sive pus. Later on he coughed up much of the same matter, smelling of rotten eggs, for several months, and lest 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, Mercurial Salivation, and Suppurating Glands. Cirrhosis of Liver and Ascites.

Wm. M., æt. 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 months 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 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 percussion, and defective movement of left chest. Cavernous sounds below humeral end of left clavicle. Crepitus beyond and breath-sound obscure. Right side less dull than left, except above scapula.—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 coloured, 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 16.-Ascites increased rapidly, and cough for a time better. Diuretics and elaterium have been given, with only slight diminution of the swelling; cough and breath again becoming troublesome, and appetite fails. Became delirious on the 22nd, and gradually sunk after. Died 22nd.

Moderate emaciation; some oedema of legs. Abdomen contained many quarts of yellow fœtid serum and a few flakes of lymph. Right lung not adherent; a few grey 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-grey colour, 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

PHTHISIS AFTER OTORRIA.

239

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 hollow of the diaphragm; nodulated on surface, of pale brick colour; right lobe adherent to diaphragm. Vessels on capsule fringed with opaque deposit, which could be seen also in the substance around the portal vessels. Capsule firmly adherent. Spleen very large (weight, 8 oz.) Patches of granular deposit on capsule.

CASE 86.-Phthisis after Purulent Otorrhea.

Mr. H. 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 expectoration. 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 expectoration. Tubular sounds in right scapular region and above it, but pretty good breath-sound.

CASE 87.-Phthisis after Otorrhea.

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 hæmoptysis to amount of three ounces after exertion, and has had some slight amount since. Had lost much flesh, which has been regained since. 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 cantharidis 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, 1862.-Well and stout, doing duty at Harwich, but has had slight hæmoptysis 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, was seen by Dr. Williams June 26, 1843.-She had had severe cough for several mouths, and occasional attacks of stridulous inspiration, occurring especially at night. Did lose flesh, but has regained. Dulness and stridulous breath-sounds in right interscapular region -Ordered iodide of potassium, with sarsaparilla, and to use an iodine lini

ment.

The little patient was 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 considerable caseous deposit in the bronchial glands, one of which was greatly enlarged, and compressed the right bronchus.-Reported by DR. SYMONDS. CASE 89.-Empyema threatening Phthisis. Paracentesis.

Recovery.

Miss B., aged 12, November 23, 1865.-Reported to have been quite well 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 ædematous; 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 10oz. 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 pneumo-thorax; 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 enlargement, 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 sometimes stopped for a few days, and then the cough has increased, The ex

pectoration as well as the discharge has the rotten-egg odour. 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 has been regularly taken in wine.

The whole left side is still contracted and dull; but less so in the upper half, where there is obscure breath-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 go to the sea-side, 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 development of growth having nearly restored symmetry of form.

I have notes of several more cases of empyema ending in complete recovery, although the compression of the lung and the long continuance of purulent 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.

R

CHAPTER XXII.

CASES OF CHRONIC PHTHISIS OR CHRONIC TUBERCULOSIS.

6

Anatomical difference between Acute and Chronic Tubercle-The latter more limited and local, and therefore more tractable-Cases of First StageSix Cases arrested and cured-Of Second Stage, Five Cases arrested 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 pulmonary consumption. If we except 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 tuberculosis rather in extent than in kind. It may indeed be said correctly that the chronic miliary grey tubercle is much harder than the acute, which, as described in several of the cases, can be crushed by firm pressure (see p. 105), but this difference is only an affair of time, like that between acute hepatisation, 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 lymphatics, 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 tuberculosis, but, from their more limited extent, they may be arrested