PHTHISIS, WITH CAVITY-RECOVERY.

283

ptember, 1869.-Heard from Dr. Stutter that the signs of pneumothorax soon disappeared, and that the patient was quite well. August 2, 1871.-Mr. M. continues quite well, and continues to get stouter.

CASE 136.-Phthisis, with Cavity. Acute Rheumatism and Endocardial Murmur. Recovery.

A married lady, aged 30, consulted Dr. Williams, October 13, 1860. Lost her mother, two sisters, and one brother from consumption. During the last four years she had had occasional cough and hæmoptysis, which on one occasion amounted to three ounces. Did lose much flesh; but after taking oil, and applying it externally also, became fat and still remains so. Lately has been taking glycerine. Cough has increased in last two months, and now she has a bad cold. Extensive dulness, cavernous sounds and surrounding crepitus in upper right chest. Tubular sounds above left scapula. -Oil ordered with phosphoric acid calumbo and orange; a morphia linctus at night; cantharides liniment.

December 24.-At the end of October, severe rheumatic pains came on with tenderness of wrists and ankles, was soon relieved by opiate salines; but she has been confined for two months. Looks well, but still has a cough. In addition to former signs there is a loud diastolic murmur at mid-sternum.

February 5, 1861.-Much better in every respect. Little cough. Physical signs same, only a trace of crepitation above scapula.

September 18, 1861.-Looks quite well, and has only slight cough and short breath, with occasional pain in right chest. Catamenia irregular and in extremes. Less dulness and more breath in upper right; no cavernbut tubular sounds.

ous,

November 10, 1862.-Weathered last winter fairly in Ireland, being free from cough. From May to September took a cold sponge bath every morning. A scaly eruption appeared on arms and legs, which Dr. Neligan cured by arsenic. During last fortnight she has had a cold and cough. Still dulness and tubular sounds in upper right chest, with slight crepitation. Cardiac murmur not audible.-Effervescing saline with opiate at night, and continue oil and tonic.

May 30, 1865.—Living at Woolwich, and wonderfully well. Only occasionally suffers from cough and rheumatic pains. Has taken a great deal of oil, but is less stout, though in good condition. Still dulness and tubular sounds through upper third of right lung. Loud diastolic murmur audible to right and along upper portion of sternum.

November 2.-Had hæmoptysis to the amount of loz. a month ago, and since then has had violent cough, with mucous expectoration. Now she is taking oil with sulphuric acid. Dulness, tubular sounds, and coarse crepitation in upper half of right lung. The patient was seen again in the summer of 1867; she was then stout, but her breath was short with some cough.

March 13, 1868.-Has lost cough, is ruddy and stout, but occasionally has palpitation, and has lately had a vesicular eruption on the hands, which was soon cured by lotion. No catamenia for twelve months. Physical signs of heart and lungs much improved. Only slight dulness and loud tubular sounds above the right scapula. The second sound of the heart is clangorous, but without murmur.

1871. Has been heard of as in good health, fifteen years after first attack.

CASE 137.-Acute Phthisis arrested.

Afterwards Calcareous

Expectoration. Lithic Acid. Nephralgia. Eczema.

Mrs. V——, aged 34, who had lost a sister in consumption, was seen by Dr. Williams, September 28, 1858. She stated that in July she had scarlatina and quinsy, followed by cough, diarrhoea, night-sweats, and great loss of flesh and strength.

Much dulness, and large tubular sounds at and above right scapula. Oil was ordered in a tonic of strychnia nitric acid and orange peel, and a morphia linctus.

June 28, 1859.-Heard that she quite lost her cough in four months; and increased in weight from 9st. to 10st. 10lbs. She also is able to sing as formerly, but her breath is still short. After this she suffered from

nephralgia, and passed some red gravel.

July 26, 1860.-Has become stout, and is free from cough. Has had occasional diarrhoea, and passed some red gravel. Physical signs same as at first visit.

July 24, 1865.-Was shut up during the last winter, but had only occasional attacks of cough and expectoration. Breath always short, and there is constant morning expectoration.

June 26, 1866.-Was well till two months ago, when, after a cold severe cough came on with green expectoration, and several times she spit up calcareous matter. Was ordered to resume the oil and tonic and linctus as before. Physical signs same.

October 18, 1866.-Heard that she had had some more calcareous expectoration and wheezy cough, and that she had been suffering from eczema over various parts of the body, accompanied by very acid urine.-Effervescing citrate of potass with iodide potassium and quassia. Gruel baths.

In this case the first disease was probably inflammation, consolidation beginning to caseate and infect the system. This was arrested by the treatment, the caseous matter remained quiescent, and, becoming petrified, was expectorated in a subsequent bronchial attack.

CASE 138.-Syphilis. Phthisis. Cavity. Recovery.

Mr. aged 30, who had lost a brother from consumption, consulted Dr. Williams, June 30, 1843. Three years ago he had ulcerated sore throat

SENILE PHTHISIS-ENLARGED BRONCHIAL GLANDS. 285

and has had attacks of it occasionally since, affecting the voice, which is at present hoarse, and rendered worse during last six weeks by cold; copious expectoration. Has lost flesh. Formerly had red and coppery patches on face, and now has them on abdomen. Dulness in upper right chest, with cavernous sounds below clavicle. Cicatrices are visible on fauces.-Ordered

full doses of iodide of potassium, with sarsaparilla, and to use an iodine and ammonia liniment.

August 25, 1846.-Wintered in Italy, and quite recovered.

CASE 139.-Senile Phthisis. Bronchitis. Enlarged Bronchial Glands.

T. C., aged 74, admitted into University College Hospital, December 12, 1845. A shrivelled, deaf old man, many years subject to cough and shortness of breath, which have much increased in the last few weeks, with mucopurulent expectoration, and much tightness across chest. Bowels costive; pulse 84, weak; urine turbid, specific gravity 1010, contains a little albumen.

Loud wheezy breathing on both sides. Erpiration loudest in upper parts, especially on left side. Some dulness in upper left front and back. Inspiration louder in lower parts. On right side expiration loud and sibilant. Inspiration mixed with submucous rhonchus in lower right, which sounds dull on percussion.-Blisters between scapula. Calomel and henbane at night, senna draught in morning. Squill, ipecacuana, and stramonium three times a day.

18th.-Cough and breathing have been rather easier. Urine free; no albumen. Is very weak, and the expectoration very purulent. Loud wheezing in all parts, with crepitus in lower half of both lungs. Carbonate ammonia was given, but he died on the night of 19th.

Post mortem 18 horis. Emaciation moderate. Extensive adhesions of both pleuræ. Those on right side most general, those on the left confined to apex and base of the lung, but very tough; several patches of dense membrane on the pleura; cartilages of bronchi much ossified, especially near the root of the lungs, which were compressed by a mass of enlarged bronchial glands, quite black. Bronchial membrane very red and covered with bloody mucus, but many of the bronchi were full of pus.

Texture of lungs generally much congested, but on scraping away the blood appeared dark grey, very tough and resisting, with numerous hardened granulations scattered through it. In posterior part of left lung, the engorgement passed into partial hepatisation at the lower part, but not sinking in water. In front this lung was not congested, but very dark grey, and at the apex were tough consolidations, extending half an inch into the lung, and with a patch of dense membrane on the pleura. Some similar masses of dark induration near anterior margin. No yellow or recent grey

tubercles were found. Lower lobe emphysematous, with large projecting air cells, quite flaccid and transparent. Right lung presented similar appearances, but with less recent hepatisation. Numerous, very dark, tough consolidations, and one contained an encysted calcareous body. The lower lobe of this lung also was emphysematous.

Heart large, weight 15 ounces. Right ventricle thick. Kidneys slightly mottled, and granular on removing capsule. A few cysts.

In this case the tubercles were all dwindled and obsolete. Dyspnoea and death caused by bronchitis passing into pneumonia in a subject previously suffering from emphysema and pressure on large bronchi by enlarged glands.

CASE 140.-Inflammatory Phthisis in Middle Age. Arrest; and Asthmatic Twenty-nine Years. Death from Hamoptysis at 84.

Dr. G., æt. 55, April 14, 1848.-Seven years ago had inflammation of the left chest, which was said by one doctor to be pleural abscess, and by another condensation of the lung. Was sent to Cadiz, and gradually improved in health; became a wine merchant; able to attend to business, but always short breathed, and often suffering from gout and neuralgia. Has been in England eight months, and has generally had some cough and wheezing. Has lost flesh lately. Now has fresh cold, with cough, hoarseness, and wheezing, and gout in his feet. Collapse, dulness, and defective breath in left front. Bronchophony below clavicle. Tubular sounds and wheeze at and above scapula. Crepitus at right apex. Clear stroke and emphysematous crackle at both bases.—Iodide and carbon. potass., with colchicum. Croton liniment (which he is in the habit of using).

1870.-Was soon relieved from attack, but had recurrences of bronchitis, with violent cough and wheezy dyspnea two or three times every year, generally in winter. He continually suffered in his digestion, which was often tried by free living; and he was occasionally visited with gout. In the last ten years cataracts formed in both eyes, and very much impaired his vision, but he continued to get about and enjoy society when not confined with severe bronchial attacks, which generally ended with opaque expectoration. The signs latterly were only those of bronchitis and emphysema, and the former contraction, and dulness having diminished. After an attack, however, in 1870, he began to cough up blood in large quantities, and so died. No post-mortem.

We can only conjecture that a rupture took place in some degenerated vessel in the old phthinoplasm after an arrest of 29 years.

DURATION OF PULMONARY CONSUMPTION. 287

CHAPTER XXIV.

THE DURATION OF PULMONARY CONSUMPTION.1

By DR. C. THEODORE WILLIAMS.

Estimates of Portal, Laennec, Andral, Louis, and Bayle compared with those of the Brompton Hospital, Fuller, and Pollock-Differences explained by Class of Patients and Mode of Treatment--Author's Thousand Cases selected from wealthy Classes-Ground of Selection explained-Method of Tabulation of Cases--Sex-Age of Attack-Family Predisposition—Origin and first Symptoms—Cases of Inflammatory Origin; their Proportion and Course of Symptoms-Hamoptysis--State of Lungs at first Visit as evidenced by Physical Signs-Classification of Stages adopted with Restrictions-Majority of Patients in First Stage, and consequent favourable Prognosis-Mortality in each Stage-State of Lungs at last Visit― Classification of Healthy,'' Improved,'' About the same,' and ' Worse ;' and Percentage of each-Relative Liability of Lungs to Attack, Excavation, and Extension of Disease-Number of Deaths-Causes-Long DurationLiving Patients more numerous and with higher average Duration-Present State described as 'Well,' Tolerably well,' and 'Invalid'— Large Proportion of First Two Classes - Hopeful Prognosis Causes of long Duration-Influence of Age and Sex on Duration-Among Females Duration shorter, Age of Attack earlier, and Age at Death less advanced than among Males-Great Age reached by some Patients-Relation of Age of Attack to Duration-Prolonging Effect of Inflammatory Origin-Pneumonic, Pleuro-pneumonic and Bronchitic-Duration of Pathological Varieties of Consumption difficult to determine-Diagnosis of Tuberculous and Caseous Phthisis obscure.

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We need not dwell on the importance of the subject which we propose to treat of in this chapter. In a country where, according to the Registrar-General, one death in every eight is caused by phthisis, it is obvious that a true knowledge of the duration of the disease and

This chapter is an abstract of a paper on The Duration of Phthisis Pulmonalis, and on certain Conditions which Influence it,' contained in the LIV. volume of the Medico-Chirurgical Transactions.