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 morning. 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. Was 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 right apex.

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 potsound, 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 substance 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 grey masses, with small yellow patches of softening in some. The lung tissue between the masses was generally red and congested, and in parts hepatised. Bronchial membrane generally much injected. Many dilated air-cells in marginal lobes.

The consolidations of the lungs in this case presented every gradation between recent acute hepatisation and the grey nodules commonly called tubercular, and the change to the opaque state (cascation) was seen in parts of both.

The case is an example of acute phthisis arising from inflammation degraded by malnutrition.

ACUTE PHTHISIS ARRESTED.

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CASE 65.-Scrofulous Pneumonia. Cavity. Death from

Hæmoptysis.

Mr. J. V., aged 28, April 9, 1867.—A brother had hæmoptysis. 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 fortnight, requiring repeated blistering and continued saline. Then expectoration 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. Moderate dulness and sub-crepitus with obscure breath posteriorly and above. Tubular sounds above right

scapula.

June 2, 1868.-Wintered at Hyères. 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. Weight has increased from 9st. 9lbs. in October, to 10st. 7lbs. in April. Cough and expectoration gradually diminished; and have been trifling in last three months.

Collapse and dulness with cavernous sounds in left front, most marked at 3rd, 4th, and 5th ribs. Clearer, with a little breath above and in upper dorsal region; more dull and obstructed below. Tubular still in upper right.

September 23, 1868.-Quite well through summer, except shortness of breath and slight cough with opake expectoration. Cavernous sounds are rather higher up, and heard in the scapular region also, but less. Heart drawn up above an inch. Rather less obstruction in lower dorsal region.

May 5, 1869-Again wintered at Hyères, regularly taking oil and acid hypophosphite. Weight has risen to 11st. 1lb., and has walked four or five miles daily.

June 25.-On his return home he attended to business in nursery grounds and hothouses, and lived more freely, and at end of May coughed up 6oz. 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 131bs. weight. Now breath pretty clear through right lung, but large tubular sounds above right scapula. Cavernous 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 left 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.

Has re

October 11.-Has been distressed, and called into exertion by the death of his father. More cough, expectoration, and weakness. quired blistering with acetum cantharidis. More crepitus in left lung, but no extension of cavity.

May 31, 1870.-Wintered again at Hyères, 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 before, but the cavernous sounds are more croaky and muffled. A little crepitus also above right scapula.-Still occasionally bilious, as now. Treatment accordingly.

August 1.-Has had a slight recurrence of hæmorrhage, 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. No crepitus at right apex, but heartsounds are loud there.

In the following week, during Dr. Williams's absence from town, hæmorrhage 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 disease appeared to be scrofulous pneumonia, the subsequent affection of the apex of the right lung was probably tuberculous.

CASE 66.-Scrofulous Pneumonia.

Cavity. Arrested.

Mother scrofulous. Is re

Mr. F. W., aged 24, January 14, 1867. ported 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

ACUTE PHTHISIS, ARRESTED.

221

sounds and coarse crepitation in mammary region, and less above. Tubular 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.

stant.

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 conGained 8lbs. more. Has lately suffered from bleeding piles. Cavernous 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 Hyères, 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. Much less dulness 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 increased 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 Hyères, and out all the winter, though often wet. Gained 14 lbs. and much strength. No cough, except in mornings, with a little dirty expectoration. Fistula has discharged more, till touched with caustic. Obscure pectoriloquy with croak on deep breath in upper left. Partial obstruction and dulness below. Tubular sounds above right scapula, but with 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 3lbs. Signs much the same.

March 31, 1870.-Wintered well at Hyères, although a bad season. Has taken three tablespoonfuls of oil with tonic once daily. Gained only 1 lbs. No material change in signs.

August 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 in

fluence.

CASE 67.-Scrofulous Pneumonia. Cavity. Arrested.

A medical man, aged 30, whose paternal aunt had died of consumption, saw Dr. Williams on October 14, 1859. In 1856 he had a bad attack of scarlatina, and has not been strong since, but remained in laborious practice 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. Wintered at Malaga without amendment; suffering much from cough and expectoration. Occasional hæmoptysis 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 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 Hyères.

October 24, 1863.-Wintered at Hyères, steadily continuing oil and tonic, and much in open air. Has improved so much in all respects that he has returned there every winter since, practising as physician. Passes summers in North Wales with further improvement in flesh and strength. Breath better, but still short on exertion, and has always had some cough, expectoration, and hoarseness. Last winter, after going out at night, had another attack of the right lung, which weakened him much; but he gradually recovered, and again gained much ground during the summer in North Wales, although the weather was wet. Dulness, collapse, deficient motion and breath throughout right chest. Loud tubular or dry cavernous sounds above. Coarse crepitation below.

June 2, 1867. Still living at Hyères in winter, and in North Wales 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. Tubular 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., æt. 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