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Of the cases of phthisis following bronchitis, which may be termed catarrhal phthisis, some arose from acute attacks, others from chronic. These last patients generally lost their cough and other symptoms in the summer, or in warm weather, but were subject to a return of them every winter, or during inclement weather. A longer, or more severe attack than usual, greatly prostrated them, and the cough now remained persistent, and was also accompanied by permanent feverishness, heat of skin, and wasting. On examination of the chest, in addition to the ordinary bronchitic sounds, patches of consolidation were detected; these did not clear up, and in some cases softening and excavation eventually took place, and. the patient lapsed into phthisis. Examples of this transition of bronchitis into phthisis have already been given.
Of the 149 cases originating in pleuro-pneumonia, in 85 no family predisposition could be traced; and this was also the case in 57 out of 118 instances arising from bronchitis.
We see, therefore, that 142 phthisical patients or 14*2 per cent. owed their attacks entirely, as far as could be ascertained, to inflammatory attacks of the lungs, thus endorsing the views of Alison, Broussais, and Addison, as to the origin of the disease from inflammatory attacks.
Hcemoptysis.—This symptom was recorded to have been present in various degrees, at some period of the patient's history, in 569 cases out of the 1,000; i. e. 57 per cent.—a percentage lower than that of the First Medical Report of the Hospital, which was 63 per cent., but nearly agreeing with that of Dr. Cotton's1 1,000 hospital cases, which was 53*6 per cent., and that of Dr. Pollock's2 1,200 hospital cases, which was 58*4.
State of the Lungs as evidenced by Physical Signs.— We shall now endeavour to describe, as briefly and 1 Op. tit. 1 Op. Ht.
succinctly as possible, the state of the lungs of these patients when they came first under observation, and afterwards to give some report of the changes which had taken place at the date of their last examination ; and the reason we do so is to give our readers some account of the local changes, whether for the worse or better, which took place in these patients, and thus enable them to form an opinion as to how far the improvement in the general health was accompanied by improvement in the state of the lungs. The relation, or in many cases the want of relation, between these two, must strike all physicians. How often does a patient gain flesh and strength and colour, and improve in breathing in a few months, and yet the physical signs show no perceptible improvement, but remain stubbornly at about the same! The converse is more rare, though we have known instances of cavities contracting and the general health making no great progress.
The record of the physical signs has been perhaps more carefully carried out than any other point in these cases: and in perusing it, a fair idea can be easily obtained of the amount of disease present in each case, with its subsequent progress; but the selection of similar cases for the purposes of statistics, and their arrangement into as few classes as possible has been attended with great difficulty. The classification of the conditions of the lung, consolidation, softening, and excavation, into first, second, and third stages, is open to objections, because such stages are not always well defined, it being sometimes difficult to distinguish between the end of the second and the beginning of the third, and again various parts of the same lung may be in different stages. What different amounts of consolidation, too, may not the first stage include! Sometimes only a small portion of the lung, like that underlying the supra-scapular or the interscapular, or the infra-clavicular region, is consolidated; in other cases two-thirds or more are involved. However, it has been found difficult to avoid some such classification for the purposes of statistics, and therefore that of stages has been adopted, with the understanding that the first stage embraces various amounts of consolidation, and that the second and third are sometimes only different degrees of the state of softening and exeavation. In none of the present cases is the evidence of physical signs alone accepted; in all it has been amply confirmed by the clinical symptoms and the course of the disease. The results have been embodied in a table, divided into two parts, showing the 'state at first visit,' 'state at last.' From this it will be seen that 6G0 patients or two-thirds were in the first stage at the first visit; 181, or 18 per cent., in the second; 145 or 14-5 per cent. in the third; and 14 patients presented the physical signs of other lung diseases, namely, bronchitis, pneumonia, pleurisy, and asthma, on which shortly afterwards supervened signs of consumption. Those in the second and third stages hardly constituted a third of the total, which shows how large a proportion came in the stage of consolidation, of which the prognosis was likely to be more favourable. As regards the relative liability of either lung to disease, of those in the first stage both lungs were affected in 205; the right alone in 287, and the left alone in 168. Of those in the second stage, 55 had the right alone affected, 69 the left alone; 55 had both lungs involved, and in many instances both in the second stage. Of the 145 in the third stage, 43 had the right lung alone affected; 53 the left, and 49 both ; but in only 4 cavities were detected in both lungs. This indicates a greater liability of the right1 lung to consolidation, but of the
1 This agrees with Laennec's conclusions; but it is at variance with Louis' and Cotton's, both of whom found the left lung more frequently affected.
Taele.—Showing State of Lungs at First and Last Report in 1,000 Cases. left1 to softening and excavation: a conclusion confirmed by the evidence of the second report of the Brompton Hospital, and by other authorities. Having briefly considered the state of the patients at first visits let us turn our attention to their state at last report. Of the 1,000 patients, 198, or nearly one-fifth, died; the deaths being distributed as follows :—
Of those who came in the first stage, 104, or 15-75 per cent. were ascertained to have died.
Of those who came in the second, 48, or 36-51 per cent.
Of those who came in the third, 44, or 30*34 per cent.
Thus we see that the percentage of mortality of the second and third stages was very much higher than that of the first; the third showing actually a double proportion of deaths: and the fact must not be overlooked as demonstrating that, although cavities may be tolerated for years, yet the danger from blood infection, after their formation, is considerably increased. In 80 out of the 150 in the first and second stages, cavities were ascertained to have formed before death.
The state at last visit of the living patients is arranged under five headings: (1) Healthy; where the physical signs of disease had entirely cleared up, and could no longer be detected. (2) Improved. (3) About the same. This last term is used to include, not only the cases in which no change has taken place, but also those which, after various fluctuations towards better or worse, presented at the last about the same amount of disease as at the first. (4) Worse. This heading is intended to signify extension of the disease, either in the same lung or in the opposite one, as well as progress in the way of softening and excavation. (5) Unknown. The table shows that among 802 living patients, the last recorded state of the lungs was 'healthy' in 34; 'improved' in 280; 'stationary' in
1 Cotton, Walshe, and Pollock confirm this.