by copious purulent expectoration, sweats, emaciation, and other signs of acute consumption. AVintered at Malaga without amendment; suffering much from cough and expectoration. Occasional luemoptysis to the amount of £iv. After a time he crossed to Tangiers, and there improved a little, but remains very weak and thin, and lately suffering from nausea and hoarseness. "Cannot take oil." Collapse, de- ficient motion, dulness, large tubular (cavernous?) sounds in right front; less 188 SCROFULOUS PNEUMONIA ARRESTED. dulness, some breath-sound audible but mixed with crepitus in back.—Ordered oil in tonic of phosphoric acid, strychnia, and tincture of orange ; the use of a cantharides liniment. To winter at Hyeres. October 24, 1863.—AYintered at Hyeres, steadily continuing oil and tonic, and much in open air. lias improved so much in all respects that he has returned there every winter since, practicing as physician. Passes summers in North AYales with further improvement in flesh and strength. Breath better, but still short on exertion, and has always had some cough, expec- toration, and hoarseness. Last winter, after going out at night, had another attack of the right lung, which weakened him much ; but he gradually re- covered, and again gained much ground during the summer in North AYales, although the weather was wet. Dulness, collapse, deficient motion, and breath throughout right chest. Loud tubular or dry cavernous sounds above. Coarse erejiitation below. June 2, 1867.—Still living at Hyeres in winter, and in North AYales in summer. Has steadily improved ; is stouter than he ever was, and has little cough or expectoration. Last winter expectorated some calcareous matter. Still collapse, deficiency of motion, dulness of whole right side of chest, but dulness diminished in anterior portion. Some breath-sound, with subcrepitus is heard, especially under clavicle, at scapula, and in lateral region. Strong percussion gives a raised pitch note in upper half. Tubu- lar and cavernous sounds to be heard nowhere, except tubular above the right scapula. Left lung quite healthy. 1871.—Remains very well in bodily health, although he has been much tried in mind and body of late. Oil has been taken at least once a day regularly. Had charge of an ambulance during the siege of Paris. Case 68.—Scrofulous Pneumonia. Cavity. Arrested. Mr. E. J., aet. 21, January 2, 1863.—Lost an aunt in phthisis. Since a cold taken two months ago, has coughed with much yellow expectoration, and lost much flesh. Complete dulness, and loud, large, tubular sounds be- low right clavicle, with crepitus lower down, and above clavicle. —To take oil, with phosphoric acid and calumba ; morphia linctus at night, and to blister the chest with acetum eantharidis. May 30th.—Much better, and gaining flesh. Still cough and opaque ex- pectoration. Still duhiess and croaky crepdtus below right clavicle. July 9th.—Continued improvement, but cough and expectoration, al- though much lessened, are not gone. Amphoric, cavernous sounds below right clavicle to third rib. Good breath below and behind.—Add sulphates of iron and quinine (aa gr. j) to tonic, with oil. July 11th.—Haemoptysis to one and half ounce. Bowels not free. An aloes pill every night. Substitute diluted sulphuric acid for phosphoric with iron and quinine, with the oil. September 10th.—Heard he was at Aberystwith ; quite well, walking several miles daily. i June 17, 1864.— AVintered at Aberystwith. Stouter than ever, without cough or expectoration, but breath is still short on exertion. Defective motion, moderate dulness, and large tubular sounds in upper third of right chest, but vesicular breath heard there, and no cavity. Tubular sounds above left scapula. The cavity was probably produced by caseating pneumonia. CASE 69.—Scrofulous Pneumonia. Cavity. Arrested. Death from Heart Disease. Miss P., aged 16.—Patient's aunt died of phthisis. Sister phthisical since. September 12, 1864.—In good health till last April, at school had cold and cough, with pain in left side, but not attended to for three weeks, when becoming worse, with quick pulse, sweats, &c, Dr. — was consulted, who ACUTE TUBERCULOSIS. 189 pronounced the disease "galloping consumption." On oil and iron con- siderable improvement took place; but the breath is still very short, the cough continues with opaque expectoration; the catamenia have not re- turned since April. Extensive dulness in right chest with large moist cavern- ous sounds in u)>per part, and obstruction and crepitus below. Coarse crepi- tation also above right scapula.—Oil to be continued in mixture of phosphoric acid, calumba, and sulphate of iron. Tincture of iodine to the chest. October 19th.—Great improvement. Catamenia have returned twice. Blood has appeared in the expectoration. Cavernous sounds drier. Large tubular sounds and, no crepitus above right scapula.—Oil to be continued with sulphuric acid, instead of the phosphoric acid and iron. June 1, 1S65.—AYintered at Cannes, pretty well; but by advice discon- tinued the oil several times, and has had more cough and lost flesh. Cata- menia only twice. Large tympanitic cavity in u)>per left front. Breath ob- scure below. Crepitation above right scapula.—To resume the phosphoric acid and iron, with the oil. June 2, 1866.—Improved much during last summer, and wintered at Cannes much better, continuing oil and tonic steadily, until two months ago, when it was omitted for a time on account of diarrhoea. AVas not con- fined to the house a day during the winter, but cough and moderate expec- toration have continued. Collapse and dry cavernous sounds in upper half. of left chest. Some vesicular breath, in barts and rough in others, on that side. May 14, 1866.—To Australia this winter, and to the Cape and Bombay last winter, taking the oil and tonic all the time ; and quite well. Gained 5 lbs. in weight. Left chest still rather duller than right, especially in lower part behind, which is contracted. 'Tubular sounds at scapula; jtecidiar dry vesicular breath-sound below, especially on full inspiration (flaccid emphysema). May 12, 1868.—Last year took a voyage to the Cape, but this year has remained in London, quite well; stronger and stouter than ever. Takes oil only at times. Fistula still open, but discharges little, and gives no inconvenience. This gentleman has been so well in the last three years, that his going away during the winter was a matter of inclination rather than of neces- sity ; and the last winter was passed in London without inconvenience. 1871.—Heard of as quite well. Case 81.—Phthisis after Scrofula in Glands. A dressmaker, aged 21, whose mother had died of consumption, saw Dr. Williams July 8, 1859. Seven years ago her cervical glands much swelled were lanced, and then healed ; but every summer the swelling returns, and is painful. Had cough all the winter, with greenish expectoration, and has lost strength and breath. Dulness and mucous rhonchus beloic left clavicle, where there is pain.—Oil ordered, with iron, quinine, and phosphoric acid, and counter-irritation with acetum eantharidis. July 15, 1860.—Took oil three months, and became much better, but cough still continues, with expectoration.—To resume remedies. December 27, 1864.—Was quite well and active for four years, but lately, being much confined in business, has had pain in the left side and shoulder, and has lost flesh. Still dulness and deficient breathing in upper left chest. October 15, 1868.—Continued better, but liable to occasional increase of cough, and often requiring the support of the oil and tonic, until the last three months, when, after a cold, the cough and expectoration, with fever- ishness, have much increased, and she has been obliged to lay by, and use various remedies, salines, blisters, &c. Is now better, but very weak and thin ; and has not been able to continue the oil for any time. More dulness and obstruction in left chest, with crepitus in parts. May 8. 1870.—Continued several weeks very ill, but at length the stomach bore the oil, and gradual improvement took place, regaining strength and some flesh, and almost losing the cough. In the last two months the cough has returned, with much opaque expectoration, sometimes offensive. Pain in left chest. Dulness and tubular sounds in iqyper left and less in right bronchial rhonchi below. May, 1871.—This patient is reported to be living an invalid life, without much cough or suffering. Case 82.— Phthisis after Scrofula of Glands and Fistula. Mr. F., aged 37, consulted Dr. Williams, April 28, 1858. A brother died of phthisis. Had suffered during his youth from scrofulous glands of the neck, which had ulcerated. During the last three years had fistula, which had been operated on, but never healed. Cough came on a year a'o-o and had continued ever since with occasional haemoptysis, and lately 'with PHTHISIS AND CIRRHOSIS OF LIVER. 199 opaque expectoration. Has lost much flesh, but regained under one j'ear's course of the oil, and ten weeks spent at Torquay and Ventnor. Dulness and loud tubular sounds in upper right chest, chiefly posteriorly. May 30, 1861.—Passed the first winter at Hyeres, and left off oil, and became worst;. The last two years have been spent in Guernsey, and oil has been steadily taken. He is much improved, but still has cough, with some yellow expectoration and occasional haemoptysis. The jihyslcal signs arc the same in the right lung, but some tubular sounds are audible also in the upper portion of the left. Case 83.—Phthisis after Separating Bubo. Death Six Years after with Pneumothorax. Mr. W. M., aged 19, was seen by Dr. Williams in consultation with Sir James Clark, in December, 1843, for a suppurating bubo, accompanied by cough and expectoration. Some dulness under left clavicle.—Iodide of potas- sium, nitric acid, and sarsaparilla were ordered, and the patient apparently recovered, and remained well till July, 1845, when he caught cold, and has had cough, expectoration, and occasional night-sweats ever since. October 16, 1845.—Dulness below left clavicle; more dulness and tubular sounds in right scapular region. Was ordered a mixture of nitric acid and tincture of hop, and Iceland moss, and to winter in Madeira. October 8, 1846.—Wintered comfortably in Madeira, and now well, except his breath is short. Flattening and dulness, with click sound on deep breath, below left clavicle and above scapula. September 30, 1847.—Tolerably well, but still has cough and some ex- pectoration. Dulness; small tubular and click sounds upper left chest; ob- scure breathing in ujgter right.—Was ordered cod-liver oil in nitric and hydrocyanic acids, and an acetum eantharidis liniment. He wintered again in Maderia, taking oil, and returned home pretty well; but during the winter, which he passed in England, he caught severe cold ; perforation of pleura took place, and he died of pneumothorax in 1849. Case 84.—Phthisis after Lumbar Abscess and Empyema. Mr. S was seen by Dr. Williams. June 5, 1844. He stated that three years before, after rigors and pain, a swelling appeared in the right lumbar region, which opened in two points, and discharged a quantity of very offensive pus. Later on he coughed up much of the same matter, smelling of rotten eggs, for several months, and lost greatly in flesh and strength. He gradually improved, but the right side of his chest remaining dull and contracted, though less so.—Ordered a mixture of iodide of potassium and sarsaparilla ; counter-irritation, with an iodine liniment. April, 1846.—Continued to improve till caught a fresh cold in March, and now has cough and soreness of chest. Physical signs not recorded. Died of phthisis in 1848. Case 85.—Phthisis after Syphilis, Mercuried Sidiration, and Suppurating Glands. Cirrhosis of Liver and Ascites. Win. M., aet. 28 ; admitted December 6, 1843.—French polisher. Lived irregularly. Four years ago had syphilis, chancre, and bubo ; treated with medicines which made mouth sore, and two mouths after, whilst still weak, was laid up two months with pains and weakness of limbs; and under treatment his mouth and throat again became sore, and cervical glands swelled and suppurated, and remained open for several months, during which he continued weak, and has not been strong since ; but has not been confined. Two months ago had an abscess in groin (not syphilitic), which 200 PHTHISIS AFTER OTORRHCEA. discharged and healed in three weeks. At this time he began to cough and expectorate ; and the breath has become short, and he has lost much flesh. Sputa opaque, viscid, rather rusty. Tenderness and dulness on ptr- cussiem, and defective movement of left chest. Cavernous sounds below humeral end of left clavicle. Crepitus beyond and breath-sound obscure. Right side less elull than left, except above scajnda.—A blister was applied to left side, and a mixture containing tart, antimony and hydrocyanic acid given. December 16.—Chest symptoms have been somewhat easier; but urine very scanty and high-colored, and there is some fluctuation in the abdomen. Liver dulness smaller than natural. Expectoration more opaque, less viscid. Dulness and cavernous sounds as before in left lung, tubular in right. January 1C>.—Ascites increased rapidly, and cough for a time better. Diuretics and elaterium have been given, with only slight diminution of the swelling ; cough andJbreath again becoming troublesome, and appetite fails. Became delirious on the 224, and gradually sunk after. Died 22d. Moderate emaciation ; some oedema of legs. Abdomen contained many quarts of yellow fetid serum and a few7 flakes of lymph. Right lung not adherent; a few gray tubercles near apex, and much more in middle lobe, forming clusters surrounded with black matter; some puckering of the pleura over it. Left lung closely adherent to chest; the whole upper lobe consolidated, and of an iron-gray color, with several cavities communicating, and some containing pus ; lower lobe partially solid also, and contained a few cavities, but no tubercles ; lower portion healthy, and without tuber- cles ; several white patches on pericardial covering of heart. Liver very small and hard (weight 2 lbs.), shrunk up into a rounded mass in the hol- low of the diaphragm ; nodulated on surface, of pale brick color ; right lobe adherent to diaphragm. Vessels on capsule fringed with opaque deposit, which could be seen also in the substance around the portal vessels. Cap- sule firmly adherent. Spleen very large (weight 8 oz. j. Patches of granu- lar deposit on capsule. Case Si).—Phthisis after Purulent Otorrhoea. Mr. II. C, aged 17.—Maternal uncles and aunts have died of consump- tion. March 28. 1860.—When a child he had an abscess under the jaw, and a purulent discharge from the right ear has gone on ever since. Has had cough every winter ; increased during the present, and attended with pain in the chest, loss of flesh, and shortness of breath. Nevertheless he looks well, and is engaged in farming. Deficient breath in front of both sides of chest. Tubular sounds above right scapula.—Ordered oil in phosphoric acid, calumba, and tincture of orange, a cantharides liniment and an aloetic pill. May 11th.—Has gained flesh and strength, but still has cough and ex- pectoration. Dulness and large tubular sounds, with croak on deep breath above right clavicle. August 11, 1862.—Oil has been taken on and off ever since last visit, and the patient is much better, but he always has cough and yellow expec- toration. Tubular sounds in right scapular region and above it, but pretty good breath-sound. Case 87.—Phthisis after Otorrhoea. An officer in the army, aged 24, consulted Dr. Williams October 16, 1860. Has had otorrhoea, after scarlatina, from infancy. For last eight months has had slight and persistent cough. Six weeks ago, when in Canada had haemoptysis to amount of three ounces after exertion, and has had some slight amount siuce. Had lost much flesh, which has been regained since EMPYEMA THREATENING PHTHISIS. 201 Dulness; deficient breath in upper portion of right back, and some tubular sounds in upper left chest.—Oil was prescribed in a tonic of phosphoric acid, calumba, and orange, and counter-irritation with acetum eantharidis liniment. July 19, 1861.—Wintered well, but complains of breath being rather short. During last few days, after hurrying himself, the expectoration was streaked. Physical signs same. June, lSi'2.—Well and stout, doing duty at Harwich, but has had slight hemoptysis occasionally, and has lately been suffering from cold and sore throat. Case 88.—Caseation of bronchial glands. Stridulous breathing. Tubercles. Miss M., aged 3 years, wras seen by Dr. Williams June 2(5, 1843.—She had had severe cough for several months, and occasional attacks of stridu- lous inspiration, occurring especially at night. Did lose flesh, but has re- gained. Didness and stridulous breath-sounds in right interscapular region. —Ordered iodide of potassium, with sarsaparilla, and to use an iodine lini- ment. The little patient wras removed to Clifton, where she improved during several months, then was suddenly attacked with bronchitis, and died in two days. On post-mortem examination there were found consolidation with partial caseation of the lower lobe of right lung, with small tubercle nodules also, and a few miliary tubercles in middle lobe. There was con- siderable caseous deposit in the bronchial glands, one of which was greatly enlarged, and compressed the right bronchus.—Reported by Dr. Symokds. Case 89.—Empyema threatening Phthisis. Paracentesis. Recovery. Miss B., aged 12, November 23, 1865.—Reported to have been quite wrell till ten days ago, when she was attacked with sharp pain of left side and shoulder, with shortness of breath and fever. Was treated by Dr. Stokes, of Canonbury, for acute pleurisy, with salines, mercurials at night, and blister ; but symptoms continue. Skin not hot. Whole left side dull without breath or voice. Heart to right of sternum.. Abdomen large. Liver down to umbilicus. Pil. hydrarg. et scill., bis die. Haust. potass, iodidi et acetat., 4 horis. November 25.—Dyspnoea increased. Pulse 130. Walls of chest oedem- atous ; abdomen increasing ; fluid in peritoneum; urine scanty ; bowels relaxed. Further delay being judged unsafe, a trocar was plunged by Dr. Stokes into the chest, above the fifth left rib at the side, and 10 oz. pus flowed ; the wound being covered with a poultice after the trocar was withdrawn, the discharge went on freely. No air was admitted into the chest during the operation; but soon after there were signs of pneumothorax; and about in ten days the discharge became offensive. Much relief to the breathing and cough followed the operation ; but the patient remained long very weak, with quick pulse, night-sweats, and bad appetite. The abdominal enlarge- ment, however, soon subsided.—Quinine, with mineral acids and cod-liver oil, was prescribed, and a generous diet with wine or malt liquor enjoined. July 9, 1867.—Weakness and offensive discharge continued long, but the first wound healed, and another opened spontaneously in front, and has generally discharged from two drachms to two ounces daily. It has some- times stopped for a few days, and then the cough has increased. The ex- pectoration as well as the" discharge has the rotten-egg odor. In the last four months there has been considerable improvement in growth and strength, and she is able to walk two miles.—Half an ounce of oil twice daily lias been regularly taken in wine. 202 CHRONIC PHTHISIS. The whole left side is still contmcted and dull; but less so in the upper half, ivhere there is obscure bradh-sound posteriorly, and loud tubular sound with slight crepitus in front. The heart beats under and to the right of the sternum. The recommendation, made before, to goto the seaside, and continue the tonics with the oil, was repeated, and was followed with great benefit. May, 1871.—The patient is reported to have completely recovered ; the discharge having stopped two years, all cough ceased, and the full develop- ment of growth having nearly restored symmetry of form. I have notes of several more cases of empyema ending in complete recov- ery, although the compression of the lung and the long continuance of pur- ulent formation around it, made the danger of infection imminent. Many other cases are less fortunate, empyema ending in phthisis. See Dr. Stokes on ''Diseases of the Chest," p. 427. CHAPTER XXII. CASES OF CHRONIC PHTHISIS OR CHRONIC TUBERCULOSIS. Anatomical difference between Acute and Chronic Tubercle—The latter more limited and local, and therefore more tractable—Cases of First Stage—Six Cases arrested and cured—Of Second Stage, Five Cases ar- rested and cured—In Third Stage, Twenty-five Cases retarded, arrested, or cured. Under this head is arranged a large group which may be considered to present samples of the most common type of pul- monary consumption. If we accept a few doubtful cases, we may add the designation " Chronic Tuberculosis," to express that the phthinoplasms occur in the form of tubercles, which are small miliary bodies, composed of indurated adenoid tissue. These cases of chronic tubercle differ from those of acute tubercu- losis rather in extent than in kind. It may indeed be said correctly that the chronic miliary gray tubercle is much harder than the acute, which, as described in several of the cases, can be crushed by firm pressure (see p. 104), but this difference is only an affair of time, like that between acute hepatization, which is soft, and chronic induration. The great difference is in extent. Acute tuberculosis is thickly scattered throughout both lungs. Chronic tubercles are comparatively few, limited chiefly to the upper parts of one or both lungs; and although they have a tendency to infect other parts, both by contiguity, and through the lym- phatics, yet there is much more chance of counteracting; "this than in the acute disease. Therefore, these chronic cases are generally not only more tractable than cases of acute tubercu- losis, but, from their more limited extent, they may be arrested or cured more completely than those originating from inflam- mation. CASES IN FIRST STAGE. 203 The short histories given are selected out of some hundreds of similar cases, not only to show what can be done by careful and continuous treatment, but also to exhibit various phases and changes in the disease under varying circumstances and remedies. It must be observed that, although all are classed as chronic cases, many have been acute, either at commencement or in some part of their course, and they altogether are fail- samples of the most common form of pulmonary consumption as it occurs in this country. The cases are arranged in some measure according to their stages and extent. First, those of the first stage, simple indu- ration : second stage, induration with softening: third stage, induration with excavation—the last cases having cavities in both lungs. Case 90.—Chronic Phthisis—first stage.—Recovery. Mrs.----, set. 33. December 14, 1852.—Sixteen years ago suffered much from a chest affection, with cough and expectoration, which continued four years. Took cod-liver oil, was frequently blistered, and long had an open issue. Eleven years ago she married, and has been much better since. Had six children. In last three months cough has returned, with much pain in the right chest and back ; suffers from sickness, and cannot take oil. Tubular voice and breath at and within right scapula. Loud long expiration above. Oil to be taken in mixture with diluted nitric and hydrocyanic acids, tincture of hop, and infusion of orange-peel; cantharides liniment to the chest. December 30.—Takes oil well, and has been freely blistered. Much bet- ter in all respects ; much less cough and pain. March 11,1853.—Continued much better till a month ago; became bilious and left off oil. AVeaker since, and confined within doors. Still tubular voice at right scapula. Breath-sound clearer. To resume oil, with gentian. November 4.—Continues in better health, but always with cough and expectoration, sometimes tinged. Worse in cold weather. Signs as before. March 30, 1854.—Wintered at Notting Hill, pretty well; but confined in cold weather. Taken oil pretty regularly. March 16, 1855.—In December had severe pain and an inflammatory attack of chest, and was much reduced, but has gradually improved. Still often pain in right chest. Appetite very bad ; urine thick ; bilious ; cough and breath have not troubled much, and signs in chest as before. Anti- bilious pills and saline. July 25, 1856.—Wintered well, suffering little in her chest; but lately weak and very bilious. Palpitation and occasional faintness. Heart-sounds loud and short. February 6, 1860.—Chest continues better, but often suffers from palpi- tation and weakness, requiring iron, &c. November 19,1863.—Better, and become stout. Now fresh cold and cough. 1868.—Has had no return of lung symptoms, but alw7ays short breath, and palpitation on exertion. Was much benefited last year by several months in Switzerland. 1871.—Tolerably well. 204 CASES OF CHRONIC PHTHISIS. Case 91.—Chronic Phthisis—first stage.—Cured by enforcing treatment. Mr.----, a?t. 23. June 19, 1863.—Quite well till twelve months ago, after close application in an office in Edinburgh, coughed up a dessert- spoonful of blood. Soon began to cough, which continued all the winter; worse in April, with expectoration, and rapid loss of i\csh and strength. Is now returning from the south coast, weak, pale, emaciated, and in a most desponding state. Says that he cannot take cod-liver oil. Much dulness, with hud reedy bronchoplumy and deficient breath in upper half of right front and back. Tubular sounds within and above left scapula, and below left clavicle. As the only chance of saving him, he was urged to take the oil in a mix- ture of phosphoric acid, strychnia, and orange. The chest to be blistered with acetum eantharidis, and a morphia linctus for the cough at night. July 1.—Takes the oil very well, and is already better. Only occasional nausea. More breath in right lung. An occasional dose of blue pill and colbcynth to be taken. February 12, 1866.—Dr. AV. heard that the patient had continued the oil and tonic ever since, and soon became wonderfully better. Has now hardly any cough, is regularly attending to business in Edinburgh, and is going to be married. May, 1871.—Heard from another patient that Mr. ----was quite well, and fully engaged in business. The condition of this poor wasted young man, with his unhappy mother, was truly pitiable at the first visit. At the second, the unexpected dis- covery that he could take the oil had filled him with hope, and his amend- ment went on rapidly from that time to a happy issue. Case 92.—Chronic Phthisis—first stage.—Arrested. A young gentleman, set. 15. May 11, 1857.—Maternal aunt died of phthisis. In last Christmas holidays, after a chill, had pain in right side, and some cough ever since. Ten weeks ago had a severe chill after playing at football, and since has suffered much from cough and weakness, loss of appetite, and breath. Dulness, defective motion, and breath-sound in whole right chest. Tubular sounds at and above scapula.—To take oil, with nitric and hydrocyanic acids in orange infusion, and use acetum canthar. June 16.—Much better. Cough nearly gone. Says breath is not short now. Still dulness, and tubular sounds at and above right scapula. November 22, 1866 —Took oil at times for several years, and much im- proved in general health and strength, but always found himself rather short-winded on exertion, and sometimes rather wheezy. Still he has kept his terms regularly at Cambridge, and studied with such success that he came out Senior AV rangier last winter. Has continued well till six weeks ago, when he caught a cold, and has had slight cough since, with an occa- sional feeling of faintness. Brcynchophony above right scapula. Percussion and breath-sounds generally dear.—To take oil, with iron tonic. 1868.—Continues well. Has now become Fellow of his college. May 3, 1871.—Has continued well generally, but had cough several times last winter. None lately. Is pale and out of condition. Chest- sounds good eyenerally, but still tubular sounds in upper right.—To resume oil and tonic. Case 93.—Chronic PJtthisis—first stage.—Recovery. A gentleman, aged 22, from Nova Scotia, visited Dr. AVilliams, Novem- ber 5, 1856. He stated that August last year he had Asiatic cholera, for which he was given a great deal of mercury, and for two months after the FIRST STAGE — CURED. 205 attack he had a cough, which disappeared before May, when severe laryn- gitis came on, and cough had continued ever since. Oil had been taken for three months, with much benefit, and he improved more during the voyage from Nova Scotia. Decided dulness and deficient motion at ami abc/ve right scapula. Breath not tubular.—Ordered oil, with tonic mixture, and can- tharides liniment for the chest. May 11, 1857.—AVintered at Hyeres, and much improved in flesh and strength. Still dulness and deficient motion and, breathing at and above right scapula. June 16, 1858.—Returned to Nova Scotia, and wintered in Madeira, taking oil the whole time and gaining weight. At present he is apparently quite well. Dulness hardly pcrcepliljle. June 24, 1859.—Returned from Italy and Switzerland quite healthy and active. Three years later he appeared in perfect health. Case 94.—Chronic Phthisis—first stage.—Arrested. Mr.---, set. 30. October 18, 1861.—A brother and a sister had died of consumption. Another brother had hasmoptysis and calcareous expectora- tion repeatedly. Has been twelve years in Syria, and three years ago, when on Mount Lebanon, was chilled, and since has had cough, some- times spasmodic and sometimes hacking. Is now pale and thin. Didness ; tubular sounds at and above right scapula. Bronchophony above left scapula. —Oil ordered with phosphoric acid and calumba, and a croton-oil lini- ment. February 25, 1862.—Improved on treatment, but lately has been much bustled, and has now more cough and chest irritation. Has not used coun- ter-irritation.—Ordered acetum eantharidis liniment. September 2, 1864.—Passed two years in Cyprus, but never free from cough, and several times had haemoptysis, once to amount of half pint. Now resides at Tangiers, but has been home for the last three months. Has lost some flesh. Dulness, large tubular sounds at and above right scapula. Small tubular sounds above left scapula. October 10, 1865.—Has been in better health during the last year at Tangiers, taking oil regularly. AVithin the last few days he has spit a little blood.—Oil to be taken with phosphoric acid and hypophosphite of soda. September 17, 18(56.—Pretty well, but always has some cough. Has twice expectorated calcareous matter. Sometimes has bronchitis, as at pres- ent, after voyage home. July, 1868.—Has suffered more during the last two winters, from ex- posure at night at Tangiers. Last November had scarlatina, and expecto- ration has diminished since. Took oil and hypophosphite steadily, con- tinuing them in the hottest weather, and has gained 101b. Still dulness, tubular sounds at and above right scapula. Some tubular sounds in upper left chest. Case 95.—Phthisis—first stage.—Cured. Mr.----, ret. 18. September 7,1863.—Mother and sister died of phthisis. Pale and fast grown, but pretty well till a month ago, after a few days1 cough, brought up several mouthfuls of blood. He was given perchloride of iron, and sent to Margate, where in the last week the cough has become much worse, with much wheezing, oppression, and feverishness. Brondiial rhonchi all over the chest, but at right apex there is crepitation and dulness. __To take oil and phosphoric acid and calumba twice daily, an effervesc- ing draught at night, and use blistering liniment. 206 CASES OF CHRONIC PHTHISIS. October 20.—Cough and fever continuing, it was necessary to give salines with antimony and opium, and continue the blistering for three weeks, when the fever abated, and he has since taken oil and an iron tonic. Bron- chial rhonchi and crepitus have subsided. Still dulness, bronchophony, and whiffing breath-sound at and above right clavicle. May 10, 1864.—AVintered at Torquay. Quite well, walking ten miles a day. Flesh and breath much improved. Has taken oil and tonic regularly. Slight dulness, and tubular sounds above right scapula. October 7.—Generally well, but has had occasional returns of cough, with crepitus at right apex. A fortnight ago coughed up a little blood, and cough continues. More dulness above scapula and below clavicle.—Blistering to be repeated. Omit iron. April 26, 1865.—At St. Leonard's. No cough, and quite well all winter. May 8, 1866.—In town all winter, attending to business. Xo remaining dulness. Only slight tubular in upper right. February 16,1870.—Quite well, and recently married. A few months ago a slight tinge in expectoration, but no cough, and breath is good. February 21, 1871.—At Christmas, and again in last fortnight, some cough and expectoration. Otherwise well, and has a fine little daughter. Some tubular sounds and rhonchi in upper chest. This patient seemed threatened with acute phthisis at first illness. His sister was quickly carried off by a similar attack. Although in a measure cured for the last seven years, he must be considered predisposed to relapse, and will always need care. Case 96.—Phthisis—second stage.—Cured. A clergyman, aged 32, of consumptive family, consulted Dr. W. July 13, 1853. For several months had cough and much expectoration, increased by heavy duty. AVorse in last two months, and in last week much reduced by a feverish attack. Has lost much flesh and strength. Once brought up a tea spoonful of blood. Moderate dulness and tubular sounds in upper left; obscure croak on deep breath.—Ordered oil in mixture of nitric acid, hop and orange-peel infusion ; and cantharides liniment. July 21.— Much better. Takes oil well. Still cough. Tubular voice and dulness in upper left, especially near spine. January 3, 1854.—Taken oil, &c, ever since. Wintered at Torquay. Quite lost cough, and otherwise well, and has resumed regular duty. May 11, 1858.—Continued pretty well, taking oil, &c, for three years. Last August, after unusual exertion, expectorated six ounces of blood ; but was not worse after. In January had cold and cough. Still some dulness and tubular sounds within left scapula. 1868.—Heard that he is still alive and well, fifteen years after the first symptoms. 1871.—Continues well. Case 97.—Phthisis—second stage.—Arrested. Miss---, set. 20. June 2,1852.—Father's mother died of phthisis. For a long time breath has been short on exertion, but cough first came on in January, and has continued with more or less pain in left shoulder. Is weak and was losing flesh, but began oil three months ago and improved especially since she has been at Hastings three weeks. Dulness; deficient breath in whole left chest, with crepitus, coarse in upper parts. Tubular sounds above right scapula.—To continue oil, with nitric and hydrocyanic acids, hop and orange tincture ; and use cantharides liniment freely on left chest. SECOND STAGE--ARRESTED. 207 August 12, 1853.—AVintered at Hastings. Much improved in flesh and strength, walking three or four miles daily. Cough moderate, but breath still short. Still dulness and deficient breath in left chest; tubular, with ob- scure croak in upper parts on deep breath. Large tubular sounds above right scapnda. October 20, 1854.—Continued to improve. Cough now7 only in morning. Collapse and dulness below left scapula. Less tubular and no croaking sound in ujtjjer. Tubular above right scapula. April 21, 1871.—In 1856 spent a year in Ross-shire, and became so strong as to be able to walk twenty miles in the day without inconvenience, and had no cough, except for a w7eek or two from fresh cold. The breath was always short. Continued well, and passed several winters in Scotland. A year ago at Bournemouth over-exerted herself in reading and other ways, and became very weak and thin, and has not since regained flesh or strength. Occasional pain in left side. Little cough till the last week, with slight expectoration. Pulse 90. Heat 100°. Collapse and contraction of left front. Heart pulsation, and dulness up to fourth rib. Obscure breath-sound and moderate dulness through left back; only slight tubular above scapula; more so above right. The oil, which had not been taken of late, to be resumed with a tonic. An effervescing saline at night, and iodine to be painted on left chest. Case 98.—Phthisis—second stage.—Arrested. Mr.----, eet. 27. May 6, 1865.—Last February, when in a weak state of health, caught a severe cold, which ended with left pleurisy. Has ever since had cough, with little expectoration and frequent huskiness of voice. Not recovered his strength or breath. Bowels not free. No appetite. Slight crepitus in upper third of left lung. To take oil in mixture of nitric acid, tinctures of nux vomica and calumba, and compound infusion of orange-peel. A daily aloetic pill. Tincture of iodine to be applied to the chest. October 6.—Cough continues, with viscid expectoration. Much wheezing at night. Breath improved, but is still weak, and suffers from palpitation. Mucous rhonchus and croak in upper left, front, and back. Tubular sounds at and within left scapula.—To continue the oil with mixture of phosphoric acid, hypophosphite of soda, calumba, and orange infusion. November 17.—Much improved in all respects. Gained 5 lbs. Strength and appetite good. Breath clearer, but still crepitus in upper half. May 29, 1866.—AVintered at Yentnor, pretty well; taking oil, &c, and out regularly till early spring, when be had congestion of left lung. Then the oil was discontinued ; he has lost flesh ; and expectoration, which had been free, has ceased, and cough and short breath have returned. Bowels costive. Dulness, and neither breath nor vocal vibration through left lung. Tubular sounds above right scapula.—Left side to be blistered with acet. cantharid. Effervescing saline, with iodid. potass, to be taken every night. To resume oil and mixture and daily pill as before. November 28.—Soon improved in breath and strength, and gained 4 lbs. Cough slight, but still some expectoration. Dulness gone in left chest. Breath-sound still mixed with crepitus in upper parts. May 2, 1867.—At Grimsby till February, then Bournemouth. Quite well, except slight cough. Has been out all through the winter, and gained 7 lb., but always continued oil, &c, and has occasionally blistered. June 21, 1871.— Remained at Grimsby for last four years, quite well, except occasional cold and cough ; and on active exertion a little wheezy. Flesh and strength better than ever. Tubular sounds and subcrepitus in upper left. Emphysematous protrusion above left clavicle on cough. 208 CASES OF CHRONIC PHTHISIS. Case 99.— Chronic Phthisis—second stage.—Cured. Mr.---, cet. 26. May 12.1862.—Two sisters and one brother have died of phthisis. At the end of November, after two months' cold and cough, had haemoptysis to amount of two pints in a week. Expectoration has since been yellow7, and attended with loss of flesh and short breath. Win- tered at Mentone and Cannes. Dulness, tubular sounds, coarse crejtitation in up)icr half of right chest. Less dulness, with weak breath-sound below. 01. c. acid, phosph. et calumb. : lin. acet. cantharid. : linct. morphia'. November 14, 1863.—AVent to Madeira in October, 1862, and gradually lost cough and expectoration ; gained weight, increasing from 8 st. (.) 11). to 10 st, 2 lb. July 9,1865.—Has been at Madeira ever since, except a month absent in 1863. Has had no illness, except biliousness. In September last was at- tacked with vomiting; and lost 27 lb. in six weeks. Has since nearly re- gained weight (10 st. lib.). Has occasional morning expectoration, but breath is pretty good. Only slight dulness and weak breathing in upper right chest. Xo crepitation or tubular sounds. July 24, 1866.—At Torquay ; gained 6 lb. Has had no return of cough, and only is occasionally bilious. Case 100.—Phthisis—second stage.—Cured. Mr.---■, get. 38. May 5, 1864.—Brother said to have lost one lung nine years ago, still living. Three years ago had perineal abscess, which healed in a week ; but ever since has had morning expectoration. Not otherwise ailing till twelve months ago, when a cough came on, which has increased much in the last three months, and for two months he has been hoarse. Dulness in upper half of right lung, with coarse crepitus. Tubular sounds above both scapulec. To take oil with phosphoric acid and calumba. Blister writh acetum cantharid. Inhale hot water with creasote, hemlock, and chloroform. November 19.—Hoarseness gone and cough much better, with less ex- pectoration. Breath still very short. Has inhaled constantly. Signs not much altered. May 18, 1865.—Has wintered at Torquay, and been out daily. Cough and expectoration moderate. Breath better. Flesh and strength good. ° Dulness, obstruction in right upper, with croak on deep breath, most In front. Large tubular sounds above left scapula. May 14, 1868.—Heard that he had, as advised, gone to Australia, where he had been quite well for two years, often riding fifty miles a day. Case 101.—Phthisis—third stage.—Arrested twenty years. A veterinary surgeon, aet, 30. August 6, 1846.—Six months' suffering from cough, copious expectoration, rapid loss of flesh, strength, and breath. Now sweats and diarrhoea. Dulness in both upper parts of chest; most right, where cavernous sounds, with obstructed breath around. 01. jecoris aselli, bis die : pil. cupr. sulph. morph. omn. nocte : liniment. aceti cantharid. October 18,—AVas blistered freely, and has taken oil regularly, increased to six drachms three times a day. Very much improved in every respect. Has gained 9 lb., can w7alk five miles, and can even run. Bowels now cos- tive. Still cavernous sounds in upper right, but no crepitus arour.d, and more breath. March 6, 1848.—AVas quite well, except breath rather short, and left off the oil twelve months. Fourteen days ago attacked with " severe pleurisy " of right side, after exposure to cold. Has been blistered, and is better but THIRD STAGE—DOUBLE CAVITY—RETARDED. 209 very weak. Still large tubular sounds above and below right clavicle, but per- cussion good. Loud sonorous rhonchus on deep breath. Slight crepitus at left base. July 29, 1850.—Took oil, &c, and soon recovered. Now walks twenty miles, and is stouter than ever ; but breath still short, and suffers from cold winds. Tubular sounds above both clavicles, but the stroke and breath-sound clear in all parts; but expiration long. September 18, 1854.—Quite well, except occasional lumbago, and in last fewr weeks cough. No oil for nine months. Some dulness, obstruction, and croak in upper right. July 8, 1859.—Generally well, except occasional attacks of cold and cough, for which he blisters and takes oil, and is soon well, gaining 121b. or 151b. Still some dulness and tubular in upper right back. 1868.—Heard continues well. -July 20, 1870.—Has been well, and attending actively to business as inn- keeper ; weight, 11 st. In May got wet, and since has had cough, and lost flesh, but says his breath is good still. Dulness and dry cavernous sounds in upper right and back. Breath heard below and in front. Has taken oil only irregularly. June 13, 1871.-—Resumed oil and tonic steadily, and recovered flesh and lost cough ; but it returned in winter, with expectoration. He was shut up, and lost appetite and strength. Not so regular with oil as formerly, and has again lost much flesh. Collapse below right clavicle, and harsh vesicular breath beloiv second, rib. Above and to mid-scapida loud dry cavernous sound. Obscure breath, with subcrepitus below. August 7.—Gained 2 lb. Still cough and opaque expectoration, and cav- ernous sounds in right back. This case records arrest of the disease for twenty years, with full enjoy- ment of life ; then renewal of disease in the same parts, and again amelio- ration, twenty-five years after first attack. Case 102.—Chronic Phthisis—third stage.—Double Cavity—repeatedly arrested. Miss----, set. 21. April 27,1849.—Always delicate, but with much pre- cocity and energy of character. Five years ago suffered for several months with cough and loss of voice. AArell after till three months ago ; cough and short breath, and a glandular swelling above left clavicle. Not lost flesh. Has never worn flannel. Slight dulness and tubular expiration above left scajnda. Iodid. potass, et sarza. ; flannel. May 30.—Glandular swelling diminished ; but still coughs, and has lost , much' flesh and strength. Signs continue. Oil, with nitric and hydrocyanic acid mixture ; capsicum liniment for the chest. February 19, 1851.—Took the oil for six months, and lost cough, and was quite well till last November, when suffered long from sore throat, and in the last month the lump has reappeared above left clavicle, with much de- pression of strength and spirits. This swelling afterwards threatened to suppurate, but subsided without discharging, and its subsidence was fol- lowed by a fever, called "bilious." In 1854 the throat again became troublesome ; and then followed a cough, with opaque expectoration, which continued through a great part of the next year. Then w7ere found signs of disease in the left lung, but the notes are not preserved. The oil and tonics were given as before, with the effect of removing cough and other symptoms. In 1857, after much vocal exertion and exposure to damp, had an inflamma- tory affection of the left lung, with dulness and crepitus in the upper lobe, which lasted several months, but was at length removed under the use of oil and free counter-irritation ; but tubular sounds remained above both 14 210 CASES OF CHRONIC PHTHISIS. scapulas ; and, more or less, cough and chest irritation continued during that and the following year. In 18(51 was so much improved in health and strength that she undertook the superintendence of a charitable institution, involving a great amount of mental and bodily exertion. In 1862, in the midst of this work, she left off all stimulants, and soon had a bad carbuncle on the leg, which for several months caused much dis- comfort and weakness. In 18(33 began to suffer again in throat and chest, with return of crepitus in left apex, which in the course of that year showed signs of excavation. Remedies were then more steadily persevered with ; and two winters were passed at Torquay, with very beneficial results as to general health; but the left lung continued, much obstructed, chiefly in its upper half, where thire remained the large croaky sounds of a contracting cavity. The lower portion was imperfectly pervious, with emphysematous stroke-sound and crepitus; and tubular sounds were heard at and above the rigid sciqjida. In the summer of 1867, feeling so much better, this lady could not be restrained from her beneficent work, and with a view to its continuance, remained in London during the winter. At the commencement of this sea- son the trial of a coke-stove in her room brought on a severe attack of suffo- cative bronchitis, which very nearly proved fatal. Orthopncea, with livid lips and nails, quick pulse and hot skin, a tight wheezy cough, and only scanty viscid expectoration. Loud prolonged sonorous rhonchi in the chest, eclipsing all other sounds, continued for several days ; yielding at length to ether, squill, and antimony, as expectorants, aided by blisters. The attack was of the nature of croupy bronchitis, and relief came with copious puru- lent and curdy expectoration ; and then were heard moist crepitus in most parts of the lung, coarse and even cavernous in both scapndar regions, chiefly the left; but the right now for the first time showeil evidence of active disease. Although the suffocative symptoms were relieved, the reduction of flesh and strength was fearful, and lapsing into rapid consumption seemed inevitable. Happily, however, the appetite returned, enabling the patient to take food, and to resume the oil with the strychnia tonic which had served her so well during the previous years. Slowly and with interruptions during that win- ter, more decidedly and steadily during the following summer, improvement took place in flesh and strength, and imperfectly in breath, for only a por- tion of the upper and lower lobes of the right lung remained effective for respiration. Between the second and fourth ribs in front, and at the upper half of the scapula behind, was a loud, cavernous rhonchus, assuming a stridu- lous or grating character at times, ivhen the breathing was more oppressed. Tli£ left upper region also presented cavernous sounds, croaking or dry at dif- ferent times; and in the lower portions the only sound was a short crackle on a deep breath. Yet the stroke-sound was clear, indicating the obstruction to be .more from emphysema than from consolidation. This interesting patient had other ailments to distress her, although it is probable that, while adding to her sufferings, they may have contributed to avert the worst results. A succession of boils—some large and painful- broke out in various parts of the body, ending in pretty complete suppura- tion. These were eventually checked under the use of sulphite of soda (gr. x or xv) two or three times daily, which for convenience was combined w?th a morphia cough mixture Another plague w7as an eruption of eczema, which appeared in the limbs and bends of joints, as the chest symptoms be- came mitigated. This was relieved by a carbolic acid liniment, and disap- peared at length after several weeks' use of arsenic. The oil and strychnia .tonics once a day have been steadily continued whenever possible. After the improvement in the summer, several bad attacks took place during the wunters 1868-9 and 1869-70, reproducing the croupy suffoca- tive symptoms of the former winter, and rendering recovery very uncertain. 3ut she did recover, and duricg the summer 1870 made considerable ad- THIRD STAGE—ARRESTED. 211 vances on her former improvement, enjoying a residence in the country of several months. The last winter (1870-71) was a greatly improved one. Although shut up entirely for seven months, she gained flesh and strength, had no severe attack, and has been able to do much writing and other official work in con- nection with charitable institutions, of which she has long been a main- spring. And this lady, so limited in breath and strength, yet still so use- ful to humanity, has cavities in both lungs, with the greater part of one in an emphysematous, imperfectly pervious state : a condition balancing be- tween consumption and asthma. Happily, the vigorous mind has not been overcome by the infirmity of the body ; and by its resolute good sense, in strictly following the advice given through all trials and difficulties, it has been mainly instrumental in prolonging a valuable life. Case 103.—Chronic Phthisis—third stage.—Arrested, Miss----, set. 26. June 22, 1863.—Often had cough, but one has been constant for the last twelve months, and in the last four months worse, with much opaque expectoration and hoarseness, and losing flesh. Dulness and crepitant obstruction through whole left chest. Bronchophony above right scapida.—To take oil in phosphoric acid and calumba mixture, to paint chest with tine, iodine, and use a linctus at night. August 3.—Much better. Less hoarseness and expectoration. Crepitus more croaky in left chest; less dulness.—Add strychnia to mixture with the oil. October 5.—Cough much better and voice clear. Has gained much flesh and strength. Been five weeks at Folkestone. More breath in lower left chest, but with hud cavernous croak. Tubular sounds above, with loud heart- sounds below clavicle. December 7.—Continues much better, and is now quite stout. Less dul- ness and croak, and more breath. May 4, 18(54.—Well through winter. Cough slight. Stouter and stronger than ever. AValks two hours. Still some dulness and croak in upper left; most front. February 28, 1867.—Heard of her as " quite well." Case 104.— Phthisis—third stage.—Arrested several years. Miss ----5 jet. 16. November 4, 1856.—Last April had scarlatina, fol- lowed by cough and irregularities of bow7els and catamenia. Cough ceased during summer, but returned a month ago, with clear expectoration and feverish symptoms. Has been losing flesh all the time. Dulness and tubu- lar sounds at right scapida. Croak above, and loose crepitus below clavicle. Oil, with nitric and hydrocyanic acids and hop. Morphia linctus. Blis- tering with acetum eantharidis. April 21, 1857.—AVintered at Ventnor, and improved very much till January, when a violent cough came on, like whooping-cough (which she had formerly), often ending in vomiting, and with much yellow7 expectora- tion. The oil was stopped for a month, and she lost much flesh. It has been resumed, and she is regaining, and the cough is much diminished. Collapse of right front chest-wall. Dulness of whole right side of chest, most behind, where, below and above scapulee, are loud tubular sounds. More vesic- ular breath-sound in front, and crepitus on deep breath below clavicle.—To continue oil, with phosphoric acid and sulphate of iron. April 20, 1858.—AVintered in Shropshire, going out regularly, except with an east wind. Has wonderfully improved in flesh and strength, and had little cough. Catamenia occurred only once (in November). Less dul- ness and more breath-sound, but still loud tubular sounds in dorsal regions. Aloes and iron pill every night. Continues oil. 212 CASES OF CHRONIC PHTHISIS. July 16, 1863.—Has wintered at Torquay, and not confined, but during winter there is generally some cough and expectoration after exertion, sometimes with calcareous concretions in it. Her flesh and general health have been good, and catamenia have been regular for two years, but breath is always short on exertion, and there is occasional pain of right chest. Has taken no oil since the winter. Dulness and large bronchophony at and above right scapula. Weak breath-sounds in lower part of left lung, and tubu- lar sounds above left scapula.—To resume oil and tonic. December 8, 1865.—Has remained in Norfolk during the last two years, comparatively well, and sometimes more active than was prudent. There is always some cough and expectoration. Loud tubular sounds above both scapidce, most on the right side, where they extend lower also, with dulness; but the breedh is rough below left clavicle.—The oil to be continued, with the addition of hypophosphite of soda to the tonic. Caution against exer- tion. &c. May 16, 1867.—Improved very much, and had hardly any cough till last March, when one came on with catarrhal symptoms, and although then moved to Torquay, has continued to suffer with weakness and sickness. Being so much better, the oil and hypophosphite were not taken regularly through the winter. Dulness and dry cavernous sounds in upper half of right back. Some vesicular breath in front. Tubular above left scapula.—To take oil with simple strychnia mixture. May 20,1869.—After three months of suffering from sickness and renewed attacks of bronchial and pulmonary inflammation, was able to take the oil and tonic again, and rallied till end of winter, when the attacks recurred again, followed by improvement in summer. Has been generally in Norfolk, going for a month to Torquay in spring. Physical signs little changed,. Flesh and strength not much diminished. June 15, 1871.—Has been since to Norfolk, taking oil and tonic regularly, and has been generally free from attacks, but has always some cough and expectoration. AVas out almost daily through the winter, but in the last three months has had inflammatory colds, and still suffers from their effects in pain on both sides of the chest, coupled with opaque expectoration, some- times offensive, and some loss of flesh and strength. Catamenia regular. / Lips and gums of good color. Moderate dulness with crepntus, and some breath in right front. The whole right dorsal region dull, with loud cavernous sounds in upper two-thirds, and coarse crepitus below. Tubular sounds with pyartial crepitus at left apex, July 7th.—Much better. Case 105.—Chronic Phthisis—third stage.—Improved. Mr.---, set. 35. May 4, 1865.—Brother and two maternal uncles died of phthisis. Two years ago, after a long bathe in the sea, became hoarse, with a cough and pain in the chest. Expectoration sometimes bloody. Passed winter of 1863 at a hydropathic establishment in Scotland, and lost much flesh. Last winter in Egypt, was better, and regained some flesh and strength. Didness anel deficient breath in right chest, most upper front. lubular sounds above right sccqnda.—OU. prescribed with nitric acid mixture. Tinct. iodine to chest. May 15, 1867. Has been to Australia and America since. Has not con- tinued the oil, but flesh pretty good and no cough, only expectoration sometimes bloody. Has had a fistula for last eighteen months. Dulness and bronchophony below right clavicle; less behind. December 17.—In Scotland ; cough returned with expectoration, and has lost 14 lb. weight. Fistula healed. More dulness and crepntus above riht scapula. Has neglected the prescriptions ; admonished accordingly. THIRD STAGE—LARGE CAVITY. 213 May 15, 1868.—Wintered at Nice, taking oil, &c, regularly, and is much better, having gained 7 lb. and lost the cough, but there is still expectoration and short breath. Less dulness, but still tubular sounds in upper right. Loud bronchophony beloic clavicle. May 25, 1869.—Gained 7 lb. more during summer in Scotland. AVintered again at Nice, keeping well, but in spring at Paris lived too freely, and took cold, and has had much cough and opaque expectoration. Dulness and moist cavernous sounds above right scapula. Has taken no oil for more than a month.—To resume oil with phosphoric acid and hypophosph. soda. May 26, 1870.—Again improved during the summer. From October to December was yachting to Malta and Alexandria from Nice, and cough in- creased, with more expectoration, in which portions of lung-tissue were found. Has lately been more careful, and taking the prescribed remedies, and is much better. Dulness and large tubular or dry cavernous sounds at and above right scapula. Tubular also above left scapula. 1871.—This patient is still continuing his yachting, which he prefers to making the care of his health the first consideration, and although at a risk, he is able to do this with much enjoyment. Case 106.—Chronic Phthisis—third stage.—Arrested,. Miss---, set. 19. August 2, 1863.—Mother died of phthisis. Has had a slight cough ten months, and has not been careful. In the last two months the cough has increased, with opaque expectoration, pain of left side, and loss of flesh. Moderate didness and, subcrepitus in upper half left lung. Breath weak below.—To take oil and acid tonic, and apply iodine. April 4, 1864.—Improved much in the autumn, but, not losing the cough, passed the winter at St. Leonard's, and was able to be out regularly, and has gained 10 lb. in weight. Dulness, deficient breath, and croaky crepitus in upper left. August!, 1864.—Cough and expectoration increased, and has lost flesh. No oil taken for three months. Crepitus more liquid. September 22.—Has taken oil, and regained flesh and strength, but has had more pain and cough and expectoration. Loud cavernous sounds in ujyier left.—To apply acetum cantharid. May 24, 1865.—Continued to improve, and soon lost the cough. AVin- tered in Dorsetshire, taking oil regularly, and walking daily, sometimes four miles. In March had a cold, and the cough returned ; but it is now moderate. Is thin, weighing only 7 st. Cavernous sounds less distinct. September 15, 1865.—Has been in AVales, walking well, and free from cough. Now weighs 8 st. 10 lb. Xo crepitus, but some dulness and collcqjse and dry tubular sounds to left of sternum. 1870.—This lady is reported as pretty well ever since, with only occa- sional ailments. Case 107.— First Acute, (lien Chronic Phthisis—third stage. Large Cavity. Retarded. Miss ____, set. 25. September 21, 1867.—Mother and sister died of phthisis. Delicate before, but no cough till July, when she had a feverish attack, with " congestion of the left lung.» Has continued extremely weak since, with constant cough, and now copious, purulent, and clotted albu- minous expectoration ; hot skin ; frequent pulse ; profuse night-sweats ; no appetite; often vomits with the cough. Bowels relaxed. No catamenia since illness. Dulness throueyh whole left chest; liquid cavernous sounds in upper third; obstruction and crepitus below.—To take sulphuric acid and strychnia mixture, with glycerine morning and noon. Evening and night a linctus, with morphia and hydrocyanic acid. October 15.—Sickness began to abate in a week, and was then able to 214 CASES OF CHRONIC PHTHISIS. take more food, and cod-liver oil with the strychnia mixture ; and there is considerable increase of strength, and reduction of fever and sweats, but the cough is still harassing at times. Large cavernous sounds in whole left front. Some crepitus above right scapida.—Continue oil and tonic, and blister side with acetum cantharid. March 27, 18(58.—Gradually regained flesh and strength, and cough and expectoration much moderated. Catamenia have returned twice, after five months"' absence. AValks out a little, and appetite pretty good. Bowels have l>een costive and piles have been very troublesome ; but after taking electuary of senna and sulphate of potass, these are relieved. Has taken oil and tonic regularly, and frequently quinine has been added. Large cavernous sounds still in front, but some breath in left back.—Oil to be con- tinued, with phosphoric acid and hypophosphite of soda mixture. December, 1868.—Has wonderfully improved in flesh, strength, and color. AVas frequently out during the summer, but now is shut up for the winter. Pulse 80. Skin cool. Catamenia regular. Feels pretty well ex- cept for the short breath, cough and expectoration, which are, however, much reduced. Physical signs little improved; but there is more breath in left back, and now no crepitus at right apex—only tubular sounds. This reprieve continued till the winter of 1869, when the appetite began to fail, and it was necessary to discontinue the oil for a time. The heart also became troublesome, being compressed by the ribs collapsing over the contracting cavity. This added to the distressing breathlessness ; and without any considerable increase of the consumptive symptoms, the urine became albuminous, and the patient died dropsical in April, 1870." Case 108.—Phthisis—third stage. General improvement, but disease advancing. Mr. ----, set. 20. April 6, 1864.—His sister and three or four of her children died of phthisis. In the last month has had slight cough and pains in his left side, and has lost flesh and color. Some tubular breath and voice above both scapulce.—To take phosporic acid and glycerine, with tinc- tures of henbane and calumba ; and to use acetum eantharidis liniment. June 28, 1866.—Regained his health, and, except a cough of six weeks at Stockholm in December, 1864, has been well till three weeks ago, when began to cough and expectorate mucus, tinged with blood. Appetite bad, and is losing flesh and strength. ' Some dulness and tubular sounds at and within right scapula. Less above left scapula. Mucous rhonchus in several parts.—To' take oil in mixture of nitric acid, nux vomica, and orange. Tinct. iodine to the chest. September 25.—Cough continued troublesome several weeks, with yellow expectoration and night-sweats ; but in last two months has improved much and gained considerable flesh. Tubular sounds chiefly confined to right apex. November 22.—Continued better till lately out in the cold, which brought on severe pain in right hip. This is removed, but in the last two days has brought up 2 oz. of blood. Gallic acid first, and subsequently acetate of lead, have been given. Didness below both clavicles. Coarse crepitus in upper left front and back.—To take sulphuric acid and o-lyCerine with a little opium. Blister with acet. cantharid. ° June 12,1867.—No more bleeding ; and has since much improved taking oil and sulphuric acid ; but still has cough, short breath, and sometimes sweats. Whole left diest obstructed with crepntus; coarse and tubular in upper part. Some crepitus at right base.—To continue oil with phosphoric acid and hypophosphite quinine, and to use cantharides liniment. November 1, 1867.—Gained much flesh, and looks well, but breath very short. Still much obstruction in left lung, and a cavity at apex. THIRD STAGE—RETARDED. 215 September 22. 1868.—Wintered at home pretty well; but breath short. In March brought up 6 oz. of blood, and less in April. Was much weak- ened, especially in hot weather ; but has recovered, taking oil with hypo- phosphite of quinine. Feeds and sleeps well. Extensive obstruction of left lung. Excavation in upper lobe. Tenderness on percussion over it. Crepitus at right apex. July 29, 1869.—Better through winter, regularly taking oil and hypo- phosphite, but appetite and strength fail in hot weather, and lately blood in sputa. Whole left side obstructed and crepitant. Cavernous sounds not evident. Respiration puerile throughout right lung. Case 109.—Phthisis—third stage.—Retarded 9 Years. A gentleman, aged 35, saw Dr. Williams July 6, 1861. Two years ago he had cough lasting three months ; was well afterwards, till in February he brought up two pints of blood. Recovered, and had no cough till April, when cough returned from fresh cold. Since then has taken oil and cream. Upper right chest tender. Some dulness, rough breathing in ujiper right. Tubular sounds above left scapula.—Ordered oil in phosphoric acid, calumba and orange tincture ; and counter-irritation with acetum eantharidis. June 21, 1862.—AVell till September, when suffered from heat. Passed winter at Nice and Rome, with little cough. Taken oil irregularly. Dulness and tubular sounds in upper right chest, with slight crepitus. Tubular expira- tion at left scapida. February, 1864.—AVintered at Pau ; passed summer in Scotland ; and at Torquay since. No cough till last fortnight, but now7 one with feverish symptoms. Dulness and tubular sounds in upper right chest. Slight subcrepi- tus at summits of both lungs. July 16, 1869.—Taken but little oil since last visit. AVintered at Pau and Rome, where he had ague. Last summer was able to shoot; but at Pau, after going out to parties, had congestion of right lung, and ever since breath has been much shorter, and cough constant. Extensive dulness in right side, with crepitation ; coarse in upper part, Tabular sounds and crepi- -" tat ion in lower left chest.—AVarned to be more careful, and to persevere with oil and tonic, and counter-irritation. December 29.—Has taken oil, &c, regularly, and was much better till a week ago, when he caught cold, which increased cough, and is now7 suffering from biliousness and piles. Small cavernous sounds at right apex; crumpling crepitus below. Tubular sounds above left sceqmla.—To have blue pill and confect. sennce with sulphate of potass. Oil to be continued, with strych- nine mixture. April 28, 1870.—AVintered at Torquay, pretty well, till a month ago, had daily rigors, followed by heat every night, and is much weaker. Taken quinine "without relief. Dulness and cavernous sounds in upper right; ob- structed breath below.—To continue the oil with a quinine mixture ; efferves- cing opiate at night. Case 110.—Phthisis after Fever. Large Cavity. Great Improvement. Deathfrom Pneumonia. Mr. M----, aged 46. First seen by Dr. Williams, with Dr. Pye Smith, October 4, 1861. After twenty years in China, was long ill with fever, and has been very weak ever since. Cough for more than a year. In low state last summer'at Dresden, and afterwards at AValton, where he coughed up half a pint of blood, and was much reduced, with profuse sweats, and ex- pectoration has since become opaque, yellow, and copious. Extreme didness, and loud cavernous voice in left front as low as heart. Same signs audible, to less extent, behind, with some wheezy breathing. Dulness and tubular sounds 216 CASES OF CHRONIC PHTHISIS. at and above right sceqnda.—OU. ordered in nitric acid, calumba, and orange mixture ; cantharides liniment; and an effervescing henbane draught at night. April 28, 1862.—Improved greatly on treatment; and wintered at AVor- thing. AVas out daily, and gained much flesh and strength. Physical signs the same. July 26.—Has lived lately inland, taking oil only once daily, and cough and expectoration are increased. November 16, 1862.—AAlntered pretty well at AVorthing. Had haemop- tysis ~ij in May, and has had more cough and expectoration since cold weather, but also more strength and easier breath. Has lately taken Dugong oil. Contraction, dulness, with small cavernous sounds in upper left chest; good breathing below. Continued in this improved state till the winter of 1864, when he was carried off by an attack of pneumonia. Case 111.—Phthisis, third stage. Repeatedly checked by Oil. Mr.----, aged 32. January 14, 1852. AVell till, two months ago, he caught cold, and since has had severe cough, with copious greenish expec- toration. Has been taking quinine in last three wreeks, and cough worse, with much pain in chest, especially on the left side. Urine very thick. Dulness and tubular sounds above right scapula; moist crepitus below. The same on left side, but to less extent.—Ordered cocl oil in mixture of iodide and carbonate of potass., hydrocyanic acid, and orange-peel; and liniment of acetum eantharidis. February 11.—Taken medicines well, and is very much better in all respects. Has been at Hastings. Crepitus gone. Breath-sound still weak in right chest. July 13.—Lost cough since May, and is stronger and more active than ever. In May had discharge from right ear, which is still deaf. Still tubu- lar sounds above the right scapula. Breath pretty clear below. December 6, 1859.—Continued well and active till last June, when, after much excitement and exertion at an agricultural meeting, he had an attack of bronchitis, with much expectoration, sometimes fetid, and was much reduced. Has since improved, but still coughs. Lately very bilious, and taken no oil. Dulness and tubular sounds in upper right. Small cavernous voice and croak above the right scapula,—To take oil in mixture of calumba and nitric acid ; and use cantharides liniment. July 2, 1862.—Continued the remedies without difficulty, and regained flesh, strength, and activity. Gained 6 lbs. and often walks twenty miles. AATas out as usual last winter. Has still some cough and expectoration, Taken no oil for two years. Tubular sounds at and above right sceqmla, left as much as right; but no crepitus or rhonchus. February 21, 1867,—In the last five years has taken little oil, as it made him bilious. Cough has increased ; breath become shorter; and now can walk only two miles. Nails convex. Dulness, collapse, and moist cavernous sounds below, the right clavicle, Breath much obstructed all down the right back. Tubular sounels above the left scapula.—To resume oil in mixture of nitric acid, strychnia, &c, Upwards of nineteen years have elapsed since this patient's first symptoms. His latter deterioration came on after long suspension of treatment, Case 112,—Phthisis, third stage. Arrested. An officer in the army, aged 35, consulted Dr. Williams July 26, 1861, He had campaigned in the Crimea, and was afterwards ordered to AVest Indies, and then to India, where he distinguished himself in the Sepoy THIRD STAGE — MUCH IMPROVED." 217 Mutiny ; and was quite well till his return to England last summer, when camped at Shorncliffe, and found place extremely cold. In March caught severe cold, and had sore throat and cough, with haemoptysis 5j and was much reduced. Improved since taking oil and iron ; but is still thin, and has short breath. Mw-h dulness and tubular sounds upper half right chest; tubular sounds above left scapula.—Oil ordered with phosphoric acid and quinine, the application of acetum eantharidis, and a morphia linctus. June 19, 1862.—-Improved much, and went to Madeira in November ; where he took oil regularly, and rode on horseback. Lost cough, and gained much flesh and strength. Dulness: dry cavernous sounds upper right third of chest, chiefly in back. February 6, 1865.—Recovered so much that he was on active duty in New Zealand during the war of 1864, endured all kinds of hardships, wet, cold, and starvation. In April had dysenter}7; in May spat blood, and was laid up with inflammation of the left lung three weeks, which much reduced him, but he recovered in all respects, except his breath heing short. Im- proved much since his return, taking oil regularly. Moderate dulness: tubular sounds high up in left lung : good breathing below. Tubular sounds above right scapula. May, 1866.—AVintered at Mentone, without cough ; gained flesh and strength. Physical signs improved. The following winter left the army, and has since resided in Madeira ; where he was well, and active in spring, 1871. Case 113.—Phthisis, third stage. Arrested. Ilccmoptysis and Death, A young gentleman, aged 14, whose family was consumptive, saw Dr. AV. December 26, 1861. He had slight cough at Eton for two months, and three weeks ago he was sent home for a bilious attack. A week later had haemoptysis to amount of gss. Still had cough and pain in the shoulder. Dulness: tubular sounds upper half left chest, most marked in the back.—Oil ordered with phosphoric and gallic acids, and acetum eantharidis liniment. April 22, 1862.—Passed winter well, but when taking iron in Jnne, spat £ss. of blood, and also had epistaxis. Still dulness; tubular sounds below left clavicle. July 17, 1866. Heard that he died in September, 1864, having wintered for two years at Cannes and Hyeres, where he improved very much, and appeared in restored health: but after great exertion, large haemoptysis came on : was treated with calomel daily for three weeks, and patient soon sank and died. On post-mortem examination a large clean cavity was found in the upper part of the left lung, which was devoid of tubercles ; but many were found scattered through the right. Case 114.—Chronic Phthisis, third stage. 3Iuch Improved, A barrister, residing in Canada, aged 42, who had lost a brother and sister from consumption, consulted Dr. Williams, June 25,1859. Had lived in Canada, and enjoyed good health till a year ago, when he had a cold and couo-h, which had recurred several times since, accompanied by expectora- tionand oppressed breathing. Ten years ago he spat up about a dessert- spoonful of blood ; has not lost much flesh or breath, but cough is still troublesome. Bowels costive. Dulness and large tubular sounds in upper right chest, front and, back. Tubular sounds above left scapida. Formerly took oil, but lately iron.—Ordered oil in phosphoric acid and calumba, with acetum eantharidis liniment. July 15, 18(53.—Oil has been taken regularly, and he has been generally better; especially during the cold weather. Has regularly officiated as 218 CASES OF CHRONIC PHTHISIS. judge in Canada. Looks thin and pale, and yellow expectoration has in- creased. Phi/sical signs are about the same. June 29, 1865.—Still resides at Toronto, continuing his judicial office. Last winter took no oil, but cream. Has more cough and expectoration. Collapse and more dulness in upper right chest. Cavernous rhonchus above scapula. July 16, 1868.—Has improved in general health and strength, and goes on circuit in Canada.without interruption, but he is thin, and always has cough and expectoration. Still loud tubular (cavernous) sounds in upper right chest. Tubular above left scajnda. This patient was very sensible of the improvement in his health and strength under the oil, as compared with iron, cream, and other means which he had tried. Case 115.—Chronic Phthisis. Cavity. Duration 18 years. Mr. M. F., aged 15, was seen by Dr. Williams, October 30, 1853. For three years he had been subject to occasional cough, which had become constant since June. Has been well and active till within the last few weeks, when cough has become worse. No expectoration at present, but a mucous rattle-sound in the tubes. Decidedly tubular sounds in both scapu- lar regions.—Ordered oil in nitric acid and calumba. March 11, 1854.—Very much improved, but always has a loose cough. Large tubular sounds above scapula, and within left scapula. Dulness at right scapula, and some mucous rhonchus. November 16, 1867.—Grew strong, and tolerably well ; but breath was always short, and often had attacks of cough, which have been worse during the last few years. A year ago he had congestion of both lungs, relieved by blistering and other treatment. He took oil; and went to Nice and Italy; and there caught fresh cold ; and since has had constant cough, with expectoration and short breath. Then tried several German baths, but received no benefit: and is now reduced in flesh and strength. Nails convex. Cavernous sounds in upper right chest; obstructed, breath-sounds below. Whistling tubular sound at left scapula.—Oil was ordered in phos- phoric acid and strychnia mixture, and acetum eantharidis liniment for the chest. To winter at Cannes. Improved much under this treatment, gain- ing much flesh and strength for twelve months. August, 1870.—Appears much broken in health, and is in great financial difficulties. Very feverish, and cough troublesome. Now quite an invalid, with extensive cavernous sounds on right side and crepitation througlwut left lung. Again improved on oil and tonics, and is living (May, 1871), eighteen years since his first visit. Case 116.—Phthisis, with Cavity. First Acute, but Arrested. Recovery. A delicate boy, aged 8, whose father had died of phthisis, was first seen June 28, 1853. Had cough, since influenza six weeks ago. Soon after was seen by Dr. AVest, who found didness and coarse crepitus in upjper left. Had lost flesh, and had profuse perspirations; but has taken oil for a fortnight, and much improved. Dulness in upper half of left chest, with loud trachea note on percussion at the top. Large tubular breath, and voice-sounds also, with coarse crackle in parts. Large tubular sounds above right scapula. The oil to be continued with acid tonic, and acetum eantharidis is to be applied from time to time on left chest. 1861.—For several years continued delicate, requiring constant care, and always taking the oil with varied tonics; residing generally at Tunbridge AVells. or on the south coast. The siejns of cavity became very distinct, butln CAVITY, CURED — LIVING AND WELL. 219 two or three years they diminished, as the general health improved ; and now there are only dulness, tubular sounds below the clavicle and above the scapula, and weak vesicular signs below. Flesh and strength now pretty good for a lad of 16. July 21,1863.—Continued well and active till three months ago, when he had a severe cold, with signs of bronchitis affecting the right as well as the left lung; and the large tubular sounds and coarse crepitus reappeared there. After repeated blistering and continued use of the oil, he gradually recov- ered, and has had only moderate cough and rather short breath ; but his strength is good, and he walks ten miles. Still coarse crepitus in upper left front. Dry cavernous sounds above left scapula. Large tubular sounds above right scapula, but breath quite good, in other parts. 1871.—Not seen since; but is reported to have recovered his health com- pletely. Case 117.—Phthisis, with Cavity, Cured. Living and well Twenty-four Years after Attack. A gentleman, aged 22, first consulted Dr. AVilliams, on October 4, 1847. Six months ago he had an eruption, followed by boils, and three months later cough and expectoration, which continued up to the present date. Dulness and deficient breath in upper portion of the left side of the chest. AVas ordered a mixture of nitric and hydrocyanic acids, tincture of hops, and henbane in decoction of Iceland moss; and counter-irritation with acetum eantharidis. August 12, 1848.-—Lost cough, and improved much in two months; but caught fresh cold a month later, and cough returned, with wasting and sickness, the latter having been caused by trying impure cod-liver oil. Dulness and dry cavernous sounds in both mammary regions; large tubular in upper back. December 5th.—Has taken pure oil in a mixture of nitric and hydro- cyanic acids, with tincture of orange-peel regularly at Ventnor, with in- crease of strength and appetite, and of w7eight amounting to 14 lbs.; cough worse at Arentnor. Physical signs the same, but croaky cavernous sound under left clavicle. May 5, 1849.—Generally better, and cough moderate. The oil occasion- ally sickens when exercise is not taken. Dulness in left side; muffled cavernous sounds below left clavicle; cavernous croak above scapula; tubular sounds above right scapula, September 25.—Continued well till a week ago, when he had haemoptysis, six ounces. May 4, 1850.—Had bilious fever some months ago, which much reduced him. Omitted oil for one month, but has since taken it regularly, and quite recovered flesh and strength; cough moderate ; physical signs the May 9, 1851.— AVell since, and out all the winter at Ventnor, with only slight cough, and no expectoration. Xo croaky or cavernous sounds in left lung; obscure bronchophony in scapular region, and breedh weak above and harsh below. In right lung, respiration tolerably vesicular; expiration long, but not tubular. October, 1852.—Embarked for New Zealand, but was wrecked in the Channel, and much exposed to cold and wet, without permanent injury. AVintered w7ell at Torquay, and went to New Zealand in September, 1853. October 28, 1863.—After arrival in Auckland, had more or less cough the first two or three years, but gradually lost it, and for the last six years has been quite well. "Held a Government office in New Zealand till his return this year. Has been married several years. Tubular breath in upper part of both sides of chest, most in the left, but good vesicular below. 220 CASES OF CHRONIC PHTHISIS. 18(57.—Has lived in England four years, wintering at Falmouth, and en- joys general good health. 1871.—Continues well. In this case w7e may fairly conclude that cicatrization of the cavities took place and that no deposit of considerable amount remains. The patient has lived twenty-four years since his first symptoms, and for the last thirteen years has had no active disease. Case 118.—Phthisis, Acute at first. Cavity. Arrested. Recovery. Living Twenty-seven Years after First Attack. An unmarried lady, aged 28, consulted Dr. AVilliams September 3, 1847. Had a cough for eighteen months, which commenced after taking cold baths, and had persisted ever since. Six months ago a remarkable purpura eruption came on her body, which had mostly disappeared, but was followed by increase of cough. Formerly had swellings under her jaws, but these had diminished. In the last two months, breath, flesh, and strength have been very much reduced. Had no appetite till she visited Margate, and on her return from that place she spat a fewr mouthfuls of blood, which relieved cough and tightness of chest. Patient at present very weak and much emaciated; has quick pulse and profuse night-sweats. Marked dulness and cavernous sounds in more than upper half of left side of chest; stroke-sound clearer below, and moist crepitation ; some moist crepritation in upper part of right side a1 so.—Ordered a combination of nitric and hydrocyanic acids, with tinctures of hop, calumba, and henbane, and a linctus containing morphia. A week later she was no better, and had loathing of food and increased emaciation. Cod-liver oil was then added to the above treatment, and two months later she had wronderfully improved in flesh, strength, and well- being, with little cough, no expectoration, and an excellent appetite. January, 1848.—Continues to gain flesh and strength ; catamenia absent; dulness and dry cavernous sounds in upper part of left lung.—Ordered a nightly pill of aloes and iron, and the continuance of the oil, &c. October, 1848.—AVell and in good condition ; cough moderate ; able to walk several miles; but breath still short, and lately has had diarrhoea; catamenia now regular ; dulness and dry cavernous sounds in upper left down to second rib; obscure vesicular breath below. AVas married in 1850 ; and Dr. AAilliams has not seen her since, but has heard that she was alive and well in 1871, twenty-four years after the first visit, and twenty-five years and a half after her first symptoms. AVhen first seen the case presented all the aspects of galloping consumption. Case 119.—Chronic Phthisis. Cavity persistent 13 years. A lady, aged 24, whose sister had died of consumption, was first seen by Dr. AAilliams July 14, 1858. Four years ago she coughed up about four ounces of blood, for which she was cupped, and remained pretty well after- wards, except a cough, which in the last four months had diminished, and she has gained flesh and strength by taking oil and good feeding. Marked dulness with loud cavernous sounels and crepitation in upper left chest; most in front.—Oil was ordered in a mixture of iron and phosphoric acid. The patient soon afterwards married. January 12, 1859.—Has been free from cough, and remarkably w7ell till six weeks ago, when she was chilled during a long journey, and has "outy swelling of the ankle. This affection soon subsided under treatment. ° 1867.—Has become stout and healthy-looking, and pretty well enjoys life ; but although little cough, there is slight opaque expectoration every morn- ing, and the breath is always short on exertion. Twice or thrice in the winter has an attack of bronchitis, sometimes with moderate haemoptysis THIRD STAGE—ARRESTED. 221 but soon recovers from them. Limited dulness and cavernous sounds in upper left chest, which are generally dry, but now moist after afresh cold. 1868.—AVell, except occasional attacks of bronchitis. 1871.—Continues stout and well looking. Has passed through much trouble, and had various ailments ; but of late little affecting the chest, which )>resents the same signs of a cavity limited by consolidation at the apex of the left lung. Case 120.—Chronic Phthisis. Persistent Cavity 20 years. A lady, aged 40, who had lost a sister from consumption, first consulted Dr. Williams June 20, 1849. There had been slight cough and expectora- tion for a year and a half, for which she had been long treated with steel without benefit. Amphoric stroke and loud cavernous sounds above right clavicle and scapula; the same signs below clavicle, though less marked'.— Ordered cod-liver oil. July 13.—Heard that she was suffering from increasing weakness, diar- rhoea, and hoarseness, and copious expectoration. Oil had not been taken.— Ordered a tonic of nitric and hydrocyanic acids, and tincture of orange, to be combined with oil at a later date. November 20.—Has taken oil regularly, and much improved in last three months, haying lost her cough for the first time in two years, and grown fat and strong. Dulness, and loud cavernous sounds above right scapula, and too less extent below right clavicle, 1856.—General health good, no cough, but physical signs the same. 1868.—Alive and well 20 years after first symptoms. In this case the disease was limited to the very apex of the right lung, ending in a cavity which remained dry long after the patient's restoration to health. Case 121.—Chronic Phthisis. Third stage. Arrested 13 years. A single lady, aged 46, consulted Dr. AAilliams December 2, 1858. Three years ago she had severe cold and cough, and became very thin. She took oil and regained her flesh, but never lost her cough, and a year ago had haemoptysis to the amount of ^iii. Her breath is always very short. Ex- treme dulness. deficiency of breath., and coarse moist crepitation throughout left lung. Large tubular sounds above left scapida. Oil wras ordered in a tonic of nitric acid and calumba and orange-peel. A saline opiate at night, and counter-irritation with acetum eantharidis on the chest. July 27, 1859.—Has been very ill in the winter, suffering from cough, frequent haemoptysis, and much loss of flesh; but after much blistering and taking oil and tonic, gradually regained flesh and strength. Now has fistula in ano. Same as at last visit, except dry cavernous or large tubular sounds in upper left chest. September 24, 1860.—Has -wonderfully recovered, and is fat and pretty strong, but breath short, and has lately fulness above the right clavicle; from emphysematous protrusion. Crepitation still throughout left lung, but with more breath. October 11, 1862.—Is wonderfully well as regards flesh and strength, and free from cough. Fistula discharges only occasionally. Physical signs much as before. May 17, 1864.—Now has only occasional cough, and is out walking all day long. Dulness and cavernous croak in upper left chest, with obstruction-sounds be- low. l\tbular sounds above right scapida. July 16, 1868.—Has continued well, taking oil in the winter. Has lately 222 CASES OF CHRONIC PHTHISIS. suffered from wreak eyes. Now has an attack of severe nephralgia. AVas relieved by effervescing saline with opium ; (oxalate crystals in urine). Has no cough. Colliqjse, with much dulness and croaky cavernous sounds in left front; croaky crepitation mixed with breath-sound in left back. January, i871.—Heard of her continuing well. AValks out on fine days. Case 122.—Chronic Phthisis, with Cavity, Arrested. Living and well 25 years after. A clergyman, aged 32, was seen by Dr. AAilliams in consultation with Dr. Hamilton Roe and Mr. Young, for the first time March 25th, 1846. He had lost four sisters by consumption. Three years ago, after great ex- ertion of voice and close application to work, he became hoarse, and had remained so ever since. Cough came on five months ago, with expectoration and shortness of breath, but no wasting. AVintered at Ventnor. Dulness and cavernous sounds in upper part of right side of chest. Breath rough below left clavicle. Sputa opaejue anel heavy.—AVas ordered a combination of nitric and hydrocyanic acids, iodide of potassium, and sarsaparilla, and to use iodine ointment. Lost cough at Ventnor, and went to Bridgewater, which did not agree with him. August 21.—Has been at Minehead, taking cod-liver oil regularly, using salt friction three times a day, and keeping a blister wound open. Has im- proved, except in breath, and expectoration is still ramiform and opaque. Slight and irregular dulness in upper part of right chest; tubular sounds above and below right clavicle and scapula, June 10, 1848.—AVintered first at Malta, which he found too irritating to his chest; next at Pisa, where he grew weaker, but was improved by the voyage. Still slight dulness; loud bronchophony and irregular breath-sound below right clavicle; but much ejood vesicular breath and stroke-sound. Breath rather irregular below left clavicle.—Ordered iron in combination with the oil, on which he gradually improved, wintering generally in Devonshire during the following years. January, 18(58.—Quite well and active ; conducting a large school, which he has done for the last twelve years. Can walk, preach, and bear exposure to any extent; and has no cough. Still dulness and tubular sounds in upper right chest, most above scapula. Marked tubular sounds above left scapula. Although the physical signs have not entirely disappeared, they are greatly diminished since the first examination twenty-two years ago, and may be supposed to indicate contraction and obliteration of the cavity. In fact, they may be considered signs of the vestiges of disease, rather than of actual disease, as the patient has enjoyed excellent health for the last twelve years. Alive and well in 1871. Upwards of twenty-five years have elapsed since the first symptoms appeared. Case 123.—Chronic Phthisis. Cavities. Arrested. Living 13 Years. A solicitor, aged 32, first consulted Dr. AAilliams, November 27, 1856. His brother died of phthisis. AAras attacked with influenza two years a°-o and ever since had cough and gray expectoration, increasing in winter and diminishing in summer. In last three months sputum has become pink and patient has lost flesh, strength, and breath. Some dulness and decided tubular breath at and, above both scapulee, mostly left.—Ordered oil in a tonic of nitric and hydrocyanic acids with tincture of orange. June, 1857.—AVintered at Pau, taking oil, &c, tilf April. Lost comdi and expectoration, and gained flesh and strength. Then went to Eaux Bonnes, and left off the oil. Lost flesh, but otherwise remained well walk- THIRD STAGE—ARRESTED. 223 ing three miles and riding twenty daily. Cough returned in last fortnight. Physical signs the same. To resume the oil May, 1858.—AVintered well in South of France and Italy, generally taking oil. Is stronger and stouter. March 5, 1859.—Well till middle of January ; since then cough and opaque expectoration. Dulness and tubular sounds in upper part of both lungs, especially in left, where there is some moist rhonchus. dune 24, 1861.—AVell and taking oil till February, when he became bilious, and omitted oil for two months. After fresh cold, cough came on, accompanied lately by expectoration and pain in front of left chest. Dulness, deficient motion and breath in upper part of left chest, front and back. Loud tubular sounds at and within scapula. Urine scanty and high-colored.—To continue oil in a tonic of strychnia and tincture of orange. Also to take an effervescing saline at night for a short period, and to use counter- irritation with tincture of iodine. May 16, 1862.—AVent to Scarborough, and gained three pounds. Physical signs also improved in autumn. AVintered at Pau, taking oil regularly, and out of doors a great deal. Cough slight, and strength good. Dry tubular sounds at and, above both scapula:; mostly left, where there is dulness. October 15, 1862.—AVell and in London at his office the whole summer. October 30, 1863.—AVorked in London all the winter, and tolerably well till summer, when cough increased after exertion, and the expectoration became tinged with blood. Has taken the oil regularly. Flattening and obscure breathing in left front; dry cavernous sounds cdjove left scapula; loud tubular above right. May 16, 1865.—Continued well and in business, with only occasional cough till lately, when only took oil once a day (instead of twice). Patient at present weak and exhausted, with irregular pulse.—Ordered oil twice a day in tonic of hypophosphite of iron and strychnia. Soon improved, and has lost cough. 1867.—Has continued well, and at his business ever since. Dry tubular sounds at and above both scapula'. Thirteen years have elapsed since this patient's first symptoms. Case 124.—Chronic Phthisis Arrested. Living 24 years after. A gentleman, aged 15. Several paternal aunts died of phthisis. Septem- ber 24, 1847.—Nine years ago, after gastric fever, was very weak, and cervical glands enlarged, and discharged several times on both sides for a year and more. A year ago had measles, followed by whooping-cough, and ever since has had cough and short breath, and been thin and weak. Superficial dulness, tubular sounds and moist crepitus below left clavicle. Loud tubular sounds and small spot of dulness within right scapula. Prescribed cod-liver oil, and a vesicating liniment, occasionally. May, 1848.—AVintered in Madeira, but did not continue the oil. Cough and breath better. Less dulness and crepitation in left front. Still tubular at interscapular. June, I860.—Another winter was passed in Madeira, and two in Egypt and Italy. Taking oil irregularly. Cough generally better, but not much improvement in breath or strength. Dr. AV. then recommended long sea voyages for two years. Accordingly he went to Australia and India, and returned much improved in flesh and strength, and quite lost cough and expectoration. Has since wintered chiefly in Egypt, which agrees well. Chest and respiratory power increased. Stroke dear (emphysema) and breath-sound rather coarse and rough in left front. Tubular sounds at right scapula. Still loud tubular sounels within left scapula. 1865.— Has enjoyed more uniform and vigorous health, and wintered three years in Scotland and England. Now in Paiiiament, and attends pretty regularly. 224 CASES OF CHRONIC PHTHISIS. December, 1866.—After skating in Scotland, attacked with pain in chest, dyspnoea, and fever, with obstructed breathing and crepitus in both lungs, most left. This soon subsided under treatment, and chest returned to former state; but, after wintering in South Hants, stomach and bowels wrere disordered more or less, till the end of the summer, when be passed six weeks at Kissengen under the goafs-milk cure, and was much im- proved. July 19, 1869.—Following winter at Cannes, which disagreed with him, causing much gastric and bronchial irritation. On return to England in spring improved, and regained flesh and strength. But stomach often out of order, and has occasional attacks of bronchitis, which now assume a wheezy character. Has lately had one ; and also inflammation of the ear and eyelids, ending in abscess. Still cough and opaque expectoration. Takes oil once a day.—Breath-sound superseded by crumpling crepntus in whole left front, and less in back. Large tubular sounds at and above lift scajiula and at right, scapida. September 26, 1870.—Last winter at Ventnor, with more care and less suffering from attacks. Flesh and strength fair. Still had recurrences of gathering in the ear and boils on the body. These have been much better since, taking sulphurous acid mixture with the oil. AVhen free from bron- chial attacks, there are always the loud tubular sounds in both scapular re- gions, and coarse breath-sound with a few large clicks in left front. A fresh cold, always blocks this up with crepitus, sometimes with bronchial wheezing at the roots and. summit ef the lung. June, 1871.—Another winter at Arentnor,and with improved health and more freedom from attacks. Flesh and strength fair. Attends to his par- liamentary duties.—Less crepitus in the lung, but as before, the harsh breath- ing and tubular sounds of old induration and emphysema in portions of the lung.—Continues oil and tonic. Case 125.—Chronic Phthisis. Double Cavity arrested 21 years. A gentleman, aged 26, first consulted Dr. ^Y., June 15, 1848. He had long been subject to occasional cough, which had become constant during last two months, and was accompanied by expectoration, loss of strength and breath, though not to any extent of flesh. Had improved on iodide of iron and bark, and counter-irritation with tartarated antimony. Dulness, crepitation, and, loud tubular sounds above and below left clavicle; loud tubular expiration above right scapida.—Ordered oil with nitric acid and tincture of orange, and counter-irritation with acetum eantharidis. August 23,1848.—Has taken oil, and is much improved in flesh, strength, and breath. Cough stopped till last few days, when he caught fresh cold. Physical signs same. September 25, 1851.—Continued well, taking "gallons of oil," but cough has increased in last three months, otherwise strong and stout. Dulness and cavernous sounds above left scapula. September 21, 1857.—AVell since, taking oil occasionally. Has had hardly any cough till the last month. Dulness and tubular sounds at and above both scapulae, most left. February 17, 1862.—Continued pretty well, but always short breathed on exertion, and more so lately, with pain in left side. Has had no oil for 5 years, but has been living w7ell and taken beer freely. Dry cavernous sounds in upper left chest; large tubular sounds above rigid scapula. Breath good in front.— Ordered oil in above tonic, with tincture of calumba. May 3, 1863.—Out all the winter, but lately distressed about his wife, who is phthisical, and suffering from mental depression. Has now more cough and expectoration. Didness, and dry cavernous sounds above both scapula?.. PREGNANCY IN PHTHISIS. 225 March 21, 1866.—Looks stout and well, but has always cough and ex- pectoration, which have increased in last three months. Also has piles. Lost his wife a year ago. Cavernous sounds at and above left scapida, ob- struction and crepitus in front. Tubular and bronchial rhonchus above right scapula. October 27, 1866.—Has continued to take oil in various tonics, quinine and sulphuric acid, afterwards phosphoric acid, hypophosphite of soda, and quassia. AVhen the urine was thick, occasionally an effervescing saline. Lately breath short, and occasionally blood in the expectoration.—Ordered oil in nitric acid and tincture of nux vomica. Living at Bognor. October 23, 1867.—Has been tolerably well, except occasional slight haemoptysis and piles. In last few days cough has increased. Cavernulous sounds in upper left chest, obstruction and subcrepitant sounds in lower )>art, puerile breath in right, except at and above scapula, where sounds are tubular. In this case cavities formed in both lungs, but in the right cicitrization probably took place. In the left the cavity has contracted, and other parts have become emphysematous. The puerile breathing in the sound part of the right lung testified to the extent to which its powers were taxed. This patient died suddenly of haemoptysis, July, 1869, on his way to the railway station ; but up to that time presented a stout and ruddy appearance and was able to enjoy life, but his breath was always short. He lived upwards of 21 years after the commencement of his illness. CHAPTER XXIII. MISCELLANEOUS CASES. Utero-Gestation in Phthisis—Arrest of Disease Tw7elve Years—Healthy Child born—Death Four Years after from Dropsy—Phthisis retarded Ten Years—Three living and two dead Children born during the time—Phthisis during Pregnancy—Death after Childbirth—Phthisis arrested before Marriage—Relapse after second Childbirth—Arrested a<>ain, and Two more Children—Phthisis after Injury to Chest, Two Cases—Pneumothorax from Perforation of Pleura—Four Cases, all recovered—Phthisis with Heart Disease—Recovery—Caseous Pneu- monia arrested—Calcareous Expectoration after, and Eczema—Syph- ilis and Phthisis ; Recovery—Senile Phthisis and Bronchial Glands en- larged—Phthisis arrested in Middle Age—Chronic Bronchitis for Thirty Years after—Death at Eighty-four from Haemoptysis. Case 126.—Phthisis, arrested Twelve Years. A Child bom. Contraction of Chest. Emphysema and Dropjsy. Mr* T____ aet. 28, September 18, 1848. Two brothers and two sisters have died of phthisis. For the last six years has been suffering from couoh and copious opaque expectoration, occasionally bloody, short breath andNvastino-. Has spent several winters abroad with temporary amend- ment Collapse and dulness in right front, with cavernous sounds in several spot*'as from several small cavities. Dulness and larger cavernous sound above scapula, Partiallij obstructed, breathing below. Tubular sound below left clavicle.—To take oil in nitric acid and orange tincture, and use can- tharides liniment, 15 226 MISCELLANEOUS CASES. Under this treatment, with generous diet, great improvement took place in flesh, strength, and general health. The breath was always short, but the cough and expectoration much diminished, except in occasional attacks, which subsequently assumed the form of asthmatic bronchitis, lasting two or three weeks, relieved by salines and small doses of stramonium. The oil was omitted only on these occasions. The right side of the chest contracted much, and the size of the cavities diminished, with signs of emj>hysema below and in left lung. In I806 she became pregnant, and in due time was happily confined, under chloroform, giving birth to a fine baby, who has lived to grow up in health. She continued in invalid health, but enjoying life and highly useful in it, till the end of 1859 ; when, without decided attacks, the breathing became so short and wheezy, that the least exertion became distressing. This was from a gradual increase of the emphysema, the resonance, crepitus and wheeze of which almost superseded, the dulness and cavernous sounds in the rigid lung. The veins and cellular tissue in the neck also became swollen from the same cause. In this state, the oil did no good ; some relief was derived from iodide of potass, and digitalis, which acted on the kidneys. Orthopncea and dropsy followed, and she died in 1860. No examination allowed. This is a remarkable instance of phthisis in its third stage being arrested ; and, through the contraction of the scar-tissue, becoming converted into habitual asthma. See Chapter XIX. Case 127.—Phthisis retarded by Uterogestation. A married lady, aged 30, who had lost two brothers from consumption, first consulted Dr. Williams, September 20, 1861. Had always been deli- cate, with small appetite. During the last two years had been living in bleak exposed situations ; not wearing flannel. Cough came on six months ago, and constant ever since, with loss of flesh and shortness of breath. Catamenia absent for two months ; patient is probably pregnant. Loud tubular voice, with dulness at and above right scapula.—Oil was ordered, with phosphoric acid and a bitter ; and a South-coast residence recommended. March 10, 1862.—Has wintered at Arentnor, going out of doors pretty regularly, and taking oil, and has gained flesh and strength. Expects con- finement in two months. More dulness and tubular sounds at and above rigid scapula. March, 1868.—Has wintered three years at Torquay, one at Hyeres, and one at St. Leonards ; generally taking oil once daily, with strychnia and other tonics ; sometimes with the addition of hypophosphite of soda. Has had three children, two living and one dead ; and, though Aveak and op- pressed through confinements, has recovered pretty well, and her general health is not worse than it was seven years ago. Has had several attacks of bronchitis, and has never lost cough, which has been remarkably harsh and grating, but less so during the last four years, when there has been more or less opaque expectoration, sometimes tinged with blood. In that time there have generally been cavernous sounds, moist or dry, in right scapular and, subclavian regions. Now there are dulness, contraction, loud tubular or dry cavernulous sounds in upper right chest, most marked in the back, but blended with vesicular breath-sound, Long expiration in upper left lung. Patient seems weaker, thinner, and her breath is shorter. May 13, 1869.—Was very languid all last summer, and her breath ex- tremely short, but gained strength in the winter at St. Leonards from which she has just returned. Cough was not bad till March, when she had fresh cold and bronchitis, affecting both lungs ; but, although now7 better still has increased cough and occasional opaque expectoration. Loud tubu- lar or cavernous sounds in upper right chest, with occasional crepitation there PHTHISIS DURING PREGNANCY. 227 and ed left apex. Stomach more fastidious than ever, and rarely takes oil, but pretty regularly glycerine with hypophosphite of soda and strychnia, or salicine once daily. In this feeble state she proved to be pregnant; and, after much oppression and weakness, gave birth to an imperfectly-formed . foetus about the seventh month. Again there was a gradual recovery, so far as to permit of her being again removed to St. Leonards, where she remained till March, ahvays suffering much from weakness, breathlessness, and cough; yet still in a limited manner enjoying the society of her family. On her return to town, in the spring of 1870, there was increased feeble- ness of all functions; more frequent, but less violent cough, and more of the opaque kind of expectoration. The dulness and cavernous sounds had hardly, if at all, spread in the right upper lobe; but there was crepitus mixed with harsh puerile breathing in the middle right lobe and in the upper lobe of the left lung. Even in this condition she again proved to be pregnant, and lived long enough to give birth to a dead child at the full term at the end of the year 1870, ten years from the commencement of the disease in the lung ; having borne three living and two dead children within that time. The surviving children are well grown and hitherto healthy. Case 128.—Phthisis during Pregnancy. Death after Childbirth. Mrs. P., aged 33, first saw Dr. AVilliams, February 4, 1859. Several of her maternal cousins had died of consumption. Had delicate health from 16 to 25, was married at 24, and improved in health afterwards, especially during pregnancies, of which she had four. Now pregnant four months ; and has been living since October in a damp cottage in Scotland, and has had a cough ever since accompanied by wasting. Dulness, crepitation, anel tubular sounds at and above both scapula?,, most marked on the left side.—Patient was ordered cod-liver oil in a tonic of phosphoric and hydrocyanic acids and tincture calumba, to use a croton-oil liniment, and to winter at St. Leonards. April 27.—Returned from St. Leonards, where she has taken oil regularly, and gained in flesh and strength, with decrease of cough, which has increased during the last fortnight. Dulness and crackle in the upper part of both lungs, most marked on the left side. This patient was prematurely confined at the end of May, and sank ten days later. On post-mortem examination, in the lungs, tubercles with a great deal of emphysema were found at both apices, and a cicatrix and remains of a cavity at the right. Gray tubercles were also scattered through the lower lobes, the left one being in a state of pneumonic consolidation. The heart was large, both ventricles were dilated, and the walls easily lacerated. Case 129.—Phthisis. Third Stage, arrested. Marriage. Two Children. Abscess in Rectum. Lung diseased again, and Cavity. Again arrested. Two more Children. Miss II., aet. 23, July 13, 1863. (Father and brother asthmatic.)—Two years ago had a cough for seven months, and was much reduced. An eminent city physician, who was consulted, said that she would not live six w7eeks. ' She was taken to Torquay, and took oil and tonics, and gradu- ally improved. Last winter the cough was moderate, but there came a swelling in left axilla, which gradually subsided, and now7 it is hardly per- ceptible. No cough at present, only wheezing occasionally. Some didness, and a croak on deep breath with tubular sounds above rigid scapula. Breath- sound generally, good.—To continue oil and tonic in winter. February 27,' 1868.—Except an inflammatory attack with some blood- 228 MISCELLANEOUS CASES. spitting in 1864, had no illness, and was so well that in 1865 she married, and has had two children, the last five months ago. After each confine- ment has had an abscess at the rectum. After exposure three months ago, . cough returned, and has since had pain in the chest, with croaky noise, and much opaque expectoration. Has taken no oil lately, only hypophosphite of lime and quinine. Didness and croaky obstruction in left chest, most upper. Tubular sounds above right scapula. May 15, 1868.—Was better till end of April, when there came more pain of left side and shoulder. Cough and opaque expectoration, and much wheezy feeling in the chest. Abscess of rectum still discharging. Croaky cavernous sound, with dulness in left front, less behind.—Chest to be blistered with acetum cantharid., effervescing saline, with opiate. To resume oil and tonic as soon as possible. June 9,1869.—Two months ago was confined with her third child. Had been remarkably well all winter, taking the oil and hypophosphite. In March cough and expectoration returned. Dulness and defective breath in upper left, but very little croak; and breath below improved. Tubular sounds and subcrejrttus above right scapula.—To continue oil with quinine and sulphuric acid. February 16, 1871.—Soon lost cough and continued well, with only morning expectoration, till last November, when she was confined a fourth time ; and since has been weakly, with more cough and bad appetite. Not able to suckle the baby. Is not reduced in flesh, but gums recede. Only slight collapse and, dulness below left clavicle. Tubular sounds above both scapulce, but vesicular sounds heard everywhere.—To resume oil with phos- phoric acid, hypophosphite soda, strychnia, and calumba. The arrest and removal of the lung disease in this case seemed to be aided by uterogestation, and perhaps by the rectal abscess. Case 130.—Phthisis after Injury to the Chest. Cavities arrested. Living Twelve Years. A gentleman, aged 25, of consumptive family, was first seen by Dr. AAil- liams, October 6, 1857. A year ago he was kicked by a horse in the left side of his chest, and since has experienced occasional pain there. A month ago, after a severe chill, coughed up an ounce and a half of blood ; a less amount since, and has lost flesh and strength. At present there is a slight cough and yellow expectoration. Dulness, large tubular sounds in both scap- ular regions, some deficient breathing in left lung. May 12, 1859. —After passing a winter at Pau, and taking oil for two months, he improved greatly in general health, the physical signs remaining about the same. Last autumn he again brought up blood to the amount of 2 ounces. He spent last winter in Somersetshire. At present has pain in the left side, and is weak. No oil; a tonic has been taken. More obstruction and sub- crepitus in upper left chest. Large tubular sounds above the rieyht scapula. October 20.—Had been taking iron tonic and oil for six weeks, and im- proved much during the summer ; but still has morning expectoration and occasional haemoptysis. Extensive dulness and obstructive sounds in left front. Large tubular (or cavernous) sounds above right scapida. August 27 I860.—AVintered at Pau, and remained pretty well, being able to ascend mountains. Considers that he has gained flesh and strength but always has cough and expectoration. Loud dry cavernous sounds m upper left. Coarse crepitation below in front. Large tubular sounds in upper riaht chest. y June 20, 1861.—Passed the winter at Pau, doing well till the last four months, when he was bitten in the leg by a dog, erroneously supposed to be mad. Cauterization was largely used, which much weakened him. Since PHTHISIS AFTER INJURY TO THE CHEST. 229 coming north has had some pain in right chest, but little cough; and lately coryza and sore throat. Dulness, obstructive crepitation in lift lung, with cavernous sounds in the upper portion, and some contraction of left chest. Tubular sounds above right scapula. April 29, 1864.—Has just finished his sixth winter at Pau. Cough and expectoration moderate, and breath improved. Two years ago a liver attack reduced him much, but he has regained his strength, and now walks some miles. Physical signs much the same. December, 1869.—Has spent five winters in the south of England, and remained pretty well, being only short-breathed, and having little cough; • but a year ago had pain in right front chest, which returned six weeks ago, and he brought up a teaspoonful of blood. Dulness, cavernous sounds at and above left scapula. Considerable amount of crumpling crepitation and obstruc- tion in left front. Tubular sounds and coarse crepitation above right scapula. The remarkable chronicity of this case, and the absence of general phthis- ical symptoms of late years, render it probable that the physical signs are partly due to dilated bronchi and air-cells, consequent on the original inflam- matory lesion. Case 131.—Phthisis after Injury to Chest. Arrested Eight Years. Death from Typhoid Fever. A young gentleman, aged 14, who had lost his mother and one sister in consumption, was first seen by Dr. AVilliams, June 12, 1860. Four years before his chest had been crushed by a cart, since which time he had had more or less cough, and was thin, but was otherwise well, till the last four weeks, when it had increased, and was accompanied by expectoration. De- ficient breath and motion in upper part of both sides of chest, most marked on the, right, where are large tubular and croaky sounds. Tubular sounds above the left scapula. Oil was ordered in a tonic of phosphoric acid and quinine ; and counter- irritation with cantharides liniment. September 29.—Much improved. Cough slight. Gained 5 lbs. in a month. Dulness, large tubular sounds upper right chest, and some crepitation in parts. June 8, 1861.—AAlntered well in Madeira, and out daily; but in April brought up three ounces of blood, in May one ounce, and on the voyage home, when a cold wind was blowing, five ounces. Nevertheless, has gained 14 lbs., and physical signs are improved, dulness being diminished in the right lung. June, 1862.—In the autumn gained 8 lbs. more, and wintered again at Madeira, but was very sick on voyage to and from the island. AVas out daily during winter, walking ten miles a day or riding twenty, but always had cough and expectoration, and once haemoptysis to the amount of one ounce. Took oil only once a day, and lost 10 lbs." in weight. Didness, dry cavernous sounds in upper right chest, with deficient breath below. Tubular sounds above left scapula. July 2, 1863.—Passed last autumn in South Devon and gained 14 lbs. ; afterwards spent the winter in Syria and Egypt, and remained pretty well, except at Cairo, where had diarrhoea, and brought up five ounces of blood in November. Then went up the Nile, and gained flesh, but lost it after- wards. Has taken no oil since March. More breathing audible in right front. Tubular sounds still in upper portion, and some crepitation and obstruc- tion in lower right back. AVas seen again in October. Had brought up an ounce of blood in August, but had taken oil, gaining 9 lbs., and was able to walk eighteen miles June 9, 1864.—Took a tour through Jamaica, Panama, Cuba, United States, and Canada. AVas well and active all the time, but took no medi- 230 MISCELLANEOUS CASES. cine, and has lost 3 lbs. Pectoriloquy in the right front and tubular sounds above both scaj>ulce. September 28.—In Devon, and quite well, walking several miles a day at the rate of four an hour. Free from cough, short breath, and haemoptysis. Physical signs improved. June 1. 1865.—AAintered in Egypt well, except catching a slight cold, with tinged expectoration, at Beyrout, and since then has been taking oil. Tubular sounds above both scapula1,, loudest above right, and some crepitant obstruction in the lower ptortion of tlie same lung. July 12, 18(57.—AVintered during 18(5(5 in Malta and Algeria, and last year in England, but caught cold when travelling, and had fever, and was much reduced. He nevertheless married in February, and went to Pau ; but became very weak, and had slight haemoptysis. In the spring visited Bagnieres, and then Italy, where improved. Dulness, dry cavernous sounds, uj/per right. Breath weak, with subcrepitus below. Died of fever in Devonshire, February, 1868. Pneumothorax from Perforation of the Pleura. The occurrence of pneumothorax in the course of phthisis from perforation of the pleura commonly causes a serious ag- gravation of the malady, and accelerates its fatal termination. These cases are sufficiently familiar not to need exemplification; but I record four remarkable cases of recovery after this acci- dent. To explain them, we need only bear in mind that the phthinoplasm which causes the rupture may be the only one, or nearly the only one, in the lungs, its accidental position near the surface leading to this peculiar result. In the same way, a large and fatal haemoptysis may be caused by a small tubercle or patch of degeneration happening to involve a large bloodves- sel and lead to its rupture. Case 132.—Pneumothorax. Gradual Recovery. Lived Twenty-one Years. Mr. D. A., set. 26, surgeon, March 17, 1846 ; seen with the late Dr. John Taylor. Sister died of phthisis. Declares that he was quite well till seven- teen days ago, when, riding a very restive horse, he was suddenly seized with severe pains in the whole left front of the chest, catching the breath. This has continued more or less ever since, with short dry cough and quick- ened breath. Pulse 120, weak. No heat of skin, and other functions nat- ural. Left chest tympanic and tender on percussion. Loud amphoric breath- ing, metallic tinkling with voice, and seymetimes with breath and heart-beat, which is a little to right of its proper place. Intercostal spaces not tie pressed in inspiration, Dulness for about three inches in the lower part of left back. Breath-sound puerile in right lung. This patient remained in a weak state for twelve months, suffering still from short breath and pain in the left chest; very little cough. He visited me in the spring of 1848, when he had improved in flesh after takino- cod- oil, but was still weak and breathless, and with sore feeling in left'chest. Now, however, the stroke was generally dull; breath-sound vert) obscure with subcrepitus. Xo metallic or amphoric sounds.—To continue oil with tonic and paint the side with iodine. I heard that his health improved after, sufficiently to enable him to °-0 as surgeon to an East India merchant ship, when further amendment "took place, and I heard of him some years after as conducting a small practice in Kent. Death announced in tk Times," 1867. PNEUMOTHORAX--REC0ArERY. 231 Case 133.—Pneume>thorax. Recovery. Living Ten Years after. A gentleman, aged 48, first consulted Dr. AVilliams December 11, 1861. He had lost bis mother and a sister from consumption, but, with the excep- tion of a sore throat four years ago, he bad no ailment till last May, when he was attacked with pain and throbbing in the left side, and with cough. In July the breath became very short; in September the expectoration was sometimes tinged with blood, and Dr. (afterwards Sir James) Simpson, on examining his chest, found the left side fixed, but clear on percussion, and the heart beating at the sternum. Dr. AVilliams, in addition to these signs, de- tected over the lower half of the left side, back and front, large amphoric blow- ing sounds, and metallic tinkling with voice and cough, and, with any occasional clicks; also tubular sounds in the upper portion of the lung. Breathing jmerile in the right lung. Pulse 100. Skin cool. Oil was ordered, with quinine, phosphoric acid and tincture of orange, and counter-irritation with canthari- des liniment. April 19, 18(52.—After seeing Dr. AV. the cough increased, but after being some time at St. Leonards, taking quinine and oil, lie improved wonderfully ; gained 18lbs. in wreight. Pulse normal and regular. Dulness, deficient breath in lower half of the left chest, but no trace of metallic tinkling or undue resonance. Large tubular sounds at and, above the scapula, and some friction- sounds in front, and at the side, where there has been some jiain. Left chest contracted, measuring three-quarters of an inch less in circumference than right. July 2.—Is in town frequently, attending at the House of Commons, and remains well. The pain and friction-sounds have ceased on the left side. December 20.—Mas w7ell till September, when he had a severe attack of measles, accompanied by cough: but was convalescent in a fortnight, and since then has been free from cough, and with the exception of breath being short, is quite well, and able to walk and hunt. Some breath-sound now heard in left front, as low as fourth rib, except near sternum, where the heart- did ness and pulsation remain. Dulness and little breath below; bronchophony above both scapula'.—To continue the oil in phosphoric acid tonic. November 18, 1863.—Quite well, and free from cough and expectoration, though often exposed to wet and night-air in yacht. Is able to shout as loud as ever. Deficient motion and stroke-sound in whole left side, which is still contracted, but loud ami vesicular breathing in front and at theside. Loud tubular sounds from the middle of scapida upwards. Tubular sounds above right scapula. October, 1869.—Generally well, and has become stout, but more or less cough. Wintered at Caithness. Still dulness and large tubular sounds at left scapula and above. The signs of pneumothorax were unequivocal in this case, and must have arisen from perforation of the pleura, by partial disease of the lung in the summer of 1861. Happily this disease was arrested, the air effused was ab- sorbed, and the lung was "gradually re-expanded. Case 134.—Pneumothorax. Complete Recovery. Well Four Years after. Air. P., set. 24, October 2, 1867.—Several half-brothers and sisters have died of consumption. Except a pain in the chest last November, from which be was well in a fortnight, has had no illness till the second week in August, when he again had pain in the front of the chest with a cough, which en- tirely ceased in two weeks ; and in September was well enough to make a tour in Switzerland, and ascended the Eggischorn with no other inconveni- ence than short breath, and occasional pain in the left side. No cough. In the last three days he has noticed a splashing noise in his chest, but says he feels well. Seems nervous and anxious, and with quickened breathing. 232 MISCELLANEOUS CASES. Pulse 90 ; heat natural. Left chest distended, tynqtanic on percussion, and with no breath-sound. Heart pulsation seen and felt to right of sternum and in epigastrium. Tubular breath and voice at left scapula; and below sjieaking or laughing is accompanied, by a tinkling echo, which can be2>rod,uced also by succus'sionl Didness in lower third of left back.—To take oil in tonic mix- ture. Left side to be painted with tincture iodine. October 14.—Much the same, Complains only of short breath, and of the splashing noise on every quick turn of his body. Cough and expecto- ration slight, induced by change of posture. Signs the same. October 22.—Continues pretty well, but breath short, and occasional pain in left chest, which is tender, especially in lower part. Hears noise less. Left side smaller, with less tympanic distension. Tinkling and splashing sound, higher in axilla and back. More, breath-sound above left sca/nda. November 18.—AVeaker, and feverish at times, with pain in side. Some- times faint on exertion, and breath short. Dulness, and absence of breath in lower half of left chest. Stroke clearer, with some breath-sounds above. Bronchophony cdwve right scapula. Heart now in ]>lacc, or a little higher and more to the left than natural. Xo tinkling, splashing, or other sign of cavity, nor flattening of walls. February 10, 1868.—Has continued steadily taking oil and tonic, and has much improved till the last week, when there has been much more pain in side, with feeling of weakness. No cough, but breath is shorter again ; ap- petite bad. Left chest more natural in shajje, but lower third, contracted; still dull, ivhile in middle is less dulness, with obscure breath. Tubular sounds at anel above scapula?. Friction with deep breath in middle front (where has been pain). Heart to left of sternum, with its apex beating above fifth rib. Nitro- muriatic acid mixture, belladonna plaster to left chest. June 9.—Quite well, except pain catching breath on exertion ; felt since leaving off plasters. Strength good, and up to usual weight. 10 stone. Same signs, except slight crepitus below left axilla.—Continue nitromuriatic mixture, opium plasters to left side. June 8, 1869.—AVell all winter, without pain or cough, but breath op- pressed by cold. Lately been a walking excursion, several miles daily, and uphill with a knapsack on back. AVeight, 10 s,tone, 8 lbs. Lower half of left chest rather duller, and moves a little left than right, but breath-sound heard everywhere except at base, where is crepitus on deep breath. September 3, 1869.—Heard that he had been walking 30 miles a day, shooting, rowing, &c, without inconvenience. In this case the discovery of the disease causing natural alarm, a late President of the College of Physicians was consulted, and expressed doubts as to the nature of the case. This led the patient to seek a third opinion, which was that of the present President of the same College, who fully con- firmed the diagnosis first given. Case 135.—Pneumothorax. Rapid and complete Recovery. Air. M----, set. 48 ; seen with Dr. Stutter, of Sydenham, May 16,1868.— Lost a brother in phthisis. Has been quite well, and gaining"flesh lately. Has been in the habit of going quickly up and down a long flight of stairs twenty times a day, up to five days ago, and lately had found the exertion cause pain in the right side, and a feeling of oppression. On that day he consulted Dr. Stutter, who ordered a mustard poultice to the side. This relieved the pain, but the breath remained short, and then Dr. Stutter found signs of pneumothorax on the right side. Now complains of nothing but shortness of breath, and a feeling of fulness in the right side. Pulse quiet, urine scanty. Lower half of right chest tympanic on percussion down to lower margins of ribs, below which liver dulness reaches down four or five inches in abdomen. Breathing amphoric, with metallic tinklin«- on PHTHISIS, WITH CAVITY—RECOVERY. 233 coughing in lower half of chest. Above breath-sound obscure and stroke rather duller than on left side, particularly on the scapula.—An effervescing saline was given for a few days, and tincture of iodine to be painted on the right chest. Afterwards oil to be taken. September, 1869.—Heard from Dr. Stutter that the signs of pneumo- thorax soon disappeared, and that the patient w7as quite well. August 2, 1871.—Mr. M. continues quite well, and continues to get stouter. Case 136.—Phthisis, with Cavity. Acute Rheumatism and Endocardial Murmur. Recovery. A married lady, aged 30, consulted Dr. AVilliams, October 13, 1860. Lost her mother, two sisters, and one brother, from consumption. During the last four years she had had occasional cough and haemoptysis, which on one occasion amounted to three ounces. Did lose much flesh ; but after taking oil, and applying it externally also, became fat and still remains so. Lately has been taking glycerine. Cough has increased in last two months, and now she has a bad cold. Extensive dulness, cavernous sounds and sur- rounding crepitus in upper right chest. Tubular sounds above left scapula. —Oil ordered with phosphoric acid, calumba, and orange ; a morphia linctus at night; cantharides liniment. December 24.—At the end of October, severe rheumatic pains came on with tenderness of wrists and ankles, was soon relieved by opiate salines ; but she has been confined for two months. Looks well, but still has a cough. In addition to former signs there is a loud diastolic murmur at mid- sternum. February 5, 1861.—Much better in every respect. Little cough. Physical signs same, only a trace of crepitation above scapula. September 18, 1861.—Looks quite well, and has only slight cough and short breath, with occasional pain in right chest. Catamenia irregular and in extremes. Less dulness and more breath in upper right; no cavernous but tubular sounds. November 10, 18(52.—AVeathered last winter fairly in Ireland, being free from cough. From May to September took a cold sponge bath every morn- ing. A scaly eruption appeared on arms and legs, which Dr. Neligan cured by arsenic. During last fortnight she has had a cold and cough. Still didness anel tubular sounds in ujgier right cliest, with slight crepitation. Cardiac murmur not audible.—Effervescing saline with opiate at night, and continue oil and tonic. May 30, 1865.—Living at AAroolwich, and wonderfully well. Only occa- sionally suffers from cough and rheumatic pains. Has taken a great deal of oil, but is less stout, though in good condition. Still dulness and tubular sounds through upper third of right lung. Loud diastolic murmur audible to right and along upper portion of sternum. November 2.—Had haemoptysis to the amount of loz. a month ago, and since then has had violent cough, with mucous expectoration. Now she is taking oil with sulphuric acid. Dulness, tubular sounds, and coarse crepita- tion in upper half of right lung. The patient was seen again in the summer of 1867 ; she was then stout, but her breath was short with some cough. March 13, 1868.—Has lost cough, is ruddy and stout, but occasionally has palpitation, and has lately had a vesicular eruption on the hands, which was soon cured by lotion. No catamenia for twelve months. Physical signs of heart and lungs much improved. Only slight dulness and loud tubular sounds above the right scapula. The second sound of the heart is clangorous but without murmur. 1871.—Has been heard of as in good health, fifteen years after first at- tack. 234 miscellaneous cases. Case 137.—Acute Phthisis arrested. Afterwards Calcareous Expectoration. Lithic Add. Xephralgia. Eczema. Mrs. Y---, aged 34, who had lost a sister in consumption, was seen by Dr. AVilliams, September 28, 1858. She stated that in July she had scar- latina and quinsy, followed by cough, diarrhoea, night-sweats, and great loss of flesh and strength. Much dulness, anel large tubular sounds at and above right scapula. Oil was ordered in a tonic of strychnia, nitric acid, and orange-peel, and a mor- phia linctus. June 28, 1859.—Heard that she quite lost her cough in four months ; and increased in weight from 9 st, to 10 st. 10 lbs. She also is able to sing as for- merly, but her breath is still short. After this she suffered from nephral- gia, and passed some red gravel. July 26, 18(50.—lias become stout, and is free from cough. Has had oc- casional diarrhoea, and passed some red gravel. Physical signs same as at first visit. July 24, 18(55.—AVas shut up during the last winter, but had only occa- sional attacks of cough and expectoration. Breath always short, and there is constant morning expectoration. June 2(5, 1866.—Was Avell till two months ago, when, after a cold severe cough came on with green expectoration, and several times she spit up cal- careous matter. AAras ordered to resume the oil and tonic and linctus as before. Physical signs same. October 18, 1866.—Heard that she had had some more calcareous expec- toration and wheezy cough, and that she had been suffering from eczema over various parts of the body, accompanied by very acid urine. — Efferves- cing citrate of potass with iodide, potassium and quassia. Gruel baths. In this case the first disease was probably inflammation, consolidation beginning to caseate and infect the system. This was arrested by the treatment, the caseous matter remained quiescent, and, becoming petrified, wras expectorated in a subsequent bronchial attack. Case 138.—Syphilis. Phthisis. Cavity. Recovery. Mr.----, aged 30, who had lost a brother from consumption, consulted Dr. AVilliams, June 30, 1843. Three years ago he had ulcerated sore throat and has had attacks of it occasionally since, affecting the voice, which is at present hoarse, and rendered worse during last six weeks by cold ; copious expectoration. Has lost flesh. Formerly had red and coppery patches on face, and now has them on abdomen. "Dulness in uprper rigid chest, with cavernous sounds below clavicle. Cicatrices are visible on fauces.—Ordered full doses of iodide of potassium, with sarsaparilla, and to use an iodine and ammonia liniment. August 25, 1846.—AVintered in Italy, and quite recovered. Case 139.—Senile Phthisis. Bronchitis. Enlarged Bronchial Glands. T. O, aged 74, admitted into University College Hospital, December 12, 1845.—A shrivelled, deaf old man, many years subject to cough and short- ness of breath, which have much increased in the last few^ weeks, with mucopurulent expectoration, and much tightness across chest. Bowels costive ; pulse 84, weak; urine turbid, specific gravity 1010, contains a little albumen. Loud wheezy breathing on both sides. Expiration loudest in upper parts, especially on left side. Some dulness in upper left front and back. Inspi- ration louder in lower parts. On right side expiration loud, and sibilant. INFLAMMATORY PHTHISIS--ARRESTED. 235 Inspiration mixed with submucous rhonchus in lower right, which sounds dull on percussion.—Blisters between scapulae. Calomel and henbane at night, senna draught in morning. Squill, ipecacuanha, and stramonium three times a day. 18th.—Cough and breathing have been rather easier. Urine free ; no albumen. Is very weak, and the expectoration very purulent. Loud wheez- ing in all parts, with crepitus in lower half of both lungs. Carbonate am- monia was given, but he died on the night of 19th. Post-mortem 18 horis. Emaciation moderate. Extensive adhesions of both pleurae. Those on right side most general, those on the left confined to apex and base of the lung, but very tough; several patches of dense membrane on the pleura; cartilages of bronchi much ossified, especially near the root of the lungs, which were compressed by a mass of enlarged bronchial glands, quite black. Bronchial membrane very red and covered with bloody mucus, but many of the bronchi were full of pus. Texture of lungs generally much congested, but on scraping away the blood appeared dark gray, very tough and resisting, with numerous hard- ened granulations scattered through it. In posterior part of left lung, the engorgement passed into partial hepatization at the lower part, but not sinking in water. In front this lung was not congested, but very dark gray, and at the apex were tough consolidations, extending half an inch into the lung, and with a patch of dense membrane on the pleura. Some similar masses of dark induration near anterior margin. No yellow or recent gray tubercles were found. Lower lobe emphysematous, with large projecting air-cells, quite flaccid and transparent, liight lung presented similar ap- pearances, but with less recent hepatization. Numerous, very dark, tough consolidations, and one contained an encysted calcareous body. The lower lobe of this lung also was emphysematous. Heart large, weight 15 ounces. Right ventricle thick. Kidneys slightly mottled, and granular on removing capsule. A few cysts. In this case the tubercles were all dwindled and obsolete. Dyspnoea and death caused by bronchitis passing into pneumonia in a subject pre- viously suffering from emphysema and pressure on large bronchi by en- larged glands. Case 140.—Inflammatory Phthisis in Middle Age. Arrest; and Asthmatic Twenty-nine Years. Death from HccmojAysis at 84. Dr. G., a?t. 55, April 14, 1848.—Seven years ago had inflammation of the left chest, which was said by one doctor to be pleural abscess, and by an- other condensation of the lung. AVas sent to Cadiz, and gradually improved in health ; became a wine merchant; able to attend to business, but always short-breathed, and often suffering from gout and neuralgia. Has been in England eight months, and has generally had some cough and wheezing. Has lost flesh lately. Now has"fresh cold, with cough, hoarseness, and wheezing, and gout in his feet. Collapse, dulness, and defective breath in left front. Bronchophony below clavicle. 'Tubular sounds and wheeze at and above scapula. Crepitus at right apex. Clear stroke and emphysematous crackle at both oases.—Iodide and carbon, potass., with colchicum. Croton liniment (which he is in the habit of using). 1S70.—AVas soon relieved from attack, but had recurrences of bronchitis, with violent cough and wheezy dyspnoea two or three times every year, generally in winter. He continually suffered in his digestion, which was often Fried by free living ; and he Avas occasionally visited Avith gout. In the last ten years cataracts formed in both eyes, and very much impaired his vision, but'be continued to get about and enjoy society when not confined Avith severe bronchial attacks, Avhich generally ended Avith opaque expectoration. 236 DURATION OF PULMONARY CONSUMPTION. The signs latterly were only those of bronchitis and enqihysema, and the for- mer contraction, and dulness having diminished. After an attack, however, in 1870, he began to cough up blood in large quantities, and so died. No post mortem. AAre can only conjecture that a rupture took place in some degenerated vessel in the old phthinoplasm after an arrest of 29 years. CHAPTER XXIV. THE DURATION OF PULMONARY CONSUMPTION.1 By Dr. C. Theodore Williams. Estimates of Portal, Laennee, Andral, Louis, and Bayle compared with those of the Brompton Hospital, Fuller, and Pollock—Differences ex- plained by Class of Patients and Mode of Treatment—Author's Thou- sand Cases selected from wealthy Classes—Ground of Selection explained —Method of Tabulation of Cases—Sex—Age of Attack—Family Pre- disposition—Origin and first Symptoms—Cases of Inflammatory Origin ; their Proportion and Course of Symptoms—Haemoptysis—State of Lungs at first Visit as evidenced by Physical Signs—Classification of Stages adopted with Restrictions—Majority of Patients in First Stage, and consequent favorable Prognosis—Mortality in each Stage—State of Lungs at last Visit—Classification of "Healthy," "Improved," " About the same," and " AVorse ; " and Percentage of each—Relative Liability of Lungs to Attack, Excavation, and Extension of Disease- Number of Deaths—Causes—Long Duration—living Patients more numerous and with higher average Duration—Present State described as "AVell," " Tolerably well,'.' and " Invalid "—Large Proportion of First Two Classes—Hopeful Prognosis—Causes of long Duration—In- fluence of Age and Sex on Duration—Among Females Duration shorter Age of Attack earlier, and Age at Death less advanced than araon« Males—Great Age reached by some Patients—Relation of Age of a£ tack to Duration—Prolonging Effect of Inflammatory Origin—Pneu- monic, Pleuro-pneumonic, and Bronchitic—Duration of Pathological Varieties of Consumption difficult to determine—Diagnosis of Tubercu- lous and Caseous Phthisis obscure. We need not dwell on the importance of the subject which we propose to treat of in this chapter. In a country where, according to the Registrar-General, one death in every eight is caused by phthisis, it is obvious that a true knowledge of the duration of the disease and the conditions which modify it, is of the greatest consequence to the community. .Many estimates have been formed of the duration of phthisis in this and other- countries, and these estimates will be found to vary to such a This chapter is an abstract of a paper on the « Duration of Phthiis Pulmo- nale, and on certain Conditions which Influence it," contained in the fiftv fourth volume of the Medico-Chirurqical Transactions. VARIOUS OPINIONS. 237 degree that a reader may well despair in attempting to harmo- nize them. A due consideration, however, of the conditions under which each estimate was made, /. e., of the number and of the social class of the patients, of the form of disease, of the mode of life and of the treatment pursued, will serve to explain many of the variations. Portal's saying that phthisis may last from 10 days to 40 years is undoubtedly true, but far too indefi- nite for our present state of knowledge. Laennee gives 24 months as the mean duration; Andral the same; Louis and Bayle 23 months, founded on the examination of 314 cases. The first Brompton Hospital Report, in 215 fatal cases, found that 40.8 per cent, died less than 1 year after attack, 45.3 per cent, between 1 and 4 years after, and 6.5 per cent, had a dura- tion of more than 4 years. Dr. Fuller, in 118 cases investigated by himself at St. George's Hospital, found that by far the greater number died from 3 to 18 months after first attack, whereas in 46 cases in his private practice he found the usual duration varied from If to 7 years, and he remarks that this discrepancy cannot be wholly explained by the social position of the sufferers and the advantages the latter enjoyed with respect to medical treatment, change of air, and proper regimen. He accounts for it by the greater jealousy with which the upper, and more educated classes are wont to watch their health, and note the earlier inroads of disease. Dr. Pollock, in his valuable work, which has contributed more than any other to our knowledge of the prognostics of consumption, gives from 2f to 3 years as the average duration of 129 cases ending in death. These occurred among 3566 hospital out- patients, the rest of whom, at the end of 2f years, were living and in a state of health favorable to the expectation of life for a considerable term. Louis's and Laennec's cases seem to have been chiefly of a rapid kind, treated with depletion, antimony, starvation, &c, or else on the expectant method, with little or no medicine. It has been urged in connection with this that a more acute form of consumption prevails in France, but no facts have been hitherto adduced in proof of this; and, on the other hand, if any one compares English hospital cases of forty years ago with those graphically described in the pages of Louis, he will find the greatest possible similarity in symptoms and_ duration, and in what, to my mind, affords some explanation, in their treat- ment. In the days of bleeding, antimony, &c, the great majority of cases of phthisis were distressing tragedies, as those who can look back on a very long experience of consumption strongly testify, and at that time the prognosis of English physicians was as unfavorable as that of French, as far as the disease was cou- 238 DURATION OF CONSUMPTION. cerned, though the different constitutions of the two races may have exercised some slight modifying influence on it. More- over, from what I saw of French consumptive patients, when residing in the South of France in 1803, there appeared to be no material difference in the nature of the cases, but a very great one in the hygienic and medicinal treatment. Climate was almost entirely relied on; cod-liver oil and tonics, though recommended, were seldom persevered with. The estimate of the first Brompton Hospital Report refers to deaths occurring among the in-patients; and those, owing to various causes, and chiefly to their having to wait so long before admission, are exceptionally bad cases. Some died within a week after admission. Dr. Pollock's statistics are taken from the broader and very extensive set of cases which the out-patient department at Brompton furnishes. These may be said to embrace all classes below the wealthy one, and what is more to the purpose, all varieties and degrees of the disease; the fortnightly visit to Brompton, not as a rule, interfering witli the necessities of oc- cupations or home cares, and thus securing the attendance of a large number who could not afford to become in-patients; while, at the same time, information as to the state of those not able to attend, is given through a form of note supplied to the patients at the hospital, or else by a letter from the relatives. Dr. Pol- lock's statistics, when viewed in relation to the few deaths and the expectation of life for the survivors, give the most favorable results for the lower classes ever published. The cases on which our estimate of the duration of phthisis is founded amount to 1000, and have been selected from private practice, the patients, for the most part, belonging to the upper and middle classes of society, and consequently enjoying many advantages over hospital patients in the avoidance of tliose ills which arise from poverty, exposure to cold, unhealthy atmos- pheres and occupations, and in the opportunities of rest, change of climate, better living, and exercise. As statistical informa- tion of disease among the upper classes is rare, we hope that these statistics may prove acceptable, as affording some facts capable of comparison with results of hospital experience, which have been well set forth by some of the above-mentioned authorities. The broad definition of pulmonary consumption, as stated at the beginning of the book, includes all the cases we have now to deal with, and also includes the most acute forms of the dis- ease, as acute tuberculosis and scrofulous pneumonia; but some of the worst forms of these are excluded owing to the around of selection, which will be shortly explained. The 1000 cases have been selected from the records of patients SELECTION OF CASES. 239 who first consulted Dr. AVilliams between the years 1842 and 1864, a period of twenty-two years. The chief ground of this selection has been the time during which the patients have been under observation. Considering phthisis to be, in most in- stances, a_ chronic disease, and that observations of its course and how it can be modified by treatment can hardly be satis- factory, unless carried on for some length of time, we have judged it advisable to select, out of a mass of records, those cases which have been under treatment twelve months and upwards. A large majority of the patients who consult physicians are seen once only, or two or three times within a short period, and there may be no opportunity of learning their subsequent history. Such cases, although supplying useful information as to the origin and varieties of the disease, are of no value in relation to its treatment, results, or duration. Yet because these cease to attend is no proof that they derive no benefit. Many come only to ascertain the physician's opinion, and are unable, through scanty resources, or through distance from town, to repeat their visits. We must not con- clude, however, that because they do not continue to attend, they are unfavorable cases, and likely to terminate within the year. Chi the contrary, all the evidence at our command points to a different conclusion. Patients frequently appear on the scene years later, having, after one or two visits, been lost sight of, who had been prevented, by various causes, from visiting the physician, but had been carrying out treatment steadily. Were we, however, to include all the cases, our numbers would be enormously swollen, but the addition could only be a large quantity of indefinite and useless material, more likely to obscure the statistics than to render them lucid. Still we must not lose sight of the fact that certain cases of phthisis prove fatal within twelve months; for instance, the forms known as acute tuberculosis and scrofulous pneumonia, though the latter does not always terminate rapidlv, but is sometimes brought by treatment into a comparatively chronic state, and in this condition may last on some years. These early fatal cases, which have been excluded, form, among the mass of consumptive patients, a very small percentage; estimated variously at three or five per cent. Against these we would balance the much larger number of patients reported as having much improved after a few months' treatment, and as affording promise of permanent recovery. As our limitation shuts out these, the few deaths may also be fairly excluded.1 1 In order to form some estimate of the proportions which the cases fatal within the year bear to those more or less improved within the same period, I 240 DURATION OF CONSUMPTION. As the duration of phthisis is such an important subject, we must crave the indulgence of our readers, if'we give a consid- erable amount of preliminary information about the 1000 pa- tients, before stating the results of the statistics. The cases were extracted from the note-books of Dr. Williams, and arranged hi tables containing twenty-five each, under the headings of Age. Sex. Family Predisposition. Date of first Symptoms. Origin of Disease. Occurrence of Haemoptysis. Date of first Visit. . State of Lungs, as evidenced by Physical Signs. Treatment by Medicine, Climate, &c. Result. Duration. The obituary of the newspapers has been closely watched, and where the patients had been lost sight of for several years without having been announced as dead, a correspondence was opened, either with themselves or their friends, to ascertain have carefully examined the records of every case of phthisis occurring during one year, the year being selected at hazard, as a sample, from the period of 22 years. Of 433 consumptive patients who consulted Dr. "Williams for the first time in 1863, 245 were seen only once, and no more was heard of them; 84 were one year and upwards under observation, and were among those, therefore, selected for our tables. Of 104 patients whose subsequent history was known for periods under one year, 8 died, 13 were at the last visit rather worse, 3 were about the same, 75 were more or less improved, and 5 were quite restored to health. Thus those improved and cured were ten times more numerous than the deaths. It can hardly be said, then, that in taking the fact of the patient being at least one year under observation as the basis of our selection, we increase the balance of favorable results, but we thereby deal with facts more carefully ob- served, and more conclusive in relation to the real efficacy of treatment. Note by Dr. C. J. B. Williams:—In determining in the first instance to select for analysis only those cases which had been under my care for a vear and upwards, I was guided by the desire to obtain more sure and reliable results than could accrue from cases during shorter periods of observation. I wished to as- certain the power of nature, aided by art, to control or arrest the course of pul- monary consumption ; and knowing the deep-seated and enduring nature of the disease, I distrusted all results not confirmed by time, and I rejected reports of temporary amendment or even cure, as unsatisfactory and inconclusive. Deaths were indeed conclusive, although not satisfactory; but the few deaths which did occur within that period were the issue of that degree and form of the disease, over which treatment never had, or is likely to have, any control. I already knew such cases to be hopeless—too rapid and overwhelming to be stayed by human power—therefore I put them out of calculation. I am quite content if our accounts are debited with the three or live per cent, which such deaths may be supposed to amount to; for although, as my son argues, the ten times more numerous "improved and cured" cases may be "set off'" against them, yet this is balancing a certain against an uncertain quantity, which brings no definite result. But it cannot be fairly said, that our selection gives nothing but chronic cases, for many of the cases are acute at commencement, or in some part of their course, and are reduced to a enronic state by treatment. AGE OF ATTACK. 241 whether they were alive, and in what state of health—a corres- pondence which, when addressed, as it often had to be, to the individual whose life was suspected, sometimes evoked ludi- crous answers. Reference to the various lists, the "Army and Navy," " University," " Clergy," and " Law," to the " Court Guide," and to the "Peerage," has often afforded valu- able information; and on this point private practice has great advantages over hospital practice, for in respect of the former, by some means or other, patients can be traced through a num- ber of years, whereas in the latter they are generally lost sight of when they quit the hospital. Nevertheless, a certain number of the tabulated cases could not be traced up to the present time ; and of these the date when last heard of, with notice of their state, is registered. Si<:x.—Of the 1000 cases, 625 were males and 375 females, or 62.5 per cent, of the former, and 37.5 per cent, of the latter. This preponderance of males cannot be regarded merely as acci- dental, for it is closely in accordance with the evidence of the first report of the Brompton Hospital, where the percentage of males was 61, and that of females 39. Among Dr. Pollock's out-patients, 60.75 per cent, were males, and 39.25 females. Age.—The ages of the patients have been arranged in the following table. This table differs in one point from many simi- lar records. Instead of the age at first visit, the age at first Aye at Time of Attack of 1000 Cases of Phthisis. Age at Time of Attack. Males. Percentage. Females Percentage. Total. Percentage. Under 10 years, . 10 1.60 3 .80 13 1.3 10 to -20 86 13.79 96 25.60 182 18.2 20 to 30 245 39.20 173 46.13 418 41.8 30 to 40 " 183 29.28 66 17.60 249 24.9 40 to 50 " 70 11.20 24 6.40 94 9.4 50 to 60 " 22 3.52 8 2.33 30 3.0 60 and upwards, . 9 1.44 o 1.33 14 1.4 625 375 1000 Average age at time of attack, Males, . .' 29.47 years. " " " " Females, . 26.06 " attack is tabulated; and this is arrived at by subtracting the history from the age at first visit. The elate thus obtained is of far more consequence in estimating the duration of disease, and the conditions which modify it, than the age at first visit, which depends upon shifting circumstances; as, for instance, the feelings and opportunities of the patients, who may come under the observation of the physician either at the commencement of 16 242 DURATION OF CONSUMPTION. their disease, or many years after, near its termination. The record of their age at'the time of the first visit would the rehire afford us but slight information as to the time of attack or its duration. It may be objected, that it is difficult to arrive at accuracy as to the date of first symptoms. And undoubtedly this is true in the case of hospital patients, with whom it is nec- essary to pursue a svstem of close cross-questioning, in order to evoke the necessary information. Dr. Fuller1 truly says on this point: " The average duration of the complaint is ordinarily, I believe, very much understated, from the fact that the infer- ences respecting its duration are drawn from the statements of hospital patients, who pay little heed to the earlier, and, as they imagine, unimportant symptoms of the disease, and pertina- ciously date their malady from the occasion on which they first experienced pain in the chest, or were frightened by the occur- rence of hasmoptysis, or found themselves unequal to their daily work." Private patients, with whom we have now to deal, hardlv err on this side, for the upper classes generally remem- ber and narrate, almost too fully for the physician, every symp- tom, early or late, of their illness. The results of this table accord with the commonly received opinion as to the period of attack. Taking the sexes collec- tively, 41 per cent, were attacked between 20 and 30 ; about 25 per cent, between 30 and 40; 19.5 per cent, under 20; and 13 per cent, above 50. "When we examine the relative liability of the two sexes in the various decades, we find some important differences to exist. Between 20 and 30—the most common period of attack for both sexes—about 7 per cent, more females were attacked than males; and again, between 10 and 20, 11.8 per cent. more. On the other hand, after 30 the reverse was the case. Between 30 and 40 the males attacked exceeded the females by 11.68 per cent., and above 40 by six per cent. These results may be said nearly to agree with those of the first Brompton Report. The average age of attack was—for the males 29.47, and for the females 26.06. Faniilii Predisposition.—The results under this head have already been given in Chapter XV, to which the reader is re- ferred. This feature was traced in 48.4 per cent, of the 1000 cases. Oricpn and First Symptoms.—In 385 cases the disease came on without any antecedent illness, and was characterized by the usual group of symptoms, more strongly marked in some cases than others, and it pursued its course free from complications, besides the ordinary ones of phthisis. In 315 cases it either 1 Op. cit., p. 413. ORIGIN AND FIRST SYMPTOMS. 243 originated in, or followed closely after, other diseases, as the subjoined table will show : Phthisis was preceded by Pleurisy and Pleuro-pneumonia in 149 Cases. " " Bronchitis . . . . . 118 " " " " Asthma (spasmodic) . . . 7 " " Scrofulous Abscesses. . . 12 " Fistula.....5 " " " " Hooping Cough . . . 6 " Croup ..... 1 « " " " Scarlatina.....4 " " " " Measles.....2 " " " " Continued Fevers ... 3 " " " " Peritonitis .... 1 " " " " Malformation of the Chest, . 2 " " " Injuries to the Chest and other Organs.....5 " 315 The number arising from pleuro-pneumonia and bronchitis is very large, reaching a total of 267, or more than one quarter of the whole, and deserves attention as showing statistically the influences of these diseases as direct sources of consumption. It is well known to physicians connected with hospitals for diseases of the chest, how often a neglected case of pneumonia or bronchitis becomes, under depressing causes, one of con- sumption ; but statistics proving this frequency are rare, if not wanting. This number, 267, or 26.7 per cent., is high, consid- ering that it is taken in a class which has opportunities of pro- tecting itself from many depressing conditions; but high as it is, it is probably much below a correct estimate for hospital patients, among whom the prevention or rapid cure of these diseases is much more difficult, and therefore less common than among their wealthier brethren. In the cases of phthisis arising from pleuro-pneumonia (pneu- monic phthisis), the course of events was generally what was painted in the examples given in Chapters VIII and X. After the attack, some portions of the lungs remained consolidated or compressed by dense pleuritic adhesions, or both these lesions existed, and tended to cripple the lungs for their respi- ratory work. The breath remained short; the patient seldom or never lost the cough, which a fresh cold or some disordering influence caused to increase, mucopurulent expectoration and sometimes haemoptysis accompanying it. Signs of softening were detected in one or both lungs, followed by those of exca- vation, and the case assumed a consumptive aspect. Of the cases of phthisis following bronchitis, which may be termed catarrhal phthisis, some arose from acute attacks, others from chronic. These last patients generally lost their cough 244 DURATION OF CONSUMPTION. and other symptoms in the summer, or in warm weather, but were subject to a return of them every winter, or during in- clement weather. A longer or more severe attack than usual, greatly prostrated them, and the cough now remained persistent, and was also accompanied by permanent feverishness, heat of skin, and wasting. On examination of the chest, in addition to the ordinary bronchitic sounds, patches of consolidation were detected; these did not clear up, and in some cases softening and excavation eventually took place, and the patient lapsed into phthisis. Examples of this transition of bronchitis into phthisis have already been given. Of the 149 cases originating in pleuro-pneumonia, in 85 no family predisposition could be traced; and this was also the case in 57 out of 118 instances arising from bronchitis. We see, therefore, that 142 phthisical patients or 14.2 per cent, owed their attacks entirely, as far as could De ascertained, to inflammatory attacks of the lungs, thus indorsing the views of Alison, Broussais, and Addison, as to the origin of the disease from inflammatory attacks. Hemoptysis.—This symptom was recorded to have been pres- ent in various degrees, at some period of the patient's history, in 569 cases out of the 1000; i. e., 57 per cent.,—a percentage lower than that of the First Medical Report of the Hospital, which was 63 per cent., but nearly agreeing with that of Dr. Cotton's1 1000 hospital cases, which was 53.6 per cent., and that of Dr. Pollock's2 1200 hospital cases, which was 58.4. State of the Lungs as evidenced by Physical Signs.—We shall now endeavor to describe, as briefly and succinctly as possihle, the state of the lungs of these patients when they came first under observation, and afterwards to give some report of the changes which had taken place at the date of their last exami- nation; and the reason we do so is to give our readers some account of the local changes, whether for the worse or better which took place in these patients, and thus enable them to form an opinion as to how far the improvement in the o-eneral health was accompanied by improvement in the state^of the lungs. The relation, or in many cases the want of relation between these two, must strike all physicians. How often does a patient gain flesh and strengh and color, and improve in breathing in a few months, and yet the physical signs show no perceptible improvement, but remain stubbornly at about the same! The converse is more rare, though we have known in- stances of cavities contracting and the general health makino- no great progress. ° The record of the physicial signs has been perhaps more care- 1 Op. cit. 2 Op. cit. •PHYSICAL SIGNS. 245 fully carried out than any other point in these cases ; and in perusing it, a fair idea can be easily obtained of the amount of disease present in each case, with its subsequent progress ; but theselection of similar cases for the purposes of statistics, and their arrangement into as few classes as possible, has been at- tended with great difficulty. The classification of the conditions of the lung, consolidation, softening, and excavation, into first, second, and third stages, is open to objections, because such stages are not always well defined, it being sometimes difficult to distinguish between the end of the second and the beginning of the third, and again various parts of the same lung may be in different stages. What different amounts of consolidation, too, may not the first stage include! Sometimes only a small portion of the lung, like that underlying the supra-scapular or the interscapular, or the infra-clavicular region, is consolidated; in other cases two-thirds or more are involved. However, it has been found difficult to avoid some such classification for the purposes of statistics, and therefore that of stages has been adopt- ed, with the understanding that the first stage embraces vari- ous amounts of consolidation, and that the second and third are sometimes only different degrees of the state of softening and excavation. In none of the present cases is the evidence of physical signs alone accepted ; in all ithasbeen amply confirmed by the clinical symptoms and the course of the disease. The results have been embodied in a table, divided into two parts, showing the " state at first visit," " state at last." From this it will be seen that 660 patients or two-thirds were in the first stage at the first visit; 181, or 18 per cent., in the second; 115 or 14.5 per cent, in the third; and 14 patients presented the physical signs of other lung diseases, namely, bronchitis, pneu- monia, pleurisy, and asthma, on which shortly afterwards super- vened signs of consumption. Those in the second and third stages hardly constituted a third of the total, which shows how large a proportion came in the stage of consolidation, of which the prognosis was likely to be more favorable. As regards the relative liability of either lung to disease, of those in the first stage both lungs were affected in 205 ; the right alone in 287, and the left alone in 168. Of those in the second stage, 55 had the right alone affected, 69 the left alone; 55 had both lungs in- volved, and in many instances both in the second stage. Of the 145 in the third stage, 43 had the right lung alone affected; 53 the left, and 49 both ; but in only 4 cavities were detected in both lungs. This indicates a greater liability of the right1 lung to consolidation, but of the left2 to softening and excavation ; a i This agrees with Laennec's conclusions; but it is at varii.n^e with Louis' and Cotton's, both of whom found the left lung more frequently affected. 2 Cotton, Walshe, and Pollock confirm this. 246 DURATION OF CONSUMPTION. conclusion confirmed by the evidence of the second report of the Brompton Hospital, and by other authorities. Having briefly considered the state of the patients at first visits, let us turn our attention to their state at last report. Of the 1000 patients, 198, or nearly one-fifth, died; the deaths being dis- tributed as follows: Of those who came in the first stage, 104, or 15.75 per cent. were ascertained to have died. Of those who came in the second, 48, or 36.51 per cent. Of those who came in the third, 44, or 30.34 per cent. Thus we see that the percentage of mortality of the second and third stages was very much higher than that of the first: the third showing actually a double proportion of deaths; and the fact must not be overlooked as demonstrating that, although cavities may be tolerated for years, yet the danger from blood infection, after their formation, is considerably increased. In 80 out of the 150 in the first and second stages, cavities were ascertained to have formed before death. The state at last visit of the Hiring patients is arranged under five headings: (1) Healthy; where the physical signs of disease had entirely cleared up, and could no longer be detected. (2) Improved. (3) About the same. This last term is used to include, not only the cases in which no change has taken place, but also those which, after various fluctuations towards better or worse, presented at the last about the same amount of disease as at the first. (4) Worse. This heading is intended to signify extension of the disease, either in the same lung or in the opposite one, as well as progress in the way of softening and excavation. (5) Unknown. The table shows that among 802 living patients, the last recorded state of the lungs was "healthy" in 34: " im- proved " in 280; "stationary" in 102; "worse" in 321; and " unknown " in 65. Excluding the unknown ones, the relative percentages are : Healthy, 4.5 per cent.; improved, 38 per cent; worse, 43.53 percent; and stationary, 13.39 per cent. If we take the cases in stages, and compare the numbers under " Healthy " and "Improved" with those under "Worse," we find that, whereas in thefirst stage the " Worse " somewhat outnumber the "Improved;" in the second they are nearly equal; and in the third the ratio is entirely changed, the number of the " Healthy " and "Improved" being nearly double that of the " Worse." Some further particulars about the changes that took place in the lungs may not be unacceptable. Where registered as "healthy" or "improved," the improvement in the physical signs of patients in the first stage consisted of dulness diminish- ing, either in extent, or degree, or in both; of the breath- and voice-sounds becoming less tubular, and more vesicular; and, in some few instances, of the signs disappearing altogether, the STATE OF LUNGS. 247 Table.—Showiny State of Limps at First and Last Report in 1000 Vases. 1st. State at first visit. 660 66.0; 287 had the right lung alone affected, ...... 168 had the left lung alone affected,...... 205 had both lungs affected, . 2d. 181 3d. 18.1 145 14.5 660 55 had the right lung alone affected....... 11 had the right in the 2d stage and the left in the 1st. 69 had the left lung alone affected,...... 35 had the left lung in the 2d stage, and the right in the 1st........ 11 had both lungs in the 2d 14 1.4 181 43 had the right lung alone affected, ...... 5 had the right lung in the 3d stage, and the left in the 2d,....... 23 had the right lung in the 3d, and the left in the 1st, 53 had the left lung alone affected,...... 1 had the left lung in the 3d, and the right in the 2d, . 16 had the left lung in the 3d, and the right in the 1st, . 4 had both lungs in the 3d stage,....... 145 presented physical signs of other diseases, but the signs of phthisis supervened after first visit. 4 had signs of bronchitis, 4 " " pleurisy, 3 " " pleuropneu- monia, 1 had signs of asthma, 2 had doubtful physical signs. State at Last Visit. 39 25 40 14 Totals, 15 5 20 5 3 14 11 2 75 48 61 184 13 4 18 16 2 53 16 2 6 13 1 3 2 198 o ^1 c 19 110 16 64 25 59 60 233 5 20 1 1 4 23 43 34 280 13 3 10 2 1 25 102 56 3 24 321 49 = 248 = 143 = 165 = 556 = 40 = 6 = 49 = 30 =133 = 32 = 3 = 14 = 39 = 1 = 8 = 4 =101 65 = 14 ^802 248 DURATION OF CONSUMPTION. percussion- and breath-sounds being normal. In those of the second stage the crepitation diminished, and was replaced In- breathing generally having some roughness or tubular character, which, in some instances, eventually gave way to healthy sounds. The favorable change in the physical signs of the third stage was shown by the dulness decreasing, the moist cavernous sounds becoming croaking and drier, and pectoriloquy being less marked and audible over a smaller portion of the lungs, sometimes being replaced by the dry whiffing or crackling sounds of emphysema, but generally by tubular breathing and bronchophony. These last signs have, in some instances, disappeared, except above and within the scapula, where, with some remaining dulness, they generally could be detected after they had vanished from other parts of the chest. The eases of restoration to complete health number 34, and include 30 recoveries from the first stage, 2 from the second, in each of which only one lung was involved, and 2 from the third stage, in one of which, wonderful to relate, were cavities in both lungs—but they were small, and the long duration of the case, viz., 22 years, afforded time for their contraction and oblitera- tion. In 16 cases out of the 1000, calcareous expectoration is noted; in 20, contraction of cavities; in 2, contraction of the \ lung without the formation of a cavity; and in 16, emphysema of the lungs was recorded. So much for the "Improved" and "Healthy'' classes. Under the heading of "Worse" we find that, in cases of the first stage, in 77 or 15.18 per cent., cavities formed in one long; in 10 in both lungs; and that softening took place in 24 others. Of those in the second stage at first visit, cavities are reported to have formed in 32 or 28.8 per cent. In order to arrive at satisfactory data as regards extension of the disease from one lung to the other, the results of the deaths are included, and thus the whole number of cases is brought into use. We find that, exclusive of 325 patients who had dis- ease of both lungs, and 80 of whom the results at last visit are unknown, 585 had one lung only attacked at first visit; of these the disease spread to the other lung in 131 instances, or in 32 per cent. Of those in the first stage, the disease extended to the other lung in 85 cases; of those in the second in 24; and of those in the third in 18. These numbers indicate that, after a certain period, the disease has less tendency to spread, but rather is apt to remain limited to one lung. As regards the relative tendency of the two lungs, the right seems rather more liable to extension than the left, and thisgreater liability exists in whatever stage of disease the left lung may be. The results of the changes in the lungs may be summed up as follows: CURES AND DEATHS. 249 A cure was effected in 4.5 per cent, of the cases ; great improvement in 38 per cent. ; the disease was stationary in 13.4 per cent. ; but in 43.5 per cent, there was more or less increase. The right lung was attacked more frequently than the left; but the left, when attacked, was more prone to softening and excavation. Where the disease extended from one lung to the other, the right lung was more liable than the left to such extension. In former times it was hardly admitted that phthisical disease of the lung was ever cured, though it might be sometimes ar- rested. The 34 cases, however, mentioned as cured, were un- doubted instances, as far as the disappearance of all physical signs can attest the fact. Yet how few were they, contrasted with the whole number of phthisical cases, and especially with the "Improved" class, in which the various steps towards ar- rest of the disease were to be found. We have now laid before our readers sufficient information to show the nature of these cases; and we think that we are not far out in stating that they include and fairly represent all forms of Phthisis, except the very acute cases, which are rare. The main questions of this chapter can now be considered. How long did these patients live? What did they die of? Of the 1000 patients, 198 are ascertained to have died; and the greater part of these succumbed to the gradual waste and de- cay of phthisis; 15 died of phthisical complications as seen below: 4 died of haemoptysis. 1 " haemoptysis and diarrhoea. 2 " diarrhoea. 1 " diarrhoea and dropsy. 2 " dropsy (from contraction of lung). 3 " pneumothorax. 1 " emphysema. 1 '' ulceration of the intestine. How long did these patients live?— 8 lived 1 year and under 2 22 " 2 " "3 v 18 " 3 " "4 23 " 4 " "5 75 " 5 to 9 inclusive. 31 " 10 " 14 " 12 " 15 " 19 9 " 20 " 30 " 198 Of 21 patients who survived their first attack from 15 to 28 years— 2 lived 15 years. 2 " 16 " 6 " 17 " 1 " 18 " 1 " 1y its means I fre- quently overcome the fastidiousness of stomach arising from debility, hysteria, or indulgence in alcoholic liquors. Salicine is another efficacious alternative of the same kind. Either of these, although a powerful tonic, has none of the herting prop- erties of quinine or iron. When the strong bitter taste is ob- jected to, a pill containing extract of hop or chamomile, or sali- cine, or quinine, may be taken after, or before, the oil and its vehicle. The bulk of the whole dose of oil and vehicle should be small, so^that it may be swallowed at a single draught; therefore the vehicle should not exceed a tablespoonful, with, at first, a tea- spoonful of oil, to be gradually increased to a tablespoonful. The dose of oil should rarely exceed a tablespoonful twice or thrice daily : when a larger amount is taken at a time, generally either it deranges the stomach or liver, or some of it passes un- absorbed by the bowels. The acid may be varied according to circumstances. The nitric generally suits best in inflammatory cases, and those at- tended with much lithic deposit in the urine: but its tendency to injure the teeth is an objection to its long continuance. The sulphuric is more eligible where there is liability to haemoptysis, profuse sweats, or diarrhoea.1 But in most cases, and for long continuance, I have found reason to prefer the diluted phos- phoric acid, which may be termed the most physiological of the acids, tending to derange the chemistry of the body less than the others. 1 The sulphurous proves useful in cases of purulent or offensive expectoration ; and when a suppurative tendency is manifest in the system. 262 SUMMARY OF TREATMENT. With some individuals the oil agrees so well, and so much improves their digestive powers, that they require few or no re- strictions in diet; but this is not the case with the majority. The richness of the oil does prove more or less a trial, sooner or later, to most persons; and to diminish this trial as much as possible, it obviously becomes proper to omit or reduce all other rich and 'greasy articles of food. All pastry, fat meat, rich stuff- ing, and the like, should be avoided; and great moderation ob- served in the use of butter, cream, and very sweet things. Even new milk in any quantity is not generally borne well during a course of oil; and many find malt liquor too heavy, increasing the tendency to bilious attacks. A plain nutritious diet of bread, fresh meat, poultry, game, with a fair proportion of vegetables, and a little fruit, and only a moderate quantity of liquid at the earlier meals, commonly agrees best, and facilitates the con- tinued exhibition of the oil in doses sufficient to produce its salutary influence in the system. In case of a bilious attack coming on, indicated by nausea, headache, furred tongue, offensive eructations, high-colored urine, and sometimes pain and tenderness of the right hypo- chondrium, it is necessary to suspend the oil, lighten the diet of the patient, and give blue pill or calomel with an aperient on alternate nights, and an effervescent saline two or three times during the day. A few days of this treatment will generally set the stomach and liver to rights, and the oil may be re- sumed, beginning with small doses as at first. In all cases during the use of the oil the bowels should be kept regular in action ; and if this cannot be done by regularity of habit and diet, it should be effected by the use of a mild daily pill of rhubarb or aloes. Such are the directions which have proved most effectual in the adtninistration of a remedy which may truly be said to have so much altered the prospects of the consumptive as to give hope of cure in not a few, and of much prolonging life in by far the greater number. But to induce patients to follow these direc- tions, and to overcome their aversion to a remedy which the prejudice of some represents as disgusting, and the experience of many may find trying to continue for so long—the practitioner will often find it necessary to use all his powers of argument and persuasion. The great plurality of patients are amenable to reason, and are willing to follow any advice that is given with confidence and clearness. To those who demur or rebel, it is o-en- erally expedient to tell the plain truth—that they have a serious disease, pretty sure to increase, and sooner or later to destroy life, if left to itself; but here is the remedy—the only one worthy of the name, which, if carefully and faithfully used, may arrest and cure the disease, and is pretty sure to retard it and prolong HYP0PH0SPHITES. 263 life more than any other known means. If the physician be- lieves this himself, he will rarely fail to carry his patients with him. I believe it firmly, and I rarely fail to make the patient take the oil, and to persevere with it, in the experience and con- viction that it is essential to his well-being and improvement. The proportion of recusants, either from waywardness of temper, fastidiousness of taste, or from intolerance of stomach, altogether does not exceed five per cent. Although my long experience assigns to cod-liver oil a place far above all other remedies in the treatment of pulmonary con- sumption and its allied maladies, it has taught me to believe also in the limited efficacy of certain other agents, audit would not be fair to pass these over in this brief summary of Treat- ment. I have already mentioned a combination of iodide of potassium and nitric acid with a vegetable tonic, as having distinctly wrought some good in consumptive cases before the pure oil was introduced. I still sometimes use this medicine in the rare cases in which cod-liver oil disagrees or cannot be taken, and I think that it is improved by the addition of a drachm or two of pure glycerine to each dose. Glycerine by itself is of little use, but it is valuable as a lubricant, and to sheathe the acrimony of mineral acids and other pungent medicines. The hypophosphites of soda and lime, so strongly recom- mended by Dr. Churchill, of Paris, have in my hands proved decidedly beneficial in certain cases. They have been tried by Drs. Quain and Cotton, at the Brompton Hospital, with only negative results; but having met with several patients who dis- tinctly ascribed their improvement to Dr. Churchill's treatment, I have thought it right to try them myself, both as a substitute for the oil and in addition to it. In the former way the results have not been generally satisfactory: the hypophosphite does not disagree, but there is no marked improvement as under the oil; and when they have been doing well under the oil, the patients generally lose flesh and strength when the hypophos- phite is substituted for it. On the other hand, it has happened to me in several cases that a patient has long been taking the oil, and, after having derived great benefit from it, halts in his improvement, or even loses ground, and then the addition of the hypophosphite has been followed by a marked change for the better; flesh and strength have been gained, and the chest symptoms have been more or less improved. In these cases I have merely added four or five grains of the hypophosphite to each dose of the vehicle in which the oil is given, always select- in^ the phosphoric as the acid, and generally substituting glyc- erine for the usual syrup-. Such precautions are necessary, he- cause the hypophosphites are very unstable in composition; the 264 SUMMARY OF TREATMENT. addition of nitric acid, or mere exposure of the solution to the air (if not guarded with glycerine or a good deal of syrup), being sufficient to convert them into inert phosphates. In my mixture of the hypophosphite with phosphoric acid, I presume the hypo- phosphorous acid is set free, and is the active agent in the com- pound. How it acts is quite uncertain. I cannot say that I agree with Dr. Churchill's views on the subject, even if I under- stand them. The hypophosphites seem to increase the failing powers of respiration and circulation. Can this be by increasing the affinity of the blood for oxygen, so that it can attract it and maintain the blood-changes even under the increased difficulties and obstructions produced by disease? Perhaps the efficacy of the sulphurous acid—Dr. Dewar's remedy for consumption—may depend on an influence not altogether unlike that of the hypophosphites. My experience of the use of the spray of sulphurous acid is limited in phthisis, and as far as it has gone has not been conclusive. But I have found the spray a most useful and agreeable remedy in various affections of the throat, whether diphtheritic or aphthous; and it has proved cleansing and soothing in some cases of foul ulcer- ation of the throat, affecting both larynx and fauces, generally syphilitic in origin, and sometimes ending in pulmonary con- sumption. If the blighting effect of damp anel impure air on the bioplasm or living sarcophytes is dependent on parasitic germs or spores, as some have conjectured, the utility of sul- phurous and carbolic acids as potent parasiticides would be in- telligible; but the whole subject requires further investigation before we can confide in it as a basis for practice. In connection with this subject, I must notice remedies ad- ministered by inhalation, which are really useful in certain cases, especially those in which the larynx and trachea are much affected, and in those attended with convulsive cough or offen- sive expectoration. I have generally found the use of inhaling instruments fatiguing and unnecessary. A quart jug of hot water, with a napkin from over the nose down to and around the jug to confine the steam, is all that is needed. To the hot water is added the drug to be inhaled; and creasote or carbolic acid, iodine, chloroform, oil of turpentine, and juice or extract of hemlock, are the articles which I have found most beneficial. A few drops of one, or of several of these combined, being put into the hot water, the inhalation is practiced through both mouth and nostrils without restraint or difficulty, and" may be continued for five or ten minutes every night, and, if need be, repeated once or twice in the day. Although the chief opera- tion of this medicated vapor is on the guttural and bronchial surface, yet a portion penetrates into the lungs, and is absorbed into the system; for iodine and oil of turpentine can be detected MOUNTAIN CURE — CLIMATE. 265 in the urine within a few minutes of the inhalation being made. Still, although proving very serviceable in certain cases, I can- not rank inhalation higher than as a subordinate remedy in the treatment of consumption. I may add, that the practice of painting the chest with tincture of iodine every night, as a gen- tle counter-irritant, is not without a certain influence in the way of inhalation; for a portion of the iodine evaporates, and slightly impregnates the air around the patient, and this atmosphere of iodine may not be without its influence for good. In the advan- ced stages of phthisis, when much purulent and often decaying matter is continually thrown off, it is very important to keep the surrounding air as pure as possible; this maybe done not only by a free supply of fresh air, not fast enough or cool enough to cause a draught, but also by the purifying influence of antiseptic agents. Condy's fluid, freshly prepared charcoal, or quicklime, kept in the room in open vessels, or the vapor of carbolic acid or creasote diffused through the air, would answer this purpose. It is hardly possible to compress into a summary the prin- ciples to guide us in the recommendation of baths and water- ing-places for the benefit of consumptive invalids. As a matter of experience, we cannot report very favorably of the results of sending consumptive patients to the sulphur springs of the Pyrenees, or to the alkaline and saline waters of Ems and other German Spas. The temporary ease to the cough and other symptoms of irritation, which they sometimes afford, is out- balanced by the increase of weakness caused by the discontin- uance of the oil and tonics, which these places of water-cure generally require. There is much better evidence in favor of those establish- ments in which consumptive patients can breathe the pure air of lofty mountains without being exposed to extremes of weather and temperature common at those heights. The strong claims of the ''mountain cure" have been already favor- ably noticed (see p. 105), and will be again considered. It may suffice here to state that experience has already justified the sending pulmonary invalids during the summer to any Alpine abode ^between 3000 and 6000 feet in height in South Europe where good accommodation can be had, and there is shelter from the coldest winds and security from damp. The advan- tage, or even safety, of such patients remaining at these heights during the winter, although strenuously asserted by several respectable authorities, is "more questionable, and cannot be affirmed without larger experience. Probably it will be suit- able only for certain cases. This has brought us to the subject of change of air and climate, which is of the highest importance in the treatment of pulmonary consumption, "it is of the greatest consequence to 266 TREATMENT OF FORMS OF CONSUMPTION. the phthisical invalid that he should breathe as pure an air as possible, and that the influence of this pure air on the blood and on the body should be increased by such gentle and varied exercise in it as his strength and the condition of his organs will permit. This is the great object in sending him to a warm and sheltered climate in winter, and to a high and dry locality in summer. It is a great but common mistake to suppose that a hot climate has any power to cure consumption. On the contrary, it is more likely to hasten its course; and we have already noticed that the most rapid forms of consumption are more common in hot climates than in cold. (See p. 105.) AVe send patients south in the winter, not to extreme heat, but to avoid extreme cold and damp and changes, which, by causing inflammatory attacks, develop the disease, and hasten its course,—to avoid, therefore, the inflammatory causes of the malady;—whilst we also counteract the decaying or phthisical tendency by the invigorating influence of open air, with its ex- hilarating and vivifying qualities of purity and freshness, and the attendant accessories of sunshine and beautiful scenery. CHAPTER XXVI. TREATMENT OF VARIETIES AND FORMS OF PULMONARY CONSUMP- TION.--ANTIPHLOGISTIC TREATMENT. Acute and Chronic, not synonymous with Inflammatory and ^STon-inflam- matory—May be acute from rapidity of decay, as well as from Inflam- mation—Sthenic Inflammation only requires decided Antiphlogistic Measures—Otherwise limited—Blisters very useful—Their management —Croton Oil—Opium and other Sedatives—Treatment of Asthenic In- flammation by Stimulants and Tonics—Cautions—Treatment of Sub- acute and Chronic Inflammations—Chronic Pneumonia—Eest and Quiet—Conservation of Strength. Cases of consumption may be divided into acute and chronic, according to the rapidity or slowness of their progress; and the distinction between the well-marked cases of the two classes, as regards both symptoms and treatment, is commonly well marked. Again, there is an equally appropriate division into the inflam- matory and non-inflammatory forms, which we have traced in their pathological varieties. And so far are these (acute and chronic, inflammatory and non-inflammatory) from beino- con- vertible terms, they mean really quite different things ; and both inflammatory and non-inflammatory consumption maybe either acute or chronic. If we bear in mind, that the course of con- ANTIPHLOGISTIC REMEDIES. 267 sumption may be accelerated either by an abundance of the phthinoplasms, or by their low vitality and tendency to decay, we can understand that either element in excess—inflammation, which produces them, or their dying nature, which decays them —may render the disease acute; and that the most galloping consumption of all must be that in which both the producing and the decaying elements go together—as in scrofulous pneu- monia and acute tuberculosis. On the contrary, disease will be both slow and partial where the consumptive or decaying ten- dency is moderate, and where inflammation can be either averted, or kept to a high standard. It is necessary, therefore, in the treatment of every form of consumption, to keep in view its consuming and decaying char- acter, and yet to look out for inflammation, which, in some form or other, is in many cases concerned in developing or aggravat- ing it. As before stated, the rule or leading principle of our practice should be to sustain the vital powers by all suitable and available means; the use of depressing or debilitating measures will be only exceptional and occasional, and limited to the short periods when acute inflammation supervenes, and calls for such restraint. For it is not every kind of inflamma- tion that requires what used to be called antiphlogistic treat- ment. In these clays we successfully treat patients under as- thenic and erysipelatous inflammations with nutritious soups, various stimulants, quinine, and iron; and the low forms of pneumonia and bronchitis which usher in or complicate phthisis are best managed by a moderate application of the same plan. Iron and quinine, indeed, are apt to aggravate the cough and dyspnoea, and other stimulants have the same effect; but diluted stimulants, infusion of bark and senega, or serpentaria, with ammonia and chlorate or nitrate of potass., are generally well borne in asthenic pneumonia or bronchitis in phthisical sub- jects. It is only in the sthenic inflammatory attacks in consumption that antiphlogistic measures are called for. In case of hard as well as frequent pulse, hot dry skin, scanty high-colored urine, together with tight hard cough, viscid or sanguinolent expecto- ration, pain in the chest and side, quickened or distressed breathing,—the abstraction of a little blood from the chest, fol- lowed by a large, warm, thin linseed poultice, covered with oiled silk; au effervescing saline draught every four or six hours, with fifteen ortwenty drops of antimonial wine, and three or four of solution of morphia,—will be about as much as can safely be done in the antiphlogistic way in a phthisical subject; and the antimony may be withdrawn when the skin becomes moist; when also the time for blistering is come, if the breathing and cough require it. 268 TREATMENT OF FORMS OF CONSUMPTION. Of the utility of blistering in inflammations of lungs or bron- chi, after the skin has become moist, I have not the slightest doubt: and manv thousands of facts, and the testimony of count- less relieved patients, have made it to me a matter of certainty, in spite of* all the modern denunciations against it. Neither is the practice so irrational as it has been represented; but I can- not afford space here to discuss its principle. And so far from their doing good by causing pain which disguises that of the disease, I And that they do'most good when they cause least pain. I therefore recommend a good-sized blister, oiled on the surface, and kept on only a short time—from six to eight hours —and followed immediately by a linseed poultice, as the first dressing. If the blister have not fully risen before, it willrise under the poultice, and discharge with little pain or irritation ; soon healing, and leaving the part ready for a renewal of the remedy, if needed. This, for acute and subacute attacks, is preferable to the practice of keeping the blister open by irrita- ting applications, which sometimes prove painful and unman- ageable, and often fail in the desired result. In more chronic inflammations other modes of counter-irritation may be pref- erable. In acute bronchitis in a phthisical subject, attended with vio- lent hard cough, with scanty or very viscid expectoration, croton oil liniment or ointment rubbed over the whole front of the chest, is sometimes more effectual than a blister. In the proportion of one part of croton oil to four of lard or soap liniment, it quickly produces a vivid erythema, which in a few hours breaks out in a crop of fine pustules: this eruption will sometimes altogether carry off the bronchial inflammation, and it generally consider- ably mitigates it.1 Of other aids useful in subduing inflammation, the most im- portant is opium or morphia. Small doses are frequently re- quired as palliatives to mitigate the cough, but from a quarter of a grain to a grain of opium or its equivalent in Dover's powder, or from one-sixth to one-third of a grain of acetate or hydrochlorate of morphia once or twice during the night, have considerable effect in subduing inflammation attended with much pain or other nervous disturbance. It is generally expe- dient to combine a grain or two of calomel to prevent the astringent effect of the opium on the biliary and other secre- tions. I have never found any evil effect from this limited use 1 Patients or their attendants must be cautioned to wash their hands after rubbing in croton oil, otherwise its effects are apt to appear in other parts touched by the hands, where they are not wanted. When croton oil is com- bined in a liniment with turpentine or camphor, or other volatile matters, it rises in the vapor, and may cause an unpleasant eruption of the face. On this account the ointment is best. ASTHENIC INFLAMMATION. 269 of mercury in phthisical subjects, and the combination also is less apt to check the expectoration than opium alone. It is of the greatest importance to do all we can to aid those secretions which have a natural tendency to relieve the inflammation— these are, the expectoration, the urine, and the perspiration. The free flow of these may not remove the inflammation, but it rarely fails to mitigate the acute forms; and if, at the same time, the attendant pain, cough, and other irritations are as- suaged by the opiate, the best steps are taken towards a natural resolution or cure before the mischievous increase of phthino- plasms can take place. Some other sedatives deserve mention as useful in helping to subdue inflammation and fever. Aconite, in tincture or extract of the root, has considerable power in lowering the pulse and diminishing inflammatory pains; but its use requires caution and watchfulness, as it may weaken the heart too much and cause dangerous syncope. The same may be said of hydrocy- anic acid, which is, however, in small doses, a useful adjunct to a saline. The veratrum viride has a steadier influence in re- ducing both pulse and heat in inflammation ; its chief inconve- nience is in its inducing nausea. The same objection applies to digitalis, which, without any power over active inflammation is sometimes very useful in steadying the pulse, and relieving the breath after the acute stage. This brings us to the subject of the asthenic stage and form of inflammation, which is common in phthisical subjects; and, because it is so, they neither require nor bear any continuance of lowering measures. Whether the inflammation be pneu- monic or bronchial, it throws out bioplasms or sarcophytes, which, if they languish and concrete, block up the tissues and interfere with respiration and circulation; but, if kept alive and active, may migrate and clear out of the affected tissues and membranes in the form of pus and mucus-cells and other excreta- ble matter. Now we may in some measure promote this result by the judicious use of stimulants and nutriment, in such forms and quantities as the patient will bear them. Often the stomach is weak and cannot digest much or solid food, and then beef-tea and other soups and broths, in small quantities and at short in- tervals, together with the diluted wine or spirit most agreeable to the Datient. Some medicinal stimulants called diffusible, such as carbonate and other salts of ammonia, spirits of chloro- form and ether, are also often beneficial in promoting the same end: tendin°- to improve the flagging circulation and secretions, and aidino- the processes of respiration and expectoration. Some medicines are supposed to have a special power in this way: squill senega, and serpentaria, for instance; but as they some- times'disorder the stomach, I do not rely much on them. And 270 TREATMENT OF FORMS OF CONSUMPTION. at this time it becomes an indication to improve the tone of the stomach by the milder tonics, such as the dilute mineral acids and light bitters; for by their help more substantial kinds of nourishment may be borne, and, together with them, that great- est of all aids to nutrition—cod-liver oil. After such attacks of inflammation as have required the use of antimony and salines, or even after those lower forms benefited by carbonate of am- monia, the operation of dilute mineral acids—especially the nitric—is often very grateful to the palate and stomach, cleans- ing the tongue and restoring the appetite and the power to take and digest solid food; and the sooner this can be effected the better. It may sometimes be commenced during a remission of the febrile symptoms in the morning, even when salines are still necessary in the evening and night; and if the remission increases to intermission of the fever, quinine, salicine, or ca- lumba may be added to the morning dose. This should be our aim: to attempt as early as possible to change the treatment from the antiphlogistic to the tonic and sustaining, still retain- ing the aid of nocturnal soothing salines and moderate counter- irritation, to keep in check any remains of the inflammatory irritation. I feel quite sure that this is a much safer and more successful practice than that which has been much recommended of late, that of giving strong tonics, such as iron and quinine, boldly throughout au inflammatory attack without regard to their immediate effects of increasing pain, cough, tightness of breath, and heat of skin. I am equally opposed to the practice of keeping patients in pneumonia and bronchitis in a state of con- stant semi-intoxication with brandy in quantities much greater than are necessary merely to sustain the failing powers. Xo doubt patients do sometimes recover under this treatment, but their recovery is more tardy than that from a more moderate and rational plan; and convalescence and subsequent health are often impaired by the craving for, and indulgence in, stimulants which this practice produces. I have known several, and have heard of more, cases of dipsomania which dated their origin from this spirituous medication. The subacute and chronic forms of inflammation occurring at the commencement or in the course of phthisis, require only the mildest antiphlogistic remedies. When the urine is scanty, high-colored, or loaded with lithates, an effervescing saline once or twice in the evening and night, an occasional mercurial aperi- ent if the liver be tender and full, and counter-irritation over the affected parts by acetum eantharidis, or croton oil liniment, or the nightly application of poultices of linseed-meal and mus- tard—are usually all the measures of this kind necessary; and in most instances the usual sustaining treatment for phthisis, with cod-liver oil and tonics, may be continued in the morning CONSERVATION OF STRENGTH. 271 and noon, with a generous diet, and a moderate allowance of stimulants. In the more persistent forms of chronic pneumonia, with ex- tensive induration of the lung of the fibroid or contractile kind, iodide of potassium in doses of three or four grains, with fifteen of bicarbonate of potass., every evening and night, together with daily painting the chest with tincture "of iodine, so long as the skin will bear it, has proved beneficial in many instances; but always combined with the usual treatment with the oil and acid tonic once or twice in the earlier part of the day. Whatever may be its mode of operation, iodine certainly has some resol- vent effect on lymphatic swellings and inflammatory effusions; but it is a wasting and depressing agent if its histolytic action be notcounteracted, and this is most effectually done by cod- liver oiKand generous living. The influence of iodine seems to be restricted to the living sarcophytes, the proliferation of which forms the bulk of soft lymphomata, bronchocele, and inflamma- tory swellings; it has less power over them in the purulent form, or when indurated, and none at all in a state of caseation. The action of mercury on inflammatory products seems to be still more limited to the early stages; and its destructive or histolytic operation on the gums and salivary glands rather favors the notion, which has been commonly entertained, that it tends to hasten the decay and softening of tubercle.1 Not the least important part of the antiphlogistic treatment of inflammatory varieties of consumption is rest of body and mind, and confinement to a uniform temperature. In all acute and febrile attacks, the repose and warmth of bed are required for some days at least; and it is remarkable how this simple nursing, with time, will sometimes soothe away acute symptoms without any active measures; and in all cases they make these measures more effectual, especially in cold seasons. The exer- cise of the voice must in like manner be limited. In a phthisi- 1 The effect of mercury on the gums reminds me that these boundaries of our flesh claim close attention in all diseases affecting the nutrition of the body. The late Dr. Theophilus Thompson particularly directed the attention of the profession to the state of the gums as a symptom of phthisis. I have long observed this, that not only in phthisis, but in other diseases of malnutrition, the gums recede, and often become inflamed and spongy; independently of any cause in the teeth, before loss of flesh or strength attracts attention. The mere advance of age causes the receding of this flesh border, and this may be accelerated by anaemia or bad living; but in many phthisical cases, in addition to the recession, there is a redness and turgidity, and sometimes a partial ulceration of the margin, in- dicating an unhealthy congestion or inflammation. It is not usually attended with soreness, in fact, often patients are not aware of its presence. It is com- monly diminished under tonic treatment, and generous diet; but the gums rarely become quite natural again. Mouth-washes or tooth powder containing tannic and carbolic acid, or other antiseptic astringents, are of some use, and correct the fetor often present in the breath. 272 ANTIPHTHISICAL TREATMENT. cal subject, to save the strength by avoiding its expenditure, is a wiser and safer course than to allow it to be wasted, and then to rely on regaining it through strengthening agents. CHAPTER XXVII. ANTIPHTHISICAL TREATMENT. Its Objects to sustain Vitality of Bioplasm and counteract Decay—"Reme- dies, Medicinal, Dietetic, and Hygienic—Of Medicinal, Cod-liver Oil the Chief—Its beneficial Effects—Mode of Action as an Oil, on the Bio- plasm and on concrete Sarcophytes, promotes resolution and ripening of Exudates—To be effectual must be given largely and constantly, to act on Phthinoplasms and counteract Decline, which may exist with- out Phthinoplasm—Cod-oil proper for Decline also—Notice of other Oils and Pats—Pancreatic Emulsion—Reasons for preferring pure Cod- liver Oil—Mode of preparing it—Sources—Modes and Times of Exhi- bition—Cautions—Tonic Medicines—Best combined with the Oil— Mineral Acids — Nitric—Sulphuric—Phosphoric—Sulphurous—Hypo- phosphites—Bitters and Tonics—Prescriptions of various Forms— Doses to be few—Antiseptics—Inhalations—Arsenic. More or less of the preceding measures may properly be brought into operation to remove or counteract various forms and degrees of inflammation which may usher in or accompany the course of Pulmonary Consumption; and they are more often required in cold and changeable seasons and climates, which derange the circulation and cause colds and inflamma- tory congestions. But the paramount and most constantly re- quired treatment is not antiphlogistic, but antiphthisical— that directed against the consumptive element; that which may improve and sustain the vital activity of the bioplasm, and re- move or counteract all blighting or hurtful agencies, which tend to pervert it from its proper fitness for the quickening and reparation of the body, into a dying and decaying matter, carrying with it waste and destruction. It is pretty obvious that to do all this—to renovate the life and material of the bioplasm and to remove or correct that which is already degraded, is not to be accomplished by any one remedy or any one class of remedies. Tonics, stimulants, antiseptics, cod-liver oil, the best kinds of nourishment, pure dry air, regulated temperature, judiciously adapted clothing and exercise, are all needed to complete the antiphthisical meas- ures; and their success will depend on their being so used, pro- portioned, and directed, as to restore and sustain the healthy functions of the body in their proper activity, and thereby to MEDICINAL REMEDIES. 273 keep the protoplasm of the blood, lymphatics, and tissues in full life and vigor, and to promote the removal or quiescence of any that may have already degenerated into phthinoplasm. It is obvious, then, that no routine plan, or fixed course of treat- ment, can succeed in working out this complex problem. The leading indications are, to nourish the textures, and to sustain the several functions of the body ; and experience has proved that certain agents have such power in this way that their use may be considered almost indispensable ; but in the use of these and of all other means, much intelligent discrimination is con- stantly required, and success will depend in great measure on the care and skill with which this is carried on. In the following sketch of the principal antiphthisical reme- dies, our time and limits require brevity; and we shall most concisely attain our end by considering them in succession, under the heads of Medicinal, Dietetic, and Hygienic measures. Medicinal remedies include cod-liver oil and other fats, tonics, stimulants, eliminants, and antiseptics. Dietetics include food and stimulants. Hygienic means refer to air, temperature, climate, habitation, exercise, and clothing. Medicinal Remedies. Of all means hitherto tried for the relief of the consumptive, unquestionably cod-liver oil has been found the most successful. This I stated in 1849, after three years' trial of its use; and so I repeat, after a quarter of a century's experience, that it is the only agent in any degree deserving the title of a remedy in this disease. Its mode of action is still a matter of uncertainty ; but we can at least offer some reasonable conjectures, in addition to those already proposed in the Summary of Treatment. That it is in itself a nutriment cannot be doubted; and that its nutri- tious properties go farther than to augment the fat in the body is proved by the well-ascertained fact that the muscles and strength also increase under its use. In fact, it has been proved to increase the proteinaceous constituents of the blood, except the fibrin, which is diminished.1 In truth, the beneficial opera- tion of cod-liver oil extends to every function and structure of the body. In cases most suitable for its use, there is a progres- sive improvement in digestion, appetite, strength, and complex- ion ; and various morbid conditions perceptibly diminish. Thus, purulent discharges are lessened, ulcers assume a healthier as- pect, colliquative" diarrhoea and sweats cease, the natural secre- tions become more copious, the pulse less frequent. It is difficult 1 Simon's Animal Chemistry, by Day, vol. i, p. 280. 18 274 ANTIPHTHISICAL REMEDIES. to comprehend how it can produce such marvellous and manifold salutary effects; but the extent to which it has been, ami still is, administered, pretty well prove that it has properties which render it congenial to the animal economy. Cod-liver oil forms an emulsion more readily than other oils, and leaves no greasy feeling in the mouth, and this corresponds with its easy digestibility and absorption from the alimentary canal. This may depend on its containing some biliary princi- ples; it often has a marked effect in increasing the secretion of the liver, and if this is sufficiently carried off by the several processes of combustion and elimination, no tendency to sickness results from its use. It is, therefore, not surprising that cod- liver oil can be administered in larger quantities and for a longer time in cold seasons than in hot; to persons who take exercise than to the sedentary ; and especially to those whose bowels act regularly and sufficiently. With many weakly persons it assists the digestive process by promoting the biliary secretion ; and, in not a few instances, I have found it effectual in improving and rendering more fluid this secretion in persons liable to gall- stones, or obstructions from inspissated bile. On the other hand, it is apt to disagree in cases of inflammatory dyspepsia, espe- cially that affecting the duodenum; in those of hepatic conges- tion, with fulness and tenderness of the hypochondria; and in all states of high fever or inflammation. All such affections should be relieved by saline effervescing draughts, mild mercu- rial aperients, and such means, before the oil is given; and, in case of persons prone to these disorders, they may be required occasionally during its use. Thus we have an oily matter, well borne by the stomach, easily diffused by emulsion through the alimentary mass, readily absorbed by the lacteals, where it contributes to form a rich "molecular base" in the chyle; apt to saponify with the basic salts of the blood; and when diffused in this fluid throughout the capillaries of the body, capable of penetrating to all the textures, and of exercising its solvent and softening action on the solid fats of old deposits, whilst it affords a rich pabulum for the living sarcophytes and bioplasm of the blood, tissue-cells, and lymphatics. Its superior penetrative and suppling properties render cod- liver oil valuable in the process of currying leather, and pre- viously to its introduction into medicine, this was its chief com- mercial use. Its fluidity and divisibility enable it to pervade all tissues of the body, and to penetrate even into caseous and im- perfectly organized deposits, and so to dissolve their solid fats and soften their concrete sarcophytes as to render permeable and supple their whole mass, and open them to the immigration of new and active bioplasm, by the operation of which their COD-LIVER OIL—CONSTANT USE REQUIRED. 275 vitality and nutrition may be improved and maintained, or if incapable of such improvement, their substance may be gradu- ally dissolved and carried off. If we call to mind also the large share which fatty transforma- tion seems to have in the processes of resolution and suppuration which terminate inflammation and clear away its products (as explained in chap, vii) we can see why the administration of cod-liver oil proves so eminently beneficent in promoting these salutary results. For that very process of fatty transformation which is so injurious and fatal when it affects vital organs, as the heart, or when it spreads destruction in the caseation of a lung, is salutary and conservative when it helps to soften and carry off the obstructing and irritating products of inflammation. "We can thus understand why under the use of the oil the cough becomes softened, and the expectoration easy, being thereby flattened and ripened {sputa concocla, crachais gras, cuds). Much more might be said respecting the action and valuable qualities of this wonder-working agent; but we cannot afford space here, and must refer to the "Principles of Medicine," Q)d eel., p. 484 et seq.) for further particulars, and for its history and the best mode of taking it. I would only add here that longer experience has further convinced me of its value as a remedy, and has proved that there need be less limitation to its use than formerly was thought necessary. For instance, it was, and often still is, said that it ought not to be given in warm weather, or in hot climates, or during the existence of any fever, inflammation, or hemorrhage. W"e now have abundant evidence that it may be taken throughout the summer, in the East and West Indies, in Madeira, and in other tropical climates. Under these circumstances, it is generally expedient to reduce the dose or the frequency of its exhibition ; and the same moderation may be required in continuing it during feverish or inflamma- tory attacks; but, as before stated, it may commonly be given after a morning meal, long before the attack has subsided, and it may contribute not a little to their removal. So soon as a patient is able to take and digest solid food, he may take a little oil after it. With respect to haemoptysis, so long as the dis- charges of blood are so large or frequent as to require the con- stanf exhibition of styptics, there is no time for the oil; neither ought solid food to be taken which fits the stomach for it; but I have found no reason to suppose that the oil has any tendency to increase the hemorriiage; whereas it certainly promotes the healing the phthinoplastic ruptures which produced it. But in such a case the oil may be given in conjunction with a styptic, and a mixture containing sulphuric, tannic, or gallic acids, sepa- rate or combined, or tincture of perchloride of iron, or liquid 276 ANTIPHTHISICAL REMEDIES. extract of ergot, with judicious flavoring, may be made an agree- able vehicle for the oil. A most important point to be observed in order to obtain the greatest benefit from the oil, is that its use should be persevered in regularly, and for a sufficient length of time. Neither the public, nor the profession, is sufficiently aware of this, and it is the more necessary to insist strongly on it. To prove truly remedial, it must be taken in quantities sufficient so to diffuse it through the system that it may affect the nutrition of every part. This cannot be effected by giving unlimited doses, as these would be either not retained or not absorbed. The doses must be moderate, and therefore they must be steadily contin- ued for an indefinite length of time; not only until there is an amelioration in the symptoms—even although such an ameli- oration may amount to the patient thinking himself quite well, which is a common case—but until all signs or symptoms of the existence of phthinoplasms are removed, and the nutritive functions are restored to a healthy state. Doubtless, it will be objected, in that case, many persons once seriously affected must continue to take the oil all their lives. So they must, I reply. It is the staff of life to them, and it is a great boon thus to have a life, otherwise despaired of, prolonged and made enjoyable at the trifling inconvenience of taking daily a dose of oil with one or two of their meals. The cases requiring this perpetual oil-preserving are chiefly those in which phthino- plastic matter has already formed to such an extent, chiefly in the lungs or lymphatic glands, that although it may have be- come quiescent for the time, trifling causes may bring it into activity, and spread its infecting influence through the frame. This phthinoplastic influence may be exerted, not only locally— producing crepitus, cough, expectoration, &c.—but also con- stitutionally, by impairing the nutrition of the body, and causing a general decline of its powers. So, even without cough, a person in whom consumption has been arrested, mav go into a decline, wasting and dwindling, without any obvious" increase of local disease. This decline may commonly be counteracted by the oil, aided by suitable tonics and generous living and healthy air: but all these latter are of little avail without the oil. A similar declining state of general health sometimes pre- cedes the development of pulmonary consumption, which may supervene at any time on the application of any exciting cause. If we endeavor to examine more closely in what this "general decline consists, we find loss of flesh a prominent feature. The nutrition of the body is at fault; and in the absence of any cause in the supplies, or in the digestive or assimilating organs, we are led to suspect the bioplasm itself to be wanting in COD-LIVER OIL COUNTERACTS DECLINE. 277 quantity or quality, or both : it lacks some of those wonderful vital properties of action, motion, growth, and multiplication, by virtue of which it normally renovates and sustains the tissues of the body in the wear and tear of life. Here is what may be called predisposition to consumption, whether heredi- tary or acquired; whether the result of conformation, or aris- ing from the operation of some depressing or deteriorating agency. As yet there may be no local development of disease. There is a general phthisis, but no phthinoplasm to begin the decay of an organ. But this soon follows. The first cold taken excites an inflammation, with its proliferating sarcophytes, and these partaking of the declining vitality of the general bioplasm, form concrete and decaying products, beginning with obstruc- tion, and ending in destruction, of the part. Or it may be some blighting influence conveyed by damp or impure air, which palsies the sarcophytes of the lymphatics in the glands or in the lungs, and thus localizes the work of consumption. Now it is manifestly most desirable to prevent this destruc- tive work before it attacks an important organ; and, in refer- ence to our present subject, the use of cod-liver oil, here is a case for its most appropriate application in conjunction with other invigorating measures. A general wasting or falling away of flesh may be sufficient to mark the decline in question ; but we may be confirmed by the appearance of swellings of the submaxillary or cervical glands, or any other symptoms con- nected with the lymphatic system. In children especially the state of these glands should be observed, and wherever they are enlarged, whatever may be the cause—teething, sore throat, otitis, or skin eruptions—such cases are sure to derive benefit from the cod-oil. The same remark applies strongly to en- largement of the bronchial glands, several times before men- tioned as having for its sign a tubular sound within or above a scapula. This bronchial lymphoma may be a sign of disorder, not merely of the bioplasm in general, but specially of that in the pulmonary apparatus, from which the bronchial glands receive their lymph stream; and the concreting of sluggish sarcophytes in them, besides possibly causing bronchial asthma, mav be preliminary to their accumulating in the adenoid tissue of the lungs also. . (See Case 88.) Now alTthese are appropriate cases for the use of the oil, together with other antiphthisical remedies, and their beneficial operation is generally soon manifest in the improved aspect and condition of "the patient. But to work a durable and effectual change, the remedies must be continued regularly for months, and even for years, and assisted by all available dietetic and hygienic means. Considering it to be most consonant with fact to conclude 278 ANTIPHTHISICAL REMEDIES. that cod-liver oil acts rather as oil, than by virtue of the iodine, bromine, phosphorus, or any other peculiar element which it may contain, it is hardly necessary to discuss the possible share which these may have in its remedial powers. Not only is the proportion of these elements too minute to have much influ- ence in determining results so prompt and so considerable as those often obtained from cod-oil, but these elements have been used in various other combinations without an approach to such satisfactory effects. On the other hand, certain other oily matters have been exhibited with a success more resembling that commonly attending the use of the cod-oil. Tims cream, bacon, mutton suet in milk, cocoanut oil, and neats'-foot oil, have been found by several practitioners to answer like the cod-oil ; and although the testimony in favor of all these falls far short of that in favor of the latter agent, yet it approximates them to it more nearlv than any evidence which can be brought in favor of iodine, bromine, or any other chemical element or combination. But it is quite possible that, in addition to its remarkable fluidity and penetrative power, cod-liver oil may owe its con- geniality with the animal economy to one or other of these elements, which are wanting in common fats, or it may be to its biliary constituent. I have tried various other oils and fats, and have heard the results of their being tried by others, and although it is certain that if persevered with, they fatten the body and so counteract the waste of consumption, they fail to produce the general salutary effects which result from cod- oil, and, in most instances, sooner or later disagree, and cannot be continued for months and years like the latter. Of Dr. DobelPs remedy, the "Pancreatic Emulsion," I have little personal experience. Not admitting either his leading idea, that failure of the function of the pancreas is the starting- point of consumptive disease, or his mode of supplying the sup- posed want by giving mutton fat beaten up with the pancreatic secretion of an animal, I have not been forward in making trial of the new remedy; and I confess that my hesitation has not been diminished by the manner in which "Pancreatic Emulsion " has been advertised and paraded before the public, as exclusively prepared by one particular chemical firm. I have heard various accounts from patients who had taken this emulsion. Some declare that they have derived benefit from it; others do not admit this. Many declare that it is quite as bad to take as cod-liver oil; and I have never found that enthusiasm with respect to its good effects, which is so common among those who have been benefited by the oil. As some difference of opinion seems to exist as to the kind of oil that is best for exhibition, it may be well to say a few words PREPARATION OF COD-LIVER OIL. 279 on this point. The dark-brown cod-liver oil of commerce, which is used by curriers, was that employed by Dr. BardslevJ of Manchester, in this country seventv years ago; and was rec- ommended by the late Dr. Darling, of London, who prescribed it with great success in scrofulous affections during fifty years. A brown oil of more or less impurity has also been in use as a remedy, first by the people, and subsequently by the profession, in Holland, Germany, Norway, and other parts of the Conti- nent, for a century past. In 1841, Dr. Hughes Bennet pub- lished bis first book on the oil, recommending its use on the authority of several Continental practitioners, and giving pref- erence to ajight-brown oil. At this date I began to prescribe this oil; but I found so much objection on the part of patients, and sometimes such real disorder produced by all attempts to take it, that I came to the conclusion that, however Dutch and German stomachs might bear it, English ones could not, at least among the upper classes. It was not until the pure pale oil was brought under my notice, that the difficulties in admin- istering it gave way; and during the last twenty-five years I have prescribed it for between "twenty and thirty thousand patients, and with such success that it was taken without mate- rial difficulty by about 95 per cent, of the whole number; and of those who thus took it, fully 90 per cent, derived more or less benefit from its use. This experience, which is in accord- ance with that of many of my professional friends, is at least quite as strong as any that can be adduced in favor of the brown or impure kind of oil; and it does seem absurd to rec- ommend the exhibition of the remedy in its offensive form, when the pure fresh oil has been proved to be at least equally efficacious. The dark-colored and strong-smelling oils owe their offensive properties to the partial decomposition and putrefaction which the livers undergo before and during the process of separating the oil from them. They thus acquire a strong fishy smell and taste, like that of lamp oil, which, although highly disgusting to most persons, are not disliked by a few who resemble Russians and Laplanders in their tastes. Dr. De Jongh, who has giveu the sanction of his name to an article widely advertised in this country for many years, strenuously advocates the superiority of the light-brown oil; but, as Dr. Garrod has well shown (" Brit. and For. Med.-Chir. Rev.," January, 1856), the facts which he adduces by no means bear out his assertions; and the general results of chemical analysis, as well as of clinical experience, are altogether in favor of the pure pale oil as carefully prepared in thiscountry and in Newfoundland. The process is thus described by Dr. Garrod : " The livers are collected daily, so that no trace of decomposition may have occurred; carefully examined, in 280 ANTIPHTHISICAL REMEDIES. order to remove all traces of blood and impurity, and to separate any inferior livers; they are then sliced, and exposed to a tem- perature not exceeding 180° Fahr. till all the oil has drained from them. This is filtered, afterwards exposed to a temperature of about 50° Fahr. in order to congeal the bulk of the margarine, and again filtered,1 and put into bottles well secured from the actioirof the air " ("Brit, and For. Med.-Chir. Rev.," January, 1850). In fact, the great object to be kept in view in the prep- aration of the oil, is"to separate its more liquid part in the sim- plest and speediest manner from all contaminating matters, so that it may be administered in the pure state in which it exists in the cells of the liver of the living or recently dead fish. Much meddling or tedious elaboration will injure it as much as care- lessness or roughness of preparation; for exposure to the air soon turns it rancid, and spoils its freshness as much as if it re- mained in the livers until they became stale. The sweetest pod- oil, if rubbed on the skin, acquires a very offensive smell in a few minutes ; hence the stench produced by the practice of rub- bing the oil on the surface of the body is so sickening as to ren- derthis mode of exhibition intolerable with many individuals. For the purposes of inunction, recommended by the late Sir James Simpson, it would be much better to use almond or olive- oil rather than cod-oil; fori feel sure that, among the upper classes at least, it would soon bring the latter into disgrace to attempt to administer it in a mode which renders it truly dis- gusting. The wonderful penetrative power of cod-liver oil on animal tissues has long caused it to be used in the leather trade, and proofs of this action in the living body occur in the smell of the oil being occasionally detected when scrofulous abscesses are opened,"after the patients have been taking it for some time previously. W7hen we consider the amount and variety of beneficial effects which result from the use of cod-liver oil, and that its exhibition ought to be continued not for days and weeks only, but for months and years, we shall perceive the vital importance of obviating as much as possible all objections of taste, smell, nau- seousness, and other causes of offensiveness to the senses, stom- ach, or system, which may impede its continued administration. I will therefore, add a few directions as to the particulars of its exhibition. (1.) The Oil.—It should be as fresh, and as free from taste and 1 I have always recommended the oil without the solid margarine and stoarine, both from the experience that it agrees better with the stomach, and from tbe views which 1 entertain as to its mode of action. Dr. Garrod has tried the solid residuum of the oil, and found that the few patients who were able to take it, derived no advantage from its use. MODE OF GIVING THE OIL. 231 smell, as it can be procured. Several of the leading chemists in London prepare during the winter season an oil, which, for sweetness and freshness, surpasses any obtained from abroad; and from December to the end of June I have found the Lon- don-made oil generally prove the best. Soon after midsummer, a supply is imported from Newfoundland, and is generally ex- cellent, being at this season quite equal to the home-made oil, with the recommendation of being considerably cheaper. The fine oil which is now largely imported from Norwav is re- markably free from unpleasant flavor, and has the advantage of keeping better than the Newfoundland, its price being about the same. The oil should be kept in a cool place, in moderate sized bottles, well corked, and not opened or exposed to the air more than is necessary. (2.) Mode of Exhibition.—Many persons, especially children, take the oil alone without any difficulty; and in such a case it seems needless to recommend any adjunct. Yet even with these, if the remedy is to be continued for a long time, it is better to give some agreeably-flavored tonic with it)"for this prevents the palate and stomach from being palled by repetition, which is very apt to occur when the oil is long taken alone, however well borne and even relished at first. To the great majority of patients it is more agreeable to disguise the taste of the oil; and this may be done by giving it in another liquid, which may also act as an agreeable tonic to the stomach. Some physicians and chemists have endeavored to render the oil more palatable by the addition of an essential oil or other flavoring matter; and in this way the taste may be nearly completely disguised. But the great objection to these " palatable oils" is, that the essen- tial oil, while it covers the taste at the time, considerably in- creases the tendency to unpleasant eructation afterwards. This effect is still more marked in the "etherized cod-liver oil," which is advocated on the ground of its stimulating the pancre- atic secretion, and thus assisting the formation of an emulsion in the duodenum; but its pungent disagreeable taste, and the frequent eructations it gives rise to, have in our experience pre- vented private patients from continuing its use for any length of time. The best way is to take the oil floating on a well- flavored tonic, such as the compound infusion of orange-peel, with the addition of a little diluted mineral acid, and either sweetened with syrup, or rendered more bitter by the addition of a little tincture of hop, calumba, quassia, or cascarilla, accord- ing to the fancy of the palate or the requirements of the stomach. Tlie bulk of the whole dose should be small, so that it may be swal- lowed at a single draught; therefore the quantity of the vehicle should not exceed a tablespoonful, or half an ounce, with a tea- spoonful of oil, which is to be gradually increased to a tablespoon- 282 ANTIPHTHISICAL REMEDIES. fill. The dose of oil should rarely exceed a tablespoonful twice or three times a day: when a larger amount is taken at a time, it generally either deranges the stomach or liver, or some of it passes unabsorbed by the bowels. The mineral acid may be varied ac- cording to circumstances. The nitric generally suits best in in- - flammatory cases, and those attended with much lithic deposit in the urine; but its tendency to injure the teeth is an objection to its long continuance. The sulphuric is more eligible where there is a liability to haemoptysis, profuse sweats, or diarrhoea. The nitro-muriatic acid suits patients best who are subject to liver disturbance. But in most cases, and for long continuance, I have found reason to prefer the diluted phosphoric acid, which may be termed the most physiological of the acids, tending to derange the chemistry of the body less than the others. The chief advantage of exhibiting the oil in such a tonic as that now recommended, is that, in addition to disguising the taste of the oil, the tone of the stomach is also kept up, so that it bears the oil in full closes and for a long period : and in this respect it is superior to orange or ginger wine, aromatic waters, lemon-juice, coffee, milk, and other vehicles that are occasionally used. In cases of peculiar weakness of stomach, with tendency to vomit- ing, I have often given a g1., or ^ of a grain of strychnia in a solution with each dose with such success, that I have been led to regard strychnia as a specific against the retching of phthisis. Infaiits and young children generally take the oil without diffi- culty ; and it is easy to disguise it in a very palatable and at- tractive form, in an emulsion with mucilage or the yolk of an Qgg, and a flavored syrup. (3.) Time of Exhibition, Diet, $c.—General experience has proved that the oil agrees best when taken during or shortly after a meal. Formerly, I recommended it to be taken from one to two hours after; but I have lately found that it rises less, and leaves the appetite more free for the next meal, if swallowed immediately after the meal. When taken on an empty stomach, it often causes eructations, with a rancid, unpleasant taste of the oil for hours. In most instances, after tbe two or three first meals is the best time, as the stomach is, with the body, more fatigued towards the close of the day; but I have known several persons to take it well at bedtime: these are generally good sleepers, whose sound repose hides any symptoms of disagree- ment. With some individuals the oil agrees so well, and so much improves their digestive powers, that they require little or no restriction in diet; but this is not the case with the majority. The richness of the oil does prove more or less a trial, sooner or later, to most persons, and to diminish this trial as much as pos- sible, it obviously becomes proper to omit or reduce all other TONICS—MINERAL ACIDS. 283 rich and greasy articles of diet. All pastry, fat meat, rich stuffing, and the like, should be avoided, and great moderation observed in the use of butter, cream, and very sweet things. Even milk in any quantity is not generally borne well during a course of oil; and many find malt liquor too heavy, increasing the tendency to bilious attacks. A plain nutritious diet of bread, fresh meat, poultry or game, with a fair proportion of vegetables, and a little fruit, and a moderate quantity of liquid at the earlier meals, commonly agrees best, and facilitates the exhibition of the oil in doses sufficient to produce its salutary influence in the system. Tonic Medicines in Pulmonary Consumption. Although cod-liver oil is to be looked to as the great anti- phthisical remedy, yet various tonic medicines are highly bene- ficial, both on their own account, as tending to invigorate the functions of the body and to improve the condition of the blood, but also as means of strengthening the stomach and enabling it to bear the long continuance of the oil, and of fulfilling other special indications. And the mutual relation which the oil and tonics bear to each other suggests the expediency of what has been found a most convenient and useful practice, to give the oil in a vehicle containing the tonic. It has been mentioned that the oil ought to be taken immediately after food; it thus is blended with the food during the process of digestion, and so rarely causes the eructations which often follow its use when taken into an empty stomach. Tonics also, especially when combined with acids,suit the stomach well at this time, although the diffusion through the mass of aliment may somewhat weaken their tonic properties. This is no disadvantage, as the milder tonics generally agree better with consumptive patients, and their strength may be increased where required. The mineral acids supply the lightest form of tonic, and of these the nitric is that best suited" for inflammatory stages of the disease. It appears to be decomposed in the circulation, and does not increase the uric acid in the urine as all the other mineral acids do. But as it sometimes acts on the bowels, it is not eligible when they are loose, and has a decided tendency to corrode the teeth, the phosphoric and sulphuric are better suited for common use. The sulphuric acid has more tonic and as- tringent power, and maybe preferred where there is a tendency to diarrhoea, profuse sweats, or haemoptysis. In common cases the phosphoric acid is the safest, not that it has any peculiar power connected with its phosphoric nature, for it is far too stable in its composition to yield phosphorus or even hypophosphorous acid but because it is a common constituent in animal struc- 284 ANTIPHTHISICAL REMEDIES. tures, and is therefore less disturbing than other acids. It is different with sulphurous acid, which may nevertheless some- times be used also, and is not disagreeable when combined with a sufficient proportion of syrup or glycerine. It is a very potent chemical agent, having great antiseptic power, and appears to be directly destructive to the low vegetable and animal organ- isms which infect bodies prone to decay. It has appeared use- ful in cases of aphthous month and fauces, and fetid or very purulent expectoration, where it may be inhaled in spray as well as swallowed as a medicine. Hypophosphorous acid has just been noticed, but this is com- monly given in union with soda, iron, and quinine. The hypo- phosphites of soda and lime were recommended very strongly some years ago by Dr. Churchill, as a most potent remedy in phthisis; in fact, they were so vaunted as to have suffered prej- udice from hyperbolical praise; and in various trials in this country were pronounced to be altogether inert. On the other hand, Dr. Thorowgood, Dr. Radcliffe, and others, have found them to possess considerable power as restoratives in weak states of the system; and I have been convinced of their utility as an aid to cod-oil and phosphoric acid in the treatment of phthisis. Like phosphorus, they are inflammable at a low tem- perature, and any virtue ascribed to phosphorus may be expected from them ; and they certainly do not disagree with the stomach and liver, as I have found phosphorus to do in my attempts to exhibit it as a medicine. In two cases of paraplegia where I gave phosphuretted oil in very small doses, in a few days it pro- duced jaundice with tenderness and enlargement of the liver. No such effect has followed the use of the hypophosphite of soda, and its beneficial effects have been shown in this way. Phthisical patients, generally with advanced disease, have long been taking the oil, with phosphoric acid and some tonic, and after improving much in flesh and other respects, come to a standstill, and get no better. Then the addition of the hypo- phosphite. in the dose of three or four grains to the usual mix- ture and oil, has produced a very marked improvement in the vigor and appetite of the patient, generally followed by increase of weight and strength. That is the empirical fact, whatever may be its rationale: and it has been proved too often to admit of doubt; and I am therefore very glad to avail myself of the hypophosphite as a supplementary aid in the treatment of phthisis. In addition to tbe mineral acids, or independently of them, other more decided tonics are very useful to improve the appe- tite and digestion, and to increase the tone of the whole system. It has been already mentioned that the milder tonics or simple bitters, such as calumba, cascarilla, chiretta, gentian, and sali- MINERAL ACIDS—BITTERS, ETC. 285 cine, are often preferable to quinine and iron, because they are borne better and for a longer time without disagreeing; whereas the stronger tonics frequently increase the cough and tendency to hemorrhage, and sometimes interfere with the regular action of tbe bowels. But where they have none of theseevil effects, and especially if there is much weakness, anaemia, or low febrile disturbance, quinine and iron are doubtless our most effective aids; and they may conveniently be given in a pill after or be- fore the dose of oil in its acid mixture, which insures the solu- tion of the quinine in the stomach. Their addition to the mix- ture would render it too nauseous to some tastes to be a fit vehi- cle for the oil. Of all the tonics for strengthening the stomach and preventing nausea with the oil, strychnia is by far the best; and as it has no heating property, its addition to the compound orange infusion supplies the most elegant and effectual form of oil-sauce that I have yet devised. It may save the need of longer descriptions, to insert in a note some of the combinations which I have been in the habit of prescribing as tonics to accompany tbe oil.1 I have found by experience, that both acids and aro- matics as well as bitters, effectually cover the taste of the oil and enable the stomach to retain it without nausea or eructation. The spicy flavor of ginger and clove in all these mixtures is far 1 R. Acidi Nitrici dil., 3*ss. Tinct. Calumba?, Syr. Zingiberis, aa 5J. Infusi Aurantii Com p., ad 3 viij. A tablespoonful to be taken twice a day with a teaspoonful of pure cod- liver oil, graduall}' increasing the oil to a tablespoonful. R. Acidi Phosphorici dil., 5SS. Tinct. Cascarillse, 5*iss. Syr. Zingiberis, 3]. Infusi Aurantii Comp., ad 3viij. To be given as the former. R. Acidi Snlphurosi, gvj. Tinct Calumba?, 3*j. Glyccrini puri, 3i^s. Infusi Aurantii Comp., ad gviij. A tablespoonful (with a little water if preferred) to be taken with each dose of oil. R. Acidi Phosphorici dil., 3s.?. Soda? Hypophosphitis, gj. Tinct Quina? Comp., giss. Glycerini puri, 3J. Inf. Aurantii Comp., ad 3viij. A tablespoonful with each dose of the oil. R. Acidi Sulphurici dil., giij. Tinct. Aurantii, 3iss. Salicini, 7)ij. Syr. Zingiberis, 3J. Inf. Aurantii Comp., ad 3"viij. A tablespoonful with each dose of the oil. R. Acidi Phosphorici dil., 3%s. Liquoris Strychnia?, gj. Tinct Aurantii, Syr. Zingiberis, aa 3*j. Inf. Aurantii Comp. ad 3viij. To be given as the former. R. Acidi Phosphorici, dil., 3*ss. Ferri Sulphatis, Quina? Sulphatis, aa ^j- Spiritus Myristicae, Syrupi, aa 3J. Aqua?, ad 3 viij. A tablespoonful with each dose of the oil. R. Acidi Phosphorici dil , 31'ij. xicidi Hydrocyanici dil., 3J. Tinct. Lupuli, Syr. Zingiberis, aa 3L Inf. Aurantii Comp., ad 3*viij. To be given with the oil as above, when the stomach is irritable. 286 ANTIPHTHISICAL REMEDIES. more agreeable than that of ether and other volatile essences which have been recommended, and they just as effectually pro- mote the pancreatic secretion, without causing eructations, as the latter generally do. Although I have expressed my thorough belief in the neces- sity of the constant administration of antiphthisical remedies in the treatment of consumption, yet I am much opposed to the practice of overdrugging in this or in any disease. Therefore it is that I recommend all necessary tonics to be combined with the two inevitable doses of oil, and that no other medicines should be given, unless called for by the urgency of particular symptoms. Thus a great many phthisical patients go on very well for weeks and months together, with their two doses daily, and enjoying all the additional benefit to be gained from gener- ous living, and health-giving air and exercise. And happy is it for them when they are also able to continue in their usual occupations, with proper caution and with a due regard to their invalid state. The antiphthisical treatment requires that there should be no fatigue, no night-work, no undue wear and tear, and an accumulation rather an expenditure of strength from day to day; but a light congenial employment of body and mind is more invigorating and conducive to health than absolute idle- ness. There is a class of agents which may be made useful as anti- phthisical remedies in those stages or forms of consumption in which there is a manifest tendency to corruption or even putre- faction in the system. I speak not of gangrene or gangrenous abscess only, in which the ultimate decomposition of"animal matter is obvious to our senses, and strongly calls for antiseptic remedies, but to those more numerous cases in which the ex- pectoration is more or less offensive or disagreeable without being putrid. That which commonly occurs in ozeena some- times also takes place in the bronchial tubes or in phthisical cavities, and calls for the use of correctives used by swallowing, and also by inhalation. In other cases, the perspiration or the faeces have an unusually offensive odor, and give evidence of their containing corrupt or decomposing matter. In all such cases the strengthening or tonic plan may well be supplemented by the addition of certain antiseptics, which have no deleterious influence on the economy. The nitro-hydrochloric or sulphurous acid may be substituted for other acids, and may be given more largely if combined with glycerine, which sheaths the irritating property of the acids. Creasote and carbolic acid, which are pretty much alike in their nature and action, I have also found of great use, and may be used in emulsion with glycerine and mucilage. The latter may also be effectively used'by inhalation with water, in vapor or in spray, two or three times a day; the PALLIATIVE TREATMENT. 287 spray will be found most agreeable in the summer, and the vapor in winter. The improvement in the character of the cough and expectoration, will be sufficient inducement to persevere; and when, from weakness or disinclination, patients get tired of the process of inhalation, it may still be useful to diffuse the vapor through the air of the apartment by means of Siegles's or Maw's vaporizers. The attendants, as well as the patient, may be bene- fited by this measure. The diffusion of mere watery vapors in the rooms occupied by pulmonary invalids is of great use during the prevalence of an east wind, and, by similar means, an anti- septic agent or oil of wood pine may be added in case of exces- sive or offensive expectoration. The only other antiphthisical remedy which it is necessary to mention is arsenic, which has recently been strongly recom- mended in France. I have tried it only to a limited extent; for, to say the truth, I have been afraid to interfere with the use of the oil and other remedies in which I have more confi- dence. The only cases in which it has seemed to me to be > useful are those of a chronic kind, with some asthmatic com- plication, especially in conjunction with eczema or psoriasis (as in Case 102). In these both health and flesh seemed to improve under its use. Arsenic possesses tonic properties, allied to those of quinine, and other undetermined influences over respiration and nutrition, which render it well deserving of further experi- mental investigation. CHAPTER XXVIII. PALLIATIVE TREATMENT. By Dr. C. Theodore Willtams. Palliative treatment useful, hut subordinate to Antiphthisical—Treatment of the varieties of Cough bv sedatives and mild expectorants—Cough mixtures, linctus, lozenges—Time and form of administration—Objec- tions to their use—Pain in the chest, how caused and how relieved— Plasters and Liniments—Treatment of Ila-moptysis—Styptics acting on the Blood—Gallic Acid—Tannic Acid—Acetate of Lead, dose and method of elimination-Turpentine—Perchloride of Iron—Styptics act- ino- on the Bloodvessels— Digitalis—Ergot of Eye—External Treatment bvcuppiu"- and blisters—Restrictions in diet and use of Ice—Treatment of ni.'ht-sweats-XiomeverVs Conclusions—Tonics—Acid sponging— Sulphuric and Gallic Acids—Quinine and Iron—Success of Oxide of Zinc—Treatment of Diarrhoea and its varieties—Bismuth—Logwood- Sulphate of Copper—Combination of Astringents with Opiates—Opiate 288 PALLIATIVE MEASURES. Enemata—Tannic Acid—Acetate of Lead—External applications— Constipation—Importance of counteracting it by diet or mild aperients •—Treatment of Bed Sores—Preventive and healing measures—Treat- ment of Laryngeal symptoms—Blistering—Inhalations—Internal ap- plications to the Larynx. Ix the preceding chapters the general treatment of Consump- tion in its antiphlogistic and antiphthisical aspects has been discussed, and we will now sny a few words on the pallia/ire treatment of the disease. Measures for improving the general health and strength of the patient and counteracting the con- sumptive cachexia are of far greater importance than those di- rected to the mere alleviation of the symptoms; but as these, by the irritation they cause, often induce sleeplessness, feverish- ness, vomiting, &c, and thus interfere with the general progress of the patient, it is obvious that we must use all means in our power to allay them, always taking care that our palliative measures do not interfere with the constitutional ones. Cough is usually the most prominent and troublesome symp- tom ; if loose and slight in amount, it had best be left alone, but when it is hard and frequent, and interferes with the patient's rest at night, it should be allayed by the use of narcotics, the choice of which and its combination with other drugs, must de- pend on the nature of the cough and the amount of expectora- tion. When the cough is hard, and the expectoration, though free, only slight in amount, linctuses, containing opium or its salts, codeia or morphia, combined with such simple expecto- rants as lemon-juice and chloric ether, are most useful. When the cough is very violent, and ends in retching and vomiting, dilute hydrocyanic acid may be added with advantage; and when the expectoration is offensive, glycerine of carbolic acid, or sulphite of soda goes far to correct the fetor, and at the same time assist the expectoration.1 Sometimes the cough is convulsive, and accompanied by a great deal of wheezy breath- ing or stridor, it may then be relieved by belladonna", stramo-- nium, or Indian hemp, in doses of a quarter or half grain in a pill at night. In some kinds of convulsive cough, with difficult expeetora- 1 A few formulae are annexed : ft. Liq. Morphia? Acetat, spss. R. Liq. Opii Sedativ. Spir. Chloroformi, 3J. Acidi Hydrocyanici dil., aa Zss. Succi Limonis, gss. Spiritus Chloroformi, zj. Mucilaginis Acacise ad gij. Aqme ad 5ij. Dose, a teaspoonful. Dose, a teaspoonful. R. Liq. Morphias Acetat, gij. (xlyeerini Acidi Carbolici, zj. Oxymellis Scilla?, gss. Mucilaginis Acaciae ad ^ij. Dose, a teaspoonful. COUGH MIXTURES—WHEN USEFUL. 289 tion, we have found a combination of bromide of ammonium with chloral hydrate very efficient.1 Strong expectorants, equally with the old-fashioned emetics, are, as a rule, to be avoided as tending to upset the stomach; but when the expectoration is difficult, or if there be temporary bronchitis^ and increased bronchial secretion, small doses of squill or ipecacuanha are indicated. When the cough is very hard and troublesome at night, a few drops of laudanum, liquor opii sedativus, or bimeconate of morphia, in an effervescing sa- line, generally allay the irritation and induce sleep. Lozenges of morphia, or morphia and ipecacuanha, or opium, are recommended as portable cough sedatives; but it is advis- able to restrict the use of these and of the cough mixtures to the night, so as not to upset the stomach, and thus interfere with the antiphthisical treatment pursued during the day. Apart from this objection to their use in the daytime, they are more required at night, their great use being to insure to the patient a certain amount of refreshing slumber, and thus in- crease his strength and appetite. J^iin in the c/iest is another symptom which sometimes requires direct treatment. It is referred to various parts of the chest, but very often to the subclavicular spaces. When it is of a dull aching kind and not markedly localized, belladonna or opium plasters generally give relief. If more poignant, mild counter- irritation with either tincture of iodine, or one of the turpentine liniments, of which the Linimentum Terebinthinae Acetium an- swers best, is advisable. If more severe, and especially if physi- cal examination detects any decided cause for it in the existence of dry pleurisy, or pleuro-pneumonia, then let recourse be had to vesication, either by means of a small blister, which is perhaps the least painful process, or by means of the liquor epispasticus, which generally acts very rapidly, or again by either the liquor iodi or the strong iodine liniment"; the last being rather painful in its action. A good form of mild vesicant is composed of three parts of a strong acetum eantharidis to one of spiritus camphoree. This has been largely used in Dr. C. J. 13. Wil- liams's practice with success; the object being to create slight vesication on a large surface from time to time, but not to cause a permanent sore. And this reminds us that we should not omit a mention of setons and issues, which were formerly in high repute among physicians, and there is little doubt that 1 R. Ammonii Bromidi, Chloralis Hydratis, aa ^iss. Syr. Papaveris, ^ss. Aquae Menth. Pip. ad 5viij. An eighth part two or three times a day. 19 290 PALLIATIVE MEASURES. much good was obtained from their use, but now that we have at our command such a variety of means of counter-irritation, most of which are more agreeable in application, and at the same time as efficacious in action, it is not wonderful that the seton, with its attendant discomforts, has fallen into disuse. Hemoptysis when so slight as not to amount to a teaspoonful, hardly requires the use of styptics, but may be treated by rest, by avoiding excitement and alcoholic stimulants, and by mild counter-irritation. Where, however, the quantity expectorated exceeds that amount, or continues to recur, it should be promptly checked; and there is the more reason for doing so if a cavity is known to have formed, or to be forming, in either lung; as such hemorrhage is likely to be more profuse, and if not checked, may end fatally. A common, and generally a very effectual styptic, is gallic acid, given in powders either alone or combined with acid tartrate of potash,1 and continued every three or four hours while the bleeding lasts. These powders are a convenient and portable form of medicine; and as but little harm follows from their being taken frequently, they can be safely left in the patient's hands; which is more than can be said of some of the more potent styptics. Tannic acid is a stronger remedy, which we have found more useful in other kinds of hemorrhage, as epistaxis, hoemateme- sis, and haemorrhcea; but in hasmoptysis it is useful to combine it with gallic acid,2 if the latter prove insufficient to check the blood flow. A more powerful styptic is the acetate of lead, but the dose and mode of administration require some care and attention. In order to produce decided effect on the bleeding, it should be given, not in two or three-grain doses, as many practitioners are in the habit of doing, but in doses of five grains at a time, in the form of a mixture with a little excess of acetic acid, every three or four hours, and where the hemorrhage is very profuse, it may be given every two hours, or indeed every hour. To prevent the constipation, colic, and the cachexia consequent on the accumulation in the system of so large a quantity of lead, a draught of sulphate of magnesia and sulphuric acid, 1 R. Acidi Gallici, Pulv. Sacchari, aa gr. x. Potassae Tartratis Acidae, ^j. Pulv. Cinnamonis, gr. j. The powder to be taken every three or four hours. 2 R. Glycerini Acidi Gallici, ^ss. Acidi Tannici, ^j. Tinct. Digitalis, zjss. Syrupi Papaveris, ^ss. Aquae ad 3viij. An eighth part to be taken every four hours. TREATMENT OF HEMOPTYSIS. 291 should be administered every morning. With these precau- tions large doses of lead have been given for several days, with the effect of checking very profuse haemoptysis, and without any bad results. Oil of turpentine in doses of ten minims and upwards is by no means a pleasant remedy, but may be resorted to occasion- ally, and the taste be covered by an aromatic infusion, as pep- permint or cloves. The tincture of perchloride of iron is rec- ommended in states of extreme weakness. The above styptics, as also alum and sulphuric acid, check the hemorrhage by causing coagulation of the blood ; we will now notice some which will probably owe their astringent power to their contracting the bloodvessels. Digitalis, in doses of half a drachm and upwards, exercises a marked effect, but its use is more adapted to haemoptysis from cardiac disease, than to this form of hemorrhage. In cases of consumption, however, where the heart's action is violent, or where the com- plication of cardiac disease exists, digitalis succeeds best; and in smaller doses it may be well combined with other styptics, as with gallic and tannic acids. Our experience of ergot of rye has been most satisfactory : we have often tried it when other styptics have utterly failed, and with prompt and decided effects ; the dose should be at least a drachm of the fluid ex- tract, and a few repetitions of it will soon test its effects, after which if success has followed, the quantity had better be re- duced, and soon discontinued. Another way of treating profuse haemoptysis is by dry-cup- ping the chest, generally in the interscapular and scapular res;ions ; and tiiis method has the advantage of immediate and decisive action, though the effects are not always lasting. A slower process of derivation, but one that answers well, when the hemorrhage is somewhat reduced by strong styptics, is the application of a blister; and we have by this means spared the patient several doses of astringent medicine, which, for his stomach's sake, must be considered highly desirable. But we must not forget to enforce the common sense measures for arresting hemorrhage, which will sometimes prove efficacions without the administration of medicines, and always greatly assist their action. The patient should be kept in bed, with his body and mind free from all excitement; his room should be cool, as also his beverages, which may be iced; and, except in cases of great exhaustion, must be quite free from all alcoholic stimulant. His diet should be restricted to nutrient liquids, such as cold beef-tea, chicken broth, milk, &c, and he can suck ice freely but we cannot sanction the application of ice to the chest__a" practice which has been known to induce pneumonia and consolidation of the lung of a phthinoplastic kind. 292 PALLIATIVE MEASURES. The bowels should be kept freely open, and tonic medicines, for tbe time, discontinued. Night-sweats should be attended to, as they greatly exhaust the patient, and often interrupt his needful slumbers; but the course of antiphthisical treatment already described sometimes has the effect of removing them without any special remedies being required. Where it does not do so, there is no lack of agents, of which one or other is pretty sure to answer the pur- pose; and we cannot understand how ^Niemeyer1 could have come to the conclusion, that "there are no means of relief for this distressing symptom;" but we conclude from his mention- ing only a few medicines, and these with doubts as to their efficacy, that he had not tried others of proved value. Where the perspirations are only slight, sponging the chest with toilet vinegar, or dilute sulphuric acid, at night is sufficient; where more profuse, a night draught of half a drachm of dilute nitro-hydrochloric, or sulphuric, acid in glycerine and water, will often answer the purpose. Gallic acid in ten-grain doses once or twice a day, is an excellent remedy, and sometimes the addition of the tincture of perchloride of iron, or sulphate of quinine, to the daily tonic will have the desired effect; but these two last drugs are apt to increase the cough, and must, therefore, be given with caution. The medicine we have found to act almost as a specific on night-sweats is the oxide of zinc, in doses of two or three grains, in the form of a pill at night. This we have given ourselves, and seen other physicians give, to thou- sands^ of patients, and the good results have generally been so prompt and lasting, that in few cases has it been necessary to continue its use for any lengthened period. Diarrhoea is a symptom which, more than any other, demands special treatment, and its continuance for any length of time produces rapid emaciation and prostration, and often places an otherwise improving patient beyond tbe pale of recovery. The diarrhoea met with in phthisis arises from more than one cause, and must be treated accordingly. If a foul tongue, a bad taste in the mouth, a tenderness in the right hypochondrium with nausea, and an unhealthy state of the faeces, show that bilious derangement exists, a dose of blue pill or gray powder, com- bined with some mild aperient like rhubarb, is required before any steps are taken to check the diarrhoea. When the purging is slight and accompanied by a decidedly acid state of the in- testinal canal, a combination of lime water,2 or bicarbonate of 1 Text-Book of Practical Medicine. 2 R. Aqua? Calcis, ^ij. Decocti Haematoxyli, ^iv. Dose : Two tablespoonfuls every four hours. TREATMENT OF DIARRHCEA AND CONSTIPATION. 293 soda with a mild astringent, as haematoxylum and carbonate or citrate of bismuth, is often sufficient, but where the redness of tongue and the persistence of the diarrhoea indicate ulceration to be going on, opium must be given, five to ten minims of laudanum or of Battley's solution being added to each dose of the mixture.1 Stronger and more effectual remedies than these, are the sulphate of copper in quarter.or half-grain doses, com- bined with opium or extract of poppy, but as the administration of the copper is sometimes followed by griping, it must be given with great caution, especially in cases where pain or tenderness in the abdomen is complained of. When the stomach is irritable, and it is undesirable to give much medicine by the mouth, opiate enematamay be used; and these as a rule comfort tbe patient greatly, by checking the diarrhoea and subduing the accompanying pain. They are generally composed of starch or gruel, containing twenty or thirty minims of laudanum, and in very obstinate cases, two or three grains of tannic acid or three or four of acetate of lead may be added. It is hardly necessary to remark, that all substances likely to irritate tbe intestinal canal must be carefully eliminated from the diet, and the patient restricted to arrowroot with milk or brandy in it, and such other wholesome nourishment as he can retain. Warm applications to the abdomen, as poultices, con- taining opium, turpentine stupes, and hot fomentations, aid in reducing the diarrhoea by diminishing the internal congestion, and lessen the pain occasionally accompanying ulceration; but this process, we know, may proceed without pain, and indeed, as Dr. Powell2 has shown, without diarrhoea. Though diarrhoea is common in the later stages of consump- tion, the opposite state, i. e. constipation, often prevails in the earlier ones, and should be counteracted, for two reasons; firstly, because it is impossible for the oil to agree if the biliary and intestinal secretions are not properly discharged, but allowed to accumulate in the intestines, causing flatus, loss of appetite, &c. ; and secondly, because phthisical patients are more liable to haemoptysis when the bowels are costive than when they act regularly. The simplest method of correcting this state is by introducing into the diet a fair amount of fresh or cooked fruit; or by sub- stituting the use of brown bread for white,, the bran in the for- 1 R. Liquoris Bi^muthi et Ammonias Citratis, ^j. Xiquoris Opii Sedativi, f^ij-iv Spir. Myristica?, z.-s Decocti Hiematoxyli, ad ^viij. Dose: An eighth part every four hours. 2 Pathological Transactions, vol. xix, p. 7(J. 294 PALLIATIVE MEASURES. mer acting as a simple irritant to the mucous membrane of the intestines. Where dietetic means fail, recourse must be had to aperient medicine, the continuous action of a mild purgative being pre- ferred to the prompt but less lasting results of a stronger one. Tbe confectio sulphuris, or an electuary1 composed of sulphate of potash and confection of senna, taken in a teaspoonful dose every night, is often sufficient; but what we have found most successful is a pill2 of Barbadoes aloes, containing H or 2 grains of the extract, combined in the more obstinate cases with \ grain of extract of nux vomica, and taken at bedtime. Dyspnoea may be relieved, if coming on suddenly, by spirits of ether and sal volatile, or by the inhalation of oxygen; if of a more chronic kind, by a combination of chlorate of potash and nitric acid. Bed-sores should be prevented by carefully watching the state of the skin of the back and sacrum, and by placing the patient on a water-bed, of which the half or three-quarter length sizes are generally preferable to the full-length ones. When the skin, though red, is still unbroken, a wash of brandy-aud-water, one part in four, has a fortifying effect, but if it is broken, collodion flexile may be applied with a view to form a protecting film, and thus afford the skin an opportunity of healing. This is. however, of little use if means be not taken to remove pressure from the part, which should be left free for dressings. A circu- lar air-cushion will do the former, but at the Brompton Hos- pital it has heen found that these soon get out of order, and cushions of down of similar shape have been substituted. An- other method employed is to apply a piece of thick felt plaster, or of the material known as " rhinoceros hide," perforated with a hole the size of the wound, and then to treat it with water dressing. Some of the worst symptoms of the disease are those which indicate the different stages of ulceration of the larynx, pricking pain in the region, difficulty of swallowing owing to the swollen or ulcerated epiglottis, hoarseness, gradually amounting to aphonia, and from time to time, convulsive dyspnoea. Here, some relief may be afforded by blistering tbe larynx externally, and by inhalations of conium, carbolic acid, or iodine, inter- nally; and we have known great comfort being given by the 1 R. Potassae Sulphatis, 2 R. Extracti Aloes Barbadensis, gr.iss. Syrupi Zingiberis, ail 5SS. ------"Nucis Vomica, gr. £. Confectionis Sennae, 5J. Potassae Tartratis Acidaj, gr. j. Dose: A teaspoonful every night. Mastiehi, gr. iss. Spiritus rectificati q. s. To be taken every night. The acid tartrate of potash is added for the purpose of dividing the pill sub- stance, and the mastich and spirit to make the pills keep for a long time. DIETETIC AND HYGIENIC MEASURES. 295 use of the sulphurous acid in the form of spray, either alone or diluted with an equal amount of water. Where the epiglottis is much swollen, temporary relief is afforded by scarifying it; and Dr. Marcet1 has had good results from applying a solution of iodine in olive oil, to the interior of the larynx with a brush. Dr. Powell finds a linctus of morphia, chlorate of potash, glyc- erine, and syrup soothes the swollen epiglottis and renders swallowing more easy; and we have seen some good done by a combination of chlorate of potash, tannic acid, and glycerine applied to the upper part of the larynx with a brush ; but we must confess that hitherto no great progress has been made in the treatment of this very distressing group of symptoms of consumptive disease, and we trust that the efforts of practitioners will some day be more successful than they are at present. CHAPTER XXIX. DIETETIC AND HYGIENIC MEASURES. By Dr. C. Theodore Williams. Effects of good diet on Consumptive patients—Object of Diet—Importance of Meat—Exemption of Butchers from Consumption—Raw Meat: when useful—Blood drinking—Vegetables and Fruits—Objections to Pastry, Salads, Pickles—Cautions as to the use of fatty and oily food—Bread and farinaceous articles—Liquid Nourishment—Stimulants—Mode of administration and uses—Varieties and Rules for their selection— Brandy and Rum best combined with Food—Cooling Drinks—Cloth- ing—Best material for underclothing—Warm Wraps—Exercise : its Benefits—Active Exercise : its Object and Varieties—Rowing—Swing- ing—Gymnastics—Walking — Passive Exercise: its Varieties—Car- riage—Sailing—Their effects—Riding—Its great advantages—Habita- tion—Soil and Site—Locality and Shelter—Temperature—Ventilation and Drainage. The dietetics of consumption form a very important item in the antiphthisical treatment, and the careful regulation of the food and drink, according to the capabilities of each patient, requires the greatest attention. At the same time it is evident that, though a sketch may be made of the system to be pur- sued, fixed rules cannot be laid down as to the variety or amount of food to be taken in all cases. i Clinical Notes on Diseases of the Larynx, x, p. 95. Dr. Marcet's formula is : R. Iodi., gr. xx. Potassii Iodidi, gr. v. Olei Olivae, Jj. 296 DIETETICS. We know that on good diet alone, without any medicinal aid, consumptive patients have increased in strength and weight, and of this Dr. Risdon Bennett has published some striking ex- amples.1 We have occasionally seen similar instances among the in-patients of theBrompton"lIospital, and they demonstrate what effect good and plentiful fare may have on those unused to it; but great improvement, on generous diet alone, has not in our experience often occurred!T Indeed, the ingestion and apparent assimilation of large quantities of food without in- crease, and with even decrease, of weight, has often struck us as a remarkable proof of the consuming nature of the disease.. The great object to be kept in view, as Dr. Pollock briefly expresses it, is "to supply the largest amount of the most nutritious food which can be digested." But this is not al- ways an easy task in a complaint where the appetite is likely to fail and the stomach is prone to derangement. Whenever it is possible, fresh meat plainly cooked and un- alloyed with rich sauces, gravy, or stuffing, should be taken two, or even three times a day, and the diet varied occasionally by the introduction of poultry, fish, and game, but a decided preponderance of butcher's meat, not overloaded with fat, should be retained. A striking proof of the importance of this point is furnished by the rarity of consumption among butchers ; and although the airy and open shops in which they live, and the amount of outdoor exercise which they take, may contribute to their good health, their exemption from phthisis must be principally as- scribed to the quantity of meat they consume, for, in addition to the cooked article taken at meals, they are in the habit of nibbling bits of raw meat while serving their customers,—a practice which explains the comparative frequency of entozoic disease in this trade. We may mention, by the way, that the use of raw meat in consumption has been much advocated in France and Germany; and we have seen some good derived from its use, when the patients were hysterical girls who would not eat; but it is in the wasting diseases of childhood, that uncooked meat is most useful. When mixed up with sugar, in the French method, it forms a palatable sweetmeat, much liked by chil- dren, though the absence of cooking renders them liable to worms from this source. Another practice, carried on in the South of France, and which we cannot regard as otherwise than disgusting, is to drink lamb's blood;2 and when at Hyeres we, ourselves, witnessed with a shudder, elegantly dressed i Medical Times and Gazette, 1869. 2 Some years ago Dr. Marcet invented some biscuits, composed of the clot of sheep's or bullock's blood and chocolate, which seems to be a less objectionable mode of trying this form of nout ishment, if it is to be tried at all. MEAT AND VEGETABLES. 297 French ladies repair daily to the slaughter-house and quaff the reeking draught, but with what result we never learnt. Fresh vegetables, plainly dressed, and a small amount of ripe fruits, as, for instance, oranges, grapes,1 apples, and pears, are to be included in the dietary; but rich pastry, savory dishes, salads, containing much vinegar, pickles of every kind, and the like, are to be carefully avoided, both as tending to upset diges- tion, and as interfering with the prolonged use of cod-liver oil. With regard to butter, cream, suet, and various other oily or greasy matters, we must-bear in mind that the stomach and liver are already somewhat tried by the regular administration of cod- liver oil, one of the most easily assimilated members of this group, but still occasionally giving rise to symptoms of bilious- ness and gastric disturbance, and it is therefore highly important not to tax these organs further by the introduction of large quantities of fatty or oily material. Great moderation should be observed in the use of these articles, and, as has been men- tioned in a former chapter, the quantity of milk should be limited. At the same time it must be remembered that there are individuals who can assimilate almost any quantity of fatty matter, and to these the above recommendations do not apply; indeed, such can and do sometimes take cream, in addition to the oil, with benefit. Moreover, where much exercise is taken more fat can be tolerated. Bread, eggs, and farinaceous food naturally complete our dietary; but we cannot recommend cheese, as it is somewhat trying to the digestion, and may take the place of more nutritious material. In cases of very advanced phthisis, when the intestinal canal cannot tolerate, or assimilate solid food, it will be necessary to have recourse to liquid nourishment, in the form of soups, beef- tea, or chicken, mutton, or veal broth, the various meat essences, and panadas, alternating the same with jelly, arrowroot, tous- les-mois, oswego, tapioca, sago, Iceland moss, and other articles of invalid diet, and these last should be nicely flavored with lemon or orange-peel, with orange flower or vanilla, so as to render them more tempting. Though we cannot go as far as Dr. Flint in the importance to be attached to the use of stimu- lants in consumption, yet we highly commend them when taken with food, and not alone, at odd times between meals, as is done by many persons—a custom more sociable than wholesome, and specially injurious to the stomach, for the gastric juice is thus stimulated to secretion, and having no food to digest, acts on the walls of the viscus, giving rise to flatulence and loss of ap- i The ■' grape cure," which is carried on by the lake of Geneva, and at Meran in the Tyrol, is supposed to diminish the excess of fibrin in the blood of con- sumptive patients. 298 DIETETICS. petite. When the mealtime comes, the food is not thoroughly relished, and, on account of the waste of the gastric juice, im- perfectly digested. The two principal uses of stimulants in consumption are, firstly, to increase appetite and promote digestion; secondly, to stimulate the heart's action, and thus obviate the tendency to death by syncope. For the last purpose it is only required in the very advanced stages of the disease; but in the first lies its principal utility, the only drawback being that stimulants are apt to increase the cough and local irritation, but they are less liable to do so if mixed with water. As regards the choice of different kinds, much must depend on the state of the organs of digestion and circulation. If the patient be not of a bilious habit and tbe cough be not troublesome, malt liquor—in the form of bitter ale, table beer, or even stout—is a capital appetizer; but in case of liver disturbance, sherry mixed with water, or hock, or chab- lis, answers the purpose better. If the cough is at all trouble- some, the amount of stimulant should be diminished, and some- times its use discontinued altogether, but the least irritating to the chest appears to be good wholesome claret; Burgundy and port are rather too fiery for this purpose. Champagne is only to be employed in cases of extreme weakness, and then but for a limited period. Brandy, gin, rum, and whiskey, are most useful in the last stages of the disease; but they are best tolerated when combined with nourishment, in the form of brandy and arrowroot, egg-flip, rum and milk, and other numerous combi- nations which the physician and nurse have to employ to insure a proper amount of food and stimulant being taken by the pa- tient. The custom of taking a cup of rum and milk in the morning, before dressing, is very beneficial to weak subjects. The thirst often complained of in the feverish stages of the dis- ease may be met by iced toast-and-water, barley-water, tama- rind-drink, seltzer-water, soda-water and milk, and other cooling fluids. Let us now notice a few hygienic measures, without which the treatment of consumption would be incomplete. Clothing.—We need not observe that consumptive patients, who are more susceptible than others to the process called "catching cold," and in whom it often sets up intercurrent pneumonia and bronchitis, should clothe warmly, though not to such an extent as to produce perspiration or diseased tat. The most important point to be attended to is the under- clothing, which for at least eight months of the year should be of flannel, lambs' wool, or some other woollen material, and should not only cover the chest completely, but also encase the whole body and lower extremities. The double-breasted lambs' CLOTHING AND EXERCISE. 299 wool jersey answers the purpose well, and should be worn with drawers of the same material, or of flannel, and with woollen socks or stockings. In the summer months a thinner clothing of merino may be substituted, but the change must be carried out with great caution. Over-clothing is also of consequence, more especially when the patient is driving out in a carriage : and in this particular he can hardly be too careful, for with a weak circulation, and but little means of exciting it, he must prevent the chilling effect of radiation from his body by wrap- ping up warmly in furs and rugs, and if this should be insuffi- cient, by supplyitig extra heat by a hot flask to his feet. Exercise.—It may be safely stated, that, in all cases of phthisis, exercise in some form or other is beneficial, and the good derived where the patients are able to avail themselves of it, is very evident, as seen by the increase of appetite, by the quickened circulation, and the sounder sleep which so often follow when exercise is taken by the patient. Whether it should be of the active or passive kind, and what varieties of each are admissible, depends on the stage and type of the disease, and also on the strength of the patient. In the early stages, where the symptoms are not active, where there has been no recent blood-spitting, and where the cough is not hard or frequent, those varieties of active exercise are of most advan- tage which most effectually expand the upper portions of the chest, thereby bringing into play the upper lobes of the lungs, so generally the seat of phthinoplastic lesions ; and by causing the blood to circulate freely through the pulmonary tissue, they prevent local congestions and fresh deposits, and aid materially in the absorption of old ones. What are the varieties of exercise which best accomplish this end? Those in which the upper extremities are raised, and the muscles connecting them with the thorax brought into activity. When the arm is raised, the numerous muscles which arise from the ribs and are inserted into the bones of the upper extremity, e.g., the pectoralis major and minor, the subclavius, the serratus magnus, &c, in contracting, raise the upper ribs, and thus increase the size of the chest cavity. This necessitates the inspiration of a larger amount of air. Dr. Silvester has called attention to this important principle, and on it has founded his excellent system of restoring respiration in cases of drown in «>", narcotism, &c. He has also recommended a modifi- cation of it in the incipient stages of phthisis. The forms of exercise which carry out this principle are; rowing, particularly the pull and backward movement; the use of the alpenstock in mountain ascents; swinging by the arms from a horizontal bar, or from a trapeze; climbing ladders or trees. Dumb-bells, as commonly used, are calculated to develop the arms more than 300 HYGIENIC MEANS. the chest; and rather tend to depress the latter by their weight. Various special gymnastic exercises, of which there is a great choice nowadays, may more or less answer the purpose; but there is one form which is particularly applicable to the object above mentioned, viz., the gymnast invented by Mr. Hodges. To make this instrument answer the purpose of a chest elevator or expander, it should be fixed, not, as it is sometimes done, at the height of the operator, but considerably above his head, in or near the ceiling, with tbe handles reaching down about to his shoulders, then, by holding the handles, and walking a few paces forwards and backwards, the arms are brought into a species of action, which, while it exercises the whole body, especially tends to expand and elevate the upper part of the chest. Walking exercise as a rule, does not work the upper extremi- ties or raise the upper ribs, but acts generally on the system by drawing the blood to the extremities and quickening the circu- lation through the lungs. In mountain ascents and in fast walking the quickening of the circulation brings the whole lungs into play, and in this way the upper lobes come into full use. If the alpenstock be used in mountain climbing, the beneficial local effects of raising the upper ribs may be com- bined with the general advantages of walking. Walking exer- cise can be taken in all stages of phthisis, provided there be no active symptoms present. Even where cavities are formed, if there be no recent inflammation, a limited amount, and per- formed on level ground, is beneficial, but great care must be taken not to overtax the patient's strength. Passive exercise may be used by the weak and delicate, even in advanced stages of phthisis, or when it is of the inflamma- tory type. Open carriage exercise, sailing, or being rowed in a boat, or carried in a hammock, are instances in all of which little muscular exercise is involved, and they may be considered as means of supplying a constant change of air, with the least fatigue, while their effect in improving the circulation and appetite, and in promoting sleep, is often very apparent. But even these make some demand on muscular and nervous power, and must not be carried to the extent of producing exhaustion in weak subjects. Riding exercise, from the time of Sydenham, has been gener- ally acknowledged to be peculiarly beneficial to consumptive patients who are strong enough to bear it; and it is difficult to find a form of exercise which so admirably answers the purpose of giving plenty of fresh air and thoroughly warming both body and extremities with so small an amount of fatigue. Habitation.—The residence of the consumptive patient should be situated on a dry soil of sand or gravel, free from admixture HABITATION. 301 with clay or other material likely to collect or retain moisture. It should stand on slightly elevated and sloping ground, so as to insure thorough surface drainage. Vegetation should be present in order to keep up the supply of oxygen, and it should not be rank, succulent, or in excess; but short, herbaceous, heathery, and flower-bespangled, like the grass fields of a dry and open country, or the downy herbage of a hillside or elevated common. Shrubs, such as broom, furze, thorn, and thin copse- wood are welcome, and a few trees, scattered or arranged with a view to shelter; but dense woods and large deciduous trees, the chief ornament of park scenery, do not add to the healthi- ness of the air, but greatly increase its humidity. There is no objection to the neighborhood of pines, especially on the north side of the dwelling, their dry shade and fragrant odor being very pleasant, and forming the great attraction of certain locali- ties, as Bournemouth and Arcachon ; indeed, the turpentine in- halations from this source are held in great repute in many parts of the Continent, and form one of the numerous " cures" so congenial to the German mind. The vicinity of marshy or swampy ground is of course to be avoided, as likely to cause malaria, and even that of low lands and valleys with a clay soil or subsoil, for moisture is generally excessive in such districts. Peat bogs, on account of some antiseptic property, do not en- gender malaria, but are not exempt from the imputation of dampness ; and any one who has witnessed the swarms of midges on a Scotch morass can testify to their capacity of breeding one kind of plague at least. The close proximity of the house to lakes or ponds of fresh water, or of slowly running streams, lit- tle below the level of the ground, is not desirable, as the amount of moisture in the air is thereby increased ; but this does not ap- ply to the margin of the sea, for there is certainly something corrective, if not antiphthisical, in salt water and the vapor aris- ing from it, which renders sea-damp less injurious than land- damp. The house should be protected from northerly and easterly winds, and well open to the south and west. The walls should be thick and the windows "large, so as to allow, if necessary, of thorough ventilation; the rooms should be lofty and airy, and the temperature kept as near 60° F. as circumstances will admit of; whilst means are taken to maintain this degree of warmth, others should not be omitted to insure a frequent and abundant supply of fresh air, either through the top of the window, or through ventilators opening outside, and also for the removal of theimpure air. We need hardly add, that the drainage ar- rangements should be efficient and complete. 302 CLIMATIC TREATMENT. CHAPTER XXX. CLIMATE. By Dr. C. Theodore Williams. Immunity of Localities from Consumption not assignable to any one condi- tion of life—Objections to High Altitude Theory—Kirghis—Icelanders and Faroese—Objections to "Koumiss" theory—Twofold Causation of Consumption—Influences originating Inflammatory Attacks—Septic Influences—Nature of disease dependent on its causation—Knowledge of Countries where each class prevails, a guide to climatic treatment— Objects of change of climate—Division of Climates into Marine and In- land—Marine—Their stimulating and equable qualities—Caution as to vSeaport Towns—Cool and moist British Coast Stations—Dry Climates of Mediterranean Basin—Warm and moist Madeira group—Inland Climates : their great diversity—Division into three groups—Calm and Soft—Dry and Warm—Climates of elevated regions—Marine Climates suitable for Consumption arising from Inflammation—Choice dependent on degree of irritability of system—Inland localities best tilted for most irritable variety—Climate of elevated regions indicated for Consumption of Septic origin—Restrictions—Residence at high altitudes important as a preventive measure—Ordinary Chronic Consumption best treated by warm, stimulating climate in winter, and cool, bracing climate in summer—Importance of Exercise—Inland Climate of Xorth America— Sea Voyages—Advantages and Disadvantages—Cautions—Certain cases of Consumption unfit for change of climate—Practice of sending Patients in advanced Consumption Abroad condemned. Climate.—We cannot attempt, in the few remaining pages of this book, to discuss the important subject of Climate, in all its relations to Consumption, but must refer our readers to what we have published elsewhere on the subject.1 What we aim at doing, now, is to point out the existence of certain indications which should form the ground for the physician's decision, as to the climate most likely to be of benefit. And here we must premise, that taking a fair survey of our present knowledge of the geography of phthisis, we cannot subscribe to any theory which assigns immunity from the disease to any one condition of life, and to that only, as, for instance, elevation above the sea, or dryness of soil, or to the use of certain kinds of food, as koumiss, blaand, &c. To the supporters of the high altitude theory, the existence of the Kirghis, who are quite" free from consumption, living on vast steppes, 100 feet below the level of 1 The Climate of the South of France as suited to Invalids, with Notices of Mediterranean and other Winter Stations, and an Appendix on Alpine Summer Quarters, and the Mountain Cure, 2d edition. THEORIES OF IMMUNITY FROM CONSUMPTION. 303 the sea, is, as Br. Charlton1 well shows, an insuperable objec- tion, which is borne out by the inhabitants of Iceland and the Faroe Isles, who live at but slight elevations above the sea, and, as regards their dwellings, under very unhygienic conditions, but are equally free from this disease. To those who consider that the use of koumiss2 or fermented mare's milk among the Kirghis, and that of blaand or the sour whey from cow's milk among the Icelanders and Faroese, is the cause of their im- munity from consumption, may be opposed the example of the dwellers on the high table lands of the Andes and of the Alps, who do not commonly use such beverages. We may here remark, that in the somewhat revolting diet of the Icelanders and Faroese, which embraces fish and flesh in an almost putrid condition, there is one article which seems more likely than blaand to explain their salubrity, viz., cod-liver oil, for this, under the name of " muggy," is consumed by all classes and largely. A more probable view, and one more likely to explain the various phenomena presented by the distribution of phthisis throughout the world, is given in page 105, viz., that its causa- tion is at#least twofold, and possibly more complex. Firstly. The influences which excite and keep up inflammatory affec- tions of the lungs, the products of which are apt to be of a lowly organized kind, tending to contraction or to caseation. Such influences are the prevalence of cold and damp weather, and frequent changes of temperature. Secondly. Septic influences, which blight and corrupt portions of the bioplasm of the blood, or of tbe lymphatics, and thus sow the seeds of decay. As, for instance, the combination of warmth and humidity, foul air, bad or insufficient nourishment, weakening diseases, and other gen- eral causes. As has been sta'ted, the co-operation of these two classes of causes often takes place and renders the effect more certain, as when a person deteriorated by foul air is exposed to chill, or when the subject of an inflammatory attack is confined in an impure atmosphere and deprived of the healthy influence of fresh air, of light, and of good food. This twofold causation of phthisis is rendered more probable by the marked difference in the kind of disease which each class of causes gives rise to. Consumption arising from the first class of influences is generally a limited disease of one or both lungs running a chronic course, and is that which prevails most largely in cold and temperate countries. Consumption arising from the second class is a disease with more marked constitutional symp- i Northumberland and Durham Medical Society's Proceedings. 2 We may mention that this drink has lately been tried at the Brompton Hos- pital on consumptive patients, but that the experiment was not sufficiently suc- cessful to warrant its continuance. 30-1 CLIMATIC TREATMENT. toms, is generally tubercular, and runs a more or less rapid course. This type, as Dr. Guilbert has well pointed out, is the prevalent one of hot countries; but instances may be found in abundance, in temperate climates, which are traced to some of the above- mentioned septic causes, foul and hot air, bad nourishment, and the like. It is evident that in our selection of a climate for a patient we should consider the probable mode of causation of tbe disease, whether it was inflammatory or septic, and frame our decision to some extent on the conclusion arrived at. Our great object in consumptive disease is to give the patient as pure an atmosphere as possible, of such thermometrical, hy- grometrical, and other qualities that it can be breathed freely and safely by him. It should, therefore, be free from extremes, humid or dry, and neither too still nor too windy, and its influ- ence on his frame should be furthered by frequent exercise of various kinds carried out in cheerful sunshine, uninterrupted by rainy, misty, or windy weather. Let us glance at the principal varieties of climate at our dis- posal, and examine what forms of the disease each is most likely to benefit. For convenience, let us divide them into Marine and Inland climates. Marine.—By this term we mean the climates of localities situ- ated on or close to the sea, and deriving their principal qualities from that element. The beneficial influence of seaside air on scrof- ula is well established, and Laennee and others entertained a firm belief that it had some curative as well as preventive power over phthisis. All the most favored winter resorts for consump- tive patients in this country are on the seacoast, and most of those in other parts of Europe are so likewise. It is very desir- able to make careful statistical comparisons as to the prevalence and mortality of phthisis and the various forms of scrofula in sea- coast places, compared with those inland. Inquiries that have already been made on these points have obtained discordant re- sults; and further information is required before any conclusions can be drawn. One point deserves mention, as it bears on the present subject. Several of the towns called seaport towns are not on the open sea, and, although they communicate with the sea, the greater number of the inhabitants are living inland, exposed to inland damp and marsh, and to the insalubrious cir- cumstances of a crowded population, on which the vicinity of the sea, or of an arm of the sea, can have no influence whatever. Such are Portsmouth, Plymouth, Liverpool, Bristol, and others; and these we do not designate marine towns, for even those near- est to the sea, as the three first, have much flat marshy ground behind them, on which the sea exercises little or no influence, salt water reaching them only at high tides. Marine climates MARINE AND INLAND CLIMATES. 305 vary according to their latitude, meteorology, soil, and shelter from cold winds, but are all, more or less, stimulating. They are also more equable than inland climates, and less liable to great or sudden changes of temperature. Though their stimu- lating character depends on the quantity of saline matter con- tained in the atmosphere, it is modified by the temperature and the amount of moisture present. As examples of these, where a large amount of humidity is combined with a moderate degree of temperature, we may cite the British and Irish warm coast stations—Torquay, Penzance, Dawlish, Ventnor, Bournemouth, Hastings, Worthing, Tenby, Cove of Cork, and others. Another class of the marine climates are those where a higher mean tem- perature is combined with a far smaller degree of moisture, the stimulating influence being thus considerably increased. Such are the Mediterranean winter resorts—Malaga, Hyeres, Cannes, Nice, Cimiez, Mentone, San lienio, Ajaccio, Palermo, Malta, and Algiers. A contrast to these is the group of Madeira, the Azores, the West Indies, and other islands, where a high mean temperature is combined with a large amount of moisture, and thus the stimulating influence is considerably reduced, and in- deed nearly neutralized by it. Inland.—These depend for their principal features on their latitude, elevation above the sea level, proximity to mountain ranges, soil, and shelter from wind, and vary greatly according to the differences they display in each of these qualities. They have not, like the marine class, any one common feature, as that of a stimulating character, for they may be bracing or relax- ing, according to circumstances. Three groups may be formed out of them : (1.) Mild climates remarkable for their stillness of atmosphere, such as Pau, Ame'lie les Bains, Bagneres de Bi- o-orre, and Pisa. (2.) Warm and dry climates, as Upper Egypt and Syria, parts of South Africa and Australia. (3.) Climates of elevated regions, varying according to the elevation of the locality and its latitude. Such are the climates of the table lands of the Andes, of the high plateaus of Mexico in America, of the Alps in Europe, and of the Himalayas in Asia, varying in altitude from 3C00 to 10,000 feet, and remarkable for their dry- ness, purity of atmosphere, and at the same time for their low temperature. When consumption is of inflammatory origin, it is our object to remove the patients from the action of those influences which have produced, and may again produce, inflammatory attacks, to place him in a well-sheltered locality, and at the same time to apply a certain amount of stimulus to the system, and enable it to develop tissue of a more healthy standard. For this pur- pose marine climates are invaluable ; and our choice between the British, Mediterranean, and Madeira groups, for a winter 20 306 CLIMATIC TREATMENT. residence, must depend, apart from other considerations, chiefly on the degree of irritability which the vascular system and the pulmonary and intestinal mucous membranes show. When this is slight, or when it is absent altogether, the dry climates of the Mediterranean basin are of great benefit, both for the purpose of preventing fresh inflammatory attacks, and of stimulating and invigorating the constitution, and thus correcting phthino- plastic tendencies. The climate of the various winter stations in the sub-Alpine Riviera can be recommended for members of consumptive families, for patients who have shown evidence of lymphatic phthinosis, for cases of chronic scrofulous pneumonia, and for the common forms of chronic phthisis; all which classes of disease derive great benefit from a winter passed in this re- gion ; and even some patients in whom the irritability is rather more marked may do well in this region if they confine them- selves to the softer and less stimulating climate of Hyeres, Cimiez, and Cannet. Cases, however, in which the irritability of the vascular sys- tem is more prominent than the wasting tendency, as described in Chapters VIII and XII, often do not thrive well in such brac- ing and exciting places, and for these the moister and cooler British coast stations answer better; but even they are some- times too stimulating, and their large number of windy and rainy days are a great obstacle to invalids taking proper exer- cise. Here it is that the soft marine climate of Tangiers or of Madeira supplies what is wanted, though the relaxing character of the latter is an objection, but it is to be met by the patient keeping up as much as possible on the hills of that island. A cooler substitute is to be found in the calm inland climates of Pau, Amelie les Bains, and Pisa, and a drier one on the banks of the Upper Nile and the inland climates of Southern Africa and Australia. For consumption originating in septic influences, a climate of great purity and dryness would seem to be indicated, and this is to be best found at considerable heights above the sea level. The remarkable results observed by Archibald Smith, Guilbert, and Hermann Weber, of residence in elevated regions on cases of phthisis contracted in hot enervating valleys, in the impure atmosphere of large cities, and in unhealthy employments, aris- ing, in fact, from causes more or less septic in kind, incline us to recommend the trial of mountain climates in this form of consumption, where it is possible to remove the patient so far, and where inflammatory complications are absent. These open and more bracing climates prove most beneficial in the more scrofulous and phthisical varieties, where degeneration and wasting of the bioplasm are marked from the beginning. LTufortunately, many subjects of the constitutional forms of RULES FOR CHOICE OF CLIMATE. 307 phthisis are too rapid in their downward course to admit of their being removed from this country at least, to the lofty regions of the Alps or Andes; but, if it were possible to foresee, either from a knowledge of the family history, or from examination of the individual's frame, that he is more likely than other people to be attacked by this variety of the disease, it would be highly desirable to fix his residence in some elevated mountain district, as a precautionary and preventive measure, and it need hardly be remarked that such persons should be brought under the in- fluence of the antiphthisical measures of pure air, and cod-liver oil and tonics early, more especially at the dangerous age of the cessation of growth. We must bear in mind that in this country the great mass of consumptive cases either originate in, or are complicated with inflammatory attacks; and it is with the view of affording the patient immunity from these, and of enabling him to take abundant exercise, that we recommend, in most cases of chronic consumption, a dry warm climate during the winter, with as much stimulating element in it as he can well bear, and when summer approaches and the sheltered winter station be- comes hot and oppressive, we advise a change to the cooler and more bracing climate of the Alpine health resorts, such as Bor- mio, Combaflaz, liigi Kaltbad, Monte Generoso, and other high stations, where he can remain till the approaching winter ren- ders his return to the warm station desirable. The great purity and somewhat exciting quality of the air in all these [daces has a vivifying influence on the bioplasm, and on all the vital functions, and generally produces a change soon in the color and spirits of the patients, and in time on their strength and flesh also. But in order to insure the good effects of air", exercise must be regularly taken, and as patients are seldom strong enough to walk for the requisite time m the open air, riding or driving should be much resorted to. We may here remark, that even patients, who are deemed fit cases to pass the winter in high level resorts, will be wise to commence their sojourn in the elevated district in summer, and thus become gradually inured to the rigorous climate, and reap all the °;ood which can accrue from it. It is the custom in America to send consumptive patients for the winter to dry inland localities, of no great elevation, as St. Paul's in Minnesota, and certain parts of Canada; and we have seen patients who have wintered there, but up to this date the evidence collected by us has not been altogether favorable to these climates, of which we imagine the dryness to be the best feature. . . . One of the most approved methods of giving a phthisical invalid change of air is by a long sea voyage, as, for instance, 308 CLIMATIC TREATMENT. to Australia and back; and facts are tolerably numerous to tes- tify to its beneficial effect, not only in the veiy early stages of the disease, but even where limited cavities have formed. This mode, however, of change of climate, is liable to some draw- backs, which are: want of opportunities for exercise, very vari- able weather and temperature, sometimes bad accommodation and food, and often ennui and home-sickness. If the patient can go in comfort, pleasure, and hope, and start in the month of October, provided that his disease is not very extensive, he may reap considerable benefit. Before we close this short notice of climate in relation to consumption, we ought to mentiou what patients ought not, in our opinion, to be sent abroad. These are, cases of acute phthisis, both tuberculosis and scrofulous; pneumonia, if the latter be in an acute stage, though if its progress, as happens sometimes, be rendered more chronic, the patient may possibly be excepted from our rule. While patients with lungs in various stages of the disease may benefit greatly by going abroad, provided the amount of lesion be not very extensive, we must add our warning to that \ of other medical writers against the cruelty and madness of allowing those, whose extreme state precludes all hope of re- covery and who are obviously near their end, to exchange the comforts of a home in their native land for the miseries of foreign exile, for it is far better for them to sink into their graves surrounded by all that art can suggest and affection supply, to assuage their sufferings, than to close life by a death- bed in a strange land, and often among strange people, to whom many of the luxuries which smooth the dying pillow are unknown. Some patients, who have been greatly reduced by inflammatory attacks, or by haemoptysis, have the appearance of being in extreme phthisis, but an examination of their lungs will show that they are not really so. These are the patients who are said to have been placed on board ship, in a dying state, and to have recovered, and it would not be well to place an absolute veto on such treatment in their cases. In conclusion, we would state that too much must not be expected from climate alone, in the treatment of so formidable a disease as pulmonary consumption; but that when its influ- ence is joined to that of medicine and hygiene, much may be done towards mitigating, arresting, and even curing, the dread malady. INDEX. Abercrombie, Dr., on tbe natural origin of tubercular disease, 38 Abscess, chronic, of lung, 173 gangrenous of lung, 176 Acute consumption, forms of, 34 Acute tuberculosis, 34 Addison, Dr. T., on indurations of the lung, 83, 84 Addison, Dr. W., microscopic observations on tubercle, 42 observations of pale corpuscles, 50 discovery of migration of sarcophytes, 52 description of fibrin in blood-clot. 57 Adenoid tissue, 46 Age in relation to haemoptysis, 135 reached in hereditary phthisis, 120 influence of, on duration, 253 of attack, 241 ; with family predis- position, 113 Aged parents, offspring of, consumptive, 110 Air, pure, 265, 304 Albuminous variety of phthisis, 89 Alison, Prof. W. P., opposed to Laennec's views on the non-inflammatory origin of tubercle, 38 on chemical conversion into fat, 62 Altitudes, influence of high, 105 treatment of phthisis by, 306 Amoeba., 53 Amoeboid properties, 51 cells, influence of heat on, 54 Ancell, Mr., on hereditary transmission of phthisis, 112 Andral, Prof. G , on inflammatory origin of tubercles, 38 on red and gray hepatization, 83 proportion of hcetnoptysis to tubercle, 128 on duration of phthisis, 237 Aneurism of pulmonary artery as cause of hajinoptysis, 133 Aneurism, case of, 136 Animals, experiments on, 92 hereditary tuberculosis of, 110 Antiphlogistic treatment, 258, 267 Antiphthisical treatment, 259 Antiseptic treatment, 2S6 Aplastic deposits, 58 Arrest of phthisis, 1st stage, 202 2d stage, 206 3d stage, 208 Asthmatic phthisis, 177 Bardsley, Dr., Sen., used cod-liver oil sev- enty years ago, 279 Bartlett, Dr., U. S. A., phthisis a sequela of fever, 121 Bastian, Dr., on amoeboid properties of sar- cophytes, 51 Baumler, Dr., on haemoptysis, 131 Bayle, Prof., description of miliary granu- lations, 37 duration of phthisis, 237 Beale, Prof. Lionel, his terms, germinal matter and bioplasm well applied to protoplasm, 53 has proved bioplasm to exist before cells, 57 observation of living properties of pus- globules, 67 Bed-sores, treatment of, 294 Bennet, Dr. Hughes, first book on cod-liver oil in 1841, 279 Bennett, Dr. Risdon, on good diet in phthisis, 296 Bioplasm, 53 Bioplasts. See Sarcophytes. Blaand, 303 Blistering, utility of, 268 best mode of, 268 Blood-drinking, 296 Bolivia, efficacy of climate, 105 Bowditch, Dr., U. S. A., on dampness of soil as a cause of phthisis, 124 Bowman (and Todd) on the vascularity of the nasal membrane, 129 Brehtuer, Dr., immunity of high altitudes from phthisis, 105 Brett and Bird, on chemical composition of expectoration, 89 Briquet, M., on hereditary transmission of phthisis, 114, Brompton Hospital Report (1st), on heredi- tary influence in phthisis, 112 on influence of sex and age, 135 on the duration of phthisis, 237 310 INDEX. Bronchial glands, 72 hemorrhage compared with epistaxis, 129 and nasal tracts compared, 129 Bronchitis followed by phthisis, 243 percentage of cases, 244 Broussais, Prof., considered tubercle in- flamed lymphatics, 37 Buchanan, Dr. G , report on the influence of damp soils in producing phthisis, 123 Budd, Dr. W., on the zymotic nature of phthisis, 100, 125 Buhl on tuberculosis from caseous mat- ter, 88 Butchers, rarity of consumption among, 296 Cacoplastie deposits, 41, 57 Calcareous expectoration, 248 Calcification of lung, 87 Cancer compared with tubercle, 45 Cancerous disease of the lung, 132 Caseation of inflammatory products, 65 of fibrin, 66 remarkable instance of, 65 of bronchial glands, 49 Caseous hepatization, 85 Cases, division and selection of, 157, 239 tabulation of, 240 of calcareous transformation, 86 of remarkable caseation, 65 of hasmoptysis, 136 of hemorrhagic phthisis, 90, 217 of fibroid phthisis, 158, 162, &c of phthisis after pleuropneumonia, 158, 160 pleurisy, 159, 160, 164 pneumonia, 163 of asthma and phthisis, 177, 180 acute, 183-195 scrofulous, 195, 202 chronic, 202. 225 with pregnancy, 225, 228 with pneumothorax, 230, 232 acute rheumatism, 233 lithuria, 234 after injury to chest, 228, 229 senile, 234 miscellaneous, 225 of suppuration, 70 Catarrhal variety of phthisis, 88 Causation, twofold, of phthisis, 303 Causes of phthisis, 103 general and local, 107 predisposing or exciting, 108 Cavity in lung, 246, 248 arrest of, 208 percentage of, 247 Cavities, double, 224, 248 Cell, theory of formation of, 52 amoeboid, 54 Cessation of discharges, cause of phthisis, 122 Charlton, Dr., theories of immunity from consumption, 303 Chemical constitution of tubercle, 66 Churchill, Dr., on the use of hypophos- phites in phthisis, 263 Chronic pneumonic phthisis. See cases. Clark, Dr. Andrew, on fibroid phthisis, 57 on artificial tuberculosis, 92 Classification of consumptive diseases, 74 Climate, 302 inland, 305 varieties of, 305 marine, 304 varieties of, 304 winter, 305 summer, 307 Clothing, 297 Cod-liver oil, wonderful benefits from, 257 See cases. mode of action, 274 plan of exhibition, 281 penetrative power of, 280 objections to dark-brown, 279 pale to be preferred, 280 inunction with, 280 preparation of, 279 palatable, 281 Cohnheim, Prof., on emigration of sarco- phytes, 51 Conservation of strength, 271 Consolidation. See Induration. Constipation, 293 Consumption, pulmonary, defined. 33 examples and progress of, 34-37 pathology and nature of, 37-106 produced by inflammation, 49, 75 in the lymphatics, 60, 90 Causation of, artificial and natural, 98-106 family predisposition and other causes of, 107-127 infection in, 127 haemoptysis in, 127-148 physical signs of, 148-156 going into asthma, 182 duration of, 236-256 prognosis in, 251 summary of treatment of, 256-266 improvement in treatment of, 257 antiphlogistic remedies in, 266-271 antiphthisical remedies in, 272-287 cod-liver oil in, 260-273. Ac. Other matters concerning pulmonary con- sumption, passim. Contraction of cavity, 248 Copland, Dr., on hereditary transmission of phthisis. 110 Cough, treatment of, 288 Counter-irritation, modes of, 268, 289 Corrigan, Sir D., on cirrhosis of the lung, 57, 76 Cotton, Dr., on family predisposition in phthisis, 110 on the non-infectious nature of phthisis, 126 on pulmonary aneurism as a cause of haemoptysis, 133 on percentage of haemoptysis in phthisis, 244 inutility of hypophosphites in phthisis, 263 INDEX. 311 Cruveilhier, Prof., on inflammatory origin of tubercle, 38 Cure, mountain, 265 grape, 297 of phthisis. See Cases. percentage of, 249 Ectasia, 134 Edwards, Mr. Virtue, statistics of Bromp- ton Hospital in disproof of infection, 126 Emphysema, with contractile disease, 180 with suppurative bronchitis, 181 Empyema, 66, 248 varieties of, 248 threatening phthisis, 201 ^ Endemic phthisis, 124 Epistaxis, 129 Euplasia, 79 Exercise, varieties of, 299 Expectoration, varieties of, 88 Extension of the disease from one lung to the other. 248 greater liability of right lung to, 248 Exudation, theory of, 52 Galloping consumption, 35, 131 Garrod, Dr., on the preparation of cod-liver oil, 279 Glands, morbid changes in, 61 Gluge, M., on tubercle-cells, 43 Gout with phthisis, case of, 147 Greenhow, Dr., on phthisis caused by in- halation of dust, 125 Groups of phthisis, 157 Growths, 44 Gruby, M., on tubercle corpuscle, 43 Damp, cause of consumption, 123 Darling, Dr., used cod-liver oil fifty years ago, 279 Davy, Dr. John., on conversion of flesh into fat, 63 his detection of fat in old exudations, 63 Deaths, number of, 249 causes of, 249 Decline, general, preceding or accompany- ing consumption, 276 counteracted by antiphthisical reme- dies, 277 may take place without phthinoplasm, 277 Degeneration, fatty, 62 of sarcophytes, 55 Degradation of tissue, 40 De Jongh, Dr., brown oil inferior to pale, 279 Dewar, Dr., recommendation of sulphurous acid in phthisis, 264 Diagnosis, difficulties of, 256 Diarrhoea, 292 Diet, efftcts of, 294 Dietetics. See Food and Stimulants. Digital clubbing, 174 Disintegration of fibrin, 66 Dobell, Dr., pancreatic emulsion in phthisis, 278 Drainage, 301 Duration of phthisis, estimates of, 236 analysis of 1000 cases, 249 in males, 252 in females, 252 understated, 241 instances of long. See Cases. causes of long, 252 influence of age on, 253 of life in phthisis quadrupled, 258 Dusty occupations cause of consumption, 125 Dyspnoea, treatment of, 294 Family predisposition, 107 explained, 109 percentage of, 111 influence of sex on, 112 influence on age of attack, 113 on duration, 118 symptoms, 114 statistics of. See Tables. Fatty degeneration, discovery of, 62 its nature, 63 of heart, 63 of bloodvessels of lung, 132 Fearn, Mr., observation of pulmonary aneur- ism as a cause of fatal haemoptysis, 133 Fenwick, Dr., on detection of lung-tissue in phthisical sputa, 59 Fevers originating phthisis, 121 Fibrinous crasis of blood, 76 Fibroid disease of lung, 58, 76 results of, 75 phthisical end of, 78 hyperplasms, 75 eases of, 162 induration of lung, 172 treatment of, 270 Fistula in ano, 81, 197, 199 Flint, Dr., on stimulants in phthisis, 297 Foetus, tubercle in lungs of, 108 Food, 295 Fox, Dr. Wilson, contributed to verify the conjectures of Broussais and Aber- crombie on miliary tubercle, 41 confirms Dr. Sanderson's conclusions on the adenoid seat of artificial tubercle, 48, 61 results of experiments on artificial pro- duction of tubercle, 92, 98 conclusions from his and Dr. Sander- son's investigations, 98-102 his researches show why Peyer's and lymphatic glands become tubercu- lous, 122 French consumptive patients, 238 Fuller, Dr., on hereditary transmissions of phthisis, 110 on duration of phthisis, 237, 242 312 INDEX. Guilbert, M., on the cure of phthisis by re- moval to great altitudes in South Auierica, 105 Guinea-pigs, experiments on, 92 Gulliver, Mr. G., microscopic observations of tubercle, 42 increase of pale corpuscles in inflamma- tion, 50 direct formation of fibrils by fibrin, 57 discovered fatty degeneration, 62 disintegration of fibrin, 65 suppuration rare in birds and rep- tiles, 101 Gymnastics, 300 Habitation, 300 Hall, Dr. Radcliffe, fatty degeneration of pulmonary \essels in haemoptysis, 132 Haskell describes an amoeba without nucleus or cell, 132 Heart disease with phthisis, 233 hasmoptysis from, 132 Hemorrhage from fatty degeneration, 142 Hemorrhagic variety of consumption, 90, 140 cases of, 141 exciting causes of, 141 Hepatization caseous, 85 Hereditary predisposition, 109 Haemoptysis, significance of, 128 relation to phthisis, 129 from congestion, 135 influence of age and sex on, 135, 136 stage of disease on, 136 on duration, 148 effects of local and general, 145 treatment of, 290 cases of, 136 percentages of different authorities, 244 author's own percentage, 244 rarity of in acute phthisis, 139 Horse exercise, 300 Hygienics, 295 Hyperplasms, cases of, 75 Hypophosphites, 263, 283 action of, 264 Ice, 291 Improper food, cause of consumption, 121 Impure air, cause of consumption, 121 Induration of lung, results of, 59 classification of, 84 red and gray, 82 chronic after inflammation, 166 degeneration of, 84 after emphysema, 176 contractile. 170 Infection, conditions of, 98 nature of, 100 of consumption disproved, 1 25 ' Inflammation, consumption arising from, 158 prolonged duration of, 255 relation to tubercle, 49 plastic process of, 49 ' Inflammation, percentage of cases in statis- tics, 243 Inhalations, 264, 294 Injury to chest, haemoptysis from, 132 cases of, 228 Inoculation with tubercle, 91 with non-tuberculous matter, 93 of guinea-pigs, 91 results of, 94 Iodine, counter-irritation with, 265 mode of action of, 271 Jourdanet, M., on prevention and cure of phthisis by removal to great altitudes in Mexico, 105 Lactation. 122 Laennee, Prof. His views on phthisis, 37 not universally adopted by his con- temporaries, 37, &o. carnification from inflammation, 76 red and gray hepatization, 83 self-inoculation with tubercle, 91 his views on tubercles criticizeiWlOl consumption caused by mentatuepres- sion, 122 connection of haemoptysis with tuber- cle, 128 explanation of bronchophony inade- quate, 151 duration of phthisis, 237 Laryngeal phthisis, 81 treatment of, 294 Lebert, Prof., considered tubercle to have a peculiar cell, 43 Leucocytes, 51. See Sarcophytes. Leukaemia, 50, 62 Lima, prevalence of consumption in, 105 Linctus, 288 Lombard, Dr. H. C, rarity of phthisis at high altitudes, 106 Louis, Prof, adopted Laennec's views, 37 hereditary transmission of phthisis, 110 phthisis after typhoid fever, 121 haemoptysis dependent on tubercle, 128 duration of phthisis, 237 description of its course vmder old, or no treatment, 237 comparison with late experience, 251, 256 Lozenges, 289 Lung, state of, at first visit, 245 last visit, 246 right, more prone to attack, 249 to extension, 249 left, more prone to excavation, 249 Lymph, gradations of, 72 kinds of, 50 Kolhker on peribronchial adenoid tissue, 96 Koumiss, 302 Kuchenineister, immunity from phthisis of high Alpine inhabitants, 105 INDEX. 313 Lymphatic glands, morbid changes in, 61 Lymphoma, 44 hyperplastic, 46 heteroplastic, 46 Madden, Dr., considers phthisis produced by a specific poison, 100 Mandl, M., considers tubercles amorphous, 43 Marcet, Dr., 295, 296 Max-Schultze describes several protoplasms without cells or nuclei, 53 Measles, cause of consumption, 122 Mental depression, instance of, 122 Mexico, effects of climate, 105 Micrology of tubercle, 42 Miliary tubercle. See Tubercle. Mountain cure, 265 Mulder, chemical relations of protein and pus, 67 Muller, J., cellular origin of tissues, 52 Murchison, Dr., pythogenic fever a cause of tubercle, 121 Niemeyer, Prof., on hereditary transmis- sion of phthisis, 108, 110 on causes of haemoptysis, and on mutual relations of phthisis and haemoptysis, 128-132 criticized, 145 considers diagnosis between tubercular and non-tubercular phthisis extreme- ly difficult, 256 Night-sweats, treatment of, 292 Norris, Dr., experiments on pervasion of colloid substances, 52 Oils and fat noticed, 278 Oil sauces, 285 Otorrhoea, phthisis after, 200 Out-patients, statistics of, 238 age of attack among, 113 Paget, Sir J., distinction of corpuscular lymph, 50 on fatty degeneration, 64 Pain in chest, 289 Pale corpuscles of blood, adhesive quality of, 49 Palliatives, 368 Pancreatic emulsion, 278 Pathology of consumption, 37-106 Peacock, Dr., early described pulmonary aneurism as a cause of fatal haemop- tysis. 133 employs the term haemoptysical phthisis, 140 Periods of treatment, 256 Phthinoplasms, derivation and use of the word, 36 applied to tubercle and all allied prod- ucts, 49 linoplasms, traced to degradation of sar- cophytes and bioplasts, 54 from inflammation, 59 also in lymphatic system, 60-62 fatty degeneration of, 64-66 suppuration of, 69 gradation of from pus and lymph, 72 their constitution shown in table, 74 traced through their varieties, 75 fibroid, 75, 78 suppurating, 79-82 concrete with fibroid, 82-85 concrete caseating and calcifying, 85-88 in adenoid tissue—artificial, 91-98 natural, 98-102 causes of, 101-106 clinical and anatomical descriptions of, in cases of consumption, passim. extent and kind to be considered in treatment, 266, 271 effect of cod-liver oil on, 275 influence requiring counteraction, 276 Phthinosis, 56 Phthisis Florida. See Galloping Consump- tion. Phthisis Pulmonalis. See Consumption, Pulmonary. Physical signs of enlarged bronchial glands, 72 of phthisis from bronchitis, 148 pneumonia, 151 congestion, 152 miliary tubercles, 152 increasing disease, 153 cure of phthisis, 154 arrest of phthisis. 156 Pleurisy, phthisis following, 160 Pleuropneumonia, phthisis following, 158 Pneumonia, phthisis following. 161 Pneumothorax, cases of recovery from, 230 Pollock, Dr., percentage of family predis- position, 110 higher in acute phthisis, 114 greater liability of males to haemopty- sis, 135 average duration of phthisis, 237, 238 comparison of sexes, 241 effects of haemoptysis, &c, 237 Portal, Prof., anticipation of the discovery of the lymphatic nature of tubercles, 47 on the duration of phthisis, 192 Post-mortems. See Cases. Powell, Dr. R. D., on the state of the pul- monary bloodvessels in haemoptysis, 133 Predisposition, family, 108 average of, 111 hereditary. 109 Pregnancy in phthisis, 225, 227 Prescriptions for tonics. 257, 286 Preventive measures, 307 Prognosis, hopeful, 251 Protein, tritoxide of, 67 Protoplasm, properties of, 53 Pulmonary aneurism, 143 Purulent phthisis, two cases of, 173 Pus, chemistry of, 67 314 INDEX. Pus, causes of formation of, 67 relation to sarcophytes, 67 residual effects of, 72 gradations of, 72 Pyaemia. See Tubercle. Quain, Dr. R., experiments on fatty degene- ration, 63 description of pulmonary aneurism in haemoptysis, 133 Rabbits, experiments on, 91 Radcliffe, Dr.. on the use of hypophosphites. 284 Rasmussen on changes of the pulmonary vessels in haemoptysis, 133 Raw meat, use of, 296 Recklinghausen, Von, on the sarcophytes, 51 on the lymphatic sarcophytes, 60 on the living properties of pus-cells, 67 Registrar-General of Scotland on damp soils, 124 Rokitansky, Prof., description of tubercle, 42 his distinction of croupous lymph, 50 his adoption of the exudation theory, 52 was an early exponent of fatty degenera- tion, 64 ascribed fibroid formation to a fibrin- ous crasis in the blood, 76 Rollett, on formation of fibres of connective tissue, 57 Rufz on hereditary transmission, 110 Sanderson, Dr. Burdon, verification of the conjecture of Broussais and Aber- crombie on the seat of miliary tuber- cles, 41 recent researches on tuberculosis, 45-48 identification of gray tubercle with lymphatic system, 61 lectures on experimental physiology, 80 process of inflammation, 79 experiments on artificial tuberculosis, 92-97 researches throw light on origin of phthisis from fever, 122 Sarcophytes, derivation of word, 51 emigration and amoeboid properties of, 51 degeneration of, 55 of lymphatics, 60 defective vitality of, 103 action of, in suppuration, 458 action of cod oil on, 275 relation to pus-cells, 79 . Scarlatina, cause of phthisis, 122 Scar-tissue, 77 Schleiden and Schwann, cellular physiology, 43 Scrofulous phthisis, 195-199 pneumonia, 34 acute, 56, 184 Scrofulous phthisis, after suppuration, 80 arrested cases of, 186 Scudamore, Sir C, tubercle in infancy, 108 Sea voyages. 307 Sedatives, 369 Selection of cases, grounds of, 23 Senile phthisis, 234 Septic influence, 103, 303 Sexes, percentage of consumption among, 241 Sexual transmission of consumption, 112 Silvester, Dr., 299 Simon's animal chemistry : analysis of tubercle. 66 nitoxide of protein in pus, 67 effect of cod-liver oil on blood, 273 Simon, Mr. John, artificial production of tubercle, 93 damp as a cause of phthisis, 123 Skoda, his consonance not explanatory of bronchophony, 150 Smith, Dr. Archibald, preventive and cura- tive influence of high altitudes on phthisis, 105 Soil, 301, 123 Stages, duration of, 249 classification of. 244 percentage of, 246 Stokes, Dr. W., subclavian murmur an early sign, 84 phthisis following empyema, 201 Strieker, amoeboid properties of sarcophytes, 51 protoplasm without cell or nucleus, 53 Stimulants, 297 Strychnia, antidote to retching, 234 Styptics, varieties of, 289 Sulphurous acid, 264 Suppuration, nature of, 67 salutary results of, 69 scrofulous, 80 Syphilis and phthisis, 234 Tables of influence of age of attack on dura- tion, 253 of age at death, 253 of age at time of attack, 241 of duration of living patients, 250 of ditto over twenty years' dura- tion, 250 of 198 deaths from phthisis, 249 of consumptive diseases, 74 of origin of phthisis, 242 of deaths of over fifteen years' duration, 249 of physical signs, 247 bearing on family predisposition, 113- 120 Tabulation of Cases. See Cases. Temperature of acute tuberculosis, 152, 256 Thompson, Dr. Theophilus, haemoptysis from cancer of the lung, 132 on wavy respiration, 153 on spongy gums in phthisis, 263 Thorowgood, Dr., hypophosphites in con- sumption, 284 IND EX. 315 Todd and Bowmann, vascularity of nasal membrane, 129 Tonics, cautions as to use of, 269 selection of, 283 Transmission of phthisis, 112 Treatment, antiphlogistic, 266 antiphthisical, 272 antiseptic, 286 climatic, 302 of diarrhoea. 292 of different forms of consumption, 270 of haemoptysis, 290 of night-sweats, 292 palliative, 288 retrospect of forty years, 256 Tubercle, artificial production of, 90 compared with cancer, 45 eruption of, in fevers, 101 gradations of, 72 Tubercle from wounds, 94 following caseation, 102 decaying consolidations, 102 local suppuration, 102 inoculation of, 91 micrology of, 42 in foetus, 108 Tuberculization, artificial. See Inoculation. Tuberculosis, its connection with pyaemia, 82, 103 hereditary, of animals, 110 cases of acute, 189 chronic, 202 Unity of consumption, 36 Varieties of consumption, 157 Ventilation, 301 Villemin, Dr., discovered production of tu- bercle by inoculation, 91 Virchow, Prof., description of tubercle, 43,44 on lymphomia, with corrections by Dr. Sanderson, 46, 47 referring all growths to proliferation of connective cells objected to, 47 his exclusive cell theory, overlooking original fibrillation of fibrin, 57 anticipated by Gulliver, in discovery of softening of fibrin clots, 66 his denial of the occurrence of miliary tubercle in a new-born infant refuted, 108 Waldenburg on hereditary transmission of phthisis, 108 Waller, Dr. Augustus, observation of emi- gration of sarcophytes in frog's tongue, 51 Walshe, Dr., on comparative liabilities of lungs to excavation, 246 Watson, Sir T., on haemoptysis from tuber- cle in the lungs, 128 Wavy respiration, 153 Weber, Dr Hermann, on influence of high altitudes in preventing and curing phthisis, 105 Wunderlich, impossibility to distinguish be- tween acute tuberculous and non-tuber- culous phthisis, 256 HENRY C. 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This is followed by the "Quarterly Summary of Improvements anx> Discoveries [n the Medical Sciences," classified and arranged under different heads, presenting a very complete digest of all that is new and interesting to the physician, abroad as well as at home. Thus, during the year 1872, the "Journal" furnished to its subscribers Eighty-four Orioinal Communications, One Hundred and Twenty-nine Reviews and Bibliograph- ical Notices, and Three Hundred and seven articles in the Quarterly Summaries, mak- ing a total of about Five Hundred articles emanating from the best professional minds in America and Europe. That the efforts thus made to maintain the high reputation of the " Journal" are successful, is shown by the position accorded to it in both America and Europe as a national exponent of medical progress :— Dr. Hays keeps his great American Quarterly, in matter it contains, and has established for itself a which he is now assisted by Dr. Minis Hays, at the ' reputation in every country where medicine is cul- head of his country's medical periodicals.—Dublin Medical Press and Circular, March 8, 1871. Of English periodicals the Lancet, and of American the Am. Journal of the Medical Sciences, are to be regarded as necessities to the reading practitioner.— N. Y. Medical Gazette, Jan. 7, 1871. tivated as a science.—Brit, and For. Med.-Ohirurg. Review, April, 1871. One of the best of its kind.—London Lancet, Ana. 20, 1870. Almost the only one that circulates everywhere, all over the Union and in Europe.— London Medical Time*, Sept. 5, 1868. The American Journal of the Medical Sciences yields to none in the amount of original and borrowed The subscription price of the "American Journal of the Medical Sciences" has never been raised, during its long career. It is still Five Dollars per annum; and when paid for in advance, the subscriber receives in addition the " Medical News and Library," making in all about 1500 large octavo pages per annum, free of postage. II. THE MEDICAL NEWS AND.LIBRARY is a monthly periodical of Thirty-two large octavo pages, making 384 pages par annum. Its "News Department" presents the current information of the day, with Clinical Lectures and Hospital Gleanings; while the " Library Department" is de- voted to publishing standard works on the various branches of medical science, paged separately, so that they can be removed and bound on completion. In this manner subscribers have received, without expense, such works as " Watson's Practice " ■' Todd and Bowman's Physiology," "West on Children," " Malgaigne's Surgery'" &c. &c. And with January 1873 will be commenced the publication of Dr. McCall * Communications are invited from gentlemen in ail parts of the country. Elaborate articles iasened by the Editor are paid for by the Publisher. Henry C. Lea's Publications—(Am. Journ. Med. Sciences). 3 Anderson's new work "On the Treatment of Diseases of the Skin, with an Ana- lysis of Eleven Thousand Consecutive Cases." As stated above, the subscription price of the "Medical News and Library" is One Dollar per annum in advance; and it is furnished without charge to all advance paying subscribers to the "American Journal of the Medical Sciences." III. THE HALF-YEARLY ABSTRACT OF THE MEDICAL SCIENCES is issued in half-yearly volumes, which will be delivered to subscribers about the first of February, and first of August. Each volume contains about 300 closely printed octavo pages, making about six hundred pages per annum. "Ranking's Abstract" has now been published in England regularly for more than twenty years, and has acquired the.highest reputation for the ability and industry with which the essence of medical literature is condensed into its pages. It pur- ports to be "A Digest of British and Continental Medicine, and of the Progress of Medicine and the Collateral Sciences," and it is even more than this, for America is largely represented in its pages. It draws its material not only from all the leading American, British, and Continental journals, but also from the medical works and treatises issued during the preceding six months, thus giving a complete digest of medical progress. Each article is carefully condensed, so as to present its substance in the smallest possible compass, thus affording space for the very large amount of infor- mation laid before its readers. The volumes of 1872, for instance, have contained SIXTY-POUR ARTICLES ON GENERAL QUESTIONS IN MEDICINE. NINETY-SIX ARTICLES ON SPECIAL QUESTIONS IN MEDICINE. TWELVE ARTICLES ON FORENSIC MEDICINE. NINETY-THREE ARTICLES ON THERAPEUTICS. FORTY-TWO ARTICLES ON GENERAL QUESTIONS IN SURGERY. ONE HUNDRED AND THIRTY-THREE ARTICLES ON SPECIAL QUESTIONS IN SURGERY EIGHTY ARTICLES ON MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN EIGHTEEN ARTICLES IN APPENDIX. Making in all nearly five hundred and fifty articles in a single year. Each volume, moreover, is systematically arranged, with an elaborate Table of Contents and a very full Index, thus facilitating the researches of the reader in pursuit of particular sub- jects, and enabling him to refer without loss of time to the vast amount of information contained in its pages. . The subscription price of the "Abstract," mailed free of postage, is Two Dollars and a Half per annum, payable in advance. Single volumes, $1 50 each. As stated above, however, it will be supplied in conjunction with the "American Journal of the Medical Sciences" and the "Medical News and Library," the whole free of postage, for Six Dollars per annum in advance. . For this small sum the subscriber will therefore receive three periodicals costing separately Eight Dollars and a Half, each of them enjoying the highest reputation in its class, containing in all over two thousand pages of the choicest reading, and pre- senting a complete view of medical progress throughout both hemispheres. In this effort to bring so large an amount of practical information within the reach of every member of the profession, the publisher confidently anticipates the friendly aid of all who are interested in the dissemination of sound medical literature. He trusts, especially, that the subscribers to the "American Medical Journal" will call the attention of their acquaintances to the advantages thus offered, and that he will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheapness never heretofore attempted. PREMIUM FOR NEW SUBSCRIBERS. Any gentleman who will remit the amount for two subscriptions for 1873, one of which must be for a new subscriber, will receive as a premium, free by mail, a copy of the new edition of Tanner's Clinical Manual, for advertisement of which see p. 5, or of Chambers' Restorative Medicine (see p. 17), or West on Nervous Disorders of Children (see p. 21). * * Gentlemen desiring to avail themselves of the advantages thus offered will do well*te forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1873, as the constant increase in the subscription list almost always exhausts the quantity printed shortly after publication. 1§0- The safest mode of remittance is by bank check or postal money order, drawn to tne order ol the undersigned. Where these are not accessible, remittances for the "Journal" maybe made at the risk of the publisher, by forwarding in registered letters. Address, HENRY C. LEA, Nos. 706 and 708 Sansom St., Philadelphia, Pa. Henry C. Lea's Publication JJUNGLISON {ROBLEY), M.D., Professor of Institutes of Medicine in Jefferson Medical Colle.g*., Philadelphia. MEDICAL LEXICON; A Dictionary of Mkdical Science: Con- taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetric*, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes; so as to constitute a French as well hs English Medical Lexicon. Thoroughly Revised, and very greatly Modified and Augmented. In one very large and handsome royal octavo volume of 1048 double-columned pages, in small type; strongly done up in extra cloth, $6 00; leather, raised bands, $6 75. The object of the author from the outset has not been to make the work a mere lexicon oi dictionary of terms, but to afford, under each, a condensed view of its various medical relation'?, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. The mechanical exe- cution of this edition will be found greatly superior to that of previous impressions. By enlarging the size of the volume to a royal octavo, and by the employment of a small but clear type, on extra fine paper, the additions have been incorporated without materially increasing the bulk oi the volume, and the matter of two or three ordinary octavos has been compressed into the space of one not unhandy for consultation and reference. It would be a work of supererogation to beatow a word of praise upon thin Lexicon. We can only wonder at the labor expended, for whenever we refer to its pages for information we are seldom disap- pointed in finding all we desire, whether it be in ac- centuation, etymology, or definition of terms.—New York Medical Journal, November, 1865. It would be mere waste of words in us to express our admiration of a work which is 60 universally and deservedly appreciated. The most admirable work of its kind in the English language. As a book of reference it is invaluable to the medical practi- tioner, and in every instance that we have turned over its pages for information we have been charmed by the clearness of language and the accuracy of detail with which each abounds. We can most cor- dially and confidently commend it to our readers.— Glasgow Medical Journal, January, 1866. A work to which there is no equal in the English language.—Edinburgh Medical Journal. It is something more than a dictionary, and some- thing less than an encyclopaedia. This edition of the well-known work is a great improvement on its pre- decessors. The book is one of the very few of which It may be said with truth that every medical man should possess it.—London Medical Times, Aug. 26, 1S65. Few works of the class exhibit a grander monument of patient research and of scientific lore. The extent of the sale of this lexicon is sufficient to testify to its nsefuiness, and to the great service conferred by Dr. Robley Dunglison on the profession, and indeed on ethers, by its issue.—London Lancet, May 13, 1865. The old edition, which is now superseded by the new, has been universally looked upon by the medi- cal profession as a work of immense research and great value. The new has increased usefulness ; for medicine, in all its branches, has been making such progress that many new terms and subjects have re- cently been introduced : all of which may be found ifuliy defined in the present edition. We know of no other dictionary in the English language that can bear a comparison with it in point of completeness of subjects and accuracy of statement.—if. Y. Drug- gists'1 Circular, I860. For many years Dunglison's Dictionary has been the standard book of reference with most practition- ers in this country, and we can certainly commend chis work to the renewed confidence and regard of »ur readers.—Cincinnati Lancet, April, 1865. It is undoubtedly the most complete and nsefn] medical dictionary hitherto published in this country. —Chicago Med. Examiner, February, IS60. What we take to be decidedly the best medical dic- tionary in the English language. The present edition is brought fully up to the advanced state of science. For many a long year "Dunglison " has been at our elbow, a constant companion and friend, and we greet him in his replenished and improved form with especial satisfaction.—Pacific Med. and Surg. Jour. nal, June 27, 1865. This is, perhaps, the book of all others which the physician or surgeon should have on his shelves. It is more needed at the present day than a few years back.—Canada Med. Journal, July, 1885. It deservedly stands at the head, and cannot be surpassed in excellence.—Buffalo Med. and Surg. Journal, April, 1865. We can sincerely commend Dr. Dunglison's work as most thorough, scientific, and accurate. We haVe tested it by searching its pages for new terms, which have abounded so much of late in medical nomen- clature, and our search has been successful in every instance. We have been particularly struck with the fulness of the synonymy and the accuracy of the de- rivation of words. It is as necessary a work to every enlightened physician as Worcester's English Dic- tionary is to every one who would keep up his knowl- edge of the English tongue to the standard of the present day. It is, to our mind, the most complete work of the kind with which we are acquainted.— Boston Med. and Surg. Journal, June 22, 1865. We are free to confess that we know of no medical dictionary more complete; no one better, if so well adapted for the use of the student; no one that may be consulted with more satisfaction by the medical practitioner.—Am. Jour. Med. Sciences, April, 1&65. The value of the present edition has been greatly enhanced by the introduction of new subjects and terms, and a more complete etymology and accentua- tion, which renders the work not only satisfactory and desirable, but indispensable to the physician — Chicago Med. Journal, April, 1865. No intelligent member of the profession can or will be without it.—St. Louis Med. and Surg. Journal April, 1865. It has the rare merit that it certainly has no rival in the English language for accuracy and extent 0/ references.— London Medical Gazette. UOBLTN (RICHARD D.), M.D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hvrs M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages ; extrs cloth, $1 50 ; leather, #2 00. It is the best book of definitions we have, and ought always to be upon the student's table.— Bvv*.hern Vied, and Surg. Journal Henry C. Lea's Publications—(Manuals). 5 ffEILL (JOHN), M.D., and &MITH {FRANCIS G.), M.D., Prof, of the Institutes of Medicine in the Univ. of Penna. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood cuts, extra cloth, $4 ; strongly bound in leather, with raised bands, $4 75. The Compend of Drs. Neilland Smith is incompara- bly the most valuable work of its class ever published In thiB country. Attempts have been made in various quarters to squeeze Anatomy, Physiology, Surgery, the Practice of Medicine, Otistetrics, Materia Medica, and Chemistry into a single manual; but the opera- tion has signally failed in the hands of all up to the advent of " Neill and Smith's" volume, which is quite a miracle of success. The outlines of the whole are admirably drawn and illustrated, and the authors are eminently entitled to the grateful consideration of the student of every class.—N. 0. Med. and Surg. Journal. There are but few students or practitioners of me- dicine unacquainted with the former editions of this unassuming though highly instructive work. The whole science of medicine appears to have been sifted, ae the gold-bearing sands of El Dorado, and the pre- cious facts treasured up in this little volume. A com- plete portable library so condensed that the student may make it his constant pocket companion.— West- ern Lancet. In the rapid course of lectures, where work for tbe students is heavy, and review necessary for an exa- mination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. Of course it is useless for us to recommend it to all last course students, bnt there is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class isthe graduates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now What it was when they left it off.—The Stethoscope. JJARTSHORNE {HENRY), M. D., Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. In one large royal 12mo. volume of 1000 closely printed pagea, with over 300 illustrations on wood, extra cloth, $4 50; leather, raised bands, $5 25. (Lately Published.) . The ability of the author, and his practical skill in condensation, give assurance that this work will prove valuable not only to the student preparing for examination, but also to the prac- titioner desirous of obtaining within a moderate compass, a view of the existing condition of the various departments of science connected with medicine. , This work is a remarkably complete one in its way, and comes nearer to our idea of what a Conspectus should be than any we have yet seen. Prof. Harts- home, with a commendable forethought, intrusted the preparation of many of the chapters on special subjects to experts, reserving only anatomy, physio- logy, and practice of medicine to himself. As a result we have every department worked up to the latest date and in a refreshingly concise and lucid manner. There are an immense amount of illustrations scat- tered throughout the work, and although they have often been seen before in the various works upon gen- eral and special subjects, yet they will be none the less valuable to the beginner. Every medical student who desires a reliable refresher to his memory when the pressure of lectures and other college work crowds to prevent him from having an opportunity to drink deeper in the larger works, will find this one of the greatest utility. It is thoroughly trustworthy from beginning to end; and as we have before intimated, a remarkably truthful outline sketch of the present state of medical science. We could hardly expect it should be otherwise, however, under the charge of such a thorough medical scholar as the author has already proved himself to be.— N. York Med. Record, March 15, 1869. T UDLO W {J. L.), M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice* of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition', thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume of 816 large pages, extra cloth, $3 25; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the office examination of students, and for those preparing for graduation. /TANNER {THOMAS HA WKES), M. D., frc. 1 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAO- NOSIS. Third American from the Second London Edition. Revised and Enlarged br Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, dergone some alterations and additions which will no doubt enhance its value materially. The conve- nience of the student has been carefully consulted in the arrangement of the text, and the directions given for the prosecution of certain dissections will be duly appreciated.—Canada Lancet, Feb. 1871. This is an excellent DissectorVManual; one which is not merely a descriptive manual of anatomy, but a guide to the student at the.dissecting table, enabling him, though a beginner, to prosecute his work intel- ligently, and without assistance. The American edi- tor has made many valuable, alterations and addi- tions to the original work.—Am. Journ. of Obstetrics, Feb. 1871. I feel that I have been instrumental in supplying a want long felt for a real dissector's manual," and this,assertion of its editor we deem is fully justified, after an examina- tion of its contents, for it is really au excellent work. Indeed, we do not hesitate to say, the best of its class with which we are acquainted ; resembling Wilson in terse and clear description, excelling most of the 60-called practical anatomical dissectors in the scope of the subject and practical selected matter. . . . In reading this work, one is forcibly impressed with the great pains the author takes to impress the sub- ject upon the mind of the 6tudent. He is full of rare and pleasing little devices to aid memory in main- taining its hold upon the slippery slopes of anatomy. —St. Louis Med. and Surg. Journal, Mar. 10, 1871. It appears to us certain that, as a guide in dissec- tion, and as a work containing facts of anatomy in brief and easily understood form, this manual is complete. This work contains, also, very perfect illustrations of parts which can thus be more easily understood and studied; in this respect it compares favorably with works of much greater pretension. MACLISE (JOSEPH). SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best style and beautifully colored, containing 190 figures, many of them the size ot life; together with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. Price $14 00. As n6 complete work of the kind has heretofore been published in the English language, the present volume will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- tain the exact relative positions of the various portions of the human frame towards each other and to the surface, as well as their abnormal deviations. Notwithstanding the large size, beauty and finish of the very numerous illustrations, it will be observed that the price is so low as to place it within tbe reach of all members of the profession. We know of no work on surgical anatomy which refreshed by those clear and distinct dissection can compete with it.— Lancet. The work of Maclise on surgical anatomy is of the highest value. In some respects it is the best publi- cation of its kind we have seen, and is worthy of a place in the library of any medical man, while the st udent could scarcely myike a better investment than this — The Western Journal of Medicine and Surgery. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given. Whfle the operator is shown every vessel and nerve where »n operation is contemplated, the exact anatomist is which every one must appreciate who has a particle of enthusiasm. The English medical press has quite exhausted the words of praise, in recommending this admirable treatise. Those who have any curiosity to gratify, in reference to the perfectibility of the lithographic art in delineating the complex mechan- ism of the human body, are invited to examine our specimen copy. If anything will induce surgeons and students to patronize a book of such rare value and everyday importance to them, it will be a survey of the artistical skill exhibited in these fac-eimiles of nature.—Boston Med. and Surg. Journal. HORNEK'S SPECIAL ANATOMY AND HISTOLOGY. I In 2 vols. 8vo., of over 1000 pages, with more than Eighth edition, extensively revised and modified. 1 300 wood-cuts; extra cloth, $t> Ou. 8 Henry C. Lea's Publications—(Physiology). TifARSHALL {JOHN), F. R. S., JXL Professor of Surgery in University College, London, A-<\ OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. With Additions by Francls Gurney Smith, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, 0 WMAN (JOHN E.), M. D. ^PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fifth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. $2 25. f>Y THE SAME AUTHOR. ---- INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Fifth American, from the fifth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 25. KNAPP'S TECHNOLOGY ; or Chemistry Applied to the Arts, and to Manufactures. With American additions, by Prof. Walter R. Johnson. In two very handsome octavo volumes, with flCO wotd engravings, extra cloth, $6 00. 12 Henry C. Lea's Publications—(Mat. Med. and Therapeutics). pARRlSH {ED WARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formula- and Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 pages, with several hundred illustrations, extra cloth. $5 00; leather, $6 00. The immense amount of practical information condensed in this volume may be estimated from the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- ences ; under Emplastrum, 36; Extracts, 159; Lozenges, 25; Mixtures, 55; Pills, 56; Syrups, 131; Tinctures, 138; Unguentum, 57, &o. We have examined this large volume with a good deal of care, and find that the author has completely exhausted the subject upon which he treats ; a more complete work, we think, it would be impossible to find. To the student of pharmacy the work is indis- pensable ; indeed, so far as we know, it is the only one of its kind in existence, and even to the physician or medical student who can spare five dollars to pur- chase it, we feel sure the practical information he will obtain will more than compensate him for the outlay.—Canada Med. Journal, Nov. 1864. The medical student and the* practising physician will find the volume of inestimable worth for study and reference.—San Francisco Med. Press, July, 1864. When we say that this book is in some respects the best which has been published on the subject in the English language for a great many years, we do not wish it to be understood as very extravagant praise. In truth, it is not so much the best as the only book.—The London Chemical News. An attempt to furnish anything like an analysis ol Parrish's very valuable and elaborate Treatise on Practical Pharmacy would require more space than we have at our disposal. This, however, is not so much a matter of regret, inasmuch as it would be difficult to think of any point, however minute and apparently trivial, connected with the manipulation )f pharmaceutic substances or appliances which has not been clearly and carefully discussed in this vol- ume. Want of space prevents our enlarging further on this valuable work, and we must conclude by a simple expression of our hearty appreciation of itl merits.—Dublin Quarterly Jour, of Medical Science, August, 1864. 5 TILLE {ALFRED), M.D., Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History Fourth edition, revised and enlarged. In two large and handsome octavo volumes. (Pre- paring.) abroad its reputation as a standard treatise on Materia Medica is securely established. It is second to no work on the subject in the English tongue, and, in- deed, is decidedly superior, in some respects, to any other.—Pacific Med. and Surg Journal, July, 1868. Still^'s Therapeutics is incomparably the best work on the subject.— If. Y. Med. Gazette, Sept. 26, 1868. Dr. Stille's splendid work on therapeutics and ma- teria medica.—London Med. Times, April 8, 1865. Dr. Still6 stands to-day one of the best and most honored representatives at home and abroad, of Ame- rican medicine; and these volumes, a library in them- selves, a treasure-house for every studious physician, assure his fame even had he done nothing more.—The Western Journal of Medicine, Dec. 1868. We regard this work as the best one on Materia Medica in the English language, and as such it de- serves the favor it has received.—Am. Journ. Medi- cal Sciences, July 1868. We need not dwell on the merits of the third edition of this magnificently conceived work. It is the work on Materia Medica, in which Therapeutics are prima- rily considered—the mere natural history of drugs being briefly disposed of. To medical practitioners this is a very valuable conception. It is wonderful how much of the riches of the literature of Materia Medica has been condensed into this book. The refer- ences alone would make it worth possessing. But it is not a mere compilation. The writer exercises a good judgment of his own on the great doctrines and points of Therapeutics. For purposes of practice, Stille's book is almost unique as a repertory of in- formation, empirical and scientific, on the actions and uses of medicines.—London Lancet, Oct. 31, 1868. Through the former editions, the professional world Is well acquainted with this work. At home and Dr. Still6's work is becoming the best known of any of our treatises on Materia Medica. . . . One of the most valuable works in the language on the subjects of which it treats.—N. Y. Med. Journal, Oct. 1868. The rapid exhaustion of two editions of Prof. Still6 a scholarly work, and the consequent necessity for a third edition, is sufficient evidence of the high esti- mate placed upon it by the profession. It is no exag- geration to say that there is no superior work upon the subject in the English language. The present edition is fully up to the most recent advance in the science and art of therapeutics.—Leavenworth Medi- cal Herald, Aug. 1868. The work of Prof. Stille' has rapidly taken a high place in professional esteem, and to say that a third edition is demanded and now appears before us, suffi- ciently attests the firm position this treatise has made for itself. As a work of great research, and scholar- ship, it ia safe to say we have nothing superior. It is exceedingly full, and the busy practitioner will find ample suggestions upon almost every important point of therapeutics.—Cincinnati Lancet, Aug. 1868. /GRIFFITH {ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods of Pre- paring and Administering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume of 650 pages, double-columns Extra cloth, $4 00; leather, $5 00. Three complete and extended Indexes render the work especially adapted for immediate consul- tation. One, of Diseases and their Remedies, presents under the head of each disease the remedial agents which have been usefully exhibited in it, with reference to the formulas containing them—while another of Pharmaceutical and Botanical Names, and a very thorough General Index afford the means of obtaining at once any information desired. The Formulary itself ia arranged alphabetically, under the heads of the leading constituents of the prescriptions. We knowof none in our language, or any other, so comprehensive in its details.— London Lancet One of the most complete works of the kind in any language.—Edinburgh Med. Journal. We are not cognizant of the existence of a parallei work.—London Med. Gazette. Henry C. Lea's Publications—(Mat. Med. and Therapeutics). 13 p ERE IRA {JONA THA N), M.D., F. R. S. and L. S. MATERIA MEDICA AND THERAPEUTICS; being an Abridg- ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and Druggists, Medical and Pharmaceutical Students, Ac. By F. J. Farre, M.D., Senior Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia.; assisted by Robert Bentley, M.R.C.S., Professor of Materia Medica and Botany to tbe Pharmaceutical Society of Great Britain; and by Robert Warinston, F.R.S., Chemical Operator to the Society of Apothecaries. With numerous additions and references to the United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the University of Pennsylvania. In'one large and handsome octavo volume of 1040 closely printed pages, with 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 00 The task of the American editor has evidently been | poeia, none will be more acceptable to the student no sinecure, for not only has he given to us all that and practitioner than the present. Pereira's Materia is contained in the abridgment useful for our pur- j Medica had long ago asserted for itself the position of poses, but by a careful and judicious embodiment of over a hundred new remedies has increased the size of the former work fully one-third, besides adding many new illustrations, some of which are original. We unhesitatingly say that by so doing he has pro- portionately increased the value, not only of the con- densed edition, but has extended the applicability of the great original, and has placed his medical coun- trymen under lasting obligations to him. The Ame- rican physician now has all that is needed in the shape of a complete treatise on materia medica, and the medical student has a text-book which, for prac- tical utility and intrinsic worth, stands unparalleled. Although of considerable size, it is none too large for the purposes for which it has been intended, and every medical man should, in justice to himself, spare a place for it upon his book-shelf, resting assured that the more he consults it the better he will be satisfied of its excellence.—N. Y. Med. Record, Nov. 15, 1866. It will fill a place which no other work can occupy [u the library.of the physician, student, and apothe- eary.—Boston Med. and Surg. Journal, Nov. 8, 1866. Of the many works on Materia Medica which have appeared since the issuing of the British Pharmaco- being the most complete work on the subject in the English language. But its very completeness stood in the way uf its success. Except in the way of refer- ence, or to those who made a special study of Materia Medica, Dr. Pereira's work was too full, and its pe- rusal required an amount of time which few had at their disposal. Dr. Farre has very judiciously availed himself of the opportunity of the publication of the new Pharmacopoeia, bybrinariugout an abridged edi- tion of the great work. This edition of Pereira is by no means a mere abridged re-issue, but contains many improvements, both in the descriptive and thera- peutical departments. We can recommend it as a very excellent and reliable text-book.—Edinburgh Med. Journal, February, 1866. The reader cannot fail to be impressed, at a glance, with the exceeding value of this work as a compend of nearly all useful knowledge on the materia medica. We are greatly indebted to Professor Wood for his adaptation of it to our meridian. Without his emen- dations and additions it would lose much of its value to the American student. With them it is an Ameri- can book.—Pacific Medical and Surgical Journal, December, 1866. fjLLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- tion, carefully revised and much improved by Albert H. Smith, M.D. In one volume 8v». of 376 pages, extra cloth, $3 00. (Lately Published.) This work has remained for some time out of print, owing to the anxious care with which the Editor has sought to render the present edition worthy a continuance of the very remarkable favor which has carried the volume to the unusual honor of a Twelfth Edition. He has sedu- lously endeavored to introduce in it all new preparations and combinations deserving of confidence, besides adding two new classes, Antemetics and Disinfectants, with brief references to the inhalation of atomized fluids, the nasal douche of Thudichum, suggestions upon the method of hypodermic injection, the administration of anaesthetics, &c. RINTON (WILLIAM), M.D., F.R.S. •°LECTURES ON THE DISEASES OF THE STOMACH; with an Introduction on its Anatomy and Physiology. From the second and enlarged London edi- tion. With illustrations on wood. In one handsome octavo volume of about 300 pages, extra cloth. $3 25. flHAMBERS (T.K.), M. D., L/ Consulting Physician to St. Mary's Hospital, London, Ac. THE INDIGESTIONS; or, Diseases of the Digestive Organs Functional]; Treated. Third and revised Edition. In one handsome octavo volume of 333 pages, extra cloth. $3 00. (Lately Published.) So very large a proportion of the patients applying to every general practitioner suffer from some form of indigestion, that whatever aids him in their man- agement directly "puts money in his purse," and in- directly does more than anything else to advance his reputation with the public. From this purely mate- rial point of view, setting aside its higher claims to merit, we know of no more desirable acquisition to a physician's library than the book before us. He who should commit its contents to his memory would find its price an investment of capital that returned him a most usurious rate of interest.—N. Y. Medical Gazette, Jan. 28, 1871. T>Y THE SAME AUTHOR. (Lately Published) RESTORATIVE MEDICINE. An Harveian Annual Oration, deliv- ered at the Royal College of Physicians, London, on June 24, 1871. With Two Sequels. In one very handsome volume, small 12mo., extra cloth, $1 00. 16 Henry C. Lea's Publications—(Practice of Medicine). fjAR TSHORNE {HENR Y). M.D., ■**-*- Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. Third edition, revised and im- proved. In one handsome royal 12mo. volume of 487 pages, clearly printed on small type, cloth, $2 38; half bound, $2 63. (Now Ready.) The very remarkable favor which has been bestowed upon this work, as manifested in the ex- haustion of two large editions within four years, shows that it has successfully supplied a want felt by both student and practitioner of a volume which at a moderate price and in a convenient size should afford a clear and compact view of the most modern teachings in medical practice. In preparing the work for a third edition, the author has sought to maintain its character by very numerous additions, bringing it fully up to the science of the day, but so concisely framed that the size of the volume is increased only by thirty or forty pages. The extent of the new informa- tion thus introduced may be estimated by the fact that there have been two hundred and sixty separate additions made to the text, containing references to one hundred and eighty new authors. This little epitome of medical knowledge has al- ready been noticed by us. It is a vade mecum of value, including in a short space most of what is es- sential in the science and practice of medicine. The third edition is well up to the present day in the modern methods of treatment, audin the use of newly discovered drugs.—Boston Med. and Surg. Journal, Oct. 19, 1871. Certainly very few volumes contain so much pre- cise information within so small a compass.—N. Y. Mf.d. Journal, Nov. 1871. The diseases are conveniently classified; symptoms, causation, diagnosis, prognosis, and treatment are carefully considered, the whole being marked by briefness, but clearness of expression. Over 2-50 for- mulas are appended, intended as examples merely, not as guides for unthinking practitioners. A com- plete index facilitates the use of this little volume, in which all important remedies lately introduced, such as chloral hydrate and carbolic acid, have received their full shareof attention.—Am. Journ. of Pharm., Nov. 1871. It is an epitome of the whole science and practice of medicine, and will be found most valuable to the practitioner for easy reference, and especially to the student in attendance upon lectures, whose time is too much occupied with many studies, to consult the larger works. Such a work must always be in great demand.—Cincinnati Med. Repertory, Nov. 1871. 1XTA TSON (THOMAS),, 31. D., Sfc. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illus- trations, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- sylvania. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. (Justready.) With the assistance of Professor George Johnson, his successor in the chair of Practice of Medi- cine in King's College, the author has thoroughly revised this work, and has sought to bring it on a level with the most advanced condition of the subject. As he himself remarks : "Consider- ing the rapid advance of medical science during the last fourteen years, the present edition would be worthless, if it did not differ much from the last"—but in the extensive alterations and addi- tions that have been introduced, the effort of the author has been to retain the lucid and collo- quial style of the lecture-room, which has made the work so deservedly popular with all classes of the profession. Notwithstanding these changes, there are some subjects on which the American reader might reasonably expect more detailed information than has been thought requisite in England, and these deficiencies the editor has endeavored to supply. The large size to which the work has grown seems to render it necessary to print it in two vol- umes, in place of one, as in the last American edition. It is therefore presented in that shape, handsomely printed, at a very reasonable price, and it is hoped that it will fully maintain the position everywhere hitherto accorded to it, of the standard and.classical representative of Eng- lish practical medicine. At length, after many months of expectation, we have the satisfaction of finding ourselves this week in possession of a revised and enlarged edition of Sir Thomas Watson's celebrated Lectures. It is a sub- ject for congratulation and for thankfulness that Sir Thomas Watson, during a period of comparative lei- sure, after a long, laborious, and most honorable pro- fessional career, while retaining full possession of his' high mental faculties, should have employed the op- portunity to submit his Lectures to a more thorough revision than was possible during the earlier and busier period of his life. Carefully.passingin review some of the most intricate and important pathological and practical questions, the results of his clear insight and his calm judgment are now recorded for the bene- fit of mankind, in language which, for precision, vigor, and classical elegance, has rarely been equalled, and never surpassed The revision has evidently been most carefully done, and the results appear in almost every page.—Brit. Med. Journ., Oct. 14, 1871. No words can convey the pleasurable satisfaction that we feel in looking over the revised edition of the admirable lectures of this distinguished author. The earnestness which marked his whole profes- sional career leads him, in a characteristic manner, to devote his last leisure hours to the correction of his preat classic work. The lectures are so well known and so justly appreciated, that it is scarcely neces- sary to do more than call attention to the special advantages of the last over previous editions. In the revision, the author has displayed all the charms and advantages of great culture and a ripe experi- ence combined with the soundest judgment and sin- cerity of purpose. The author's rare combination of great scientific attainments combined with won- derful forensic eloquence has exerted extraordinary influence over the last two generations of physicians. His clinical descriptions of most diseases have never been equalled ; and on this score at least his work will live long in the future. The work will be sought by all who appreciate a great book.—Arner Journal of Syphilography, July, 1872.: We are exceedingly gratified at the reception of this new edition of Watson, pre-eminently the prince of English authors, on "Practice." We, who read the first edition as it came to us tardily and in frag- ments through the "Medical News and Library " shall never forget the great pleasure and profit we derived from its graphic delineations of disease its vigorous style and splendid English. Maturity of years, extensive observation, profound research and yet continuous enthusiasm, have combined to give us in this latest edition a model of professional excellence in teaching with rare beauty in the mode of communication. But this classic needs no eulo- gium of ours. The selection of Prof. Hartshorne as the American editor, is to us peculiarly gratifying and must insure even larger popularity and more general sale to American readers. Every guarantee is thus afforded that in every part the book will be found up to the times. Will it do to repeat the re- mark we have seen somewhere: " No library can be considered complete without it?" Although the phrase may not savor of originality, it is, neverthe- less, most emphatically true.—Chicago Med. Journ July, 1872. '' Henry C. Lea's Publications—(Diseases of Lungs and Heart). 17 J?LINT {AUSTIN), M.D., **- Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, extra cloth, $4. (Just Issued.) The author has sedulously improved the opportunity afforded him of revising this work. Portions of it have been rewritten, and the whole brought up to a level with the most advanced condition of science. It must therefore continue to maintain its position as the standard treatise on the subject. Dr. Flint chose a difficult subject for his researches, and has shown remarkable powers of observation and reflection, as well as great industry, in his treat- ment of it. His book must be considered the fullest and clearest practical treatise on those subjects, and should be in the hands of all practitioners and stu- dents. It is a credit to American medical literature. —Amer. Journ. of the Med. Sciences, July, 1860. We question the fact of any recent American author In our profession being more extensively known, or more deservedly esteemed in this country than Dr. Flint. We willingly acknowledge his success, more particularly in the volume on diseases of the heart, In making an extended personal clinical study avail- able for purposes of illustration, in connection with cases which have been reported by other trustworthy observers.—Brit, and For. Med.-Chirurg. Revieio. In regard to the merits of the work, we have no hesitation in pronouncing it full, accurate, and judi- cious. Considering the present state of science, such a work was much needed. It should be in the hands of every practitioner.—Chicago Med. Journ. With more than pleasure do we hail the advent of this work, for it fills a wide gap on the list of text- books for our schools, and is, for the practitioner, the most valuable practical work of its kind.—N. 0. Med. News. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, extra cloth, $4 50. which pervades his whole work lend an additional force to its thoroughly practical character, which cannot fail to obtain for it a place as a standard work on diseases of the respiratory system.—London Lancet, Jan. 19, 1867. This is an admirable book. Excellent in detail and execution, nothing better could be desired by the practitioner. Dr. Flint enriches his subject with much solid and not a little original observation.— Ranking''s Abstract, Jan. 1867. Dr. Flint's treatise is one of the most trustworthy guides which he can consult. The style is clear and distinct, and is also concise, being free from that tend- ency to over-refinement and unnecessary minuteness which characterizes many works on the same sub- ject.—Dublin Medical Press, Feb. 6, 1867. The chapter on Phthisis is replete with interest; and his remarks on the diagnosis, especially in the early stages, are remarkable for their acumen and great practical value. Dr. Flint's style is clear and elegant, and the tone of freshness and originality TjlULLER {HENRY WILLIAM), M. D., ■*- Physician to St. George's Hospital, London. ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. Dr. Fuller's work on diseases of the chest was so favorably received, that to many who did not know the extent of his engagements, it was a matter of won- der that it should be allowed to remain three years out of print. Determined, however, to improve it, Dr. Fuller would not consent to a mere reprint, and accordingly we have what might be with perfect jus- tice styled an entirely new work from his pen, the portion of the work treating of the heart and great vessels being excluded. Nevertheless, this volume is of almost equal size with the first.—London Medical Times and Gazette, July 2C, 1867. w HLLIAMS {C. J. B.), M.D., Senior Consulting Physician to the Hospital for Consumption, Brompton, and WILLIAMS (CHARLES T.), M.D., Physician to the Hospital for Consumption. PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- ment. With an Analysis of One Thousand cases to exemplify its duration. In one neat octavo volume of about 350 pages, extra cloth. (Just Issued.) $2 50. previous author; but probably there is no malady, the treatment of which has been so much improved within the last twenty years as pulmonary consump- tion. To Ourselves, Dr. Williams's chapters on Treat- ment are amongst the most valuable and at tractive in the book, and would alone render it a standard work of reference. In conclusion, we would record our opinion that Dr. Williams's great reputation is fully maintained by this book. It is undoubtedly one of the most valuable works in the language upon any special disease.—Lond. Med. Times aad Gaz., Nov. 4, 1871. He can still speak from a more enormous experi- ence, and a closer study of the morbid processes in- volved in tuberculosis, than most living men. He owed it to himself, and to the importance of the sub- ject, to embody his views in a separate work, and we are glad that he has accomplished this duty. After all, the grand teaching which Dr Williams has for the profession is to be found in his therapeutical chapters, and in the history of individual cases ex- tended, by dint of care, over ten, twenty, thirty, and even forty years.—London Lancet, Oct. 21, 1871. His results are more favorable than those of any LA ROCHE ON PNEUMONIA. 1 vol. 8vo., extra i SMITH ON_ CONSUMPTION; ITS EARLY ANDRE- cloth, of 500 pages. Price $3 00. BUCKLER ON FIBRO-BRONCHITIS AND RHEU- MATIC PNEUMONIA. 1 vol. Svo. $1 25. FISKE FUND PRIZE ESSAYS ON CONSUMPTION. 1 vol 8vo,, extra cloth. $1 00. MEDIABLE STAGES. 1 vol. 8vo., pp. 2f>4. $2 25. SALTER ON ASTHMA. 1 vol. Svo. $2 50. WALSHE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Third American edition. In 1 vol. 8vo.. 420 pp., cloth. $3 00. 18 Henry C. Lea's Publications—yrracnce oj meaxctne). ROBERTS { WILLIAM), M. D.. ■*•*' Lecturer on Medicine in the Manchester School of Medicine. Ac. A PRACTICAL TREATISE ON URINARY AND RENAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- ond American, from the Second Revised and Enlarged London Edition. Id one larjre and handsome octavo volume of 616 pages, with a colored plate , extra cloth, $4 50. (Just Ready.) The author has subjected this work to a very thorough revision, and has sought to embody in it the results of the latest experience and investigations. Although every effort has been made to keep it within the limits of its former size, it has been enlarged by a hundred pages, many new wood-cuts have been introduced, and also a colored plate representing the appearance of the different varieties of urine, while the price has been retained at the former very moderate rate. In every respect it is therefore presented as worthy to maintain the position which it has acquired as a leading authority on a large, important, and perplexing class of affections. A few notices of the first edition are appended. The plan, it will thus be seen, is very complete, aui the manner in which it has been carried out is in the highest degree satisfactory. The characters of the different deposits are very well described, and the microscopic appearances they present are illus- trated by numerous well executed engravings. It only remains to us to strongly recommend to our readers Dr. Roberts's work, as containiug an admira- ble rCsumi of the present 6tate of knowledge of uri- nary diseases, and as a safe and reliable guide to the clinical observer.—Edin. Med. Jour. The most complete and practical treatise upon renal diseases we have examined. It is peculiarly adapted to the wants of the majority of American practition- ers from its clearness and simple announcement of the facts in relation to diagnosis and treatment of urinary disorders, and contains in condensed form the investi- gations of Bence Jones, Bird, Beale, Hassall, Prout, and a host of other well-known writers upon this sub- ject. The characters of urine, physiological and pa- thological, as indicated to the naked eye as well as by microscopical and chemical investigations, are con- cisely represented both by description and by well executed engravings.—Cincinnati Journ. of Med. J) ASH AM { W. R.), M. D., ■*-* Senior Physician to the Westminster Hospital, Ac. RENAL DISEASES: a Clinical Guide to their Diagnosis and Treatment. With illustrations. In one neat royal 12mo. volume of 304 pages. $2 00. (Just Issued.) The chapters on diagnosis and treatment are very good, and the student and young practitioner will find them full of valuable practical hints. The third part, on the urine, is excellent, and we cordially recommend its perusal. The author has arranged his matter in a somewhat novel, and, we think, use- ful form. Here everything can be easily found, and, what is more important, easily read, for all the dry details of larger books here acquire a new interest from the author's arrangement. This part of the book is full of good work.—Brit, and For. Medico- Chirurgical Review, July, 1870. The easy descriptions and compact modes of state- ment, render the book pleasing and convenient.—Am. Journ. Med. Sciences, July, 1870. A book that we believe will be found a valuable assistant to the practitioner and guide to the student. —Baltimore Med. Journal, July, 1870. The treatise of Dr. Basham differs from the rest in its special adaptation to clinical study, and its con- densed and almost aphorismal style, which makes it easily read and easily understood. Besides, the author expresses some new views, which are well worthy of consideration. The volume is a valuable addition to this department of knowledge.—Pacific Med. and Surg. Journal, July, 1870. MORLAND ON RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. 1 vol. 8vo., extra cloth. 75 cents. TONES {C. HANDFIELD), M. D., f Physician to St. Mary's Hospital, Ac. CLINICAL OBSERVATIONS DISORDERS. Second American Edition. extra cloth, $3 25. Taken as a whole, the work before us furnishes a short but reliable account of the pathology and treat- ment of a class of very common but certainly highly obscure disorders. The advanced student will find it a rich mine of valuable facts, while the medical prac- titioner will derive from it many a suggestive hint to aid him in the diagnosis of "nervous cases," and in determining the true indications for their ameliora- tion or cure.—Amer. Journ. Med. Sei., Jan. 1867. ON FUNCTIONAL NERVOUS In one handsome octavo volume of 348 pages, We must cordially recommend it to the profession of this country as supplying, in a great measure, a deficiency which exists in the medical literature of the English language.—New York Med. Journ., April, 1867. The volume is a most admirable one—full of hints and practical suggestions. — Canada Med. Journal, April, 1867. f)N DISEASES OF THE SPINAL COLUMN AND OF THE NERVES. " By C. B. Radcliff, M. D., and others. 1 vol. 8vo., extra cloth, $1 50. C7EISSL (H:„ ^ A COMPLETE TREATISE ON VENEREAL DISEASES. lated from the Second Enlarged German Edition, by Frederic R. Sturgis, M.D. octavo volume, with illustrations. (Preparing.) Trans- In one 20 Henry C. Lea's Publications—(Diseases of the Skin). TK7ILS0N (ERASMUS), F. R.S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN," consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. Such a work as the one before us is a most capital and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his book on diseases of the skin has long been re- garded as one ot the best text-books extant on the subject. The present edition is carefully prepared, and brought up in its revision to the present time In this edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases.—Cincinnati Lancet. No one treating skin diseases should be without a copy of this standard work.— Canada Lancet, iugust, 1863. We can safely recommend it to the profession aa the best work on the subject now in existence in the English language.—Medical Times and Gazette. Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin.—British and Foreign Medical Review. B Y THE SAME AUTHOR. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- eases of the skin. In one very handsome royal 12mo. volume. $3 50. (Lately Issued.) *JELIGAN {J. MOORE), M.D., M.R.I.A. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M. D. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. Fully equal to all the requirements of students and young practitioners.—Dublin Med. Press. Of the remainder of the work we have nothing be yond unqualified commendation to offer. It is so far the most complete one of its size that has appeared, and for the student there can be none which can com- pare with it in practical value. All the late disco- veries in Dermatology have been duly noticed, and J^Y THE SAME AUTHOR. their value justly estimated ; in a word, the work is fully up to the times, and is thoroughly stocked with most valuable information.—New York Med. Record, Jan. 15, 1867. The most convenient manual of diseases of the skin that can be procured by the student.—Chicago Med. Journal, Dec. 1866. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of disease. Extra cloth, $5 50. The diagnosis of eruptive disease, however, under I inclined to consider it a very superior work, com all circumstances, is very difficult. Nevertheless, Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the "Practical Treatise." and we are bining accurate verbal description with sound vi^ws of the pathology and treatment of eruptive diseases. — Glasgow Med. Journal. A compend which will very much aid the practi- tioner in this difficult branch of diagnosis Taken with the beautiful plates of the Atlas, which are re- ma.rkable for their accuracy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man.—Buffalo Med. Journal. TJILLIER {THOMAS), M.D., Physician to the Skin Department of University College Hospital, Ac. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. Extra cloth, $2 25. We can conscientiously recommend it to the stu- dent; the style is clear and pleasant to read, the matter is good, and the descriptions of disease, with the modes of. treatment recommended, are frequently illustrated with well-recorded cases.—London Med. Times and Gazette, April 1, 1865. It is a concise, plain, practical treatise on the vari- ous diseases of the skin ; just such a work, indeed, as was much needed, both by medical students and practitioners. — Chicago Medical Examiner. May. 1865. A NDERSON (MrCALL), M.D., -£*- Physician to the Dispensary for Skin Diseases, Glasgow, Ac. ON THE TREATMENT OF DISEASES OF THE SKIN. With an Analysis of Eleven Thousand Consecutive Cases. In one vol. 8vo. (Publishing in the Medical News and Library for 1873.) The very practical character of this work and the extensive experience of the author, cannot fail to render it acceptable to the subscribers of the "American Journal of the Medical Sciences." When completed in the "News and Library-," it will be issued separately in a neat octavo volume. Henry C. Lea's Publications—(Diseases of Children). 21 &MITH (J. LE WIS), M. D., *"' Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. Y. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Second Edition, revised and greatly enlarged. In one handsome octavo volume of 742 pages, extra cloth, $5; leather, $6. (Now Ready.) From the Preface to the Second Edition. < In presenting to the profession the second edition of his work, the author gratefully acknow- ledges the favorable reception accorded to the first. He has endeavored to merit a continuance of this approbation by rendering the volume much more complete than before. Nearly twenty additional diseases have been treated of, among which may be named Diseases Incidental to Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, and the various forms of Paralysis. Many new formulse, which experience has shown to be useful, have been introduced, portions of the text of a less practical nature have been con- densed, and other portions, especially those relating to pathological histology, have been rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of the page, the number of pages has been enlarged by more than one hundred. 227 West 49th Street, New York, April, 1872. The work will be found to contain nearly one-third more matter than the previous edition, and it is confidently presented as in every respect worthy to be received as the standard American text-book on the subject. Eminently practical as well as judicious in its teachings.—Cincinnati Lancet and Obs., July, 1872. A standard work that leaves little to be desired.— Indiana Journal of Medicine, July, 1872. We know of no book on this subject that we can more cordially recommend to the medical student and the practitioner.—Cincinnati Clinic, June 29, '72. We regard it as superior to any other single work on the diseases of infancy and childhood.—Detroit Rev. of Med. and Pharmacy, Aug. 1872. We confess to increased enthusiasm in recommend- ing this second edition.—St. Louis Med. and Surg. Journal, Aug. 1872. riONDIE {D. FRANCIS), M.D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, extra cloth, $5 25 ; leather, $6 25. (Lately Issued.) teachers. As a whole, however, the work is the best American one that we have, and in its special adapta- tion to American practitioners it certainly has no The present edition, which is the sixth, is fully up to the times in the discussion of all those points in the pathology and treatment of infantile diseases which have been brought forward by the German and French squal.—New York Med. Record, March 2, 186S. l/ITEST {CHARLES), M.D., ' ' Physician to the Hospital for Sick Children, Ac. LECTURES ON THE DISEASES OF INFANCY AND CHILD- HOOD. Fourth American from the fifth revised and enlarged English edition. In one large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 50; leather, $5 50. Of all the English writers on the diseases of chil-1 living authorities in the difficult department of medi- tfren, there is no one so entirely satisfactory to us as | cal science in which he is most widely known.— Dr. West. For years we have held his opinion as I Boston Med. and Surg. Journal, April 26, 1866. judicial, and have regarded him as one of the highest | s T>Y THE SAME AUTHOR. (LatelyIssued.) ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., extra cloth, $1 00. MITH(EUSTACE), M. D., Physician to the Northwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, extra cloth, $2 50. (Lately Issued.) This is in every way an admirable book. The scribed as a practical handbook of the common dis- modest title which the author has chosen for it scarce- eases of children, so numerous are the affections con- ly conveys an adequate idea of the many subjects sidered either collaterally or directly. We are upon which it treats. Wasting is so constant an at- acquainted with no safer guide to the treatment of tendant upon the maladies of childhood, that a trea- children's diseases, and few works give the insight ti*e upon the wasting diseases of children must neces into the physiological and other peculiarities of chil- sarily embrace the consideration of many affections dren that Dr. Smith's book does.—Brit. Med. Journ., of which it is a symptom; and this is excellently well April 8, 1871. done by Dr. Smith. The book might fairly be de- pUERSANT (P.),M.D., ^~ Honorary Surgeon to the Hospital for Sick Children, Paris. SURGICAL DISEASES OF INFANTS AND CHILDREN. Trans- lated by R. J. Dunglison, M. D. In one neat octavo volume, extra cloth, $2 50. (Now Ready)_______________ PEWEES ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. Eleventh edition. 1 vol. 8vo. of 548 pages. *2 80. 22 Henry C. Lea's Publications—(Diseases of Women). A YE LING (JAMES H.), -*■ *- Physician to the Hosoital fo WILTSHIRE (ALFRED). M.D., Assistant Physician- Accoucheur to St- and Physician to the Hospital for Women and Children. Mary's Hospital. THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Including Midwifery, and the Diseases of Women and Infants. With an American . Supplement, edited by William F. Jenks, M.D. A monthly of about 80 octavo pages, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 cents each. Commencing with April, 1873, the Obstetrical Journal will consist of Original Papers by Brit- ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, r practitioners, we believe it is unequalled. In the i ?'™^thAen?, «o g 6 ** that tln"»--«»<*"M«« libraries of reading physicians we meet with it ( uanca< Au«- 18ba- oftener than any other treatise on diseases of women. | It is so short a time since we gave a full review of one book on diseases of women, that book should be , and we can only congratulate the author on the ' 1 nomas. ' — Amtr. Jour. Med. Sciences, April, I brilliant reception his book has received —N Y Med 1872- i Journal, April, 1869. Henry C. Lea's Publications—(Diseases of Women). 23 TJODGE (HUGH L.), M.D., "*•-*■ Emeritus Professor of Obstetrics, RYANT (THOMAS), F.R.C.S., •*-* Surgeon to Guy's Hospital. THE PRACTICE OF SURGERY. With over Five Hundred En- gravings on Wood. In one large and very handsome octavo volume of nearly 1000 pages, extra cloth, $6 25 ; leather, raised bands, §7 25. (Just Rexdy.) The distinguished reputation of the author and the extended experience which he has enjoyed as surgeon to one of the largest of the London hospitals, are an earnest of the value of his labors. Though entitled a "Practice of Surgery," it will be seen by the subjoined summary of the contents that it is by no means confined to operative surgery, but that it presents also a view of the prin- ciples which should guide the surgeon in his daily practice. Nearly all of the very full series of illustrations have been prepared expressly for the work. sxjnycavr^A.1?.-^- of coisttetntts. Introduction.—i. On Repair and Inflammation, n. On Traumatic Fever, Septicaemia, and Py- aemia, in. On Trismus and Tetanus, iv. Delirium Tremens, v. Contusions : Wounds of the Scalp, Blood Tumors, Osteitis, vi. Injuries of the Cranium, vn. Concussion of the Brain, vni. Injuries of the Brain and its Membranes, complicating Fracture, ix. Compression of the Brain, x. Re- sults of Injuries to the Head. xi. On Fractures of the Skull, xn. The Operation of Trephining. xm. Diseases of the Scalp and Cranium, xiv. Spina Bifida, xv. Injuries of the Spine, xvi. Intra-Spinal Inflammation, Spinal Paralysis, Railway Concussion, xvu. Fractures, Dislocations, and Wounds of the Spine, xvm. Curvature of the Spine, xix. Injuries and Diseases of the Nerves. xx. Surgical Affections of the Nose. xxi. Surgical Affections of Larynx and Trachea, xxn. Sur- gery of the Chest, xxin. Wounds of the Heart, xxiv. Diseases of the Arteries, xxv. Aneurism. xxvi. Ligature of Arteries, xxvn. Injuries and Diseases of the Veins, xxvin. Affections of the Lips, etc. xxix. Diseases of the Jaws, etc. xxx. Affections of the Pharynx, xxxi. Injuries of the Abdomen, xxxn. Hernia, xxxin. Varieties of Herniae. xxxiv. Trusses, xxxv. Surgery of the Anus, xxxvi. Diseases of the Integuments : Wounds, xxxvir. Poisoned Wounds, xxxvm. Burns, xxxix. Skin Grafting, xl. Boils, etc. xli. Gangrene, etc. xlii. Ulcers, xliii. Mor- tification, xliv. Erysipelas, xlv. Diseases of the Lymphatics, xlvi. Diseases of the Kidney. xlvii. Diseases of the Bladder, xlviii. Diseases of the Prostate, xlix. Urinary Deposits, l. Stone in the Bladder, li. Lithotrity. lii. Lithotomy, liii. Stono in the Female Bladder, liv. Stricture of the Urethra, lv. Retention of Urine, lvi. Affections of the Penis, lvii. Haemato- cele, etc. lviii. Diseases of the Testicle. lix. Sterility, lx. Affections of the Female Geni- tals, lxi. Ovariotomy, lxii. Venereal Disease, lxiii. Syphilis, lxiv. Tumors, lxv. Anatomy of Tumors, lxvi. Tumors of the Breast, lxvii. Diseases of the Thyroid Gland, lxviii. Wounds of the Joints, lxix. Dislocations, lxx. Dislocations of the Upper Extremity, lxxi. Disloca- tions of the Lower Extremity, lxxii. Pathology of Joint Diseases, lxxiii. Diseases of Special Joints, lxxiv. Treatment of Joint Disease, lxxv. Excision and Amputation in Joint Disease. lxxvi. Osteo-arthritis. lxxvii. Diseases of the Bones, lxxvui. Tumors of Bone, lxxix. Frac- tures, lxxx. Fractures of the Upper Extremity, lxxxi. Fractures of the Lower Extremity. lxxxii. Complicated Fractures, lxxxiii. Gunshot Injuries, lxxxiv. Feigned and Hysterical Dis- ease, lxxxv. Affections of the Muscles and Tendons, lxxxvi. Ganglions, lxxxvii. Orthopaedic Surgery, lxxxviii. Anaesthetics, lxxxix. Shock, xc. Amputation, xci. Special Amputations. xcii. Elephantiasis, xcm. Affections of the External Ear. xciv. Parasites. WELLS (J- SOELBERG), ' ' Professor of Ophthalmology in King's College Hospital, Ac. A TREATISE ON DISEASES OF THE EYE. First American Edition, with additions ; illustrated with 216 engravings on wood, and six colored plates. Together with selections from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume of about 750 pages: extra cloth, $5 00; leather, $6 00. (Lately Issued.) mend it to all who desire to consult a really good work on ophthalmic science. The American edition of Mr. Wells' treatise was superintended in its passage through the press by Dr. I. Minis Hays, who has added some notes of his own where it seemed desira- ble. He has also introduced more than one hundred new additional wood-cuts, and added selections from the test-types of Jaeger and of Snellen.— Leavenworth Med. Herald, Jan. 1870. Without doubt, one of the best works upon the sub- ject which has ever been published ; it is complete on the subject of which it treats, and is a necessary work for every physician who attempts to treat diseases of the eye.—Dominion Med. Journal, Sept. 1869. In this respect the work before us is of much more service to the general practitioner than those heavy compilations which, in giving every person's views, too often neglect to-specify those which are most in accordance with the author's opinions, or in general acceptance. We have no hesitation in recommending this treatise, as, on the whole, of all English works on the subject, the one best adapted to the wants of the general practitioner. — Edinburgh Med. Journal, March, 1870. A treatise of rare merit. It is practical, compre- hensive, and yetconcise. Upon those subjects usually found difficult to the student, he has dwelt at length and entered into full explanation. After a careful perusal of its contents, we can unhesitatingly com- ZA WSON (GEORGE), F. R. C. S, Engl, Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorfields, Ac. INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In one very hand- some octavo volume, extra cloth, $3 50. It is an admirable practical book in the.highest and best sense of the phrase.— London Medical Timet and Gazette, Ai;iy 18, 1867. 30 Henry C. Lea's Publications—(Surgery, &c). J A URENCE (JOHN Z.), F. R. C. S., Editor of the Ophthalmic Review, Ac. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In one very handsome octavo volume, extra cloth, $3 00. (Lately Issued.) For those, however, who must assume the care of tion of the opticardefects of the eye, the pohll8her diseases ana injuries of the eye, and who are- too has giver.increased value by the add. »u » « J, " much pressed for time to stud/ the classic works on pages of Snellen s test-ty pes, so genera ly use 1 test the subject, or those recently published by Stellwag, the acuteness of vision^»»d^"Vh„R hf«„ I. ,-ide" Wells, Bader, and others, Mr. Laurence will prove a tain in this country. The 7»»"« J*«^f" ', d *h safe and trustworthy guide. He has described in this rably enlarged and improved by the revismn «^ edition those novelties which have secured the confl- ditions of its author, expressly for the An encan dence of the profession since the appearance of his edition —Am. Journ. Med. bciencts, Jan. 18(0. last. To the portion of the book devoted to a descrip- WALES (PHILIP S.), M. D., Surgeon U. S. N. MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations : embracing Minor Surgery, Band- aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred and forty-two illustrations on wood. In one large and handsome octavo volume of about 700 pages: extra cloth, $5 75; leather, $6 75. A Naval Medical Board directed to examine and report upon the merits of this volume, officially states that " it should in our opinion become a standard work in the hands of every naval sur- geon;" and its adoption for use in both the Army and Navy of the United States is sufficient guarantee of its adaptation to the needs of every-day practice. , /THOMPSON (SIR HENR Y), •*- Surgeon and Professor of Clinical Surgery to University College Hospital. LECTURES ON DISEASES OF THE URINARY ORGANS. illustrations on wood. In one neat octavo volume, extra cloth. $2 25. With These lectures stand the severe test. They are in- structive without being tedious, and simple without being diffuse; and they include many of those prac- tical hints so useful for the student, and even more valuable to the young practitioner.—Edinburgh Med. Journal, April,"1869. Very few words of ours are necessary to recommend these lectures to the profession. There is no subject on which Sir Henry Thompson speaks with more au- thority than that in which he has specially gathered his laurels; in addition to this, the conversational style of instruction, which is retained in these printed lectures, gives them an attractiveness which a sys- tematic treatise can never possess.—London Medical Times and Gazette, April 21, 1869. J>Y THE SAME AUTHOR. ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHBA AND URINARY FISTULAS. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, extra cloth, $3 50. (Lately Published.) This classical work has so long been recognized as a standard authority on its perplexing sub- jects that it should be rendered accessible to the American profession. Having enjoyed the advantage of a revision at the hands of the author within a few months, it will be found to present his latest views and to be on a level with the most recent advances of surgical science. With a work accepted as the authority upon the I ably known by the profession as this before us, must subjects of which it treats, an extended notice would | create a demand for it from those who would keep be a work of supererogation. The simple announce- J themselves well up in this department of surgery.__ uient of another edition of a work so well and favor- | St. Louis Med. Archives, Feb. 1870. T 'AYLOR (ALFRED S.), M.D., Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. by John J. Reese, M.D., Prcf. of Med octavo volume. (Preparing.) The present edition of this valuable manual is a great improvement on those which have preceded it. It makes thus by far the best guide-book in this de- Seventh American Edition. Edited Jurisp. in the Univ. of Penn. In one large partment of medicine for students and the general practitioner in ourlanguage.—Boston Med.andSuro. Journal, Dec. 27, 1866. T) Y THE SA ME A UTHOR. (Nearly Ready.) THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two very large octavo volumes. This great work is now recognized in England as the fullest and most authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Ameri- can profession, the publisher trusts that it will assume the same position in this country. Henry C. Lea's Publications—(Psychological Medicine, &c). 31 rTUKE (DANIEL HACK), M.D, ■*- Joint author of " The Manual of Psychological Medicine," Ac. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of tbe Imagination. In one handsome octavo volume of 416 pages, extra cloth, $3 25. (Now Ready.) The object of the author in this work has been to show not only the effect of the mind in caus- ing and intensifying disease, but also its curative influence, and the use which may be made of the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- ject have long been familiar to the profession, but no attempt has hitherto been made to collect and systematize them so as to render them available to the practitioner, by establishing the seve- ral phenomena upon a scientific basis. In the endeavor thus to convert to the use of legitimate medicine the means which have been employed so successfully in many systems of quackery, the author has produced a work of the highest freshness and interest as well as of permanent value. DLANDFORD (G. FIELDING), M. D., F. R. C P., •*-* Lecturer %n Psychological Medicine at the School of St. George's Hospital, Ac. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages: extra cloth, $3 25. (Just Issued.) This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of more value to the practitioner in this country, Dr. Ray has added an appendix which affords in- formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment be called upon to take action in relation to patients. actually seen in practice and the appropriate treat- ment for them, we find in Dr. Blandford's work a considerable advance; over previous writings on the subject. His pictures of the various forms of mental disease are so clear and good that no reader can fail to be struck with their superiority to those given in irdinary manuals in the English language or (so far as our own reading extendsj in any other.—London Practitioner, Feb. 1871. It satisfies a want which must have been sorely felt by the busy general practitioners of this country. It takes the form of a manual of clinical description of the various forms of insanity, with a description of the mode of examining persons suspected of in- sanity. We call particular attention to this feature of the book, as giving^t a unique value to the gene- ral practitioner. If we pass from theoretical conside- rations to descriptions of the varieties of insanity as w INSLOW (FORBES), M.D., D.C.L., #c. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo volume of nearly 600 pages, extra cloth. $4 25. J EA (HENRY C). SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; extra cloth, $2 75. (Lately Published.) We know of no single work which contains, in so small a compass, so much illustrative of the strangest operations of the human mind. Foot-notes give the authority for each statement, showing vast research and wonderful industry. We advise our confreres to read this book and ponder its teachings.—Chicago Med. Journal, Aug. 1870. As a work of curious inquiry on certain outlying poiuts of obsolete law, "Superstition and Force" is one of the most remarkable books we have met with. —London Athenaeum, Nov. 8, 1866. He has thrown a great deal of light upon what must be regarded as one of the most instructive as well as interesting phases of human society-and progress. . . The fulness and breadth with which he has carried out his comparative survey of this repulsive field of history [Torture], are such as to preclude our doing justice to the work within our present limits. But here, as throughout the volume, there will be found a wealth of illustration and a critical grasp of the philosophical import of facts which will render Mi. Lea's labors of sterling value to the historical stu- dent.—London Saturday Review, Oct. 8, 1870. As a book of ready reference on the subject, it is of the highest value.— Westminster Review, Oct. 1867, nf THE SAME AUTHOR. (Late'y Published.) STUDIES IN CHURCH HISTORY—THE RISE OF THE TEM- PORAL POWER—BENEFIT OF CLERGY—EXCOMMUNICATION. In one large royal 12mo. volume of 516 pp. extra cloth. $2 75. The story was never told more calmly or with literary phenomenon that the head of one of the first greater learning or wiser thought. We doubt, indeed, If a uy other study of this field can be compared with this for clearne^s, accuracy, and power. — Chicago Examiner, Dec. 1S70. Mr. Lea's latest work, "Studies in Church History," fully sustains the promise of the first. It deals with three subjects—the Temporal Power, Benefit of Clergy, and Excommunication, the record of which has a peculiar importance for the English student, and is a chapter on Ancient Law likely to be regarded as final. We can hardly pass from our nieuti»>n of such woi!;* as the.-e—with which that on ".Sacerdotal Celibacy'' should be included—without noting the American houses is also the writer of some of its in< original books.—London Mhenaum, Jan. 7, 1371. Mr. Lea has done great honor to himself and this country by the admirable works he has written on ecclesiologicaland cognate subjects. We have already had occasion to commend his "Superstition and Force" and his "History of Sacerdotal Celibacy." The present volume is fully as admirable in its me- thod of dealing with topics and in the thoroughness— a quality so frequently lacking in American authors— with which tliey are investigated.—.V. Y. Journal of Psychol Medicine, July, 1870. 32 Henry C. Lea's Publications. INDEX TO CATALOGUE American Journal of the Medical Sciences American Chemist (The) .... Abstract, Half-Yearly, of the Med. Sciences Anatomical Atlas, by Smith and Horner Anderson on Diseases of the Skin Ashton on the Kectum and Anus Attfleld's Chemistry Ashwell on Diseases of Females Ashhurst's Surgery Barnes on Diseases of Women Bryaut's Practical Surgery . Blandford on Insanity . Basham on Renal Diseases . Brinton on the Stomach Bigelow on the Hip Barclay s Medical Diagnosis . Barlow's Practice of Medicine Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Buckler on Bronchitis .... Ilumstead on Venereal .... Humstead and Cullerier's Atlas of Venereal Carpenter's Human Physiology . Carpenter's Comparative Physiology . Carpenter on the Use and Abuse of Alcohol Carson's Synopsis of Materia Medica . Chambers on the Indigestions Chambers's Restorative Medicine Christison and Griffith's Dispensatory Churchill's System of Midwifery . Churchill on Puerperal Fever Condie on Diseases of Children . Cooper's (B. B ) Lectures on Surgery . Cullerier's Atlas of Venereal Diseases Cyclopedia of Practical Medicine . Dalton's Human Physiology . De Jongh on Cod-Liver Oil . Dewees's System of Midwifery Dewees on Diseases of Females . Dewees on Diseases of Children . Druitt's Modem Surgery Dunglison's Medical Dictionary . Dunglison's Human Physiology . Dunglison on New Remedies Ellis's Medical Formulary, by Smith . Erichsen's- System of Surgery Eiichsen on Nervous Injuries Flint on Respiratory Organs . Flint on the Heart..... Flint's Practice of Medicine . . F ownes's Elementary Chemistry . Fox on Diseases of the Stomach . Fuller on the Lungs, &c. Green's Pathology and Morbid Anatomy Gibson's Surgery..... Q luge's Pathological Histology, by Leidy Galloway's Qualitative Analysis . Gray's Anatomy..... Griffith's (R. E.) Universal Formulary Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gross's Pathological Anatomy Guersant on Surgical Diseases of Children Hartshorne's Essentials of Medicine . Hartshorne's Conspectus of the Medical Sciences Hamilton on Dislocations and Fractures Heath's Practical Anatomy . Hoblyn's Medical Dictionary Bodge on Women . Hodge's Obstetrics . Hodges' Practical Dissectiens Holland's Medical Notes and Reflections Horner's Anatomy and Histology Hudson on Fevers .... Hill on Venereal Diseases Hillier's Handbook of Skin Diseases Jones and Sieveking's Pathological Anatomy Jones (C. Handfield) on Nervous Disorders Kirkes' Physiology..... Knapp's Chemical Technology Lea's Superstition and Force PAGE 1 11 3 Lea's Studies in Church History . La Roche on Yellow Fever .... La Roche on Pneumonia, ic. Laurence and Moon's Ophthalmic Surgery . Lawson on the Eye..... Laycock on Medical Observation . Lehmann's Physiological Chemistry, 2 vols. Lehmann's Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever ...».■ Maclise's Surgical Anatomy .... Marshall's Physiology..... Medical News and Library .... Meigs's Obstetrics, the Science and the Art . Meigs's Lectures on Diseases of Women Meigs on Puerperal Fever Miller's Practice of Surgery . Miller's Principles of Surgery Montgomery on Pregnancy . Morland on Urinary Organs . Morland on Uitemia Neill and Smith's Compendium of Med. Science Neligan's Atlas of Diseases of the Skin Neligan on Diseases of the Skin Obstetrical Journal Odling's Practical Chemistry Pavy on Digestion Prize Essays on Consumption Parrish's Practical Pharmacy Pirrie's System of Surgery . • Pereira's Mat. Medica and Therapeutics, abridged Quain and Sharpey's Anatomy, by Leidy . Ranking's Abstract..... Radcliff and others on the Nerves, &c. Roberts on Urinary Diseases .... Ramsbotham on Parturition .... Rigby's Midwifery...... Rokitansky's Pathological Anatomy . Royle's Materia Medica and Therapeutics . Salter on Asthma...... Swayne's Obstetric Aphorisms Sargent's Minor Surgery .... Sharpey and Quain's Anatomy, by Leidy . Simon's General Pathology .... Skey's Operative Surgery .... Slade on Diphtheria..... Smith (J. L.) on Children .... Smith (H. H.) and Horner's Anatomical Atlas Smith (Edward) on Consumption . Smith on Wasting Diseases of Children Solly on Anatomy and Diseases of the Brain Stille"s Therapeutics Tanner's Manual of Clinical Medicine Tanner on Pregnancy Taylor's Medical Jurisprudence . Taylor's Principles and Practice of Med Jurisp Tuke on the Influence of the Mind Thomas on Diseases of Females . Thompson on Urinary Organs Thqnip.-on on Stricture . Todd on Acute Diseases . Wales on Surgical Operations Walshe on the Heart Watson's Practice of Physic . Wells on the Eye .... West on Diseases of Females Weston Diseases of Children West on Nervous Disorders of Childre West on Ulceration of Os Uteri What to Observe in Medical Cases Williams's Principles of Medicine Williams on Consumption Wilson's Human Anatomy . Wilson on Diseases of the Skin . Wilson's Plates on Diseases of the Ski Wilson's Handbook of Cutaneous Medicine Wilson on Spermatorrhoea Winslow on Brain and Mind Wohler's Organic Chemistry Winckel on Childbed Zeiosl on Venereal . 'J-**' .'*»* *1 ^ ■'.•■Mr: ^* *. $ tJ3g HI NLM001224730