SCROFULOUS PHTHISIS ARRESTED.

233 scesses formed in the hip and knee; but under the influence of cod-liver oil and sea air, he gradually got well, the knee remaining stiff. Afterwards had several scrofulous abscesses, which all healed under the same treatment. In the last eighteen months the abdomen has become full of fluid, and tender to the touch; there has been occasional diarrhoea, and cough and slight hæmoptysis have come on. Dulness and tubular sounds at and above right scapula. Superficial dulness and fluctuation in abdomen. Oil was ordered in liquor potassæ and tincture of orange, and an iodide of potassium ointment for the abdomen.

March 7, 1861.—Abdominal swelling soon subsided, and he has generally improved, but still has infirm health, and has lately had ulcers in the foot and leg connected with diseased bone. Still has cough and occasional hæmorrhage from lungs and bowels. Signs in the chest the same.

May 1, 1866.-Continues infirm, but attends to business, generally at Brighton. Has lately had more cough with some hæmoptysis. Oil has been taken in above mixture. Dulness and obstruction in whole right side. Tubular sounds in upper region.-Oil ordered with sulphuric acid and

calumba.

Not seen after. Heard of his death in 1870.

CASE 79.-Phthisis arrested. Scrofulous Abscesses. Death Ten Years after from Subacute Pleurisy.

Mr. G., aged 17. Fair complexion; family phthisical; mother afterwards died of scrofulous pneumonia.

First seen November 4, 1848. In May returned from Germany, and a fortnight after caught cold and spat a little blood. Cough continued after, and in August brought up large quantities of blood. Was starved, leeched, and cold vinegar kept constantly to the chest. Is very much reduced in flesh and strength, and breath is very short. Pulse 120, skin hot. Has been under the care of an eminent physician, who declares his case to be hopeless, and that he cannot live six weeks.

Dulness, defective motion, and crepitus superseding breath-sound throughout right lung. Moist cavernous sounds, and most dulness, in upper part. Some dulness and mixed crepitus at left apex also.

Cod-liver oil prescribed, with mixture of nitric and hydrocyanic acids tincture of hop and orange peel: morphia linctus for the cough, and a blistering liniment.

In a week considerable improvement. Pulse reduced to 100, appetite good, cough and expectoration less, strength increasing.

Cavernous sounds now drier, and extend from right clavicle to fourth rib. July 10, 1849.—Continued to improve in all respects, although shut up in London through the winter. Has gained much flesh and strength, but breath still short on exertion. Cough moderate, with opaque expectoration. Has continued oil regularly. Collapse, dulness, and small dry cavernous sounds below right clavicle to third rib. Obscure vesicular breath below

and in the back, with clearer stroke. Tubular sounds, but no crepitus at left apex. A few days ago, after walking in the heat, fainted, and has spit some blood since.

He afterwards gradually improved in flesh and strength, and the cough became little troublesome, with only morning expectoration. The next winter was spent in the neighbourhood of London, and the following year he went to Torquay, where he continued to improve, riding on horseback. Last year one of the knees became painful, and the joint swelled much. It proved to be a scrofulous abscess, which opened and has been discharging since; and another has since formed in the thigh, connected with diseased bone, and has discharged enormous quantities of matter. He was consequently so much reduced, that, when brought to London, Sir B. Brodie thought he would not live ten days. However, by resuming the oil with quinine, and taking liberally bitter ale and a very generous diet, gradual improvement followed in flesh and strength, and the discharge from the wounds diminished. The cough, which had entirely ceased, has lately returned, with some opaque expectoration.

Note of physical signs not kept.

May 31, 1854.-Abscess in thigh quite healed, the knee-joint anchylosed. His health is fair, with little or no cough. The last three years have been passed in London or at Fulham. He has continued the oil and a liberal diet. Lately, after the exertion of throwing a large dog into a river, he brought up an ounce of blood.

Right front still flattened and rather dull, but much less so than formerly, with some puerile vesicular breath-sound. Tubular sounds only close to sterMore dulness and deficiency of breath in dorsal regions, and slight crepitus in parts.

пит.

[A sad but remarkable episode connected with this case deserves to be recorded. The patient's mother, who had most devotedly nursed him and dressed his wounds during his long and trying illness, was attacked with scrofulous pneumonia, which in a few weeks ended in excavation and death. Previously she had been quite healthy and strong.]

1858. He continued in good health till the beginning of this year, when, travelling in Spain, he was attacked with ague at Madrid, and returned to England broken in health and very bloodless. On May 7, Dr. R. D. Harling found him suffering from pleurisy of the right side, with effusion, which resisted all treatment; and as the extensive effusion threatened suffocation, it was determined to attempt relief by paracentesis. This was performed by Mr. P. Hewett on May 17, with complete temporary relief, the fluid drawn off being clear serum, forming a fibrinous clot on standing. The dyspnœa, however, soon returned; and on the 20th the operation was repeated, a smaller quantity flowed, and was now somewhat turbid, but not purulent. In four days the breathing had again become as difficult as ever; but the patient refused to submit to another operation, and died on the 26th.

PHTHISIS AFTER FISTULA, ARRESTED.

235

Unfortunately, post-mortem examination was not permitted, and the precise condition of the chest at last remains doubtful; but, after the evidence of advanced consumption at first, and the wonderful recovery from this and from extensive scrofulous suppuration subsequently, the enjoyment of tolerable health for four years are all most remarkable; and no less so the fact, that the fatal attack brought on by adequate external causes did not present the purulent or consumptive character of his former diseases.

CASE 80.-Phthisis (Scrofulous Pneumonia?) after Fistula. Long sea voyages. Recovery.

Mr. -, aged 21. Towards the end of 1860 had an abscess near the rectum, which has left a small fistula. After much anxiety during that winter, in April, 1861, had left pleuropneumonia, which was treated by calomel and opium, salines, and repeated blisters. In June the fistula was still discharging. Much loss of flesh and strength. Still cough and purulent expectoration, and occasional recurrences of pain in the left side. Dulness, deficient motion and breath in lower two-thirds of left chest. Loud bronchophony at and within left scapula; crepitus on deep breath.-Ordered the oil, with nitric acid tonic. A saline with opiate at night. Cantharides liniment to the side.

Had lost cough, but There are now coarse

November 9.-Rapidly improved and gained flesh. it has returned in last week. Fistula still open. crepitation in left back, and cavernous sounds at scapula. General dulness rather less.-To continue oil tonic and liniment.

May 28, 1862.-Wintered in Madeira, and pretty well; but after fast riding once spit three ounces of blood; and in April caught cold, with increase of cough and expectoration. Taken oil regularly, and not lost weight. Still much dulness and obstruction in left chest. Obscure cavernous sounds in scapular region. Large tubular sounds above right scapula.

June 6, 1863.-Passed winter in Natal and Capetown, returning by way of Brazil. Has taken oil and tonic regularly. Quite free from cough and expectoration; and is in good flesh and strength. Discharge from fistula slight. Signs of cavity more obscure, and some improvement in breath and percussion sounds.

May 21, 1864.-In October went the voyage to Australia, and after a month there has just returned. Quite well the whole time, except slight hæmoptysis at Capetown. Gained 7 lbs. Loud tubular sounds at left scapula; some breath-sound, weak in some parts 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;

peculiar 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 necessity; 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 below left clavicle, where there is pain.-Oil ordered, with iron quinine and phosphoric acid, and counter-irritation with acetum cantharidis.

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 feverishness, 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 upper 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.

PHTHISIS AFTER SCROFULOUS ABSCESS.

237

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 ago, and had continued ever since with occasional hæmoptysis, and lately with opaque expectoration. Has lost much flesh, but regained under one year'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 Hyères, and left off oil, and became worse. 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 hæmoptysis. The physical signs are the same in the right lung, but some tubular sounds are audible also in the upper portion of the left.

CASE 83.-Phthisis after Suppurating Bubo. Death Six Years after with Pneumo-Thorax.

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 potassium, 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 expectoration. Dulness; small tubular and click sounds upper left chest; obscure breathing in upper right.-Was ordered cod-liver oil in nitric and hydrocyanic acids, and an acetum cantharidis liniment.

He wintered again in Madeira, 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 pneumo-thorax 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 offen