removing it purulent matter was observed to pour out from an opening in the posterior mediastinum. This was traced to the body of the third dorsal vertebra, which was carious; the disease did not penetrate to the spinal canal, but there was a small abscess of the size of a pea outside the theca of the cord. The matter from the mediastinum also poured out from the posterior and lower part of the upper lobe of the lung, in which was an abscess about the size of a small egg. The right lung generally adherent. Its substance was partially consolidated by clusters of grey tubercles. At the apex were some opaque and partially excavated; and around each of these the lung texture was deep, red, and consolidated, but soft. Posterior portions of this lung all much congested, but crepitant. Liver large; weight, 3 lbs. 13 ozs.: much congested, as was also the spleen.

CASE 74.-Acute Tuberculosis from Pyaemia. Purpura. Epistaxis.

Richard H., aged 47; admitted October 28, 1843. Groom; of irregular habits; lately ill-fed. Lost a brother in phthisis. Has had three attacks of rheumatism; two in last four years. Six months ago attacked with severe pain in side, with difficult breathing; was bled to syncope, and relieved, but has been ailing ever since, attending at a dispensary. Has had a succession of abscesses in legs and thighs, which, after discharging, have healed. Is much reduced in flesh and strength. About a month ago began to cough, with night-sweats, and increasing shortness of breath, and weakness. Three weeks ago his nose began to bleed, and this has recurred several time since. Ankles are now cedematous, and there are a number of purpura spots on many parts of the body. Urine scanty; slightly albuminous. General dulness and defective breath in left chest; most below clavicle. Abdomen enlarged, and some fluctuation over tympanitic intestines. Epistaxis recurred several times in the next week, greatly reducing his strength, whilst the skin became hot, with continued purpura spots, and more cedema of the legs. Extreme depression; more crepitus was heard in both posterior regions; and he died November 10.

Body much emaciated. All posterior parts of livid purple colour. Arms and legs ædematous. Several ecchymosed spots in costal pleura. The whole anterior surface of both lungs mottled with spots from in. to in. in diameter, of irregular rounded shape, having a pale yellow spot in the centre, and a deep red areola well defined around them. These spots were found to be miliary tubercles, with extreme congestion or ecchymosis in the texture, and similar nodules were found thickly scattered throughout the substance of both lungs, more in the left than the right, but not more at the apex than at the base. The tubercles were of a pale buff colour, but firm, though friable on hard pressure, and arranged in bud-like clusters. The interstitial parts of the lung were red, in front bright and containing air; but posteriorly of a very deep red, almost black, and on incision exuded frothy red fluid. Three pints of yellow serum in peritoneum, and a

few threads of lymph. Liver large, high in chest, and two inches below margin of ribs. Weight, 4 lbs. 2 oz. Surface coarsely mottled with predominance of pale colour. Texture hard and tough, and capsule adherent. Spleen large; weight, 8 oz. Several yellow tubercles in its substance; some softened, and, under the microscope, exhibited pus globules. Right kidney granular, and with several cysts containing lithic acid and urea.

CASE 75.-Phthisis. Acute Tuberculosis.

Edwin H. S., aged 32, admitted February 20, 1845. A painter; well-fed and clothed, and no ailment till last winter, when he had slight cough and short breath, but was well in summer. This winter the cough has returned, and in the last two months became severe, with great increase of dyspnea, and rapid loss of flesh and strength. Now respiration is very frequent and laboured, and cannot lie down. Lips and cheeks livid. pectoration mixed, purulent, scanty, and difficult.

Ex

Left chest moves less and sounds duller than right. Little breath-sound, but crepitus short and coarse. On right side much crepitus also, with a little more breath. Same signs behind, but with more dulness at the base of the lungs, and whiffy tubular near the roots.

A blister was applied, and chlorate of potass. and carb. ammonia in offervescence with nitric acid, given every three hours, and five grains of calomel; two ounces wine.

February 21, 1845.-Lividity diminished, but dyspnoea not relieved. Pulse 140. Blister rose well. Urine scanty, contains albumen and lithates. Another blister between shoulders. Five grains calomel and half a grain opium at night.

February 23, 1845.-Dyspnoea continued to increase, with more weakness and lividity; and he died this morning.

Examination 28 hours after death.

Body emaciated; veins of neck and arms much distended with blood. Livid discoloration of all posterior parts of body. General adhesions of the pleuræ on both sides; very dense posteriorly and laterally. Both lungs much engorged with blood in parts unoccupied by tubercles, which were found in various forms in every part. At the left apex was a large cavity, with another mass below it containing a smaller cavity, and several others in other parts. That at the apex contained cretaceous matter, and a concretion of size of a barleycorn was found loose in it. The walls were in state of grey induration. Several tubercles were grey, others passing into the yellow state with more or less softening. At apex of right lung was dense opaque false membrane, quarter of an inch thick, covering a cavity which communicated with several large bronchi. In the outer part of this lobe was another cavity lined with false membrane. Many tubercles, miliary and in clusters, were scattered through the other lobes, and their outer margins were emphysematous. Bronchial glands enlarged, containing black matter.

Heart large, weighs 13 ounces. Right ventricle somewhat thickened. Fibrinous coagula in both ventricles-that in right extending into pulmonary artery, and bearing impress of semilunar valves (therefore existed before death). Kidneys were healthy. Liver somewhat nutmegged, from hepatic venous congestion..

P. S., aged 23, admitted January 4, 1848.-Formerly farm labourer; lately policeman. Health good till 24 years ago; had syphilis, for which he was salivated, and was quite well in a few months. Thirteen days ago was chilled whilst on duty, and began to cough and expectorate, and felt very weak. He vomited much dark green matter the day before admission, and that morning an eruption came out over the whole body. This rash, which is obviously measles, is now fully out, with suffused eyes, flushed face, and urgent cough and short breath. Pulse 88; tongue furred.-Ordered saline antimonial: calomel and haustus sennæ.

January 5.—Expectoration more viscid, partly opaque. Eruption was out in morning; now more faded. Pulse 100; soft, reduplicated.

Breath-sound obscure, especially in right back. Mucous rhonchus, most on left side.

Blister to chest.

January 6.-Breathing more embarrassed. Face much congested, almost livid. Expectoration in ragged opaque masses, floating in brownish liquid. Left back dull; crepitation on both sides. Cupped between shoulders to 3iv., and later in the day, on right side to žviij.

January 8.-Breathing was much relieved yesterday, but to-day became as bad as ever; and this morning had 3xi. blood drawn in full stream from the arm, with some relief, but he is very weak.

At the visit carb. ammonia and nitre mixture substituted for the antimonial. At night the dyspnea increased, and a blister was applied.

January 11.-In the last two days breathing easier, and face less livid. Urine abundant; s. g. 1029, with plenty of lithates.

January 13.-Breathing easier in morning, but always worse at night, preventing sleep. Pulse frequent, jerking, sometimes irregular, and weak ; urine 24oz.; s. g. 1021, contains a little albumen. Breath-sound weaker on both sides, superseded by irregular crepitation. Tubular above right scapula.

January 15.-Breathing more laboured, with pain in right side. Lividity increased. Pulse frequently irregular. Crepitus rises higher, and breathsound weaker.

Died on the 16th.

Sectio 46 horis post mortem. Both lungs contain numerous miliary tubercles scattered through their texture; none hard, but some are grey, transparent, and offer some resistance. Others are red and soft, yet firmer

ACUTE TUBERCULOSIS-ARACHNITIS.

231

than the tissue around. At the apex this distinction is most obvious, where are red bodies as big as a pea, sinking in water, while the intervening tissue is comparatively free, but the lower lobes are much congested, and the right partially hepatised posteriorly: even here the slightly firmer miliary tubercles can be felt scattered through it. A patch of recent lymph on posterior surface of right lung. Other organs healthy.

The remarkable points in this case are, the rapid production of miliary tubercles in twenty-four days, the suppression of the rash, and increase of the pulmonary oppression; and the soft plump character of the tubercles in their most recent state.

CASE 77.-Acute Tuberculosis. Tuberculous Arachnitis.

Miss K., aged 9, January 23, 1849.-Seen with Dr. Guillemard of Eltham. Delicate since inflammation of chest some years ago, but better than usual on her return from Dover in November. In December, had a cough with remittent fever, which much reduced flesh and strength. Four days ago came on pain in the head, and intolerance of light, with fœtid discharge from left ear; increase of cough and feverish heat, pain and tenderness of right hypochondrium; scanty urine. No dulness, but general bronchial rhonchi through the chest masking all other sounds. Pain was relieved by opium, but other symptoms increased, and death ensued in ten days.

Numerous miliary tubercles, yellow in parts, were found scattered through the lungs and spleen; and granulations on the peritoneum, the covering of the liver, and in the arachnoid and choroid plexus of the brain. The pulmonary tubercles were rather large, and could be crushed by firm pressure between the fingers (recent).

CHAPTER XXI.

CASES OF SCROFULOUS PHTHISIS FROM INFECTION THROUGH

LYMPHATICS, CONNECTED WITH GLANDULAR SCROFULA, FISTULA, ABSCESS, &c.

Twelve cases generally arrested for several years-Phthisis after Purulent Otorrhea-Fatal Dyspnea from Caseous Bronchial Glands-Threatened Phthisis after Empyema-Recovery.

THE succeeding cases are grouped together to exemplify a connection between pulmonary consumption and several local diseases which are commonly considered scrofulous; for example, chronic glandular swellings, suppuration and caseation-lumbar and other abscesses connected with scrofula of the bones-fistula ani-and purulent otorrhea. In some instances the pulmonary disease and the local one may be the result of one common or constitutional defect, a decaying tendency of the whole bioplasm: but in others the one has succeeded to the other so distinctly as to warrant the inference that an infection has spread from one part to another; and in all such cases the lymphatic system must be considered the conveying channel; and if the result be not localised by an accidental inflammation, the disseminated phthinoplasms will begin in the adenoid tissue in the form of miliary tubercles.

CASE 78.-Scrofulous Glands and Abscesses. Phthisis. Mr. L., aged 35, first seen by Dr. Williams October 12, 1858. He had had scrofulous abscess in the neck since childhood, and at a later date ab

These cases are not the best of the kind which could be produced, and I regret that, after the long delay which has occurred in the publication of this work, there is no time left for searching my large records for better.