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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 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, especially at margins, which were very thin and flaccid. A large cell, of the size of a marble, projected 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 grey and opaque. A tough opaque membrane also covered much of the middle lobe, and similar opaque tissue appeared around the blood-vessels 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 membrane, 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. Walls 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 3 lbs. 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. Williams, July 28, 1858. He stated that in 1832 he had had a cough and expectorated blood and calcareous matter; he was considered consumptive, was ordered to Madeira. He returned much improved, and gradually recovered, 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 with prolonged wheeze in left upper front and right

back. Emphysematous clearness below.-Was ordered a mixture of iodide of potassium, bicarbonate of potash with squills, stramonium and hops, and to winter in a warm climate.

May 7, 1859.-Was 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 inflammation of the lungs, from which he slowly recovered; but in the following year had an attack of hæmoptysis (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 summer. Has spent several winters in the south of Europe with benefit. The last two have been passed at home, and there have been several attacks, lasting six or seven weeks. During the last summer was in Wales, able to walk several miles and to climb mountains. A fortnight ago was attacked with rigors and oppression, and coughed up a quantity of dark blood, and has been suffering from cough and dyspnea 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 spinal curvature; anterior upper regions project, stroke-sound clear, with harsh puerile breath-sound; irregular dulness and loud tubular sounds at and above both scapula, with coarse crepitus below, with lessening breath-sound downwards; only obscure short clicks at left base, which is rather duller than the right. The chest was freely blistered with acetum cantharidis; 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, expectoration 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 scapula.

Notes have not been kept of the subsequent history, which 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 attacks came on generally two or three times during the winter, sometimes with symptoms of bronchitis and coryza, and sometimes with oppres

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sion, pulmonary congestion, and sometimes hæmoptysis; but all with dyspnoea, lividity, and cough ending in profuse purulent expectoration; and then the tight wheezy obstruction in the lungs was replaced by coarse 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 sarsaparilla. Iodine liniment.

Dec. 14th.-Cough and expectoration has been slight. General health improved; but now more cough, disturbing sleep. Still dulness with cavernous sounds in right subclavian and mammary regions; below, tubular expiration.

April 17, 1843.-Wintered at Hastings. Cough moderate. In the last few days has been expectorating blood. Breath-sound weak below left clavicle. Still loud cavernous expiration below right clavicle.

September 20th.-Has remained in the neighbourhood of town, much in open air, taking the acid and sarza. No cough or hæmorrhage. Sounds only tubular below right clavicle.

April, 1844. Has wintered in Italy. Free from chest symptoms, but weak. Same signs.

November 1, 1845.-Has continued well till a few days ago, when having caught cold, he spit some dark blood, without cough. Still a little dulness, and tubular sound in upper right. Expires 180 cubic inches. Height 5 feet 9 inches.

1860.-Lived in Italy for some years, and subsequently in the West 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 decidea 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 somewhat 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 postmortem-Acute Cases arrested, five-Acute Tuberculosis-Rapid PhthisisSix fatal Cases with post-mortem-Origin from various Causes-Caseous Glands-Abscess-Measles combined with Tuberculous Arachnitis-Postmortem 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 localised as to resemble those of inflammation more than those of scattered tubercle. But they have proceeded so rapidly to excavation, and so early declared their phthisical character, 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 Chap. XI.

Their acute and very consumptive character approximates them to those of Acute Tuberculosis which follow: but the disseminated and adenoid distribution of the miliary tubercles in the latter strongly marks them as a distinct variety of consumptive 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. Has lost much flesh and strength. Ex

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pectoration was streaked; now viscid and opaque. Pulse 84; respiration 27. Urine high coloured. 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, which is quite dull, and agophony is 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 23rd. Still much cough and expectoration, but less viscid, and no blood. Pulse 120. Less dulness in left back, and more breathsounds.

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. cascarillæ.

December 24.-Cough increased, with rusty sputa, and pains on both sides, with increasing weakness. More crepitus and dulness in posterior regions. 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 days more cough, rusty expectoration, and increasing 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.

The

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 muco-purulent matter. upper and posterior part of this lung was in a state of grey 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 organised lymph, which contained in its interior opaque patches of yellowish-white colour, 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 partially thickened with numerous isolated pits, apparently ulcerated follicles; and several were found also in the bronchi of the left lung.