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INFLUENCE OF INFLAMMATORY ORIGIN. 313

shorter duration of the malady in femaies may be explained by the stronger frame and better power of resistance possessed by the male, which enable him to battle with the disease for a longer time, and allow more chance for treatment, etc., to have effect.

Origin.—Does the mode in which a case of phthisis commences affect its duration? or is it immaterial, when the disease has once attacked the constitution, what the mode of origin may have been—as, when the heavens are thickly covered with clouds, and no blue sky is visible, it is then too late to look towards the quarter from which the storm commenced?

There is little doubt that this is not the case with phthisis, for the mode of origin has great influence over the form and character of the disease and its duration. Compare a case of phthisis originating in bronchitis, which is gradual and local in its development, and the general eruption of miliary tubercle following an attack of typhoid fever I Our statisties do not at present include a sufficiently large number of instances of the different modes of origin to estimate the effect of each on the duration, but we are able to do so in the case of inflammatory origin. It will be remembered that 149 of the cases originated in attacks of pleuro-pneumonia, from which the patients recovered, with lungs more or less crippled by adhesions, by consolidations, or by both. Did these patients live a longer or a shorter time than the average? Among 29 who have died, the mean duration was 9 years 6f months, and the 120 who still survive have on an average also lived 9£ years, thus exhibiting an extension of life beyond the ordinary, of nearly 2 years for cases having an inflammatory origin. In 64 of these cases hereditary taint was traced; but it is not worth while to consider the duration of these separately, as the number of deaths is small, and it has been already demonstrated that family predisposition exercises no curtailing influence over the duration of the disease.

To further investigate the influence of the inflammatory origin on the duration of consumption, at Dr. Burdon Sanderson's suggestion, I selected a small number of cases which exhibited the inflammatory origin most strongly, and were entirely free from family predisposition. Not only was the disease directly traceable to the pneumonic or pleuro-pneumonic attack, but in every case lesions more or less extensive, the result of such attack, remained behind, and were easily detected by the physical signs. The duration of these cases confirms still more strongly the conclusion, that inflammatory origin has a prolonging influence over the duration of phthisis. Among 10 patients who have died the average duration was 12 years 10 months: among 20 who still survive it is 11 years 8£ months.

Bronchitis was the origin of the disease in 118 patients —19 dead and 99 living. Here a different conclusion presents itself, though we hesitate in accepting it on account of the small number of deaths. The average among these was less than 6 years; among the living 99 it was slightly over 8£ years: a great contrast to the deaths, and one which rather invalidates^ any conclusion arising from them. We may assume, however, that if the origin from bronchitis has any prolonging influence on the duration of phthisis, it is not equal to that of pleuro-pneumonia.

We should have been glad to arrive at some conclusion as to the duration of such varieties of phthisis as have been demonstrated by post-mortem examination; for instance, of caseous phthisis free from miliary tubercle, and of the same in which it is present, of the contractile form of phthisis, of acute and chronic tuberourbsis, but for this purpose a vast number of post-mortems are necesDIFFICULTIES OF DIAGNOSIS.

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sary, which we have not at present available. A perusal, however, of the clinical examples already given will give the reader some idea of the good or bad prognosis of a certain group of cases.

Looking at the forms of phthisis from a clinical point of view, we have been led, from careful observation among the in-patients and the still more numerous out-patients of the Brompton Hospital, as also among private patients, to believe that the varieties of consumption merge imperceptibly one into another, and that while duly recognising them, it would be unadvisable to draw a hard and fast line between them.

How can we lay down a strict rule as to what cases are tubercular, and what are not? Or again, as to the time when a case of chronic catarrhal pneumonia becomes tubercular? Niemeyer1 admits that ' the development of tuberculosis in lungs which are already consumptive, as a result of inflammatory action, sometimes takes place in a manner so latent as to make it extremely difficult, if not impossible, to recognise the fact with certainty.' And Wunderlich2 says 'that even by the behaviour of the temperature it is not possible to distinguish acute tuberculous from acute non-tuberculous phthisis.' We quite agree with these opinions; and though we have been often able to detect the supervention of acute tuberculosis during life, and to prove our diagnosis by post-mortem examination, yet when grey tubercle is formed in the lungs more gradually, and the process has a very chronic course, we admit that it has sometimes escaped our observation, as it has that of others.

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CHAPTER XXV.

SUMMARY VIEW OF TREATMENT EN PULMONARY CONSUMPTION. By Dr. C. J. B. Wiixiams.

Author's Retrospect of Forty YearsDiscovers a Great Improvement in the Besnlts of Treatment, chiefly due to the use of Cod-liver Oil and the Tonic planDuration of Life in Phthisis QuadrupledModern Treatment chiefly sustaining and Tonic, but not excluding moderate Antiphlogistic Measures where required: soon returning to Tonics and OilMode of Action of OilPlan of Exhibiting itCautionsNecessity of Enforcing its Continued Use Adjuvant Remedies—IodineHypophosphitesSulphurous AcidInhalationsMineral Waters in ConsumptionMountain CureAir and Climate.

On taking a retrospect of an experience of forty years in the treatment of Pulmonary Consumption, I can trace a remarkable improvement in its success, as judged by the results. During the first ten years of that period the beneficial effects of the treatment were very limited, being chiefly confined to incipient cases, and to those patients who were able at an early stage and for long continuance to resort to more favourable climates, such as can be obtained by voyages to Australia or India. My general recollection of the histories of the developed disease at that time is that of distressing tragedies, in which no means used seemed to have any power to arrest the malady; the tardative and palliative treatment employed was little satisfactory ; and life was rarely prolonged beyond the duration of two years, assigned by Laennec and Louis as the ordinary limit of the life of the consumptive.

RETROSPECT OF FORTY YEARS. 317

In the next period of ten years (from 1840 to 1850) a marked improvement took place in the results of treatment, apparently in connexion with the allowance of a more liberal diet, and the habitual use of mild alterative tonics, as they might be termed, particularly iodide of potassium with sarsaparilla or other vegetable tonic. These were first given in conjunction with liquor potassae or an alkaline carbonate; but the lowering effect of the alkali led to the substitution of a mineral acid, generally the nitric; and a combination of this description (iodide of potassium, two grains; dilute nitric acid, fifteen drops; tincture of hops and compound fluid extract of sarsaparilla, of each one drachm; with an ounce of water or infusion of orange-peel) became the favourite prescription, until it was superseded by something which was much more efficacious. Several of the earlier of the cases recorded were treated in this way, and with improved results, in respect of the general health of the patients and diminution of the cough and expectoration.

It was in the latter half of this period that chemists began to produce cod-liver oil of sufficient purity and freshness to be fit for the human stomach; and I have no hesitation in stating my conviction that this agent has done more for the consumptive than all other means put together. And so far is this remedy from having' had its day and gone out of fashion,' that in my experience its usefulness and efficacy have gone on increasing in proportion to the greater facilities for obtaining it in a pure state, and to the improvements in the manner of administering it, in combination with various tonics, and in connexion with certain rules of diet and regimen. Many of the cases narrated in the preceding pages are striking proofs of the efficacy of this remedy, not only in the general results of cure or prolongation of life, but also in detached passages of the abridged histories, in which im

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