Columbia (MnitJer^ttj) mtI)eCitpoflmlork College of ^fjj'gicianss anb ^urgeong Hiferarp X' PROGNOSIS CONSUMPTION LOStDON PBISTED BY 8P0TTISW00DE AND CO. NKW-STBEET SQUARE Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/elementsofprognoOOpoll \ V- '^, •-'% irAND OF CHRONIC PHTHISIS. GIRL vEt. 13. {Engraved from a Photoqraph.) (See page 23 1 . ) THE ELEMENTS OF PROGNOSIS IN INDICATIONS FOE THE PEEVENTION AND TEEATMENT. BY JAliES EDWAED POLLOCK, M.D. FELLOW OF THE EOTAi COLLEGE OP PHYSICIA2;a ; PHTSICLLS" TO THE HOSPITAL FOR CONSUSIPTIOX AND DISEASES OF THE CHEST, BROIIPTON ; FELLOW OF T'HE ROYAL MEDICAL AXD CHIRUKGICAL SOCIETy ; MEMBER OF THE PATHOLOGICAL SOCEBTT OF LOXDOX, AND OP THE HAHVEIAX SOCIErY ; JIEJIBER OF TTIE ROYAL COLLEGE OF SCHGEOXS, IHELANTD ; FORMERLY PHYSICIAN TO THE WESTEKX GEXKRAL DISPEXSART ; PHYSICIAN" TO THE QUEEN IKSORANCE COMPANY ; SOCIO DELL' ACCADEMIA DEI QLTRm OF liOME. ' Pulmouarj' consmnption is no more than a fragment of a great constitutional malady ■which it would be vain to think of measuring by the stethoscope, and which it belongs to a higher discipline than any mere skill in auscultation rightly to comprehend.' Latham. LONDON : LONaMANS, GREEN, AND CO. 1865. 511 PREFACE. I OFFER NO APOLOGY for adding to the already numerous list of works on Consumption. The subject is still incomplete, and must remain so till a higher knowledge than any which we yet possess shall have utilised, and rendered available for practice, the immense collection of facts which the literature of Phthisis now presents to the student. The observations recorded in the following pages are the result of a minute study of cases at the Hospital for Consumption, extending over ten years. They have been carefidly and impartially made, and are, I conceive, due to the Profession. It is hoped that, as simple re- cords of facts, they will be accepted as a contribution to the pathology of the disease. It win be seen that I have from these facts attempted a classification of Phthisis, and have sought to indicate its varieties and their ultimate progress by such natural characters as shall assist us to their recognition in the daily work of practice. The illustration of all which tends to induce chro- nicity in tubercular disease, of the forms in which it be- comes most prolonged, and of the influences which assist its arrest or retardation, has received especial attention, and will, it is hoped, prove of interest. VI PEEl'ACE. An attempt has been made for the first time to assign a relative duration to the dijOferent varieties of Con- sumption. In the diagrams given, the result of many- observations has been represented to the eye ; but, although constructed with mathematical accuracy from the materials available, they only express the averages of a few thousand cases, and the deductions will be regarded as merely approximations to truth. For the considerations on general pathology, and for all purely theoretical statements advanced, I should apologise to the class of readers for whom this work is intended, whose early studies and later experience may lead them to regard these as superfluous. The tendency of the present day to break up patho- logy into fragments ; the undue importance assigned to auscultation ; and the temptation to allow the convenience of a subdivision of practice in large cities into many departments, to represent a similar sepa- ration in the great laboratory of nature, must be my excuse. By repeated reference to the impossibility of con- sidering any morbid phenomenon as single ; to the constant unity in all actions of the system ; and to the general import of all local disease, I have endeavoured to unite the branch of pathology considered in these pages to the general science from which it has occa- sionally been sought to sever it. 62 Uppeb Brook Street, Q-rosvenoe Square: Sejptember 1865. CONTENTS. CHAP. PAGB I. PRELIMINARY . . . . . . 1 II. GENERAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE 5 III. RESISTANCE OF THE SYSTEM . . . .16 IV. PHTHISIS — A DISEASE OF THE SYSTEM . . 38 V. DURATION OF PHTHISIS . . . . .51 VI. THE PREMONITORY STAGE OF ORDINARY PHTHISIS . 80 VII. ACUTE PHTHISIS 99 VIII. ORDINARY PHTHISIS THE FIRST STAGE ITS NA- TURE AND RESULTS . . . . .110 IX. FIRST STAGE THE DEPOSIT ABSORBED . . 115 X. ORDINARY PHTHISIS — THE FIRST STAGE — ITS HIS- TORY — SIGNS AND PROGNOSTICS . . .122 XI. CHRONIC FIRST STAGE : THE DEPOSIT TOLERATED 148 XII. CALCAREOUS DEPOSITS IN THE LUNG . . .160 XIII. CHRONIC SECOND STAGE . ^ . . .166 XIV. CHRONIC THIRD STAGE 190 XIV*. STRUMOUS PHTHISIS 243 XV. AGE A MODIFIER OF PHTHISIS .... 253 XVI. RHEUMATISM, GOUT, DISEASE OF THE HEART . 270 XVIL EMPHYSEMA OF THE LUNG WITH PHTHISIS ASTHMA — CHRONIC BRONCHITIS . . .280 XVIII. MENSTRUATION PREGNANCY LACTATION . . 293 Vlll CONTENTS. CHAP. PAOE XIX. HiEMOPTYSIS 3(i2 XX. GASTRIC SYMPTOMS DIARRHCEA, FISTULA . . 312 XXI. PNEUMOTHORAX 321 XXII. HEREDITARY INFLUENCE 336 XXIII. PREVENTIVE TREATMENT OF PHTHISIS — INFANCY — CHILDHOOD ...... 350 XXIV. PREVENTIVE TREATMENT OF PHTHISIS : OCCUPATION 363 XXV. THE SPECIFIC TREATMENT OF PHTHISIS . . 376 XXVI. THE DIRECT TREATMENT OF PHTHISIS . . .'?82 XXVII. TREATMENT OF THE DIFFERENT STAGES OF PHTHISIS 398 XXVIII. CLIMATE 410 LIST OF ILLUSTEATIONS. The Hand op Chronic Phthisis Frontispiece POETEAIT SHOWING THE FLATTENING OF THE WaLLS OE THE Chest in Chronic Cavity , , .to face page 197 Diagram (No. 1), showing the relative Duration of the varieties of phthisis, and its combina- tions with other affections .... ,, 51 Diagram (No. 2), showing the Curve formed by the lines representing the relative average Duration of the varieties of Phthisis , „ 51 THE ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAPTEE L PRELIMINARY. An accurate knowledge of the questions concerned chap. in estimating tlie prognosis, or probable course and ^- termination, of any given case of phthisis, can only be arrived at by possessing a practical acquaintance with the disease itself; with its origin, history, and most usual course and terminations ; with its average duration, its modification by treatment, by inherited or individual tendencies, and by its complication with other diseases ; and, finally, with the actual physical condition of the patient on whom we are called to pronounce an opinion. Without such general knowledge, the most accu- rate physical examination and the most refined tact in estimating symptoms must fail in estabhshing more than a diagnosis, — perfect, it may be, as regards the present, but fallacious as representing the future of our case. From a want of perception of this fact arise the mistake so commonly made, of trusting exclusively to auscultation, and the ill repute which the most refined methods of exploration of the chest have occasionally B I ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, met with from shrewd and sensible observers of symp- ; - toms alone, who have often had occasion to conduct through many years of safety individuals who had been stethoscopically condemned to an early death. There is frequently not only a want of correspon- dence between symptoms and physical signs, but con- tradictions between these two kinds of evidence will be found so striking as to weaken the confidence of the unreflecting in either of them. The patient with cavity, who is therefore physically in the last stage of phthisis, may preserve for years a fair degree of health, and in colour, flesh, and appearance forbid even the supposition of disease ; while others in the first stage (by ausculta- tion) succumb to the constitutional disorder attending an extensive tubercular deposit, and the blood depra- vation which has been its cause. Individuals die in all stages of phthisis, and with infinite variety as to the ex- tent of lung disease : they also perish with much vari- ation as to the mode, and therefore as to the existing symptoms, the progress of few of such cases when watched with a discerning eye being exactly ahke. The physical signs and the concurrent systemic events often advance pari passu, but by no means invariably ; the one set of phenomena does not necessarily imply the other ; and while neither should be neglected or over- looked, it becomes the highest office of the physician to regard and careftiUy balance the evidences to be derived from both sources. The one cannot be weighed against the other, but the neglect of either would be unphilosophical. The man who in the present day pretends to despise physical aids, is in darkness while surrounded by light ; the auscultator who condemns his patient from certain sounds in his lungs, and neglects to regard the rounded hmbs and rosy colour, the tran- quil pulse and unimpaired digestion, by which the same individual evidences a healthy sanguification on which the system may draw for its supphes for years to come, PEELIMINARY. I is in the position of one who declares that the building chap. is falhng because a wintry storm has displaced some ■ — i- — bricks from his roof. That a disease whose earliest organic manifestations and latest destructive results are most prominently seen in the lung should be capable of detection by that most certain kind of evidence which appeals to our senses, is indeed of great value. To measure the extent and appreciate the stage of mischief in the pulmonary structure was a great achievement of the preceding generation of observers ; but in our later refinements and additions to physical knowledge we must beware of attaching to it too high or too exclusive a value. Vital phenomena are of primary importance ; systemic disorder, waste of tissue, blood depravation, kill the patient, who in rare cases only can be said to have perished from destruction of pulmonary structure, as an analogous amount of local disease is often tolerated for years in other individuals. For merely diagnostic purposes we are now possessed of means and knowledge which, applied by competent observers, are sufficient to establish the nature of our case, and the extent of existing local mischief, the negative evidence also derived from physical signs being very satisfactory and valuable. Diagnosis, however, whose perfection is so desirable to the scientific observer, and which must be esta- blished as the basis of his treatment, falls very far short of the requirements of the patient from his medical attendant ; and if the individual himself is satis- fied that the nature and extent of his disease is known, and its treatment scientifically arranged, his friends - have a reserve of questions to be answered, and appeal to the physician for a higher knowledge than even that which he has exhibited in his recognition of the affec- tion. Is it to be fatal? How far can life be pro- longed ? Are the remedies of removal to foreign t ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, climates admissible ? — and an infinite number of social ^; problems connected with the habits, engagements, and relations of the patient arise, which cannot be answered by a statement of stethoscopic information. The whole history of om' case and its relative standing in the great history of the disease are here appealed to ; and while mistakes involve, on the one hand, not only the character of the medical adviser, but the far higher consideration of painful anxiety and apprehensions to others, and domestic events of vast importance ; on the other, a correct appreciation of the probable future strengthens the uncertain-minded, saves pain of the deeper kind, and lends a confidence to our treatment which enhances its actual value to the sufferer, and gains merited approbation for his adviser. The importance of prognosis cannot, therefore, be over-estimated, whilst its very meaning involves an acquaintance with all the knowledge which can be accumulated on the disease and on the individual, from a study both of physical signs and of symptoms. The experience of a very large number of cases must be brought to bear m elucidating these interesting problems, and the actual as well as the relative value of auscultatory and vital phenomena ascertained, in order to arrive at even an approach to truth in this investigation. It is not proposed to write a history of Phthisis, nor to weigh the merely diagnostic value of signs and symptoms, but to offer facts derived from the expe- rience of the writer, and in some instances from that of others, which, by illustrating the ordinary history and progress of the disease, its varieties and anomalies, shall furnish us with data for a method of prognosis which shall not be empirical. GENEEAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE. CHAPTEE II. GENERAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE. As we have been led by investigation to recognise chap that all healthy functions are performed in accordance > — ^ with a pre -arrangement, and exhibit an invariabihty in action evidencing the presence of an exciting cause, so it is of disease. Disease is somethmg more than a negative condition, or simple departure from the laws of health. It is true that there is a disturbance of normal actions, but there is no merely chaotic and con- fused result. The new state of things is not nature let loose, vital condition overturned, and disorganisation resulting from the annihilation of previously existing forces. Properly speaking the word ' disorder ' cannot apply to disease. The new condition is simply a sub- stitution of one set of actions for another ; and this is not the less true because the transition is productive of mischief to the economy as a whole. So far as natural laws are concerned, the morbid process is as much under their influence as the healthy. There is never one moment of interregnum ; such a cessation of government would be death ; that is, the cessation of all vital law. There can be no action without law ; m other words, without a defined, limited obe- dience to governing power. Disease is therefore only another phase of nature's processes — a new form — ^but equally subservient to rules as health. Wlien a machine is broken, its action as a whole is put an end to till the • same train of movements is restored by re-instating its component parts exactly as they were. If it continue to act partially after an injury, its motions are only im- ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. II. Time and systemic resistance. System recovers, tolerates, or yields perfect continuations of the original force, not new actions, obeying other laws. It is not so with vital actions. Here, too, there is often imperfect perform- ance of functions ; but, when once organic disease is estabhshed, new laws come into play and new forces. The difference between the machine and the animal is vitahty. The former is made to represent one train of uniform action dependent on a single force ; the latter represents many forces capable of conjoint, indepen- dent, or successive actions, whose obedience to natural laws never ceases. We can thus view disease as a defined series of actions in accordance with equally definite causes ; and if in morbid conditions we can only recognise disor- der, the failure is in our powers of observation or of reasoning. It is a great help thus to study diseased action as we regard other vital phenomena, and on this foundation alone can our advances be made. The characteristic features of all chronic organic affections as contrasted with acute diseases, are derived from the length of time through which they may be prolonged, and from the resistance of the system to their progress. The nature of the structural changes undergone may not be widely different from those in more rapid affections, but the systemic disorder assumes a different attitude. The system may resist and throw off the structural disease and recover its own balance ; or, after a period of violent reaction, it may tolerate and sustain the local disorder as an irremediable injury, continuing the functions of the body with diminished power, but with- out much manifestation of disturbance to the general health ; or the vital powers may gradually yield, and so exhibit the phenomena which constitute the final stage of all organic changes. The individual organ primarily affected will, of neces- GENERAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE. "i sity, modify the nature of this resistance, toleration, or chap. yielding of the general system, according to its own - ^^' standing and relations in the animal economy. Any Organ interference with its structure will alter the train of atocS/ phenomena, which are necessarily dependent on its in- "i^'iifies. tegrity. Modifications in the respiratory, circulating, and hepatic functions will naturally follow lesions of the central organs of these systems ; and, while the effect on the whole economy cannot be measured by the extent or degree of local mischief, the morbid symptoms, which are referable to systemic disturbance, will take their tone from the organ which is the seat of disease. Impairment of its appropriate functions will be felt Physio- by the system at large in a manner peculiar to the function physiolo2;ical import of the healthy ore-an. Thus pul- of organ P,, '-,. .„ T ^ 1 ,1 • modifies. monary inflammation will produce, not only the constitu- tional disturbance consequent on the lesion of a vital organ, but respiratory effects implying an interference with the appropriate functions of the lungs, the decar- bonization of the blood, pulmonary exhalation, etc., and so of cardiac and renal inflammation. Another class of phenomena results from the dis- Organs turbance of organs dependent on that first affected ; as 0^^^^^^^^°' engorgement of the lungs consequent on obstruction first at- in the right side of the heart. In like manner organs allied in function become Organs secondarily affected, and the gravity and import of this fincfiJn reflected disorder must enter into our calculations in estimating the real amount of systemic suffering. Mere contiguity, or continuity, of structure often Contiguity, gives rise to new constitutional disoi'der by extension of the original affection, as pleural inflammation in tubercle. Secondary attacks on distant organs are of great Secondary importance in estimating the gravity of chronic affec- distant T- tions, as they indicate, not merely an extension of g^°s- disease to a new and hitherto unaffected structure, but 5 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, a persistence, and perhaps an increase, in the blood "■ - crasis and vital causes which have originated the dis- order. Such are deposits in the glands of the ileum, or tuberculous ulceration of the larynx in phthisis. The systemic disturbance may thus be modified by the influence of secondary organic alterations, as v^ell as by those of a primary order, and each of these having a separate relation to the whole economy in proportion to their pecuhar functions, a summary of all must be made in estimating these vital effects. In considering the gravity of the chronic disease of an organ, we have therefore to examine the nature of its own lesion, and the results to its functions with rela- tion to the system ; the amount of injury to the parts alhed to it, and likely to become engaged in the morbid changes ; the influence of continuity of structure, of mere neighbourhood of position ; and secondary attacks on clistant parts due to an extended constitutional disorder. All organic All orgauic discasc is absolutely systemic disease; as, systemic, ffom the impossibihty of any function being singly im- paired, no organ can stand alone in the economy. Products Not only does the system at large sympathise with becoir^^ the local injury (as in the fever attending a suppuration), added to j^ut thc products of discascd alterations become added to the blood. That the fever which we call sympathetic in acute inflammations has its origin from these two sources, reacting on each other, seems little doubtful. The resolution of the local disease and the cessation of the blood disorder terminate the attack, if the result is to be favourable ; but the frequent supervention of chronic organic alterations in the convalescence from acute illness, argues a continuance of the blood dyscrasis, probably of the same nature which caused the primary attack. The identity of successive lesions of the same or of remote organs powerfully strengthens this view. GENERAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE. 9 The organ which is apparently earliest affected, and chap. whose influence is most observable throughout the series .J^ of morbid actions which ensue, generally gives the name ^^^"^ ^^t^""* to the disease ; but the mechanical extent to which its rai disease structure is altered or destroyed is not per se the measure milure of of the injury inflicted on the system, nor of the gravity systemic of the case. This is exemphfied in slow enlargements of the liver, cystic disease, or cuThosis, with but slight im- pairment of health ; or in the chest by the obliteration of the respiratory space of one lung by fluid in the pleura, which often occurs unsuspected by the patient ; or in the toleration by the system of a single large tubercular cavity. It is probable that there is no such thing as purely No purely functional disorder of organs. The latest researches ciisord"er'^ have proved an intimate connection to exist between the ultimate cells of a secreting organ and the secretion itself, which, in certain instances at least, is accom- panied by a cell- exudation. The whole epithelial tract is frequently imdergoing this process. The con- stant waste and renewal of tissues, on which the in- tegrity of all structure depends, if interfered with by what we are accustomed to call functional disorder, is imperfectly performed, and an alteration in the vitality, if not in the form, of the cell results. It is only when an accumulation of disorder has altered the essential nutritive action of an organ, and caused its increase or diminution in size, or a new pro- duct to be mixed with its own structure, — in other words, when the error in its nutrition, and therefore in its functions, has reached a certain height, and has made considerable progress, that we call the disease ' organic' But the difference is in degree, and not in character ; the process is the same in both cases. Let us now examine whether we can observe any Origin of • r. .. IT 1 r> 1 • 1 • orgauie uniformity m the disturbance ot system which mva- affections riably takes place in chronic organic afiections. First, ^^Zks^^^ 10 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. II. From fevers and after preg- nancy. Com- mence- ment of organic disease. System stands at a lower average state. as regards the commencement of any organic affection, it very frequently seems to arise from an acute inflam- matory attack. The urgency of the local symptoms, the suddenness of the seizure, the greater violence of pain, and the accompanying state of system called fever, characterise and stamp it as acute. An organ so attacked very commonly remains in some form of altered struc- ture, which obtains in time the name of chronic disease ; but it is very questionable whether this acute attack was not the result of preceding, slow, and hitherto unheeded changes in its nutrition and its function. Again, organic disease has frequently its apparent origin in pecuhar states of health, or in fevers of an acute character. The pneumonia after rubeola, which, when unresolved, often runs into tubercles after the lapse of months — the enlargement of liver or spleen after ague, and softening of the brain after fever, are instances of the latter ; while the invasion of tubercle after pregnancy illustrates the former. When such changes in organs as are recognisable by our various methods of diagnosis do not ' resolve', or dis- appear, after the acute attack which has appeared to originate them, a new condition takes place, very inter- esting, if not very hopeful. The system has accom- modated itself to the altered structure and to the im- paired function ; the fever subsides, the pain becomes trifling, secretion from the injured organ returns, but in a lessened degree, or with manifest differences in its composition, and a condition which is called ' delicate health' renders the patient an invalid, perhaps, for hfe. This state deserves study, and has an undoubted use in the economy which has not been suflficiently dwelt on. Its leading features are, emaciation and resulting mus- cular weakness, impairment of all the processes of assimilation, and a marked tendency to a renewal of irritation in the already enfeebled organ by causes of whatever kind, which in a state of perfect health would GENERAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE. 11 lead but to slig-lit disorders, such are cold catchiii"; and chap. . . II errors in diet. To this we might perhaps add, a sin- ■ — r^ — ' gular immunity from epidemic and other acute affec- tions which do not directly and ordinarily fall on the organ diseased. The system is, in fact, in a lowered state in all its powers. It has adapted itself to an inferior par of health, for the condition described can scarcely be called disease ; and, like a machine which has been damaged in one part, the remainder of its complex mechanism must be worked at less pressure, if it is to work at all. With one lung obhterated by pneumonia, it is plain that the respkatory requirements of the system can only be half satisfied, and that to restore the balance we must either reinstate the breathing organ in its integrity, or reduce the volume of blood to be aerated, the amount of carbon to be exhaled ; and hence, secondarily, the various tissues of the body requiring to be oxygenated and supplied with caloric. Till this balance is struck in acute disease, the suffering of the patient is often very great ; but when antiphlo- gistic measures, low diet, blood-letting, sudorifics, pur- gatives, and free secretion from various organs, have lowered the system to a par with the powers of the weakened organ, a great rehef is obtained. Very fre- quently these measures are resorted to without any view to such a result, but nature will (herself) by a hsemorrhage, violent sweating, or profuse secretions, right the machine, and restore the balance between the weak organ and the requirements of the system. In cases of chronic disease when the emaciation Prognosis takes place early, before much organic mischief has lessfa™^ occurred, and the system has been, in a manner, pre- ^ouraWe . . . ■when first pared for the invasion, there is often a tendency to attack chronicity estabhshed from the outset, which enables j^JJifhy* us to form a prognosis as to time, more favom^able than system. if the structural alteration had suddenly invaded a 12 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, system working at full power. The latter condition ■ _ ^^- . is rapid and often uncontrollable ; the former is gradual, accompanied by less disturbance, and is more tolerated by the vital powers. We shall have occasion to point out how this consideration is of valuable importance in our prognosis of phthisis. Eecm- We have next to remark that all chronic organic acute °^ affections exhibit a liability to a recurrence, more or attacks, less frequent, of acute attacks. Their downward pro- gress is, in fact, accomplished rather by a succession of attacks, than by a continuous but slow disintegration of the impaired structure. The mischief thus inflicted on the organ is seldom wholly repaired, and the succeed-^^ ing embarrassments are generally ^successively more and more grave in their nature. Those latest in the history of the disease are never hmited to the organ which has given its name to the affection, but the Secondary sccoudary disturbance of other parts assumes a pro- tionf^^ene- i^i^iGuce whosc urgcucy and danger might well entitle rally prove jt to bc Called the leading disease, and which demands in treatment a primary consideration. So far have we been deceived by medical nomenclature, that while it is generally the secondary complications which prove fatal, we accord to the primary the importance of the name, and often a monopoly of the treatment directed to subdue the disease. Systemic reaction in organic disease of an insidious character appeals to follow the rule that all violent commotions are of short duration, and this may be one of the reasons why a succession of attacks is observable, rather than a continued and sustained disturbance. The hectic of phthisis almost always occurs thus, and the longer the interval the more chronic is to be the dura- tion of the case. A long sustained febrile access with- out intermission is only seen in the more rapid invasions of tubercle, in which indeed the affection, even when GENERAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE. 13 prolonged for months, ceases to deserve the name of chap. chronic disease. v_i^L_ When the disorder of system has reached a certain Romis- height and much exhaustion of vital force has occurred, toward^''*' as well as extensive structural disease, these remissions *^^^ ^^°^^- cease, and a febrile condition, in its own tendency con- tinuous and scarcely under control of remedies, prevails, which constitutes the last stage of organic affections. , The termination of even such cases is generally pre- cipitated by some secondary disease ; and it is to be remarked that in chronic affections of organs, life rarely Life rarely dies out gradually as the powers decay in old age, but giaduaiiy. a superadded local disorder, as diarrhoea in phthisis, extinguishes the last remains of vital power, and ends the case. We have to remark, therefore, that chronic affec- Chronic tions, with true intermissions between the acute attacks ^khtrue on primary or secondary organs, are likely to last longer intermis- 1 1 •1*11 ••••• a sions issts than those m which the systemic irritation is continuous, longer, or exhibits little tendency to intermit. The daily re- mittent character of true hectic is not here spoken of ; but successive attacks of febrile irritation and local disorder, with appreciable intervals of time between them, during which the constitutional symptoms con- siderably or wholly abate. It is obvious ft'om the preceding observations, that if the ordinary course of chronic disease be to proceed by a succession of attacks, each of which in a degree sub- sides for a time, we may, in practice, be frequently led into error by mistaking one such access for an urgent 0"^ acute and irremediable disorder. The degree of its danger is necessarily to be estimated by the order in Avhich it stands to others ^^^'^^• of a like kind which have gone before it ; and it is to be remembered that the natural tendency of all chronic disease is to proceed by steps, alternated with remissions. The extent of local structural mischief is also a correc- tive, and should always be weighed against the con- 14 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, stitutional symptoms. A circumscribed, limited deposit V- — ,^ — - of tubercle in one lung will remain dormant for years, The extent and suddcnlv break up, soften, and leave an excavation, of local T . -^ ,. , V • • 1 _p 1 • mischief the systcmic disorder being seen m an attack oi hectic, tiTO^^^^' sweating, and emaciation, which almost threatens the life of the patient. Yet, if the deposit be limited to one part, and if (as pathologically proved) the diseased product be walled in by plastic matter thrown up as a preservative barrier between the healthy and diseased portion of the lung, such attack will subside, the soft- ening and excavation being a truly remedial, natural effort, and the system may and frequently does recover itself, the fever subsides, and every trace of the disease, excepting the physical signs of a cavity, and the symp- toms of slight expectoration and dyspnoea on exertion, disappears. The patient in this case is in the lowered condition already described, and lives, in fact, at a standard of respiration, in the largest sense, beneath that at which he stood when in health. Were we to measure the danger of such an attack by the intensity of the constitutional disturbance alone, we should err ; the elements of prognosis consisting in the order in which this invasion has occurred, in the localisation of the deposit of tubercle, and in our careful estimate of the inherited or other constitutional tendencies of our Few die of paticut. It is uotorious that few patients die with only i^nthe^bng. ouc cxcavatiou in the lung, and that the most rapid ' consumption' consists in an extensive deposit through- out both lungs. Systemic Systcmic disorder is to be regarded as composed of composed two scts of reactions — those resulting from the indi- of two sets vidual org;an first in the chain of disease, and those of reac- o _ ' tions. from the secondary affections. With a single organ, as liver or lung engorged, the constitutional symptoms are grave, and more merit the title of acute than those occurring in a later period, when many secondary de- rangements have arisen. GENERAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE. 15 The fever is more active and its character more ciiap. sthenic than when many organic functions are clis- - ^^/ . turbed and linked together in their aberrations, yet the Primary latter is the more serious condition. a*cTteTiian The hectic fever from an empyema rapidly pro- secondary. duced is illustrative of the former state ; the secondary systemic irritation from a dropsy depending on conges- ted hver or kidneys, whose disorder is itself a result of mitral obstruction, may afford an instance of the latter. In this case the number of functions conjointly and simultaneously impaired give its peculiar character to the systemic disturbance, and their sum producing a general exhaustion of vital force is the measure of danger. Each individual organ has probably its own mode Each of reacting, gastric inflammation quickly depressing the ^l^^^^^ nervous and circulating systems, while uncomplicated its own pulmonic inflammation is much more tolerated by on the" them ; and if this difference be observable in acute system. affections of organs, it is very probably reflected and continued in their chronic disturbances. It is therefore manifest, that the danger is infinitely increased when various organic affections simultaneously react on the system. 16 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAPTEE III. EESISTANCE OP THE SYSTEM. CHAP. III. Nature competent to the cure. We must now examine tlie resistance of the system to diseased action in its three attitudes of 1. Eesistance terminating in recovery ; 2. Eesistance just sufficient to tolerate the mischief and preserve the organism at par ; 3. Eesistance which is overpowered and succumbs, the organic affection proving fatal. In one or other of these conditions ah our cases will be found, and on our due estimate of the forces em- ployed will depend our ability to calculate the result. Resistance terminating in recovery. That Nature is competent to the cure of many dis- orders of the system, is a proposition which may be regarded as accepted by practical physicians of the modern school. The cessation of fevers within a cer- tain period more or less prolonged ; the spontaneous re- 'solution of acute organic inflammations, as pneumonia ; of membranous inflammations, as pleuritis and perito- nitis ; and of acute rheumatism, within calculable terms of time, may be accepted in proof. It is undeniable that under any treatment, or no treatment, such recoveries take place sufficiently often to establish, not only their possibility but their frequency. The influence of various methods of treatment (or interference with the natural processes) is not here under discussion. The fact can be doubted by no one who has devoted hunself to the study of disease, and remains as patent and susceptible EESISTANCE OF THE SYSTEM. 17 of proof as any other pliysiological event. That nature chap, unassisted by art can therefore resist internal clis- . ^^}' . . tiu"bances of the system, and repair even structural alterations of vital organs, is undeniable. The earliest attitude of the system when injury has been inflicted from without is resistance; and all phenomena ex- liibited, all departures from a state of health have inseparably stamped upon them this feature. It may be difficult to discriminate the disorder existing from the remedial effort at repair, but the tendency to shake off and expel the offending agent is traceable in every symptom. This is very capable of demonstration in acute disorders where the course is rapid and the ter- mination susceptible of proof; but it has not been recognised as the rule in chronic affections, and in the latter is less evident than in the former, owing, no doubt, to the long periods throughout which their pro- gress is continued, and to the variety of pathological phenomena from time to time developed in their course. Above all, secondary lesions mask the original attack, and divert attention from the condition of the organs primarily affected. Yet it cannot be doubted that the rule which prevails in the one is equally powerful in the other. Although the intensity of the symptoms may vary, the difference between acute and chronic diseases is rat]ier in time than in mode, and there are a large number of features common to both. In the more detailed portions of this work, the processes of resistance and repair will be more minutely dwelt on ; but it is now souQ'ht rather to examine the broad characters of all chronic affections, and to establish the resistance of the system as a fact common to both acute and pro- longed diseases of org-ans. The mode of resistance may be thus viewed : — First. There is a preparation to reduce the volume The vo- of the circulating fluid, and to waste the tissues, in order biood°and° that the systemic requirements may not be beyond the t'l^ tissues •^ -^ ./ ./ redixced. C 18 ELEMENTS OF PROGNOSIS IN CONSUMPTION. Local dis- order iso- lated. Morbid deposits absorbed, or altered. Eemis- sions. Eesistance evident in acute dis- Pnenmo- nia. powers of the injured organ to supply. This is accom- phshecl by increased secretion and by muscular waste, by absorption of fat from the tissues, and, to some extent, by deposit of morbid material. The secretions so increased may contain both their natural constituents and additions, which are commonly derived from the detritus of the system. Secondly. The local disorder becomes circumscribed, and, in a certain sense, isolated by plastic exudations, which prevent its extension to neighbouring parts, and oppose obstacles to its increase in the organ attacked. Thirdly. Morbid deposits so isolated are in many cases absorbed; in others altered in chemical character and removed from the system. Fourthly. In whatever constitutes the blood disorder or the local affection, there are distinct remissions to allow of improvement in blood components and in the nutrition of the tissues, the local disorder at such periods remaining in a quiescent state. We are familiar with the phenomena of systemic disturbance which follow any severe local disorder of organs, and have called this group of symptoms by the name of fever. Shivering, increased temperature of the body, rapid hard pulse, thh^st, anorexia, and lessened secretions indicate successive shocks to the nervous, circulating, and assimilating systems. The abruptness of the transition from perfect health, and the compara- tive shortness of the duration of the attack as a whole, are well-described by the term 'acute.' And when such a train of phenomena is set in motion by a cause outside the system, it is no doubt typical of the slower changes which occur in chronic affections. A pneu- monia caused by the direct apphcation of cold to the surface in a healthy subject, with its concomitant fever, presents many analogies with a deposit of tubercle in the lung, and its accompanying systemic disorder. There is this difference, that the tubercle is probably RESISTANCE OF THE SYSTEM. 19' due to a preceding depravation of the blood, and chap. certainly to intrinsic causes ; but the pneumonia may . ^^^' . occur from agencies entirely extrinsic, and the indi- vidual attacked may be healthy. As regards the re- sistance by the system resulting in a favourable termi- nation and resolution, the pneumonia may be examined with advantage, and will elucidate the present views. The object of all reaction of the organism as a whole, when a local injury has been sustained, is directed to counteract existing mischief; to isolate the diseased part, and thus prevent the extension of the morbid action ; and, finally, to repair any disorder of structure. In the series of actions which we have called ' morbid,' we can find thus a definite meaning. The conservative and reparative functions of the system are as essential to its existence as are its powers of assimilating nutri- tious material. They are, it is true, only occasionally exercised, but they are always present, and are hke the fire-engine which is kept at hand, yet may rarely be required. In a pneumonia we find the respiratory function interfered with by a sudden chill. The nervous shock is great and indicated by the rigor ; the heart, driven to violent contractions, sends a larger supply of blood more forcibly driven. The local result is exudation of a plastic material into the lung tissue, which annihilates for the time its respiratory function, and insures com- jjlete rest for the organ. Aerification of the blood is performed at double power in the opposite lung, as in- dicated by the compensatory puerile respiration. In Effusion of the bloody sputa we have only an evidence of much ^l^^ ^ congestion, and the exudation has relieved the ex- treme vessels, as no doubt a hsemoptysis does in tubercle. In many cases we have a walhng ofi" of the affected portion of the lung, as in lobular pneumonia ; and, in most cases, we perceive a tendency to hmit the mischief Secretion supervenes and is a relief The a relief. c 2 20 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. III. Spontane- ous cures of acute pneumo- nia. Analogy between pneu- monia and a deposit of tubercle in the lung. system, meanwhile, so long as exudation goes on, retains the pulse at a high pressure. It falls when secretion takes place, and it would have fallen more rapidly if a pulmonary apoplexy had occurred instead of a pneumonia. In the anorexia we can read a plain indication to stop the supphes of respiratory food, and to lower the requirements of the blood for air, and of the tissues for nutritive support. If, as before pointed out, the organism were to remain at full working power, with only half the respiratory space necessary to its normal action, the embarrassment would be propor- tionably greater. The blood is therefore reduced in volume, the tissues are wasted, and thus relief is obtained. When the period ft)r absorption has arrived, the local structural alterations and the systemic action will together subside, and even where no treatment of an active kind has been resorted to, the case will ter- minate spontaneously in from 18 to 30 days, the lung being pervious and the patient convalescent, though below his usual average of flesh and strength.* By contrasting an acute with a chronic affection of the same organ, we have an opportunity of seeing the same laws at work in both. In tracing the analogy between the natural pro- cesses in a pneumonia and in a deposit of tubercle as indicative in both of a conservative energy on the part of the system, it must be remarked that in both the febrile disturbance seems to have a common object, viz. an abatement of the requirements of the blood for air, and the necessary reduction of the tissues. In the local * Througli the kindness of tlie late Dr. Todd, I have witnessed many of these spontaneous cures of pneumonia, the treatment consisting of the external application of turpentine fomentations, and the only medicines used being the acetates of potash and of ammonia. Nor were such cases always ministered to by stimulants, as is erroneously stated by some. No doubt the homoeopathic reports of the Vienna hospitals were obtained from cases identical with these ; but the fact to be deduced from both series of observations is, that Nature is sufficient for the cure of a single acute pneumonia in a previously healthy subject. EESISTANCE OF THE SYSTEM. 21 action there is a tendency in both cases to circumscribe chap. • • • III the deposit in the huig ; and in the ultimate changes m . ,_^ the tuberculous mass we may observe a throwing off of the morbid exudation when it cannot be tolerated, nor raised to a higher organisation. The hsemoptysis has its analogue in the bloody sputa of pneumonia, and a more careful consideration of its meaning would often lead us to regard it as a salutary relief to the local con- gestion of the lung. The hsemorrhage in the early stages of tubercle is rarely dangerous, and never fatal ; and the symptoms denoting irritation of the lung are generally lessened by its occurrence. As importing a severe lesion of the lung it is a grave symptom, but considered only as a hemorrhage it is trivial. The tendency in all diseased action may be assumed to be towards cure ; and this is seen in the resistance opposed by the system to the progress of all lowering structural changes. Malignant growths would seem to Even be exceptions. We cannot, it is true, detect in the gro^hs morbid product itself any tendency towards structural ^'"^^^ ^*^" 1 i . . *^ . erea. improvement, but its progress is opposed by the vital powers. In rare cases, even cancer is circumscribed by plastic firm exudations, which insulate and compress it so that the indurated mass withers and disappears.* The locahsed tubercular deposit, whether consisting Tubercle of grey, single, miliary masses, or of a softer and more ^^^°^^®<^- diffused exudation, has no doubt, in many instances, been absorbed or thrown off. The frequent occurrence of small cicatrices in the lung attest this ; and there is now no doubt thaf many individuals undergo slight attacks of tubercle which they outlive, and from which there is complete recovery. In such instances, after wast- ing, febrile accesses, cough, hsemoptysis, expectoration, and the presence of physical signs indicating a solid * See Pathological Transactions for 1862. In this and similar cases the cancer has been reproduced in other organs after years of latency ; but the original tumour in the breast entirely disappeared. 22 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP, deposit in the apex of one lung, the systemic disturb- . ,. , ' _ > ance subsides, tlie patient regains flesh and strengtli. Strumous and all pectoral symptoms cease. It is also not to be hi^SS-en cloubted that in children a species of strumous deposit capable of takcs placc in the lung, which is capable of absorption a sorp lou. ^|.-|^Q^^^ having undergone either a cretaceous or horny change, and without having softened. Children with all the physical signs and all the active symptoms of phthisis have raUied almost from the grave, and the abnormal sounds have disappeared, while the general health has been reestabhshed.* Conversion In otlicr cascs, as is well known, the conversion of i^nt^mr^^ tubercle into a cretaceous mass, which is ultimately ex- taceous pectoratcd, evidences the resistance made by the system matters."^ to the progrcss of organic disease. When the effused morbid material is incapable of absorption, it becomes chemically altered ; its animal portion is taken up into the system, and the purely earthy salts are finally ehminated. Analogies to this conservative action are to be found in some of the degenerations of tissues, which it is more than probable have a similar end to subserve. Resistance Where absorptiou or conversion of the morbid ma- totoTerate. tcrial is impossible, the powers of nature are not less seen in the further stages of diseases accompanied by Exuda- organic changes. If resistance cannot be completed by the removal of deposits m either of these modes, an attempt is made to procure their isolation, and a plastic exudation will often effectually stop the further progress of the morbid action, ^he adhesions and thickenings of the pleura around portions of a lung, the * In certain of these cases the deposit of tubercle has been in the bronchial glands, but in others there can be no doubt that the lung itself was affected, the physical signs being of undoubted character and at the base. ' When enlarged glands in a scrofulous patient ultiniatelj^ disap- pear, we may conclude almost with certainty that we haye witnessed the cure of a tuberculous disease.' — Cars^oell. tions con eerratiye, RESISTANCE OF THE SYSTEM. 23 seat of tubercle, are highly illustrative. Without them, chap. the smallest deposit, if it soften, may give rise to a fatal _i^L_^ pneumothorax, while they also answer another purpose, in limiting the incessant movement of a part under- going irritation. The interstitial exudation of plastic lymph below and around chronic cavities in the lung is another example ; a deposit with marked tendencies to extension being thus walled off and isolated. Analogies to this are found in the cysts with which Apoplectic apoplectic clots are often observed to be surrounded ^^^^^' in the brain, and in similar envelopes provided for cysts musket balls in various parts of the body, parenchy- ^^^^g°*^ matous and inm cular. The occurrence of softening of that form of tubercle Softening which appears incapable of more favourable changes, ^a^tioTof is to be regarded in a similar hght, its expulsion from ca\'ity to the system being the end to be achieved. The forma- garded as tion of a cavity in the lung is onjy a clearing out of all t^Se^e. morbid material ; at the expense of much structural mischief to the lung, it is true, but the effort is curative in its tendency, and not destructive. This fact was re- cognised by Laennec. Patients will live for years with such cavities, who would have succumbed to the hectic and wasting inseparable from the softening of a differ- ent crop of tubercles. The excavation in the lung can be and is tolerated, and unless in instances of pro- fuse hsemorrhage, or from the supervention of pneumo- thorax, death never occurs from a single cavity in the lung. A repetition of deposits in other parts of the pulmonary structure, and the consecutive softening of these, together with various secondary lesions, destroy the life which, in the first instance. Nature, in her con- servative powers, had essayed to save. Nor are the Systemic systemic changes less characteristic of resistance to the charSi- progress of chronic morbid chana;es than the local. The i^tie of reduction of the sohds of the body, the emaciation, muscular waste, and absorption of fat, are necessary (as 24 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. ' already stated), in order to establish a balance between > r-^— the system as a whole, and the organs which are to supply it. In any diminution of respiratory space caused by inflammatory attacks on the lung, bronchi, or pleura, an immediate reduction of the respnatory requirements of the body becomes a necessity, and is accomplished by the waste consequent on fever, and by secretion. The rehef in acute bronchitis from purga- tives is illustrative of this point, and the most distress- ing cases of respiratory difficulty from such attacks occur in the robust ; those who have been akeady weak- ened and thmned by previous illness suffering compara- Eemis- tivcly httlc. A remarkable feature in all chronic organic e}"mptoms. affcctious is coustitutcd by the remissions which occur in their progress, and which allow time for a favourable reaction from the exhaustion and emaciation by which the patient has been reduced. During these pauses the system recovers, and, by increased activity of the nutri- tive processes, muscular waste is replaced, the blood is renewed, fat is again formed, and a very decided increase in weight takes place. It is difficult to account for the occurrence of these pauses, otherwise than by assigning them to efforts of the system to build up the losses it has sustained ; and theoretically it is possible to con- ceive that by deposit of morbid material, or by extra- ordinary and increased secretions (as in the hectic sweatings of phthisis), the blood is freed from impu- rities with which it has been loaded, and opportunity given for its enrichment by an increase of red cor- Exampies pusclcs, and Other nutritive constituents. Examples of aiidhearr thcsc pauses in chronic affections are common enough. disease. Tlicy are seen in phthisis remarkably, and in various disorders of the circulation dependent on disease of the walls or valves of the heart. In these two instances it is possible to account for them as arising, in pththisis, from the causes just stated ; and in cardiac obstruction, either from an hypertrophy which counterbalances the. RESISTANCE OP THE SYSTEM, 25 valvular difficulty, or from the terminal portion of the chap. circulation being relieved by an effusion of the serum ,J . of the blood (anasarca). ISFor are organic alterations of tlie cerebral structure without illustrations of these remissions in symptoms, although brain affections are perhaps more uniform in their progress, however slow, than those of other organs. A fresh accumulation of morbid matter in the blood may (as in gout) induce an exacerbation, and give rise to an ' attack.' And it is indeed easier to account for the access than for the remissions which occur in all affections. To whatever cause, they may be due, we are not to overlook the opportunity which they offer in practice for an attempt, which is almost always successful, to assist in the re- parative processes by improving the quality of the blood, regulating the secretions, and by judicious and abundant food, and occasionally by stimulants, by free exposure to the open air, and by the moral help of removal and change of air and of scene, to second the curative natural efforts of the system. These are the golden moments, and if from some mistaken theory we overlook them, or through fears of inflammation should persist in a low regimen, and the use of de- pressing drugs, we are counteracting the attempts to rebuild and repair, towards which the vital system is labouring with all its powers. It may further be remarked of these remissions that Local and it is almost invariably seen that local mischief and con- tSf ^^" stitutional disorder subside simultaneously. The rapid symptoms SllDSlClG formation of a cavity in the lung, and the expectoration together. of the softened tubercle, are accompanied by the most As in violent constitutional disturbance, and by hectic, which thriuug. threatens the existence of the patient ; yet, in numerous instances, the local irritation ceases. The cavity remains, but almost ceases to secrete ; its walls approximate, and in certain instances close up, while, pari jjassit with these structural improvements the patient regains health and 26 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. III. The inter- mission period. Resistance of the nervous system. vigour. The condition of such a person is highly de- monstrative of the fact, that nature can tolerate certain lesions of organic structure, and that the general health may continue, under such circumstances, but very slightly impaired. It is obviously on the duration of this pause in active symptoms, and cessation of the spread of local mischief, that the length of the patient's life depends ; and the prognosis must be dehvered mainly from the evidence which the system offers as to its powers of resistance during these periods. Weakened and reduced, but not exhausted, by the fever and wasting accompanying the early development of organic disease, a cessation of activity in the morbid processes leaves the patient at a standard much below that of health. He is living, in point of nervous, cir- culating, and respiratory functions, at a lower level. The great industrial centres of the animal economy have received a shock ; and, being less abundantly supphed with nutritive material, are not only manufacturing less tissue, but the actions sustained are done with less ex- penditure of power, and the system goes at half, or it may be, two thirds speed. There is less blood circu- lated, less blood aerified, less carbon consumed, and many of the secretions are diminished in quantity. The muscular system has been reduced, as is an army which has sustained a defeat. With less waste of tissue daily undergone, there is less production of heat and less toleration of cold. Pallor of skin and of tongue evidence the diminished supply of red corpuscles, and anaemia, with all its characters, is witnessed in varying degrees. The most important portion of the system to notice is the nervous. It is not the earhest to feel and record mischief in very chronic affections, and perhaps it is the last to yield ; but on its vigour depends the duration of the case. Its sensibility and power as a regulator of EESISTANCE OF THE SYSTEM. 27 other vital actions, and its very intimate connection chap. with the integrity of those functions of the body which . ^^^- . are controlled by the moral and intellectual, are much concerned in the prolongation of chronic disease. In as far as mental configuration is modified by nervous power, the latter becomes a powerful resister of morbid actions. The vigorous will maintaining control over the body is seen in our most prolonged cases, and seems to be the inseparable condition of great vitality opposing bodily weakness. The observation will, doubtless, re- call to many readers the noble intellects and high generous spirits, self-denying and thoughtless to reck- lessness of physical suffering, whom we have, with wonder and admu-ation, seen compelling an emaciated and almost useless body to do its daily work, till death has at last appeared to come more by a relaxation of the will to live than by a victory of the physical body over the living soul. ' Not until disease is shaped and realised into something which can be seen or heard or touched, and can be called by a name, is it wont to engage the nervous- system perilously,' says Latham. And so to the end ; it is the last element of vitahty in the field of struggle and the last to yield. ' The nervous system has the heart for its gnomon or Heart's dial of the clock,' says the same author ; and extreme fndeT of ^ rapidity of the heart's action, while it has a most grave nervous . . ,. . , ° power. import m acute disease, is also an accurate measure of the failure of nervous power in chronic affections. The acceleration of the pulse during a febrile attack is not here alluded to ; but a uniform high range of pulse, deficient in force, which, although it vary in number, is never below a high rate. It is rarely under 100, and may run up from this to 140, or till it is impossible to be reckoned ; and there is no more disastrous symptom. In various chronic affections the muscular walls of the heart are thinned and softened ; but, unless this has taken place, the action of the heart in these remissions 28 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CFAP. III. Secretions. Acute attacks on other organs. Increase of weiglit from im- proved nutrition. of symptoms falls to a more healthy average, and the pulse acquires fulness. As a rule, the secretions are diminished during inter- missions in chronic diseases. The uterine secretion is a marked instance of this, and the catamenia are often absent, and almost always lessened in amount. May not this subserve the purpose of preventing undue waste of blood ? In connection with this it may be remarked, that generative activity will often remain till the very close of chronic organic affections ; and the fact is rather opposed to the above statement ; but this function is so influenced by various vital and emotional conditions, as to justify our considering it exceptional. Its over-activity in such cases is certainly not conducive to prolongation. The occasional occurrence of acute attacks on other organs than that which has given a character to the ill- ness, is generally witnessed in this period of remission, as, in the course of a prolonged phthisis in a gouty sub- ject, the gouty fit will not commonly occur while the patient is undergoing hectic from softening tubercle, but comes on in the intermission period of which we are speaking. So of skin diseases, rheumatism, or any of the complications which may be called of blood origin. The purely secondary disorders, which stand in the relation which intestinal ulceration holds to tubercle in the lunar, are not here alluded to. They occur in any period of the illness, and occasionally, but not commonly, alter- nate with the primary affection. Their advent may be regarded as an extension of disease, and breaks up the intermission. The nutritive powers of the system, fortified by the improved quality of blood and by recruited nervous power, soon evidence the vital tendency to repair ; and increase of weight almost invariably occurs, unless the system be so weakened that it cannot rise beyond a certain level. In 3,872 cases of phthisis examined RESISTANCE OF THE SYSTEM. 2^ during a three months' stay in the Hospital for Con- chap. sumption {2ncl Med. Repo)% 1863), it was found that . ^^^' . 2,487 had an increase of weight of from 5 to 15 lbs., while 1,385 had lost weight to a similar amount, the excess in number of those who gained over those who lost being 1,102. Pauses in local mischief and in febrile or other con- The sys- stitutional disturbance are not, however, invariably ac- lowpar? companied by increase in nutritive power and repair of the tissues. Some of our cases are standing still, and, in spite of every effort to take advantage of the cessation of activity in the disease, the system seems to remain simply tolerant of the morbid condition, and no more. Like a vessel ' lying-to ' at sea in a light wind, no progress is made and none is lost, except in that inevitable drifting on the sea of time. We have often in practice had occasion to notice such cases, in which medical treatment (as tonics) seems thrown away, and we are compelled to regard our work with but little complacency. JSTevertheiess these instances (which are fortunately rare) are not without encouragement, when we remember what might be, and the student of chronic disease has much to learn from them. They illustrate the possibility of maintaining an exact balance between waste and production; and, if no extra de- mand be made on the system while in this condition, it may preserve such balance for an indefinite period. On the other hand, any sudden call for an outlay of a slight strength may prove fatal. A journey, an unusual emo- auce^fatai. tion, the removal from a hospital, often extinguishes the flicker of hfe.* * In tlie Hospital for Consumption this lias often been observed. One of my patients having taken it into his head to leave, expired while stooping to put on his stockings. Another died while on his way to the gate. A poor fellow whose life had been singularly prolonged, but who was by no means in an advanced stage of emaciation, died a few days after his removal to his home, although he had been able to walk about the wards and grounds before leaving, and was sufficiently provided with all comforts and even luxuries in his lodging. 30 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP, III. Causes on which it depends. Eifects of age on duration. Period of growth. The duration of the intermission period is of course uncertain, and its extension or termination is due to many causes. While it lasts, it is only a toleration of disease ; when it terminates, it is either by a renewal or by an extension of the morbid processes. Its duration depends on a variety of causes, which concurrently promote the vitahty of the system. An originally good constitution, the non-inheritance of special disease, the direct inheritance of longevity (as when parents and grandparents have lived to a great age) ; the nature, and of course the limited extent, of local disease ; the integrity of other organs, and of the sum of vital actions represented in digestion ; the absence of fever ; a vigorous nervous system, as indicated by a uniformly quiet pulse ; a tranquil and regulated but powerful will may be enumerated among the causes which tend to prolong the duration of the intermission in chronic organic disease. To these must be added considera- tions derived from age. Should the patient be at the period of growth, the peril is greater, the chances of duration are less. Organic changes then advance with such rapidity, that the diseased process marches ^:>(2r^ passu with the nutrition of the body. The blood is charged with material for the production and sustain- ment of new tissues, and the organic elements destined for growth are readily perverted into morbid matter. The essence of some chemical formations is here ; and, without affirming that their origin is invariably con- nected with altered nutrition, it may be safely held tliat to an imperfectly formed or deficiently organised plasma we can trace the elements of tubercle and of other morbid deposits of low vitality. The period of growth then, and of rapid renewal of tissues, is opposed to the long duration of a tolerance of already existing organic disease. The tubercle, or the cancer, or the morbid growth, is assailed by an abounding circulation and an active nervous power ; and its removal or ab- RESISTANCE OF THE SYSTEM. 31 sorption is attempted by increased vascular action and chap. efforts in their nature inflammatory. And these efforts , ^: , partake of the character of those natural processes for the nutrition and repair of the body which are inherent to the age of growth. It is true that certain instances of great toleration of disease are found at this period, and it is conceivable that the very processes which are destructive in some may, by their excessive activity, overpower the local mischief in others, and cause the absorption of the offending substance. Instances of this will be given, but meanwhile the general fact must be sustained, that the duration of disease, and the tolerance manifested by the system in these intermis- sions now under consideration, are less at the period of growth, and much increased at an age when the body has completed its natural processes of increase, and has only to furnish material for the repair of daily loss. Very chronic affections are found as a rule in indi- Very viduals over 40 years of age, and age must enter as c^eTse a distinct element into all our calculations regarding found in the prolongation of any chronic disease, or the duration over 40, of the pauses between its attacks which we have been noticing. As a whole, then, it may be stated that everything which tends to promote slowness in organic changes, healthy or diseased, is also conducive to pro- longation of the intermissions or pauses which occur in the progress of chronic diseases of organs. The intermission ends either by a renewal and ex- intermis- tension of the original morbid process, or by the ad- ^^°"*^'^'^- dition of secondary attacks on other parts, or by both of these concurrently. The more common of these modes is the first. From a certain accumulation of morbid matter in the blood, due to the original causes of contamination, and to the detritus of the material already deposited, or from some local congestion deter- mining a degree of inflammatory activity in the part already affected, the local disease becomes again a 32 ELEMENTS OF PROGNOSIS IN CONSUMPTION". CHAP. III. Secondary- disorders. Secondary sympa- thetic disorders. The longer delayed the greater the dura- tion. source of irritation to the system, or the blood again elaborates unhealthy material in the same locahties as formerly. In cases where the morbid matter has an inherent tendency to soften and break up (as in yellow tubercle), the resumption of activity in the symptoms is often due to a commencement of this process, or a new and extended deposition may take place. The secondary organic disorders are those wliich clearly arise as sequences to the primary structural af- fection. They may be due to the same cause, and only indicate a real extension of the morbid influence, as in the tubercular deposits in the peritoneum, or mucous glands of the intestine, in phthisis ; or they may occur from the intimate connection of the functions of two distinct organs, allied by their circulation and nutrition, as in engorgement of the liver and kidneys from val- vular disease of the heart. In certain rare cases con- tiguity of organs seems to predispose them to a simple extension of morbid action from one to the other ; as we have seen in pleural inflammation of the right side from chronic hepatic disease. Secondary sympathetic diseases of structure, the two organs affected being remote from each other, must be very rare, if at all possible. Such cases as appear to belong to this class are invariably due to the same primary cause, and that probably of blood origin. The order in which secondary diseases occur is de- termined by the operation of many causes, some of which are peculiar to the disintegration of the organ primarily affected, and others to the yielding of the system to the morbid action. As a rule, it may be stated that the longer the development of secondary disease is delayed the greater will be the ultimate prolongation of the case, and the more remote the danger. This principle is applicable to secondary dis- ease in all the forms mentioned. As wiU be seen, our most prolonged cases of phthisis are those m wliich RESISTAXCE OF THE SYSTEM. 33 the organic complications are absent till the very last ; chap. while on the other hand the most rapid form of con- . ^^}- . sumption is that where many organs are engaged sinuil- taneously in the morbid action, and where the (so called) secondary attacks, as diarrhoea and the laryn- geal complication, assume a formidable importance almost at the beginning of the affection. Secondary diseases of organs may or may not be May occur attended by an increase in the local extent of the ^ease"o"f primary affection. When they are so, the danger is primary greatly multiplied. They may also be coincident with ^^°^ ^^ ' an advance in the stage of the primary local disease, the extent remaining unaltered. This is the more common of the two conditions, and the least perilous for the moment, although ultimately of great import- ance as an element for calculating the duration of a given case. The union of the two states, extension of structural disease and a downward step in the con- dition of that already existing, coincident with any secondary attack on a distant organ, forms the worst group of symptoms which can occur. In certain cases a secondary disease will leave the Or aiter- primary unaffected, or even relieved, the two appearino- ^atewith to alternate. Although theoretically more favourable l^s . exudation of the latter is often accompanied by con- gestion of the neighbouring tissues, we must assign some other cause for its production. To those who favour the theory of the epithelial Bronchitis origin of tubercle, it may appear possible that bronchitis ^ «"Pposed may be an originating cause, or, at least, that a sub- inflammatory state of the mucous membrane of the smaller tubes may cause such structural alterations as to give rise to the deposit in the lung. With the theory in question we are not now deahng, but the experience of practice forbids this mode of accounting for phthisis. Consumption is not found to be fairly traceable to irri- tation of the bronchial membrane. Ordinary bronchitis is not its antecedent; and cough, without preceding catarrh, is its common history. Louis says, 'a very small number of patients referred, with a fair amount of precision, the occurrence of first symptoms of cold to 24, 36, 48 hours after the action of the cause to which they assigned it.' Cough also may be entirely absent in the premonitory and in the first stage of phthisis, and in latent cases may be unknown to the patient for months and even years. The peculiar habit Habit of of body which is prone to attacks of bronchitis is by bronchitis no means the phthisical, and that constitution which ^"'^ ^°?- 1 . -T . (, -, sumption tends to the induction or emphysema of the lung (and different, closely allied to bronchitis) seems almost antagonistic to tubercle. The well-known shapes of the chest in these diseases, which, although not universal, are still typical and characteristic, and therefore highly distinctive, are opposed in almost all their measurements and aspects. The long and flat chest of tubercle stands in contrast to the rounded short build of bronchitis. Bronchitis is often superadded to phthisis, and a minor degree of it is always present in the active form of the disease; but these complications are due to the local irritation 4B ELEMENTS OP PROGNOSIS IN CONSUMPTION. in the bronchial tubes from tubercle, and not to a sus- ceptibility to inflammatory action peculiar to the phthisi- The con- ^al. Finally, the consumptive patient is not more hable sumptive ^\^^^ othcrs to take cold, and bears exposure to the air, not pecu- 1T-1 • 111- liarly cvcn whcn coid. With sometnnes remarkable impunity. tScoid. ^^ epidemics of influenza, which w^e know to attack those with a pecuharly sensitive bronchial membrane, the phthisical so often escape as to lead to the supposi- tion that they have acquired an immunity from such attacks. The popular idea opposes tliis, but the fear of ' cold catching ' is not verified by observation of the consumptive in numbers. The delicate girl, who has been wasting for months without cough, arrives at the period when softening occurs, or the bronchial membrane is irritated, and is said to have taken cold ; but this is not strictly the case, A common catarrh is easily thrown ofi" by the consumptive, and an acute bronchitis is a rare occurrence. Fever and wasting are the early symptoms of phthisis, and not cough of a catarrhal character. Such are some of the considera- tions which seem to contradict the theory that tubercle is due to bronchitis. Authorities are also pretty well agreed upon this point.* Phthisis That phthisis is not a merely local disease is abun- a klj^'^'^^^ dantly proved by the varied phenomena accompanying disease. its development and history. That it is not a merely lung disease is equally obvious. The nature of its earliest symptoms, which point to a deeply seated con- stitutional disturbance, has been noticed ; it remains Its con- to adduce evidence from its general characters. Its currence • ti^ ^ , ,^ indifFe- concurrence m dmerent organs at the same time is ^™*^ itself a manifestation of a producino; cause due to organs. i o systemic disorder. That the lung only exhibits a higher capacity for its development is a well-known pathological law ; and the axiom of Louis, that after • * Rokitanskyj Louis, Ed. Syd. p. 156 5 Cotton, ed. 1852. PHTHISIS A DISEASE OF THE SYSTEM. 49 tlie ao-e of fifteen the existence of tubercles in tlie lim2;s chap. . . . IV forms a necessary condition to their development else- • <^ — - where, is evidence of the constitutional origin of the j^^^^ disease. The post-mortem appearances in fatal cases Post-mor- exhibit the multiform action of this destructive agent.* ^'g^Jg)^" No organ escapes, and the patient dies not with one local affection, but with many. The constitutional symptoms exhibit a special cha- Systemic racter, and are quite distinct from the disorder accom- pecidiaT panying a pure inflammation of the lung. The early tophthi subfebrile condition, emaciation out of all proportion to the local disease, hectic of severity often present before softening, the remission occurring in its course, constitute a group of symptoms characteristic and suffi- cient in many cases to indicate the affection long before physical signs can aid us. The predisposing causes of the disease may also be here mentioned, and will here- ISIS. }■ * Morbid conditions of other organs coexistent witli tubercle in the lungs : — Of cases. Pleura inflammation false membranes effusion Trachea ulcerations ....... -^ Larynx epiglottis ....... -J Pericardial effusion, heart softened . . . . -j^ Stomach distended — softened , . . . . J^ — (perfectly healthy, i) Intestine, small, ulcerated ...... |- — large, — . . nearly the same Lymphatic glands, tubercular ..... ^ Liver fatty ^ Spleen softened \ ^ Kidneys, tubercles J * ° ** Peritoneum effusion ....... ^ — Louis, Ed., Sydenham. Inflammation, lungs and pleura ..... ^'o Ulcer larynx, epiglottis i Pericardial effusion -J^ Heart, diseased (Andral) -I Peritoneal efiiision ....... ^ Stomach soimd only in ^ — Laennec. E 50 ELEMENTS OP PKOGNOSIS IN CONSUMPTION. CHAP. IV. Predispos- ing causes ofPhthisis. Fixed con- clusions on the na- ture of Phthisis essential to prog- nosis. after be dwelt upon more in detail. An examination of many thousand cases sliows that in-door and seden- tary pursuits are attended by a marked proclivity to consumption, and this not only from interference with the respiratory function, but from originating a defi- ciency in the great processes of nutrition and sangui- fication. Whatever depresses vital power — exhausting passions, grief, long-continued drains on the system, bad or insufficient food, the close air of rooms — induces the cachexia, which is in itself a systemic disorder. In treating of prognosis it seems highly essential to start with fixed conclusions and certain knowledge of the nature of the affection. If we are to regard phthisis as a merely local disease, giving rise, in its progress, to systemic disturbance, our measure of the danger must be gathered from the amount and the stage of disease in the lung. From this course haye arisen and daily continue to arise innumerable mistakes, prejudicial to the character of the medical attendant, and injurious to the best interests of the patient. How common it is to say of a case, ' there is a cavity in the lung,' and to condemn it on the false idea that all such cases are short-hved ; and with what surprise we have seen even eminent pathologists regard a raUy of the general health under such circumstances. There are many such cases, and the practical physician is bound to remember them. The extent or stage of local mischief is no measure per se of the danger of the patient, and until the cases hitherto regarded as merely exceptional be included in the ordinary history of the disease, and studied as part of its customary phenomena-, we may have diag- nostic accuracy, but our powers of forming a correct prognosis will be small. In this section we have there- fore not been dealing with abstract pathological ques- tions, but with facts of most practical bearing and essential to the establishment of a more certain mode of prognosis. 1 1 . . 1 i ^ s, I 1 y^rm ists. "s ! 1 j — 1 --. ^ Wavy vt ''fvrsl^S t:af0e. •^ ■ j> vspirayto;fy SounfiL. ,-• ' L. Chrowu •Am^nck SMa q0 iJ^T^^^jSMd-^ f/. Chroxm. Jajfie/ r-^ V . y x' V^ / ^ \ 1 \ r^ 1 Aafy ovt \Tr4'A \ X" /^ Ec Wi^di Wn.9h>.'\ j ^ . 1_ _ "^ -V. Digibii(. Ckibii ytn, ^ ^ Fh/MjSiJi With mDrfrum o/nJuii.TfiJVJfnA hxm.n mf f^ > . . N s ToleratiR d'J^ifil^ 1 V s, \ 1 ^ ^ PhtMsis wtMv susbeind edy Cdtam-enui. y \:\ \\i\ . . 1 1 / Pz^nAmy. la^fahm n^l^bhi ^is^ 1 i , 1 \ Qriaiti^ pw/i arMtf/ it^nr ^-e. Vrf. . / IftGRftM lbid/_ / Uv \, JRc Ehih^^sj^^ . / r 7 \ ■■ Jrepresentincthe\ 1 \ [ ' I .^ /relative duration! BnayM bis^emphysejisML Fhrh^ 's£sl. 1 ■-«J •^ OFTHE VARIETIES OF PHTHISIS AND ITS l\ COMBINATIONS/ 1 ^ 0" Ph ys:u^ou '/^ Signs e^Jhe'^ai woft^ '^^ZIT '■O- ^ > r \ WITH OTH ER / n iitdZoL v^A^ r^/^£v-jI ^- 2 - ^ : - f 2 ^ \ > ^ * 3 S 5 ^ - 1 y / ~T~ / \ D^-^^^Sf^O / A -- — \ \ I I IE u. O Z ^/j / \!:^ = o jj^ ^ 1 i : , i 1 1 ■ ^ -- -^ ■ ^ -^ - . ---i - i - ^ / 1 - 1 1 " — 1- N L "~~ — ' ^^ \ ■"- V i i ' . *■ ^ , 1 1 i •v . \ \ i --^ 1 j \ - \ -- ^^ - --I 1 ' ' ■ i - 1 ■^ s ^ -- i § ■S '1' ^ fs j ■^ 1 s' ' ;^ 1 1 h$\ "^ """'"1 . f ^ ^ K ^: 1 ^. .1} ' i 'to' S' -IS' ^ ^ § i » ■'^' N ™; '.t^ 5>' .>■>>> '^ ^ -K ,^ "Si S , '\ Ijii"?^ ^^^ ^H -^ .'Jl^il ^■^ ■ 1 i ■S i i^ ^^g^^l^ .n^S:$-^.l -^.c-l^^'-^'v ' 1 : ■g 1^1 s^^^sH .^i^' ^$^^..$ fcs ^.>> 1 .: 7^~^j"^ j^tii 1.':^ '^: i^'-^-^ j-s -*^ - J.^^ J ^ i ^'"*^":^^^^ "^ I'^^l "^t rr:"f>-" f " ^^ 1 > .;: -^ ^-^ ~^ - : i \ ' \ ' !^' 1 ^^' s 1 J -i? '^ - -"? ^ ■- -v - ^5 •< ^ i 5 ^ ^ '^ '^ § 'i li ' ■ "^ -^ '^ 5> ^ S -5: fe .^ -^ ^ -5 ^ ^' -c ^ ■ ^" ^' ^ ^ '^ S ^ ^ ^ 1 ^ Q^'«n^^^d;^R;^$S;^^Q:;,g,i£;^^;^^^^;'^lt^F^c^,^^-r5 ' | [ DUEATION OF PHTHISIS. 51 CHAPTEE V. DURATION OF PHTHISIS. The basis of all prognostic calculations regarding chap. cases of consumption, must be founded on a knowledge ■ '—-^ of the actual average duration of the disease. And yet fomfdeTon there is no knowledge so difficult to obtain, and there vestigation, to be referable to several heads. The different varieties of the disease itself, and its modifications by the various agents referred to in this work, stand at the head of these. So long as phthisis continues to be viewed as a single affection of invariable progress and termination, will contradictory opinions be offered as to its average duration. It is only by study- ing its natural divisions and assigning to each its separate and appropriate place, that we can hope to arrive at an accurate estimate of its length. Were a calculation of the duration of fevers to be made from records includ- ing the exanthemata as well as typhoid, the intermit- tents and remittents, it is obvious that no records of accuracy or value for practical purposes could be de- duced from such a method. We should reject such a classification, as unscientific and useless. Tuberculosis possesses, in the single fact of a certain amount of uni- formity of the morbid material, a basis which includes all its subdivisions, but such wide deviations occur m its progress and results, that no average which should be E 2 '6^ ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP, of tlie slightest use in practice could be derived from * — r — ' the most careful records of all the instances of the disease which ever occurred under observation, were they viewed as a single affection. It is plain, that from so loose an opinion as Portal's, ' that the disease lasts from eleven days to forty years,' we can gather no knowledge available for our daily work of estimating the clanger of individual cases. The mental habit, too prevalent in the profession, of regarding phthisis as a uniform, destructive, and irremediable disease, stands therefore in the way of obtaining the very kind of informa- tion likely to advance our knowledge of it, and of estimating the true duration of its several varieties. Difficulties Further difficulties will be found in the manner of ob- taining information from the patients themselves, in the obscurity of the earliest symptoms of the disease, in the position of the different observers as regards locahty, in the form of the affection commonly prevalent under their notice, as well as in the necessary hmit to the experience of most medical men. First, the answer of the patient to the question, ' Hoiu long ill ? ' will almost invariably be given, even by the most truthful, with reference to the existence of a group of symptoms which he fancies to be the most important. Thus, if cough have existed for six months with severity, or if the individual have been prevented from working for the same period by increasing weakness, the answer will be ' six months,' although a year or two previously he may have had liEemoptysis, attacks of sweating, or some grave alteration of health indicating the be- ginning of the tubercular affection. A very careful cross-examination of the patient is absolutely necessary if the actual commencement of his disease is to be searched for. In hospital cases, especially if the first answer given be noted down, we are almost certain to record an error. Again, there are very few patients able to give in a single reply a correct description of m ascer- taining du ration of phthisis. The patient, DURATION OP PHTHISIS. 53 the earliest symptoms and first beginnings of a chronic chap. disease. A skilled questioner can alone obtain accurate - _ ^' - information of the kind desired, and even among pro- fessional men we have occasionally to witness the ac- ceptance of statements, as to the commencement of the disease, which are manifestly incorrect. Another source of error arises out of the very Latency a nature of the case. A disease which has remained — r — ' character have been selected, and such only as pre- sented the physical signs of consumption retained. All spurious or doubtful cases have been rejected, and every affection but phthisis sifted out. About three thousand five hundred thus selected for analysis Avere thrown into groups, according to their pecuhar features, every case-paper being separately studied, margined, and classified, and the duration at the period of leaving off attendance at the Hospital recorded. It became evident in this slow and laborious task that the disease in its largest numbers classified itself, and the varieties described are therefore not artificially or theoretically arranged, but are only the reflection of facts. When characters so prominent as to disclose many points of similarity were evident, the cases naturally grouped themselves, and it only became necessary to state the leading features at the head of each class, in order to perceive how frequently resem- blance occurred. The larger characters are of course alluded to, and so far and no ferther is a classification advisable or even possible. It is understood that no two cases of phthisis, nor indeed of any other disease, are precisely alike, but certain broad features are stamped on every instance of disorder suflicient to show that they are akin to others with similar manifes- tations. And this proves true, not only of the history of the affection, but very markedly of its character. Figures As rcspccts the absolute duration of the disease, f^^pToxi- either taken as a whole, or in its several varieties, the mative. figures givcu are approximative, but do not represent the real length of the cases, excepting in the instances where death occurred, which are few in number com- pared with the total. When, therefore, the dm-ation of a class is stated, it is to be understood that the figures given represent merely the length of time for which the case had lasted^ from the earliest sym]jtom up to the latest DURATION OP PHTHISIS. G7 period while under observation, tlie actual duration chap. being, of course, very much longer than this. In all ^ — - cases where the replies given were unsatisfactory or vague, either from evident inaccuracy on the part of the patient or his friends, or from want of memory of the events occurring at the commencement of the disease, the period is marked indefinite, and in calcu- lating the averages from these figures the indefinites are in certain instances spread over the whole of the cases, but it is stated where this has been done. By these means and the help of a skilled mathema- tician,* well practised in calculations as apphed to Hfe insurance, we are able to present the Tables appended. In arranging the classes it was necessary to assume a certain standard, to be called ' ordinary phthisis,' in which, of course, a large number of our cases is to be found, and it was decided that this name should have reference to duration, and hiclude all cases Avhich pre- sented the ordinary features of phthisis and had lasted eighteen months. They would thus stand between the acute or rapid form of the disease, and the more chronic or prolonged. The other classes were formed as stated after a natural arrangement from possessing characters common to all in the same group. The next great groups to ordinary phthisis are, Natural ' chronic first stage,' ' chronic second stage,' ' chronic third stage,' and subchvisions of these will be found as ' diffused tubercle ' and ' tolerated cavity,' which possessed sufficient interest to render their separate study advisable. The large class of ' strumous phthisis,' includes all who manifested the scrofulous diathesis in a marked degree. The other divisions explain them- selves. The locahsation of tubercle, the occurrence of profiise hasmoptysis, the complications with asthma * My best acknowledgments are due to J. R. Campbell, Esq., M.A., of tbe 'Queen Insurance Company,' for the manner in wbich be bas executed tbis task, f2 groups. V. 68 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, and disease of the heart, the influence of the rheuma- tic diathesis, and the origin in acute diseases, with the influence of pregnancy and lactation, appeared to de- serve separate consideration in detail and a distinct column in the Table. Some other classes there are rather scantily illustrated, and therefore of less value, but it was thought better to include them in our con- sideration of the disease. Amongst them will be found the curious symptom of digital clubbing, about which some interesting details will be found elsewhere. As a sign of chronicity in phthisis it possesses undoubted value. Viewing the disease as a whole, in which are in- cluded all its varieties, it must be evident that the opinions of the older authorities quoted on the charac- ter to be assigned to it, were incorrect. Consumption lasts much longer than has been stated by pathologists, or than is believed by the public. Many cases at which we are inclined to smile, which were given up by doctors, but outlived the prediction to arrive at old age, were undoubted recoveries from phthisis. Many more were instances of an early invasion of the disease with subsidence of the symptoms, and long tolerance of the deposit. When these cases are con- sidered, added to the known instances occurring in the practice of all of us of tubercle in every stage, including cavity, being resisted and tolerated by persons other- Yv'ise healthy for eight, ten, and even twenty years, — we are compelled to acknowledge the undoubted ten- dency to extreme chronicity which this affection often manifests. It will be remarked how such cautious and skilled observers as Clark and Wilhams have ex- tended the nominal period of duration to four years, the latter authority attributing the supposed extension of the term of the disease to the use of cod-hver oil. We go a step further, and maintain that owing to a greater accuracy of diagnosis the revelation of a DUEATION OF PHTHISIS. 69 lengthened duration of consumption formerly sus- chap. pected but now certified has taken place, and that v„3— _ of this fact we can be as secure as of any other obser- vation on the natural history of disease. We beheve also that the term of the disease has been extended not only by the use of oil but by the sensible, non- specific, and supporting treatment which modern prac- titioners follow, and by the omission of the lower- ing, antiphlogistic and depletory measures formerly so common. Especially, blood-letting has been given up, and the pleuritic pains of phthisis, and its fre- quently-recurring hsemoptysis, are no longer bled for. In the face of such facts as we are able to record, we cannot wholly agree with Sir J. Clark that the greater means of the wealthy, and the possibihty of obtaining all comforts and luxuries, have been the chief means of addino; to the lenofth of life of the phthisical. Some of our most prolonged cases have been among the out-patients of a London hospital ; among mechanics, following unhealthy trades, and with but scanty supply of wholesome food, eaten in ill- ventilated and dusty chambers, without possibility of obtaining change of air, or even enough of fresh air ! It is doubtless true, that these deprivations are perni- cious agents, and that they shorten hfe in the phthisical and the non-phthisical ; but we urge that if, in spite of such obstacles to resistance or recovery, consumption is so frequently seen in a prolonged form, the period of its duration as a whole, could it correctly be ascer- tained in all classes, poor and rich, must be far higher than even the highest estimate which has been offered by the boldest or most, hopeful investigation. It will be seen from the Table that the average duration lohile under observation, of all the cases taken together, was two years, six months, and three-fifths nearly ; but this represents only a part of the period of the affection ; and in it are included cases of the most acute and rapid 70 ELEMENTS OF TROGNOSIS IN CONSUMPTIOxV. form, as well as those which had become chronic. How much longer did these patients live ? (deducting the 129 who died while under treatment) is our ques- tion. But who shall reply to it ? Figures can do no more, and the results of many years' study of such cases, with unusual opportunities, is so far unsatisfactory that we can only prove that, out of 3,566 cases only 129 had died at the end of two years and something over six months. Yet still, out of these recorded observations, the fact is evident that, even while the average dura- tion, during the time they were under observation, is so high, a much longer term must be assigned to the greater number of those who were surviving when the last note was recorded. On this point it is interesting to note the ' state on leaving hospital ; ' and most care- ful calculations have been made to elucidate it. On the whole, the condition of these patients has been favourable to the expectation of life for a considerable term ; and although it would be impossible to calculate such expectation with accuracy, or from figures to derive a conclusion capable of being applied to indivi- dual cases of phthisis, yet it is easy to see that the whole average duration of the disease must be raised beyond even the period assigned to it by the observers referred to. But the calculations given, referring to the duration of phthisis, taken in all its forms, have Httle practical value. It is when we come to study the relative dura- tion of the different varieties of the tubercular disease, that something applicable to the exigencies of our daily practice arises. No one could with reason assign a duration to any given case from a perfect knowledge of the most perfect statistics on phthisis, taken as a whole, ever put together ; but with the assured infor- mation that certain varieties of disease tend to great prolongation — say a single cavity in the right lung — in a male aged forty and without hereditary taint ; and DUKATION OF PHTHISIS. 71 with tliis knowledge, strengthened by the history of chap. numbers of instances of a similar kind, we may safely ^ r - offer a prognosis, based on rational facts, that such a case may last not only four, but twice four years. Judging from the older views on the subject, such a patient would be in the last stage of consumption ; but while assigning it a place in the third stage, we may prognosticate for it a duration far beyond that of many individuals who are in the stage of softening. The elements of chronicity mean only the conditions under which a given amount of estabhshed disease in the lung may be tolerated ; and in the description of the several classes, an endeavour has been made to assign to each the features by which they are re- cognisable, and to estabhsh on rational grounds an estimate of their possible duration. Of course any empirical assertion in prognosis is to be avoided ; and it is not pretended that these calculations can enable us to state with certainty the duration of a single case ; yet the knowledge that such a course of the disease in an individual is not only possible but probable, because certain conditions prevail, is a reasonable apphcation of science to practice, and will be found to secure credit to the physician, and, by calming the fears of the patient in chronic cases, to add the important element of hope to his other favourable conditions. And the same may be asserted of the rapid form of phthisis, where a prognosis truthfully delivered may save many cruel but well-intentioned efforts on the part of friends, and permit of the patient contmuing to be surrounded by home comforts instead of being removed to a foreign country. With a view to throw additional light on tlie con- ditions which favour chronicity, a Table has been con- structed, which shows in a tabular form some of the leading facts regarding 1,200 cases, which have been divided into classes of 300 each, according to their 72 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, duration for ' six months^' ' one year^ ' one to two — ^ — ' years,' and ^four years and over.' These cases were not selected, but taken just as they occurred in going over the hospital note-papers. The influence of age, sex, predisposition, stage of the disease, the being confined to one or extending to both hmgs, and of the existence of hectic, hgemoptysis, of laryngeal, and of gastric disorder, are seen in numbers, and convey a certain amount of information, which is given more in detail in the chapters on each subdivision. GENERAL ANALYSIS OF CASES OF DIFFERING DURATION. (1200 in all. 300 eases of each class examined.') Six One One to Over four months' year's two \ ears' years' Totals diuration duration duration duration Males 202 172 185 170 729 Females .... 98 128 115 130 471 Age under 20 76 76 52 44 248 „ between 20 and 30 126 117 121 115 479 „ „ 30 and 40 68 73 89 87 317 „ over 40 . 30 34 38 54 156 1st stage of disease (deposit) . 116 122 73 84 395 2nd „ „ (softening) 98 95 98 99 390 3rd „ „ (cavity) . 86 83 129 117 415 Both lungs affected 138 131 159 161 589 One lung affected . 162 169 141 139 611 Hsemoptysis had occurred in 140 170 185 206 701 No liEemoptysis 160 130 115 94 499 Hereditary predisposition in . 96 95 87 84 362 Diarrhoea had occurred in 50 59 76 54 239 No diarrhcea .... 250 241 224 246 961 Larynx affected in 27 32 26 19 104 „ not affected in . 273 268 274 281 1096 Hectic sweatings now present in 156 184 157 140 637 „ „ formerly „ 60 39 49 60 198 Not remembered to have existed 94 77 94 100 365 When first examined found to be losing flesh and strength 262 267 238 256 1023 „ stationary or gaining . 38 33 62 44 177 Vomiting a symptom in 37 28 47 36 148 Were emaciated to the 1st degree 158 142 126 135 561 2nd „ 127 156 153 127 563 3rd „ 15 2 21 38 76 The leading features of the above Table may be stated in a condensed form. DURATION OF PHTHISIS. 73 Sex. — In all the periods of duration, GO -75 per cent. chap. were males, and 39*25 per cent, females. It is else- - "" ; where stated that phthisis tends more to extreme pro- longation in males tlian m females; but in this Table the disproportion does not much increase in the cases of longest duration ; instances of extreme chronicity not being included in it. Age. — The age of the greatest prevalence of con- sumption in all its forms is from 20 to 30 ; next to which is the decade between 30 and 40 ; then the period under 20 -, and the least of all is that over 40. Eelativelt to Dueation. — The largest number of Under 20. cases under 20 were found in the periods of duration of six months and one year, while the smallest number at this age appears in the four years column. This age is little favourable to chronicity ; 17"74 per cent, only of the whole reached four years of duration. The more rapid and acute forms of phthisis prevail at this early period of life. Between 20 and 30 years of age, which may be called 20 to 30. the great period when consumption is most common and most destructive, the numbers in the different periods of duration are nearly equal. Between 30 and 40 the numbers in the short periods ^^ *° ^*^- decline, while those in the longer increase ; age showing a very decided influence in lengthening the duration of the disease. Over 40, 13 per cent, of all the cases occurred ; 4*5 Over4o. per cent, of them reached a duration over four "years. Stage. — In the 1,200 examined, the largest number stage. ; were found to be in the third stage (415, or more than one-third.) The first stage of the disease was found to exist in ^i^^s*- the greatest numbers in those who had attained one year of duration ; next, in those of six months' duration. After four years, out of the 1,200, 7 per cent, remamed still with evidence of unsoftened deposit in the liuigs. 74 ELEMENTS OF PROGNOSIS IN CONSUMPTIOlY. CHAP. V. Second. Third. One or both lungs. Hsemopty- sis. The numbers in the second stage were equally dif- fused over the four mentioned periods of duration ; and after four years of illness, there were as many found so circumstanced as there were at six months. This shows the frequent occurrence of exceeding slowness in this stage. The third stage was attahied by 7 "IB per cent, m six months. The greatest number of cases of this class was found to have been ill between one and two years, and at the end of four years as many as 117 out of 1,200, or 9 '7 5 per cent, were found with the- signs of cavity. The deductions from the view thus exhibited in large numbers of cases, when analysed, as regards the stage of disease, will amply bear out the views advanced re- garding the slowness of the progress of the greater num- ber of cases of consumption. It will also show that stage ' per se ' is not a measure of the danger of the case, nor of the chances of life for the patient. One or both Lungs. — In a nearly progressive ratio, as the duration increased so did disease extend to the second lung. In 138 cases at six months this result was observed ; yet, out of the 300 who outlived four years, as many as 139 (46'33 per cent.) were found with a single affection only. In the first instance, doubtless a more acute form of the disease had created very extensive local mischief, yet out of 589 who had both lungs affected, the large proportion of 161, or 27 "33 per cent., reached the duration of four years. This'symptom occurred in 701 out of the 1,200 cases, 58-41 per cent. ; but of the 300 who reached the dura- tion of four years, 66*66 per cent, had it ; so that it cannot be considered as denoting in all cases a rapid progress of the disease. It was found in progressive frequency as the duration increased. Diarrhoea. — This symptom had occurred in 19-91 per cent, of all the cases. In those which had attained the duration of four years, 246 out of 300, or 82 per DURATION OP PHTHISIS. tO cent., wore found without it. Its absence is very ini- chap. portant as an element of chronicity. - — >; — - Larynx. — This part of the air-passages was affected in 8-66 per cent, of the whole number of cases ; but of those who attained the duration of four years, only 19 (out of 300), 6-33 per cent., had symptoms of laryngeal irritation. The extension of disease to the organ of voice, although a much less frequent complication than diarrhoea, is a bad prognostic indication. Hereditary Predisposition. — This is taken to imply Hereditary one or more members of the family of the patient. £on^'^-'^°^^' The disease was hereditary in 30-16 per cent, of all the cases, and of those so circumstanced the numbers giving the first two periods of duration, viz. 96 and 95, closely approximate, while a like approximation will be seen to exist between the numbers exhibiting the two latter periods of duration (87 and 84). Emaciation. — The degree of emaciation observed in Emacia- cases of different duration was noted. A slight wasting *^°°' was marked 1 ; a more marked loss of flesh, 2 ; while 3 denoted a very great degree of marasmus. In observ- ing the progress of chronic phthisis, this method proved useful, it being found impossible to weigh any but the more remarkable cases. A large number, as might be expected, were much wasted within the first six months of the attack, but a considerable proportion recovered from this so far as to regain a certain amount of flesh, yet below their former average ; and it is remarkable that after four years' duration of illness, only 127 out of the 300 cases (42*33 per cent.) were wasted to the second, and 38 to tlie third or extreme degree. The inference is, that after the first onset of the disease and its customary reduction of weight, a certain rally is made when the case becomes chronic, although the patient never fully regains flesh. A condition of moderate emaciation seems essential to the Ions; con- tinuance of the tubercular disease. An explanation of this has been offered elsewhere. 76 ELEMENTS OF PROGNOSIS IN CONSUMPTION. Hectic. Vomiting. Relative suscepti- bility to improve- ment by treatment. Hectic— This symptom, marked by the febrile access and sweatings, was found to exist in 53-09 per cent. of the cases examined when they first presented at the hospital, the patients naturally applying for advice during some increase of their S3^mptoms. 16-50 per cent, had previously suffered in this way, while 30-41 per cent, could furnish no account of any distinct attack of hectic. It can scarcely be supposed that the disease had existed in a latent or quiescent form in all of these, and a certain deduction must be made for inaccuracies of memory or description; yet even with this reserve, it is evident that a large number had phthisis in its slow form without any febrile access of marked severity.* Vomiting. — This urgent symptom was present in severity in 12-33 per cent, of all the cases. In those who had already attained one year's duration it was found in the smallest proportion, and most marked in those between one and two years ill; while 12 per cent, had it among those who survived over four ' years. The actual state of the patient was carefully noted in all cases when he presented, and also on leaving, to show the result of treatment. When first examined, 85-25 per cent, were losing flesh and strength, and the greatest susceptibihty to improvement was found in cases which were in the two years' class ; and next to them, in the four year cases. * Louis states that one-fifteenth, of his cases were 'latent,' that is had no cough; but naively adds, that fever was common in the latent period; a fact inconsistent with the English idea of 'latency.' DURATION OP PHTHISIS. 77 sqiuoin UI uopu-mci agujaAy (MooiracoOi-HiOi— icot^t^oocoi-ioco ^lococooic-iiOi— i.-ioi^ — f cb65t-~cbcb>-^cbMcoi^ibiMOOr^r^a>'>iwoococ-i65cbo6iOcOf^ i-lTtlcOCO(MCO0 C3020-*t^O«5lOCO>-lr-(C0':t< lOCO»OC5i— 103 CDi-H(MrHi-lr-<>-li-l >-l rHi-( CO t-H CO CO CO co" D^imjopm uoi^tjjno; 00lOffliCDr-(cO-*l C005CO-*t^C5lO 0000CO>-l(MCOa0COO>a3o co^asos .-ii>.i-H CO t^ coc.^.|-HCOr-( Ico o CO r- CK. c^ i^ CO OS .-H CO o *" 2 "^ COCOCOi-Hi-Hi-H I-H CO CO lea CO 00 ^ CO «= O «5 CO rH CO CO O OS r-H -H 02 CO tJ( CO -* t- (N CO i-H IC r-l CO t- C;, ^.,_H ^rH rH r-l rHCOrH O -^HrH |W5 1-* CX> oS'cOrH COt^^COCO COrHrHOO COCOCOCOOO OOCO t~-0O CO UO o »o CO i-H ^ ^rHi-HO. COrH CO (MCDCOt- rHr-l 05rH rH(M CO co" cOCOCOOCOiO «5 00«3CO COi-H(M»OCDi-H -^CO <3>C0 30 COCOrHCO CO— 1 i-Hi-H CO rH CO o CO ■ lO «5 Thi 1 g 1 O m o H Ordinary Phthisis Chronic 1st stage „ 2nd „ . . . „ 3rd „ . . . Wavy Inspiration Chronic, Diffused Tubercle Tubercle at base of Lung . Strumous Tubercle . Age over 45 . . . • Rapid waste Digital Clubbing M. Cordis : Rheumat. : Phthisis Tolerated cavity Retracted cavity Ctma. Suspended Pregnancy — Lactation Origin in acute disorders . Rapid Phthisis . Bronchitis: emphy. pht. . Fistula : pht. . Syphilis: pht. . G-astric symptoms: pht. . Larynx: pht. Cretaceous expectoration . Profuse Hsemopt. Marked predisposition . .' Injurious occupations . Oil very beneficial Marked cases, all stages . J 78 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. V. The above table reads thus : — Of ' ordmary phthisis ' 690 cases occurred, of which 30 lasted, up to the latest observation, for three months, 82 for six months. &c. &:c., and 98 for indefinite periods. The average duration of each case of this class is 15-22 months, &c. In calculating the averages the ' indefinite periods ' were not considered. It is composed from the cases under my own ob- servation, and the greatest care was taken to ascertain the exact commencement of the disease. The labour of years is here exhibited in a page. In the following tables (B. & C.) the age and diu-ation up to the time of death, in 828 hospital cases, is given ; but the statements as to the earhest symptoms of the dis- ease are taken from the case papers, no unusual pains having been bestowed on the question. On that point they are, therefore, less reliable than the preceding, as the information supplied is the work of many observers more or less competent. Table A. Tcthle of Duration of Disease up to the time of death {sex not stated), in 129 instances noted by the author. S ^ " ,S ,a S S S M § cl a PI a a s a to -pd Dm-ation U o 1 o o o O o ^ ^ ^ o ^ ^ 'i S tb Total r-H •^ •^ CO "^ QO OS 1—1 Both sexes 17 12 18 8 9 6 2 4 2 10 9 4 2 26 129 AVERAGES. Average duration (indefinites not included), 2 years 9 months and a^ths, or 2 years 9 "32 months. Average duration (indefinites divided equally among the respective ages), i. e. 2 to each of the 13 epochs. 2 years 11-81 months. Average duration (indefinites divided proportionately among the cases, according to number), about 2 years 9-28 months. This table being founded on the most careful enquiries, regarding the commencement of the disease, gives a higher average duration than those which follow. DURATION OF PHTHISIS. 79 Table B. Duration of Disease up to time of death in 505 casGP. {Males.) CHAP. V. Age Duration Averages Years J 1 1 6 Months Z & 1 li 2 .^ 3 H 4 5 6 7 8 9 10 Vi 15 20 t-i ^ 3 Under 10 1 1 6 ,, 15 1 1 1 3 1 4 „ 20 20 25 6 9 2 1 2 1 66 1 4 ,1 25 23 23 21 15 3 5 1 1 1 1 94 1 5-49 „ 30 21 33 11 25 6 9 2 1 3 1 112 1 7-71 „ 35 11 30 13 14 3 5 8 3 2 3 92 2 0-58 „ 40 8 19 14 10 2 4 3 1 2 63 1 8-95 „ 45 4 14 9 6 2 2 1 1 1 1 41 2 2-78 „ 50 1 10 6 1 1 2 1 2 24 2 0-50 „ 55 1 3 3 1 8 1 8-25 „ 60 ,, 65 „ 70 „ 74 1 1 2 0- 91 157 7590 17|28 5 17 13 7 3 1 1 505 Average duration of all the cases, 1 year 7-66 months. Table C. Duration of Disease up to time of death in 323 cases. {Females.) Age Years 6 Months Years Totals Average Duration 1 1 ii 2 n 3 3i 4 4i 5 6 7 8 10 12 15 20 Yr. Months 10 1 1 1 3 1 6 15 4- 6 3 2 1 16 1 3 90 15 23 8 9 7 4 66 1 6 95 17 25 8 13 1 10 2 2 78 1 7 30 4 31 8 14 5 7 3 1 73 1 10 35 4 16 7 4 1 2 1 1 36 1 5 40 2 12 1 2 2 2 21 1 6 45 7 2 6 1 2 1 1 20 2 1 50 1 1 1 2 1 1 7 5 55 2 2 1 60 Total 1 1 2 47 123 39 52 3 29 1 19 4 4 1 1 1 323 The average of all the averages is 1 year 10 months. It will be remarked in both of these tables how the dm-ation of the disease is increased by age in both sexes. 80 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAPTEE VL THE PEEMONITOEY STAGE OP ORDINARY PHTHISIS. CHAP. In tlie observations already made on phthisis as a > disease of the system, it has been sought to estabhsh the fact that the constitutional disorder precedes the local. We have now to consider the value of the earliest symptoms. When any physical signs of esta- bhslied deposit in the lung are present, the disorder has ceased to be premonitory, and a certified lung dis- ease is present. Stethoscopic evidence must therefore be excluded. The facts to be examined imply considerations of the circumstances out of which the disease is sup- posed to arise, and an analysis of the earliest symp- toms. The earliest symptoms are the coincidence of emaciation and the febrile condition, and wasting is in Wasting almost all instances the first. Its earliest manifestation the earliest • i ,• p , i t ,• j ±1 • • c symptom. 1^ ^^ absorptiou 01 the adipose tissue and a thinning or the muscles. Its diagnostic character depends on the absence of sufficient cause. The appetite may be good, the secretions regular, the supply of food abundant. There may be no drain on the system, yet emaciation beyond the lowest average of the individual steadily proceeds. This emaciation is more marked in indi- viduals of middle hfe, m whom the processes of nutrition have long been impaired ; but it is also, as we believe, present in all cases of phthisis, excepting those of the most acute form. It is more marked in those who have been previously stout, and more perilous. It is PREMONITOEY STAGE OF ORDIXARY PHTHISIS. 81 progressive and not recovered from, and is thus dis- chap. tinguishable from tlie transient alterations in weight, . ^^- . dependent on seasons of the year, variations in diet and exercise, &c., which many undergo harmlessly. The sensation of weakness is also greater than in these latter. The absence of any preceding acute disease should of course be ascertained. Dyspepsia, in its various forms, may reduce the weight, and it will be necessary to distinguish the functional gastric disorder from that which so commonly attends all stages of acute phthisis. Wasting alone is not sufficient to alarm. It is the Fever, coincidence of this symptom with the febrile state which indicates organic mischief. Dry heat, chills in the afternoon, and occasional remitting perspirations, with an accelerated pulse, uniformly too high, but increased towards evening, form a group of characteristic symp- toms. Gastric disorder, especially in children, and the influence of malaria, if the patient have been exposed to it, are to be carefully remembered in diagnosis, as both of these conditions may produce symptoms iden- tical with those of early consumption. Symptoms clearly referable to blood disorder are Blood dis- occasionally present, and when ascertained have a de- °^'^®'^* cided value. I have observed purpura in several cases of impending phthisis. The red streak on the gums, noticed by Thompson,* is rarely found in the premo- nitory stage, but a paler and narrower streak than that figured may be occasionally present. The secretions are not of necessity affected, and although a febrile condition may lead to an excess of lithates in the urine, there is no invariable character of that secretion accompanying the stage of phthisis which we are considering. * Clin. Led. on Pulm. Consumption, with additional Lectures by his son, Dr. E. Symes Thompson. Lect. x. 1863. G 82 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP. The disorder of digestion described by Dr. Bennett,* _ ^.^' > and characterised by acidity in the primas vise, has, in Acid pro- -^y experience, a constant relation to phthisis only in digestion, the acute form of that disease, of which it constitutes a distinctive character. Of 50 cases of incipient consump- tion, observed with peculiar care, with a view to eluci- dating this point, in 3 only was acidity a marked symp- tom ; in 27 the digestion was more or less impaired (generally shghtly), and in 20 it was decidedly good. If to the foregoing we add a general feeling of malaise, of depressed nervous power, and of insuffi- ciency for the requirements of business or the daily occupations of the patient, we shall have a sum of vital phenomena, inconclusive, it is true, as regards the ac- tual seat of the organic mischief, but indicative of blood changes of a serious character. Some local symptoms may at this time exist, as cough, dyspnoea, pain in the subclavicular regions, and hsemoptysis; but they are rarely present unless the physical signs of deposit in the lung are suffi- ciently estabhshed to be recognisable by a skilled ob- server. They do not, therefore, enter into our present considerations. The reverse of the above picture may be seen occa- sionally, viz. where phthisis is silently developed, giving no warning, and manifesting no symptoms, till the physical conditions of lung-disease are established ; but is most rare. Carelessness or recklessness on the part of the patient, or the absence of medical observa- tion, may account for such symptoms being overlooked ; but in cases which have been carefully studied, the above may be recognised as the conditions most com- monly prevailing. The following case, carefully watched from the out- set, illustrates the foregoing remarks : — * See Bermett : Path, and Treatment of Pulmonary Consumption. Edin. 1869. TREMONITOEY STAGE OF ORDINARY PHTHISIS. 83 X. JEt. 48. Six feet three in height, well made, wide CHAP, chest, good muscular development ; parents free from chest . j' , disease ; one sister and one daughter died of phthisis. This Case. gentleman led an active, regular life, took much exercise on foot, often in the country, and spoke in public at least twice a week. For the year preceding Feb. 1855, had complained of unusual fatigue on exertion, and though of very cheerful disposition, he often looked and felt fagged. For two previous years I had remarked in him the gradual formation of arcus senilis, which was now a perfect ring. In the spring of 1855, he suddenly got much weaker, felt unable to take his usual walks, began to lose flesh rapidly, his face looking worn, and the calves of his legs becoming flabby. Appetite became indifferent, but he continued to live well, and took two or three glasses of wine daily. He had no cough, nor expecto- ration, no pain nor dyspnoea, urine natural, pulse small, averaged 85. Slight chills and sweats now began; chest normal ; no physical signs whatever. In June, profuse sweats, debility, purpura on the legs. A careful examination (Dr. H. Roe and myself) showed a general diminution of the healthy tone of the percussion note, but this was not localised. In July, went to Schwalbach, and took a course of chalybeate waters, and, contrary to our advice, bathed daily in a mineral bath at 84°. In August, I met him on the Rhine, and was shocked at the change in his appearance. He was wasted to an extreme ; his features fallen away, his legs so thiu he could scarcely walk. He had that peculiar feeling of weakness and pain across the sacrum which indicates, when chronic, a high degree of vital exhaustion. The sweating was profuse, wetting a mattrass every night, so that he was obliged to use two beds. Pulse always over 100. He had a short, frequent, dry cough, no expectoration, no haemoptysis, slight dulness, rough, loud inspiration, expiratory murmur prolonged, and a sen- sible amount of vocal resonance over the apex of the right lung; signs which were slight, but had not been observed be- fore. His instant return to England was advised, and the use of gallic acid and cod-liver oil, with an alkaline tonic, and coun- ter-irritation over the right lung. Instead of this, he went to Switzerland, and lived on milk, and in five weeks returned to England. To my surprise, and that of Dr. Roe, he had gained flesh remarkably ; the sweating much less, strength vastly improved. The physical signs were, however, per- G 2 84 .ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP, sistent (Sept. 1855). In March, 1856, lie had no constitu- ^I- tional disorder, had regained weight within a few pounds of his former healthy standard, and a very careful examination failed to detect any 'physical signs ivhatever. This case was published in the ' Lancet,' * Aug. 9, 1856, and the foUomng remarks appended by me: — ' The question here arises. Was this a case of phthisis ? and speaking with diffidence, when we have no oppor- tunity of verifying the reply, I would answer, that in its history, its progressive symptoms, and its physical signs, we are bound to regard it as such.' Unfortunately the question resolved itself. Towards the end of the year 1857, this gentleman again presented febrile symptoms of a remittent character. He thought that the former diagnosis had been wrongly made, and put himself under homoeopathic care, till within a week of his death ; so that nothing was done for him. He died in July 1858, of pneumothorax, the result of the rupture of a cavity in the right apex ; and the physical con- dition was ascertained by the late Dr. Todd, Dr. Watson, and by myself. Necessary If wc examine the circumstances out of which the tiJTnsirex- disease is supposed to arise, with a view to their ana- amining a lygis, Ave shaU ouly get a negative help, or at best a supposed general and abstract truth, from which it is difficult or Sie e^arii™ inipossiblc to rcasou down to the individual case on est stage, wliicli wc may have to decide. Nevertheless, the fol- lowing are considerations which we must mentally m- clude in our reasoning : — This violent disturbance of the system, is it due to recent acute disease yet unre- solved ? to a pleurisy or pneumonia undetected, for instance ? Physical evidence here decides. May But has the subsidence of an acute disease been fol- i^n f cut? lowed by this train of symptoms instead of by a conva- disease. * Lectures o?i the History and Constitutional Characters of Phthisis, delivered at tlie Hospital for Consumption^ by J. E. Pollock, M.D. 'Lancet/ Aug. 9, 1856. PKEMONITOEY STAGE OF ORDINARY PHTHISIS. 85 lescence ? If so, the chances are that the threatened disease is tuberculous. The following tables give a view of 76 cases of phthisis distinctly originating in acute disease, which occurred in my own practice. Table 1 gives the acute diseases in the order of their frequency as originating causes ; Table 2, the ages : — Tabus 1. Table 2. Acute Disorders. Fever, originated . No. of cases. 17 Aff€s ^vken attacked. Age 1 under c 2 years To. of ases. 2 Hubeola 14 3 „ ... 5 Pertussis . 13 5 „ ... 9 Pneumonia . 10 10 „ ... 12 Scarlatina . 8 15 „ ... 7 Variola 6 18 „ ... 3 Pleurisy 4 20 „ ... 4 Influenza 2 25 „ ... 7 Dysentery . Cholera 2 2 30 „ ... 35 „ ... 5 6 Ag'ue .... 1 40 „ ... 8 Boils .... 1 45 „ ... 4 Diphtheria • 1 60 „ ... 51 „ ... 3 1 * OT >^a *81 76 Of these 76, 18 had hereditary predisposition to phthisis. The first Medical Eeport of the Hospital for Consumption gives the parental predisposition as ex- isting in 24J per cent, of all cases of phthisis. It will Fever, be remarked how fever stands at the head ; measles and hooping-cough coming next ; while pneumonia and pleurisy are less active agents than fever. The rheumatic and gouty constitution deserves a Eheiima- separate and careful consideration, for it is undoubt- and dfJ*-"*' edly intimately associated in certain instances with ease of the the tubercular. In the Hospital for Consumption, out phthisis. of 1 973 cases of phthisis, 275 had previously had rheu- matism. f * Of these, 5 had two aflfections consecutivelv. t 2nd Keport, 1863. 86 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP. la my own practice,* out of 67 cases of rheumatism ._\^' ■. in persons affected with tubercle, 49 had rheumatism before, and 18 had it after phthisis was established ; and it is not uncommon to have to treat acute rheumatic fever in the wards of the Consumption Hospital. The allied affections of gout and disease of the heart are often present in tubercular phthisis. It does not appear that rheumatic fever often directly leads to tubercle, but it is sufficient for our present purpose to remark, that the two temperaments very frequently go together, the phthisical patient having attacks of rheumatism, and the rheumatic falling into consumption. Eheu- matic parents frequently also beget tubercular children, and vice versa. In certain rather rare instances, I have noticed the gradual occurrence of murmurs over the aortic and mitral valves, coincidently with the slow development of tubercle in children of the strumous habit. Case. A. A slender boy of 14 has been under my care since he was 8 years old, for enlarged glands and tonsils. Two years ago, with slight, dry cough and sub-febrile symptoms, a deposit in the right lung took place, evidenced by dulness, bronchial respiration, and dry crackle under the clavicle. These signs are persistent, excepting the crackle, which is replaced by a coarse character of respiration and loudly prolonged expiration. There is some flattening of the chest walls at thiri side. He is thin, and has never regained flesh. Within a month there has been gradually developed a rather rough systolic aortic murmur, very distinct in its character from that caused by anaemia. He has no systemic disturbance, excepting that the pulse is occasionally up to 90. He has severe dyspnoea, and complains of slight pain in the cardiac region occasionally. I presume that a partial thickening of the valve has occurred, analogous to that which results more rapidly from acute rheumatism. Age in The agcs at which acute diseases induced phthisis eases. ^ should be remarked. Erom 3 to 15 (the ages when epi- * See the chapter on 'Rheumatism and Phthisia.' PREMONITORY STAGE OF ORDINARY PHTHISIS. 87 CHAP. VI. demic disorders of children most prevail) is the greatest frequency,and from 20 to40 when fever is most common. The prognosis for duration is not good in this class of cases, as will be noticed hereafter. The influences of pregnancy and of lactation as ori- Pregnancy ginating causes of phthisis deserve to be considered. Son.^^*^*^" The following are the results of my observations on Causes. 155 cases of phthisis in patients who had recently been confined : — Plitliisis existed before pregnancy, in . „ Ibegan during pregnancy, in . „ began at confinement Total No. of cases. . 66 . 48 . 51 . 155 As regards lactation as a cause, 94 cases were care- fully investigated, with the following result : — PhtHsis began during lactation, in „ „ from weaning period . Lactation for 1 year, as apparent cause „ over 1 year ,, „ „ 2 years „ Total No. of cases. . 54 . 16 . 10 . 11 . 3 . 94 In five well-marked cases hsemorrhage at labour Hsemor- appeared to be an exciting cause. While on this cauS^ subject I endeavoured to ascertain the fecundity of the parent, as judged by the number of children and the influence of frequent confinements as a cause of phthisis. In 210 cases in which the commencement of the dis- ease was associated with pregnancy or lactation, the Number of number of children was as follows : — children. No. of No. of cases. cases. 1st pregnancy 49 8th pregnancy . 4 2nd ditto . 36 9th ditto . . 2 3rd ditto . 43 10th ditto . . 2 4tb ditto . 26 11th ditto . . 1 6th ditto . 23 14th ditto . . 1 6tb ditto . 13 7th ditto . 10 Total 210 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP. VI. Malaria. Its anta- gonism to phthisis. This table shows both the number of the pregnancy at which the disease manifested itself, and also the number of children born to a phthisical parent. It will be seen that 49 cases of phthisis occurred at or near the time of the first pregnancy, 36 at the second, and so on. From a consideration of these observations, it may be concluded that the period of gestation and of de- livery, as also that of lactation, especially when pro- longed, is fraught with peculiar danger to individuals predisposed to phthisis. And there can be no doubt that the disease not uncommonly begins at such times. The peculiar state of the vascular system and of the blood itself during pregnancy, the rapid reduction of the volume of the uterus after labour, whereby the blood is loaded with fibrin ated material, and the re- duction of all the tissues of the body ; the haemorrhage at the time of labour, and the subsequent drain on the system by lactation, which can be but badly afibrded in persons of weakly habit, are all conditions predis- posing to the commencement of organic disease. In forming an opinion on cases of early phthisis, therefore, regard must be had to the influence of pregnancy and lactation. If malarious influence has been present, the diag- nosis of tubercle is far less likely, as we recognise in the marsh poison a sufficient cause to account for the phenomena. The concurrence of the phenomena of malarious aflections, even of the minor kind, with tubercle in the lung, is most uncommon. During a residence of seven years in Eome, which is a well- known resort for phthisical invalids, I never saw or heard of a case of intermittent fever in persons afiected with consumption ; and although the tendency of all minor ailments there, as neuralgia, headache, &c., is to assume a remittent form, a marked immunity in this respect for the phthisical was very observable, while PREMONITORY STAGE OF ORDINARY PHTHISIS. 89 among the healthy Enghsh residents there were abiui- chap. dant cases of disease directly dependent on, or modified . ^'^- , by, malaria. The prolonged gastric disorder of adults and of chil- Gastric dren, severe dyspepsia, involving the secondary pro- affectil^s^ cesses, and depurating organs (kidneys and hver), and produce all local affections, as of joints, chronic abscess, syphihs, toms. the cachexia of mercury, the mesenteric disease of children under 15, are to be looked for in every case. It is scarcely necessary to a,dd hysteria to this list. The symptoms of prolonged bronchitis are hable to Bronchitis, be mistaken for those of this period of phthisis, but more commonly for a later stage of the disease. The history, physical condition of the chest, and the nature of the expectoration, should guide us, and in most cases a safe conclusion may be drawn ; but bronchitis, in certain instances, passes into a form of phthisis, and at the phthisical age (as well described by Bennett), or in old age (Maclachlan, who says that ' senile phthisis is usually a sequence of chronic bronchitis '). These obscure cases must be allowed for in our prognosis, and our highest skill will often be taxed to account for certain phenomena present. It is to be remem- bered that the cough of the earliest stage of tubercle, if present at all, is dry and irritative, and that expecto- ration is generally absent, and it should never be for- gotten that it is for constitutional disorder and not for local symptoms that we have to account. The absence of assignable cause is a most important Absence of element in our obscure cases. Having; eliminated all ^^^'g^^^^'^ affections likely to be confounded with phthisis, having considered all the causes hkely to originate it, we may have a residual severe constitutional disorder without antecedent disease or apparent origin, and can at once refer to tubercle as the probable pathological disturb- ance impending. We shall do well to remember also, as before stated, 90 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. VI. Phthisis rarely begins ■with the symptoms of catarrh. The nega- tive atti- tude of phthisis. Non-eon- cixrrents. External struma. Eachitis. that phthisis very rarely begins with the symptoms of catarrh. When we have thus reasoned out and reduced our evidence to form, we have to consider the age, the inherited tendencies, the individual constitution and former ailments of our patient, and the duration and sequence of his present symptoms. Nor should we omit from our consideration the nega- tive attitude of phthisis, and its isolation with regard to other diseases. According to very numerous observa- tions, it is ascertained that phthisis is rare in persons actually the subject of open strumous abscesses. It may occur before the glands are affected, or after cica- trisation, but it is not often found to begin during their suppuration. Also, although there are individual ex- ceptions, it is not common in those who have had ex- ternal glandular disease. The frequency of strumous affections in phthisis is represented in the following table, on a total of 300 cases of tubercle in the lung, occurring in individuals of marked strumous temperament : — External glands, enlarged „ ,, ulcerated . Diseases of joints „ eyes _ . „ mesenteric glands Cerebral .... Spinal disease Lumbar abscess . Total No, of cases. 2 21 6 12 2 89 It wiU be observed that these figures represent the instances occurring in 300 persons of marked strumous habit, but these are taken out of 4530 cases of phthisis. Phthisis is rarely found in persons with rachitic de- formity of the chest, or rickets generally. My own experience, and that of my colleagues, amply confirms See also tlie chapter on < Strumous Phthisis.' PREMOXITOEY STAGE OF ORDINARY PHTHISIS. 91 this statement. The deformed chest is very uncommon chap. VI in the consumptive. It may not be out of place here > r^ — - to state, that phthisis, although ordinarily found in in- ^o™^ °f dividuals of the well-known consumptive build (narrow, flat, and long chest and alar scapulae), also occurs where every measurement is ample, and the chest cavity is fully developed.* Skin ajETections of almost every form, especially those skin dis- accompanied with febrile action of the system, are most rarely found in the phthisical habit, and at the period of the invasion of phthisis. The parasitic and conta- gious varieties may appear, and chiefly in children, but the constitutional (as psoriasis) are very uncommon. Herpes, urticaria, pityriasis, and acne, may be con- sidered exceptions. The state of the skin in the phthi- sical is to be remembered. It is generally delicate in texture, rarely freckled, is soft to the touch, and the perspiration easy. As hectic advances it is paler, softer, and ansemic. The openness of the pores, and extreme readiness to perspire, would almost seem to be a safe- guard against skin disease. Tumours of all kinds are rare in phthisis, the cystic f Tumours. as well as other varieties. I have, however, frequently met with bronchocele. The peculiar condition of the blood called anaemia, * See, for many interesting remarks on this subject, Dr. Cotton, Phthisis and the Stethoscope, 3rd edition, 1864. t I give Rokitansky's list of non-concurrents with phthisis ; but the text records my own experience : — Cystic formations. Tumours. Coarctation of the thoracic space (by pregnancy, ovarian tiunours, &c.), bronchocele, typhus, intermittent fever, aneurism, rickets, venosity — whether a preponderance of venous blood in the system or from congenital cyanosis, hypertrophy of the heart, emphysema, dilated bronchi. (See Rokitansky, Sydenham, Ed.) I have seen tubercle combined with enormous ovarian tumour (through the kindness of Mr. Spencer Wells), and in several instances have verified the existence of patent foramen ovale in cases of phthisis, both when cyanosis had occurred during life and where this symptom was absent. 92 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, deserves careful consideration in our study of the pre- - _ ^^' . monitory stage of phthisis. Its characters are well- ABsemia, knowH and easily recognised. Excessive pallor of skin, concurrent, touguc, and conjunctivse ; a delicate texture of skin, with a colour often shading off into olive ; small and often rapid pulse, easily excited, but soon subsiding ; deficiency of the catamenia, and paleness of the dis- charge ; dyspncEa on exertion ; short dry cough ; oedema of the ankles ; faintness or positive syncope ; deficient and enfeebled nervous power ; pain in left side ; diges- tion impaired ; tongue pale and flabby ; bowels very costive. With these symptoms we have a blowing murmur over the aorta accompanying the systole, and frequently a venous murmur or whiz in the jugular. The blood itself is thin and watery, and deficient in red particles, but has an excess of white coi-puscles. Of all the conditions of health to which the name of consumption has been popularly given, this one is most commonly taken for a manifestation of tubercular disease, and is that which least frequently is found associated with phthisis. I have carefully noted 125 cases of anaemia with murmurs, but in none of them was there any sign of tubercle, while in a very few instances have I observed the concurrence of the two conditions. These patients are very numerous, and afford by their number abundant opportunities of test- ing the truth of the above observation, which, so far as I know, is original. The girl with extreme ansemia is always supposed to be consumptive ; but a glance will often enable us to decide on the real nature of the case. The diagnostic points are these. In this affec- tion the build of the patient is generally antiphthisical, and in spite of her colour and dehcate appearance, there is neither loss of flesh to any great extent, nor fever. The presence of the murmurs (arterial, venous, or both) will decide as to the existence of extreme anasmia. On the other hand, the mobility, percussion, and tone PREMONITORY STAGE OF ORDINARY PHTHISIS. ^'^ of the respiratory sounds are normal, and tliis even chap. where cough, dyspnoea, and hasmoptysis may have ex- r^ — - isted for months. The important blood changes which characterise this condition seem almost antagonistic to tubercle ; for not only is phthisis not a concurrent state, but these cases very rarely proceed to the deve- lopment of tubercle in the lung. When we regard the causes of ansemia, although they belong to that class to which consumption is commonly attributed, yet they are more peculiarly referable to two errors against health — seclusion from air and light, and a wrong quality of food. The sufferers are the victims of our subterraneous kitchens and back shops, and of that atrocious domestic system which deprives young women in service of open-air exercise and enjoyments pe- culiar to their age. Secondarily, a depraved appe- tite arises, and tea with bread and butter comes to form their sole diet, as all healthy desire for meat soon vanishes. These devitalised plants, which never see the sun, languish in nervous power, and furnish our worst cases of hysteria. The nutrition of the body, however, does proceed, and although the blood has become impoverished, the tissues scarcely waste, but become loose and flabby, and organic Hfe is insuffi- ciently nourished. Eeasoning theoretically, we may say that anasmia Contrasts consists in a deficiency of certain necessary ingredients ^nffimia in the blood, while phthisis may have a similar de- a"*! . . ficiency, but has also a superadded contamination. ^ Comparing symptoms, ansemia wastes those organs and tissues dependent on an abundant supply of red blood ; phthisis wastes all tissues by furnishing them with impure blood, and leaves a residual deposit. The phenomena of aneemia are those of insufficiency; those of phthisis of impurity of the vitalising fluid. The results of both classes of disease are more strik- ingly divergent than their symptoms. Few disorders 94 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, of blood origin are so manageable as anaemia. Fresh >^Il^ air, light nutritious diet, exercise to promote blood changes, and the metallic tonics with warm aperients, do wonders for these poor faded plants, which so remind us of London gardening! In phthisis we have to eliminate a poison as well as to restore lost healthy constituents of the blood. Hence the uncertain issue of our cases, the shght contamination of some terminating in minute deposit tolerated for years ; the more acute constitutional disorder in others, rapidly fatal ; or the deposit softened, excavated, and the patient righted for the time. These and other results of tubercle, which are to be again treated of, illustrate the nature of the early disorder; but for purposes of prognosis and diagnosis sufficient has been said. Anae- mia and phthisis are rarely coincident, and the exhausted state of blood in the former need never be confounded with consumption. The ansemia induced in the more advanced stages of phthisis is not here alluded to ; the blood gets drained of its red particles in tubercular as in all chronic affections ; but we are now treating of the earhest and premonitory symptoms. Hereditary Considerations derived from the hereditary constitu- sition^°" ^^^^ ^^ ^^^^ patient may assist us much at this stage, when we are without the means of forming a physical diagnosis. Parental disease, the age at which the tubercular habit was developed in the parent, or in the brothers or sisters of the patient, the likeness of the latter to father or mother, and a memory that males transmit disease with much greater tendency to sons, and females to daughters,* are considerations which will help in our diagnosis. The habihty to disease which is inherited from * Fathers ti-ansmit diseases to sons in 59 per cent, of cases. „ „ daughters in 43 „ „ Mothers „ to daughters in 56 „ „ „ „ sons in 40 „ „ — 1st Hep, Hosp. for Consumpf., 1849. PEEMONITORY STAGE OF OEDINARY PHTHISIS. 95 several progenitors is greater than when one only chap. transmits the tendency. Thus, two parents phthisical - ^ - are more likely to have consumptive offspring than when one only has been phthisical; and the greater the number of collateral relatives so affected, the higher the danger to which an individual standing lower in the family tree is subjected. In regarding the inherited predisposition to disease, the generation immediately preceding is of the first importance (as parents), then those a step higher (as grand-parents). The deaths of brothers and sisters from phthisis evidence a strong family tendency, but the originators of that tendency are the parents and more remote ancestors. There is Forms of little doubt also that forms of disease are transmitted, ^i^ease I know of families whose members were successively mitted. swept off by acute phthisis as they arrived at the same age, and of others where the chronic type of disease prevails, and its individuals struggle on to middle age with cavities in the lung. The hsemoptysical tem- perament is commonly shared by several members of the same family, and successive individuals die of pro- fuse bleeding from the lungs. A most remarkable and fatal case, with persistent and distressing fits of cough- ing lasting for five and six hours consecutively, and entirely uncontrolled by remedies, which was long under my care, was succeeded in the same family a few years later by the son of the lady, with precisely the same symptoms. But illustrations of this fact are familiar to every one in practice. It is well in all instances to ascertain the type of disease which pre- vailed in older members of the same family, or in brothers and sisters, as our prognosis will be much assisted thereby. The following diagnostic summary will assist : — 1. Emaciation not to be accounted for by recent acute disease, ordinary dyspepsia, or alterations ELEMENTS OP PKOGNOSIS IN CONSUMPTION. in the habits of the patient ; progressive, unaf- fected by the quantity of food taken. 2. Fever of the remittent type, chiUiness, dry heats, sweats sometimes profuse, more commonly par- tial, pulse over 100, with exacerbations morn- ing or evening, the last more common. 3. Grave disorders of digestion, nausea, anorexia, thirst, furred tongue, early occurrence of diar- rhoea, in certain instances great acidity of the prim^ vise. This class of symptoms belongs to phthisis of the acute form. The symptoms included under these three heads to be regarded with great suspicion. The following- cir- cumstances to be carefully analysed as causes : — 4. Eecent acute affections not followed by perfect convalescence, yet which have not left dis- tinct organic changes (as unresolved pneu- monia, pleurisy, &c.). Among those most to be dreaded are fever in all its types (excepting the pure intermittent), and eminently the zy- motic class. 5. The existence of the rheumatic diathesis in the individual or in his parents. 6. In the female, pregnancy ; recent confinements ; haemorrhage at labour ; prolonged lactation in those hereditarily predisposed to tubercle. 7. The presence of prolonged bronchitis, which may pass into phthisis ; this is more common in the aged. 8. The hereditary tendencies, their number, near- ness of relationship, the age at which parents, brothers, sisters, were attacked, and the forms of their diseases. 9. The absence of assignable cause for grave altera- tions of health. PREMONITOEY STAGE OP ORDINARY PHTHISIS. 97 10. The occurrence of the sjnnptoms without pre- chap. ceding catarrh. ^ <^ — - 11. The conditions rarely concurrent with tubercle to be remembered, are : — a. External suppurating strumous glands. h. Emphysema of the lung. c. Eachitis. d. Skin diseases. e. Tumours. /. AuEemia, with the characteristic murmurs. The prognostics remain to be briefly stated. In this Prognos- period of the disease they resolve themselves into *^^^' simple diagnosis. In the consideration of the premo- nitory symptoms of any affection, where the primary question to be resolved is the presence of the disease at all, it is difficult to assign a value to the varying con- ditions of the case. Is this phthisis.^ is our problem before stethoscopic evidence is possible ; and having established sometliing like certainty about the nature of the impending disorder, we shall do well to be reti- cent in opinions offered about its termination. Never- theless the following may be remembered : — a. The insidious form of phthisis, scarcely announced insidious in its beginnings, is more likely to become fSi-dyto"^^ chronic than that which invades with acute i^ecome „ „ chronic. access oi lever, h. The acute form is ushered in with much febrile Acute action, and considerable gastric disturbance ; die ®^'™i^*°™^- chronic rather by a gradually progressive ema- ciation than by fever. c. Severe sweating is indicative of rapid cases. Sweats. d. Very slow emaciation is most frequently seen in Phthisis in the phthisis of advanced life, the changes in the nfr'''^^'^ nutrition of the body generally proceeding to a great degree before local disease is established. H 98 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. VI. Phthisis succeeding acute aflfections. After • pregnancy. Eheumatic tempera- ment. Hereditary tendencies to certain forms of Absence of assign- able cause. Non-con- currents present. 9 k e. Phthisis succeeding acute affections, * as fever, rubeola, &c., generally belongs to the tolerably rapid form of the disease, but not inevitably to the most acute. /. Phthisis after pregnancy, and during lactation, is generally rapid. The rheumatic temperament tends to chronic rather than to acute phthisis. The multiplication of hereditary tendencies in a single case, has more a diagnostic than a prog- nostic value. The form of phthisis which pre- vailed in other members of the same family may help us to estimate the probable future of the case. If two or more brothers have had, say, chronic phthisis, the chances are in favour of the development of the same type of the tubercular disorder ; if a brother or sister has been struck down by the acute variety at the same age, we may fairly anticipate a similar progress. The absence of assignable cause for any case pre- senting the features of early consumption, is a feature favourable for chronicity. Where neither individual temperament, previous disease, nor hereditary tendencies are present, the prognosis for a slow rather than an acute form of the disease may safely be formed. Where any of the conditions rarely concurrent with phthisis are observed, as emphysema, &c., the consumptive disease is often latent, and generally slow. * In 72 cases of tliis class, the average duration of wliicli, wlien under observation, was 22-78 months, 19 v^ere in the first, 32 in the second, and 21 in the third stage. Of 6 deaths, 1 occurred within 6 months, 1 within a year, 1 in 2 years, 2 in 4 years, and 1 at the eiid of 5 years from the commencement of the disease. The deaths occurred between the ages of 5 and 18 years of age. The predisposing diseases were per- tussis, which caused 3 deaths; pneumonia causing 2j and rubeola caus-> ing 1 death. ^. J ACUTE PHTHISIS. 99 CHAPTEE VII. ACUTE PHTHISIS. Undeviatijs^g continuity of the morbid actions is the chaP, • ... VII character of this form of the disease. I distinguish two ■ ^■1-' varieties : 1. Tlie acute injlammatory^ in which the local Twovarie- disease is a combination of inflammatory products and of tubercle ; 2. A passive exudation of crude tubercle invading the whole of both lungs, with slight febrile disturbance. The first may prove fatal in a few days Acute in- or be prolonged over some months, and the latter du- toly.'^^' ration is more common ; the second is fatal in a few months. The history of the first is continuous fever, Symptoms. with exacerbations, but without remissions ; rapid hard pulse, becoming feebler and quicker ; great heat and irregular sweats, early gastric and intestinal disturbance, sometimes from the first ; shown by red tongue, thirsty nausea, vomiting, anorexia, diarrhoea, rapid and con- tinuous waste of tissues, great exhaustion, restlessness, dyspnoea, occasional dehrium when near the fatal close. The physical signs may indicate an extensive deposit in one or in both lungs simultaneously, shown by dulness on percussion, bronchial respiration and voice, and pro- longed expiratory sound ; and the evidence of deposit is not locahsed to one spot as at the apex, but is diffused, often very extensively, and may be more intense at the base. The signs of softening are early present ; the stages of the disease being indeed undistinguishable, fine crepitus appearing in patches, mixed with bronchial sounds, clicking, coarse rales, pleural frictions, and, H 2 100 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. VII. Passive exudation. Descrip- tion. finally, evidence of inflammatory action in all the tissues of the lung. Should cavities form they are irregular, undefined excavations, and the signs run into those of softening ; the circumscribed form of cavity I have never seen. 2. The passive exudation of crude tubercle is dis- tinguished by all the physical signs of deposit in the lung without softening, great didness all over the chest, fixity of its walls, deficient respiratory sounds, followed speedily by bronchial respiration and voice. The moist sounds are absent or developed in portions of the lung, only not intensely. A general malnutrition of the body, rapid waste, sub-febrile condition, no excessive sweats, skin hot and dry, are the symptoms. The digestive system often remains unimpaired to the last. Death occurs in three or four months. This is a rare form of tubercular disease, and, according to my observation, is seen only where the hereditary taint is strongly marked. Acute Inflammatory Phthisis. In 1816, Cruveilhier writes ('Essai sur 1' Anatomic Pathologique ' ; Paris, 1816, tome ii. p. 167) : — ' La forme de phthisic pulmonaire que je viens d'indiquer ne se trOuve decrite dans aucun auteur moderne ; en hsant le premier livre des epidemics d'Hippocrate, j'en ai rencontre une description tres-exacte.' He then quotes the following passage from Hippocrates, which I subjoin in Enghsh from the Sydenham edition : — ' Consumption was the most considerable of the diseases which then prevailed, and the only one which proved fatal to many persons. Most of them were affected in the following manner : fever, accompanied with rigors of the continual type, acute, having no complete intermission, but of the form of the semiter- tians, being milder the one day, and the next having an exacerbation, and increasing in violence ; constant ACUTE PHTHISIS. 101 sweats, but not diffused over the whole body; extre- chap. mities very cold, and warmed with difficulty ; bowels r^ — • disordered, with bilious, scanty, unmixed, thin, pungent, and frequent dejections. The urine was thin, colour- less, unconcocted, or thick with deficient sediment. . . Sputa small, dense, concocted, but brought up rarely and yn\h. difficulty ; and in those who encountered the most violent symptoms, there was no concoction at all, but they continued throughout spitting crude matters. The fauces in most of them were painful from first to last, having redness with inflammation, defluxions thin^ small, and acrid ; they were soon wasted and became worse ; having no appetite for any kind of food through- out; no thirst ; most persons delirious when near death.' Case of Acute Phthisis. ' Dr. Law did not believe that the records of mecli- Case, cine afforded an instance of any case of the kind running its course as rapidly as this had done, its duration being only ten days.' The subject of it was a boy a^t. 5 years. Was reported never to have been strong ; had had dropsy twice. Strikingly handsome, fine delicate skin, light hair, blue eyes. Seized with shivering and general sickness, after being out playing all day. When admitted, urgent dyspnoea, face deeply congested, skin burning hot, pulse 160. Posteriorly, dull 'percussion from top to bottom, both sides and to the same extent, bron- chial breathing, tuith large coarse crepitus. Death on the sixth day after admission, and tenth day of his illness. Each lung was from apex to base iu a condition of pneumonia, in- termediate between the first stage, or that of hyperaemia and red hepatisation, with small tubercles scattered through them, but more crowded near the base. The anterior mar- gins of the lungs were emphysematous, and in these portions alone there were no tubercles. The bronchial mucous mem- brane was universally congested. Dr. Law thought if ever a case deserved to be called one of acute phthisis, it was this. It exliibited, in a 102 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, very striking manner, the peculiarity of the tubercles >_I^L_. being even more numerous at the base than at the apex of the organ, and deposited equally in both lungs. He was well assured that the child had no indication of chest affection before this attack. Dr. Law was dis- posed to consider the pneumonia and tubercular depo- sit in this, and in all cases of acute phthisis, as a simul- taneous result of a single pathological effort, and very analogous to what occurs in inferior animals, in whom disease runs a much more rapid course than in the higher, although the former are much less susceptible of it than the latter. Nor is it alone in running its course within a shorter time in the lower than in the higher animals that the disease differs ; but in this, that in the latter there is a kind of gradual development of it, consisting, as it were, of distinct stages. In the lower animals these all run into each other. In the pulmonary disease affecting cattle in this country it was common to find the lungs of animals that had died after a very few days' illness, in a state of hepatisation, with tubercles in the midst of the hepatised lung. He remarks that although it is quite true that tubercles act as foreign bodies on the pulmonary parenchyma in the midst of which they are deposited, and produce around these an areola of pneumonia ; still, while he admitted this, he also beheved that pneumonia was the precursor of the tubercular deposit.* Case 2. B. set. 13. Fair hair, delicate complexion, well nourished. In September, leading a healthy country hfe, in full vigour, taking daily horse-exercise ; living well. Wasting, first symp- tom, which rapidly progressed, and excited alarm. In Feb., when I saw him, dry cough, dyspncea, daily chills, sustained - high pulse (120), sweats partial, great heat of surface, anorexia, nausea, but rarely to vomiting, bowels regular, t. furred, great thirst, extreme feebleness, and much marasmus. Dulness, * Dr. Law. Beports of the DuUin Path. JSoc. ; Dub, Quar. Jour, Med, Science, May, 1864. ACUTE PHTHISIS. 103 gurgle, cavernous blowing for three inches below right cla- CHAP. vide : dulness, 7)ioist crepitus, tubular respiration for some ^^^- inches left apex, over the remaining parts of both lungs, rough, coarse tone of inspiration ; expiration prolonged and, loud, with occasional click everywhere. The usual remedies failed to produce even transient relief; oil and tonics were not even tolerated Death in March from exhaustion ; no delirium. There had scarcely ever been expectoration. Duration, six months. I have placed these cases at the head of this section,, as typical of the most acute forms of phthisis. The Hippocratic description* wants only physical signs to render it a complete history, and merits the comment . of Cruveilhier : ' Admirons la sagacite d'EQpjDocrate, voyons le reconnaitre la phthisic au miheu de tant de symptomes bien propres k lui donner le change. Que serait-ce s'il avait pu, comme nous, interroger les cadavres ? ' It is incomplete, but worthy of study, as representing the leading features of acute phthisis ; the continuity of the fever, the accesses being so redupli- cated as to run into one another, and daily increasing in violence ;.the deep disorder of digestion ; the paucity of what we would call ' chest symptoms,' and the per- sistent waste of vital force. All these are characters of the gravest constitutional disorder, proceeding to a fatal result, with no check or intermission. Dr. Law's case is of the highest interest. A dehcate strumous child is attacked by what would have been an ordinary pneumonia in a healthy subject. Death occurs on the tenth day, and tubercles are found throughout both lungs, the interspaces being blocked up with in- flammatory products ; and we cannot but agree in the opinion that the pneumonia and tubercular deposit in this and in all cases of acute phthisis ' are the result of a single pathological effort.' * It is obTious that the type of fever in the Hippocratic records is the intermittent, dependent on malarious influence ; and all ancient descrip- tions of febrile disorder seem to be referred to this standard. 104 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. VII. Acute phthisis of this form must indeed be regarded as composed of these two elements — an inflammation of acute violence, and a constitutional disorder which determines a deposit in the lung of the lowest grade of aplastic formations. The local disease is a combination of inflammatory products and of tubercle, the systemic affection reflects both disorders, and the patient dies from continuous febrile disturbance. Such cases are of frightful rapidity, but they are fortunately rare. The second case exhibits the more common form of acute phthisis, and the differences between it and the first are to be observed rather in duration and intensity than in kind. The same continuity of febrile disturbance and deep impairment of all the processes engaged in nutrition distinguish it, while the local changes are found in an extensive deposit throughout both lungs, which (the disease being prolonged over a greater time) may in portions have reached the stage of excavation. The inflammatory products were also found in every tissue of the lung, red hepatisation, intense congestion of the bronchial membrane, and thickened pleura. Above all, it is to be remarked that there are none of those barriers to the advance of the tubercular deposit which in our cases of prolonged character are found as a result of conservative inflammation below and around hmited areas of tubercle, wa,lling and separating it off, and circumscribing its progress. The lung in such cases is friable, congested, and disorganised in all its tissues. Passive exiidatiou. Case. Post mortem. Passive Exudatio7i of Crude Tubercle. Gr. H. set. 17. A delicate-looking lad, narrow and shallow in the chest. Came to Eome with his family to pass the winter. His parents had left England for the health of a daughter declared to be consumptive ; and had already lost three or four children by phthisis. This boy was apparently perfectly well on arrival ; he rather suddenly, and without ACUTE PHTHISIS. i05 any apparent cause, began to lose flesh and strength ; and CHAP, this proceeded so rapidly that, in the course of two months, he ^^^^- had the aspect of advanced phthisis. His appetite was un- impaired, and he daily rode on horseback ; he had no cough, no expectoration, no hgemoptysis. Pulse small, weak, rapid. He began to have chills and moderate night sweats about a fortnight before his death. Physical signs — the whole chest duller than natural, and this dulness increased daily till it was very manifest. The respiration, at first deficient, was dry and tubular throughout, the voice bronchial. Remark able impairment of the '^nobility of the chest on both sides. It appeared fixed down. Dyspnoea on the slightest exertion was bis only distressing symptom. He faded rapidly away, and died within three months ; without any secondary affections, as diarrhoea, and without gastric disturbance. He also had never expectorated anything whatever. Towards the end he coughed a very little — not sufficient to attract the notice of any one, nor to distress himself. I examined the body with Dr. Deakin, twenty hours after death. The entire extent of both lungs was solidified by a deposit of grey and yellow tubercle throughout their whole structure. We had no leave to examine the other cavities of the body. This case is also rare, and it belongs to tlie class of acute phthisis rather from the undeviating con- tinuity of its course to a fatal result, than from the active nature of its symptoms. The whole of both lungs was invaded by tubercle, but the inflammatory products were wanting, and the febrile disturbances slight. It was almost a passive deposit. Here are to be remarked the singleness of the disease (it was tubercle alone), the marked family taint, the absence of secondary affections, the absence of fever, the pro- gressive waste, the entire obliteration of respiratory space, and the persistence of the deposit in a solid form. The patient died in the first stage of phthisis. I have noted personally 179 cases of rapid con- Analysis tmuous phthisis, of which 113 were males and 66 cases. females. The proportions of phthisis (all forms) in the sexes is 53 per cent, males to 47 per cent, females, in 106 CHAP. VII. ELEMENTS OF PEOGNOSIS IN CONSUMPTION. the Eegistrar-General's report ; and, in the First Eeport of the Hospital for Consumption, it stands 61 per cent, for males to 32 per cent, for females. My observations give 63-13 per cent, of males and 36-87 per cent, of females in this form of the disease. The influence of age and sex is given below. Age. Males. Females Age. Males. Females Under 7 yrs, 7 to 10 „ 10 „ 15 „ 15 „ 16 „ 16 „ 17 „ 17 „ 18 „ 18 „ 19 „ 19 „ 20 „ 2 2 6 5 4 7 1 1 2 3 5 4 2 20 to 25 yrs. 25 „ 80 „ 30 „ 85 „ 35 „ 40 „ 40„45 „ at 65 „ Total . . 25 24 22 9 6 1 13 21 5 7 2 118 66 Age. The age at which there is greatest proclivity to this form of phthisis is from 20 to 35 in both sexes, but men exhibit a greater liability than women after that age. There is no immunity even in advanced life. A case, 2dt. 63, was fatal in 3^ months with formation of cavity. Maclachlan [Pract. Treatise on Dis. and Infirm- ities of Advanced Life : Churchill, 1863) gives a case — male sst. 73 ; death in less than 3 months, and within 6 weeks of cavities forming. Hasse gives a rapid phthisis case, ast. 89, male ; and Blakiston a case, £et. 73 ; death in 6 weeks. Of my 179 cases, 8 died while imder observation, of which 4 were males and 4 females ; the fatal result in the males occurring between 35 and 45, in the females between 18 and 30 : Two died in 2 months. One „ 3 „ One „ 4 „ Three „ 6 „ One „ 9 „ Time in J subjoiu a Table, showino; the time in which each •wmcneaen pit i i • -i stage was stagc 01 the discasc was reached m 172 cases, and the reached. ACUTE PHTHISIS. 107 period also in which the opposite lung became engaged chap. in 139 cases : — ^ ^^^' Time. stage 1. stage 2. stage 3. Both lungs engaged 1 montli 2 months 3 „ 6 „ 9 „ 1 1 2 2 3 8 18 7 9 6 13 33 24 29 22 2 13 32 26 26 20 As a record of the extent of local mischief this is intelligible enough ; e.g. at the end of two months 13 had cavities ; 13 had both lungs affected; 8 were in the stage of softening, and one was still in the first stage. The proneness to destructive change in the tubercle is sufiiciently marked. The influence of hereditary predisposition on these Heredi- cases is undoubted. Out of 179 only 34 could posi- enel™^'" tively state that there was no family taint either parental or remote. Examining symptoms, we find that 82, or nearly Earityof one-half, had no hsemoptysis, whereas the proportion gis™*^^*"^" with this symptom in both sexes and all forms of phthisis was found to be 63 per cent. (First 3Ied. Rep. IIosp. for Consumption). The discrepancy favours the idea that the inflammatory congestion of the lung is relieved when blood exudes, and certainly points to local depletion as a remedy indicated by the symp- toms. In most cases of phthisis a slight spitting of blood undoubtedly relieves the patient for the time, by lessening congestion and irritation of the lung tissue. Gastric irritation and diarrhoea are early, prominent, Gastric and alarming symptoms in acute phthisis. In my ^y^P*^'^^^' cases, 97 (out of 179) had marked gastric disorder, thirst, anorexia, nausea or vomiting, and red tongue from the beginning. Diarrhoea was present in 27 cases Diarrhcea. within the first three months, and in all at some period of the disease. 108 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. Continuous febrile disturbance, pulse above 100, > chills, excessive heats, not always ending in sweating, Fever. or with profusc sweatings, were symptoms present in all cases. Out of 64 females above the age of puberty, the catamenia were absent in the first three months of illness in 28 ; and it will be found that this function rarely contmues in acute febrile phthisis. Prognostics. 1. Eapid continuous waste of tissues. 2. Continuity of febrile distm-bance with exacer- bations ; no clear intermissions. 3. Early gastric and intestinal disturbance. 4. Physical evidence of diffused deposit in the lung, and of inflammation of its tissues, the signs of each being with difficulty distinguished. 5. Eapid changes in the physical signs, and those of all stages being found simultaneously in one or both lungs. 6. Marked hereditary taint. 7. In females, early suppression of the catamenia, or their non-appearance at the age of puberty. The concurrence of these conditions, or of many of them, stamps the disease with a fatal character. The prognosis for time is to be gathered from the intensity of the fever, and from its contmuous character. The fatahty of this form of the disease is unquestionable, its progress is entirely uncontrolled by remedies, and if once recognised we can but warn the friends of the patient of the inevitable result. Difficulty The only difficulty in diagnosis is that a similar form an diag- q£ fevcr, sustaiucd and continuous with exacerbations, and an equal amount of constitutional disturbance may arise from a rapid invasion of tubercle Hmited to one portion of the lung, which undergoes the changes of softening and excavation with extreme rapidity, or from nosis. ACUTE PHTHISIS. 109 an old deposit rapidly breaking up. In tins case it chap. often happens that a prognosis, if hastily formed, may - , -^ prove incorrect, as the constitutional disturbance not uncommonly diminishes, and the patient considerably recovers flesh and strength, when a cavity has been formed. The following diagnostic points will assist : — 1. In acute general phthisis the physical signs are not hmited to one spot nor to one lung, but are diffused and almost always double. With these are mixed signs of undoubted inflammatory origin, as fine crepitus, dulness at the base, rales of varying intensity, or pleural friction sounds. The gastric disturbance uni- versally present in acute phthisis "running on unchecked to a fatal course, is comparatively rare as a symp- tom in cases where a localised deposit in one lung is rapidly breaking up, and if present is much less intense. 2. The history of the case : evidence of a former deposit in the afiected lung will be found either from the patient's account or from his medical attendant. If present, the case is at once removed from the category of acute phthisis. Other considerations, derived from the age, temperament, and hereditary taint, will occur to everyone ; but the elements of a true prognosis will be found in those now stated. Passive hut Rapid Exudation of Crude Tubercle. The prognosis is to be derived from its diagnostic features, which are peculiar and rare. The univer- sality and rapidity of the deposit in both lungs, and the progressive waste of the system, the hereditary taint, and the absence of chest-symptoms and of acute fever, are the leading characters. I have never known such cases either to pause or recover. 110 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAPTEE VIII. OEDINARY PHTHISIS — THE FIEST STAGE — ITS NATURE AND RESULTS. CHAP. VIII. The first stage con- sists in a deposit re- cognisable by physi- cal signs. Two varie- ties of tubercle. Yellow, more tendency to soften. The premonitory stage, with its grave indications of danger, having passed, a deposit of tubercle in the hmg takes place, giving rise at once to such altered physical conditions of the chest, that certain phenomena become manifest which admit of no conjecture as to their ex- istence, but by careful observation may have a definite value assigned to them. We shah consider the indi- cations to be derived from these and the accompanying symptoms in detail ; but it is first necessary to regard the disease now established by the hght of our latest knowledge, so that knowing its natural history and tendencies, we may be prepared to form a prognosis founded on a surer basis than any merely speculative theories can afford. The deposit which takes place in the lung may consist of at least two varieties, the grey and the yellow * tubercle ; the former semi-transparent, the latter opaque and firm. The first is generally found scattered throughout the lung (at least in the early stages), and the changes which it undergoes are slower than those which take place in the yellow variety. Softening is earlier in the latter, and a tendency to form aggregated masses is more observed in it. Whether from inherent tendencies to destruction, or from changes which have their origin in the adjacent structures attacking it with more facility, it is certain that the * Rokitansky, Louis, Laeixaec, Carswell. THE FIRST STAGE — ITS NATURE AND RESULTS. Ill yellow variety has in it more elements of danger than chap. the grey. On the other hand, the grey has a greater - — r— ' tendency to dry and contract, and yielding its animal ^^°y *^ constituents to absorption, may leave only a residuum contract, of earthy matters in the lung. These two varieties are often mixed together, and in the advanced and de- structive changes of consumption the yellow gets the ascendent, and may be found alone to represent the mischief done. Whether we believe, with Bennett, that Theories ' tubercle is a new formation in an exuded blood plasma,' or with Addison, that it is a modification of a pre- existing texture, ' a fibrinosis,' with Hokitansky, pseudo- albuminous ' perhaps mechanically deposited,' with Prout, is not so material for practical purposes as the recognition of the fact, that it is unorganised (as all ^^^ or- adniit), and incapable of being raised to a higher, al- though it may fall into a lower condition ; and in deal- ing with its characteristic properties, for our present purpose we have only to remember those which in- fluence its history and progress in the living economy. An exuda- Structurally, it is non-vascular, and may be regarded as an exudation from the capillaries, chiefly into the air vessels. (Carswell, Cruveilhier.) Under the micro- scope it presents granular points, corpuscles without nuclei, free fat. (Kokitansky, Bennett, Beale, &c.) It No ceils exhibits no tendency to form perfect cells, but rather further abortive corpuscles, which form slowly, and slowly ^7nJ°^" break down. Elementary molecules are not formed capable of further development. Chemically, tubercle is composed of animal matter. Chemical with much albumen, salts of phosphate and carbonate tionf°^^' of lime, with a little soda. (Bennett.) Tubercle pos- sesses no fibrous stroma, as cancer. The tissue which is occasionally seen mixed with it in expectorated matter, is disintegrated lung (Andrew Clarke), and only means that so much pulmonary structure has been destroyed. Tubercle is only capable of extension by 112 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. VIII. Extends by in- crease of deposit,not by growth. Destruc- tive changes, chemical not vital. Grey va- riety tends to cure or chronicity — why ? Yellow tends to greater rajjidity and danger. Four con- ditions of the stage of deposit recognis- able in practice. Absorption of the deposit. The depo- sit remains unchanged an increase of the morbid matter exuded, it has no power of growth, as cancer. The destructive change which takes place in tubercle is not a vital act, but is determined by a ' conversion of the chemical com- ponents arising out of an interchange of the elements.'* Such is a brief summary of the leading facts about the nature of tubercle, on which the greatest number of the best observers seems to be agreed. We have thus at least two varieties of deposit, which exhibit differences on which may depend the most important results. The grey scattered tubercles may remain in the lung for years, causing Httle irri- tation, having very slight tendencies to undergo che- mical alterations of a destructive character, but retain- ing a possibility of undergoing absorption of a portion of their components. In this change they may dry and be converted into horny matters, or be decomposed and leave only a chalky residue. We have here the ele- ments of chronicity in the stage of deposit, and such result is found in multitudes of cases in practice. The other form of tubercle, from its tendency to mass itself together, and from its greater inherent proclivity to undergo destructive changes, contains most obvious elements of rapidity and danger. Eemembering, then, the tendencies of these varieties of tubercle, let us examine the history of our cases. We shall find, in analysing numerous instances of the stage of deposit, that four conditions are possible : — 1. An absorption of the deposit, leaving the lung- structure uninjured, while the constitutional symptoms wholly subside. 2. The deposit remains unchanged in the lung, and is simply tolerated for an indefinite time, the tubercle not causing any local irritation of importance, and the constitutional symptoms subsiding. Also, no further deposit takes place. * RoMtansky, edit. Syd., vol. i. p. 299. THE FIRST STAGE — ITS NATUEE AND EESULTS. 113 3. An alteration in the deposit, by which its animal chap. portion is absorbed, and the earthy alone remains; tlie ■ -,— ^ chano-e being; accompanied by a termination or a mate- Chemical .-,?.. "r" P 1 • T 1 rrn • f • alterations rial diminution or the systemic chsorder. Ihis lorm is in tiie either complete or partial ; in the first instance, the "^^p"^'*- cretified tubercle is expectorated, and the injury to the lung repaired ; or it may remain imbedded in the lung for years, causing neither local irritation nor constitu- tional disturbance. In the partial recoveries due to Partial re- cretifaction the systemic disease continues, and at some due to ^ indefinite period a second crop of tubercle is deposited, c|iemicai I- \ ■•■ ' changes in part of which, at least, continues to undergo similar thetu- changes to the first, and the patient expectorates chalky ^^° ''^' matters, while some of the tubercular masses soften, and a mixed condition remains, exhibiting both the tenden- cies to cure manifested by the cretifaction of successive deposits, and the local and constitutional symptoms due to the ordinary process of softening. 4. The fourth termination of the first stage of Destmc- phthisis is the most common, and consists in the ei^ng° aggregation into masses or groups of the single tubercles, which disentegrate and soften, involving the neighbouring structures of the lung in this destruc- tive process. The most advanced pathology recognises these results, and a philosophic prognosis must include the possibility and relative probability of their occurrence. It win be now our duty to examine the evidence on which each of them rests, and the circumstances in individual cases which render one or other of them the termination most hkely to ensue. The causes most influential, if not absolutely the Causes only ones concerned in leading to one or other of Auence^the the four results, appear to be the following : — ^'^y ^^' 1. The nature of the tubercle deposited. 2. The form in which it is deposited. I 114 ELEMENTS OF PROGNOSIS IN CONSUMPTION CHAP. 3. The degree of irritation or inflammation of tlie VTTT • ._ . ' ^ surrounding structures. 4. The cessation or continuance, or the revival of the constitutional disorder, v^hich produced the tubercle. FIRST STAGE — THE DEPOSIT ABSORBED. 115 CHAPTEE IX. FIRST STAGE — THE DEPOSIT ABSORBED. The possibility of the complete absorption of the chap. deposit of tubercle in the lung does not rest on the ^ ^'^' - same kind of evidence as the other propositions. As Complete we cannot demonstrate the existence of tubercle in the of thT ^'^^ living luno; neither can we assert the fact of its removal } indefinite long periods Total CO Of these tliirty-eight were associated with the second stage of phthisis, and twenty-two with the third stage. State on leaving hospital. Better . 19 Worse (two dead) . . . .17 Stationary 24 Total 60 This sign is therefore not only often found as a cha- racteristic of slow first stage, but when associated with signs of more advanced disease in the lung, may even then be accepted as indicative of a tendency to pro- longation and chronicity. CHAP. X. 134 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. X. Left more frequently the seat. Associated affections. In 238 cases tlie localisation of this sign was ascer- tained to be — On tlie left side in On both sides in Total 166 cases 56 „ 238 In only 20 instances out of 238 was it found that other affections were or had been present. They were as follows, and do not possess much value : Morbus cordis . . in 6 cases Taenia • ' „ ^ „ Pleurisy . V 3 „ Struma . 2 Illieumatism . J? 3 jj Anaemic murmur ?> 3 li Ague „ 1 case. Total 20 Physical signs aris- ina: from highest A'aliie. Viewed as a whole, those physical signs are of liighest value which arise from the irritation of lung tissue, lung of the ^^^^ ^^^^J ^^ Called inflammatory. ' Induration of tissue rather than the tubercle, is the cause of the physical signs in the first stage ; ' * and we may add that it is also the key to the prognosis. If we could deduct the inflammatory element from the local disorder, the residual tubercular deposit might be tolerated for years ; and whether such deposit softens from an in- herent tendency to decay, and in so softening irritates the lung, or from inflammatory actions induced in the surrounding tissues, it is certain that the degree of the lung irritation is the measure in direct ratio of the de- structive rapidity of the case. It is in this light alone that physical signs become serviceable in prognosis, and they are never to be regarded as an exact measure of the quantity of tubercular deposit, but rather of this Walshe. Ed. 3rd. 1800. LOCALISATION OF TUBERCLE. 135 — plus the products of inflammation in the various chap, structures of the knig.* , -^- . The locahsation of the deposit possesses much interest Locaiisa- in a prognostic point of view. The relative frequency d°poSt.* '° of tubercle commencing on the right and left sides has been calculated, but to little purpose. Laennec thinks the right lung more frequently affected, Louis the left, ps^^* and Cotton the left.f Softening begins more frequently on the left (Cotton and Walshe), and my own observations confirm this, but for the first stage this consideration has sHght prognostic value. J Somewhat more important is the part of the lung The part of invaded. In the vast majority of cases tubercle is first ^""s ™°^'° .,. 1TT--1T important. deposited m one or other apex, it begins m the base much more rarely ; in two cases only in the thousand analysed by Dr. Cotton, and ' once in sixty or eighty cases ' by Walshe. I have found sixty-four cases in a total of 4,530, with the physical signs most marked, signs at from the commencement, at the base. Analysis of sixty-four cases in which the physical signs were at the base of the lung. Of these fifty were males, and fourteen were females. In the first stage were 3 cases. . second „ 59 „ third „ 2 „ The apices of the lungs were clear in 32 cases. Signs of incipient disease in apex 32 „ * The same remark applies to the vital capacity of the chest, as ascertained in Hutchinson's experiments with the spirometer. The average reduction of respiratory space in the first stage of phthisis was found to be 30 per cent. t Softening generally begins at the posterior part of the apex. J Stokes has seen more recoveries when the disease was confined to the right Imig. base. 136 ELEMENTS OP PROGNOSIS IN CONSUMPTION. The duration of these cases up to the time when they were last seen was as follows : — Duration 6 months 1 year 1| years 2 „ 2^ „ 3 „ No. of cases 6 16 7 6 9 2 Duration 4 years . 5 „ . 6 „ . . . 10 „ . .. Chronic indefinite periods No. of cases 2 1 2 2 13 Total 64 State on leaving hospital. Better 19 Stationary 14 Worse 20 Once seen . . . . .. ,11 Total . . 64 1 infer from these cases that a primary development of tubercle in the base of the lung tends to chronicity. The average duration of ' ordinary ' phthisis while under observation was found to be 15-22 months, while that of disease at the base of the lung is 2 6 '3 5 months. As the ages may prove interesting I subjoin them. Age and sex of cases of disease cor^imencing at the base of the lung. Age Males— No. of Pemales— No. of 20 years 2 2 25 „ 3 3 30 „ 12 2 35 „ 5 1 40 „ 8 1 45 „ 11 3 50 „ 3 2 55 „ 4 61 „ 1 64 „ 1 Totals 50 14 PHYSICAL SIGNS AT THE BASE. 137 The comparative infrequency of tubercle commencing chap. at the base of the lung in females is worthy of remark. , -^ . The age at which such exceptional instances occur Signs at most commonly would appear to be from thirty to hffemaies. fifty-five ; there were none under twenty. This may be common at accounted for by the abstraction from this table of the age ad- cases described as ' strumous phthisis,' in 300 of which ^^^^^^ ' forty-six presented the chief physical signs at the base of the lung, most of them being under the age of twenty. In this latter form I have also observed that the cases were ordinarily of a prolonged character, so that the general truth may be assumed, that tubercle beginning at the base of the lung is commonly slow in progress. And this is to be regarded as only one illustration of a Law affect- law elsewhere referred to, that in proportion as phthisis S.*^^^" deviates from its ordinary and well-knoiun course^ in so much does it tend to he prolonged beyond its average duration.^ The value of symptoms as prognostics has shortly to Value of be considered. Z^^Z- Hasmoptysis is often one of the earliest, always the t^'''^- most alarming to the patient. It occurs in about 63 Hsemo- ptysis. * There is a low form of partial pneumonia, generally attacking and limited to one base, beginning with insidious symptoms of a lowered state of health, and remaining persistently for some weeks or even months, which is very apt to be mistaken for an attack of tubercle. It occurs chiefly in men about middle life, engaged in anxious occupations, as merchants, medical men, &c., Avho, neglecting the early symptoms of disordered health, continue at the wheel in spite of feelings of great muscular weakness, disorder of digestion, and a subfebrile state. The signs are those of pleuro-pneumonia of one base (the right perhaps more commpnly). The evidence of solidification, more or less perfect, will be found in dulness, tubular breath sounds, &c., which are succeeded by a subcrepitant rhonchus, slow to disappear or resolve. There is slight cough, dyspnoea, but not rusty sputa. The general health is much disordered, and a pyi'exial state always prevails. Though very slow, these cases will get veil if treated by perfect rest, change of air, liberal diet, and a fair allowance of stimulants, regulation of the secretions, and comiter-irritatiou repeated over the affected part. I have witnessed several complete recoveries, the physical signs entirely disappearing, and ' the health beinp: restored. 138 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. Its cause. Hsemo- ptysis a relief. Influence ofqiiantity. Profuse haemo- ptysis. Its influ- ence. per cent, of all cases of plithisis, and is more frequent as 3 to 1 in the first stage.* It is due at this period to extreme congestion of the pulmonary vessels, arising from the local inflammatory action accompanying the deposit of tubercle, and from pressure on the pul- monary veins. It is analogous to pulmonary apoplexy. It is rare in early hfe, more common from twenty to forty. Its quantity may vary from a streak to a pro- fuse loss to be measured by cupfuls. It cannot be accounted for by breach of surface in the lung or vessels, such as occurs in the second or third stages of phthisis, but is plainly the result of an intense conges- tion. Viewed in this fight it is undoubtedly a relief to the local disorder, and this result is certainly witnessed in the later stages of phthisis, when we often see the patient relieved from distressing cough, dyspnoea, and pain, and the fever subside after a moderate hasmo- ptysis. Our present question is, does it equally relieve the lung in the stage of deposit ? We believe that this can be answered affirmatively, and the opinion is con- firmed by practice and authorised by theory.^ The amount of the haemoptysis involves other considera- tions. If quantity is to be considered as evidence of the degree of congestion, cases of profuse loss should turn out unfavourably, unless indeed the relief fr-om the depletion should more than counterbalance the ill effects of the great intensity of the vascular turgescence which preceded and gave rise to it. I have observed 351 cases of profuse hasmoptysis, of which 204, or more than one half, occurred in the first three months of the illness, so that this symptom is by no means rare at the beginning of phthisis. In twenty- eight instances it took place between the third and sixth * 1st Medical Eeport of Hospital for Consumption. 1849. t See chapter on Acute Phthisis, where it is shown that haemoptysis is more rare in that form of the disease. See also chapter on Heemo- ptysis. INFLUENCE OF HiEMOPTYSIS. 139 month, and in thirty-eiglit between six months and one chap. year. In tracing the duration of all cases of profuse — -,- — - lia3moptysis, and in all stages, the average of the whole was 30'35 months while under observation. But it was observed that although the average dura- tion of the whole case was about fifteen months above that of ordinary continuous phthisis, the first stage was comparatively short, in other words, that the softening softeuiug occurred early. Out of 351 cases only forty-five had °^T'^ remained in the first stage when examined, 142 having undergone softening, while 164 had cavities. If, then, this form of the disease is ultimately rather prolonged, the retardation occurs in the second and third, and not in the first, stages. It would thus appear that con- siderable congestion of the lung is unfavourable to the quiescence of the tubercle deposited, which is rendered more prone to undergo destructive changes by this condition, and that the vascular turgescence of the part, although doubtless reheved by the loss of blood, has not been sufficiently so to comiterbalance the ill effects of the congestion. We may presume that fibrinous Fibrinous products remain, and a condition of the surroundino- ^^'^J.f^ X ^ O 1 Cllldlli • lung analogous to that caused by inflammation, which adds to the permanent mischief undergone by the organ, and which doubtless is readily involved in the softening, changes afterwards to take place in the tubercle. For these reasons an early profuse hasmoptysis is to Early pro- be regarded as a bad prognostic, the softening being hSmopty- likelv to take place early, and the remission in the ^^^ '^ ^^^4 PIT 1 -11 x)rogiiostic progress oi the cusease to occur only at a period when tor the du- ration of the first already much structural mischief has taken place.* The stage. * The prognostics to be derived from sliglit repeated liaeuiopt^'sis are on the other hand not favourable, this being- the commencement of the ordinary form of phthisis. Again, the most acute form of tubercular disease in the lung is often characterised by the absence of li£emopt3^sis. On the whole, T place little reliance ou this symptom or its absence as a prognostic, altliough I have felt bound to give the reader the result of my investigations. 140 ELEMENTS OF PROGNOSIS IN CONSUMPTION. 'CHAP. X. Tendency to repeti- tion. Fever. Gastric symptoms. Eapid waste. tendency to its repetition is also to be remembered. This occurred in 151 instances out of 351 cases. In every instance of fatal liosmoptysis wliicli I have wit- nessed there had been previous attacks. From the nature of the cough and matters expecto- rated there is little to gather for prognostic purposes in this stage. The nature and intensity of the fever has been already dwelt on in the preceding chapter, and need not be repeated. Uniformly high pulse, one or even two exacerbations of fever in the twelve hours ; a hot skin ; chills, frequent and followed by partial sweats, are of evil import unless they steadily subside after a maximum of intensity. The same may be said of gastric symptoms of severity, thirst, nausea, anorexia, red tongue, vomiting, diarrhoea. The febrile condition united to these fea- tures of disease constitutes acute phthisis, . and their continuity means death. Eapid waste of flesh deserves notice. Sudden great alterations in weight are perilous, and in phthisis they generally occur in persons who have been in rather full flesh. The most rapid reduction I have witnessed (and verified) took place in three months, from 12 st. b^ lbs. to 8 St. 5 J lbs., a loss of 4 st. ! 1 have care- fully examined twenty-eight such cases. No. of cases 1 stone 1| stone 2 stone 24 stone 3 stone 4 stone In 5 weeks 1 had lost 1 ,, 2 months 4 „ respec- tively — 1 2 — 1 „ 3 „ 7 „ 1 2 1 — 1 1 „ 4 „ 3 „ — — 2 — 1 ,, 6 „ 3 „ — 1 1 1 ,. 8 „ 1 „ — — — — 1 „ 9 „ 1 „ — 1 „ 10 » 3 „ 1 1 1 „ 12 „ 5 „ „ 1 — 1 — 2 1 Total cases 28 RAPID REDUCTION OF WEIGHT. 141 The lowest weight when in health of any of these chap. individuals was 10 st. He lost in five weeks IJ st. ^_ ^/ . The rest averaged 12 st., and one was 14 st. 10 lbs., who lost 3 st. in eight months ; another whose healthy- weight had been 13 st. was reduced to 10 st. in three months. Twenty out of the twenty-eight examined were between twenty-five and thirty-five years of age. Six were in the first stage, ten in the second, and twelve in the third stage of phthisis when examined, showing that the period of deposit was exceedingly short, and the softening and destructive processes accelerated. The proposition may perhaps be laid down, that rapid and considerable- emaciation in the early stage of phthisis is indicative of local changes in the lung of corresponding speed, and that persons of Persons in full flesh becoming tuberculous are more likely to have nkety to the acute than the latent or insidious form of the '^^^'•^^^ rapid form disease. The converse of this proposition when apphed ofphtiiisis. to the later stages of phthisis is not always true, namely, that in cases where flesh is regained the tu- bercular disease in the lung improves pari passu. It may do so, but more commonly the lung affection remains stationary while the nutrition of the body increases. It may further be remarked that the great- Males most SU.D1 GCt to est and most rapid reduction of weight took place in rapid re- males duction of maiLs. ^ ^ ^ ^ weight. The following propositions comprise a summary of summary the elements of prognosis in a given case of phthisis ^e^Qt*sof^' in the first stage : — prognosis 1. Of the two kinds of deposit, scattered and aggre- stage! gated tubercles, the latter is the more serious. 2. The physical condition of the lung is never to be regarded singly and without reference to the symptoms. 3. The physical signs resolve themselves into those indicative of simple deposit, and those arising from irritation of the lung. 142 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. 4. Moderate duliiess of the percussion note, and ^ — ^ — - alterations in the intensity and duration of the respira- tory murmurs, but cliiefiy of the expiration, have reference more especially to the tubercle deposited. 5. A tubular quahty of the respiration, dry crepi- tation and crackling, with sibilant and other rhonchi, combined with a more intense dulness of the percussion note, may be referred to the greater condensation of the lung from inflammatory products, and to irritation of the minutest air vesicles. This class of signs, if per- sistent, is the more grave. Li certain instances they are capable of removal by local depletion, while the former are permanent. 6. Wavy inspiration, if a single sign, is of doubtful import ; but if long persistent, generally means slow phthisis. 7. Wavy inspiration, if accompanied by the signs referable to condensation of the lung tissue from in- flammatory products, is indicative of rapid phthisis. 8. Alterations in the chest walls in the first stage indicate an already long-existent cause, and are not unfavourable prognostics for duration. 9. A deposit in the apex (the ordinary form) is more likely to undergo rapid changes than a similar condition at the base of the lung. 10. Deposits at the base occur most frequently in children (the strumous form), and in adults about middle age. This form is rare in females, and generally means slow phthisis. 11. Hasmoptysis in the first stage indicates conges- tion of the lung. When profuse, its , import is bad, as implying a likeliliood of the rapid passage of the tubercle into the second stao;e. o 12. Cases of profuse hasmoptysis in the first stage may afterwards become chronic, and the average dura- tion of cases so commencing is above that of ordinary phthisis. FirxST STAGE — SUMMARY OF TROGNOSTICS. 143 13. Profuse haemoptysis is likely to be repeated in chap. the later stages, and so forms an element of danger. . -^- 14. The intensity of the fever and absence of com- plete remissions, with gastric symptoms of severity, taken, together, indicate rapid phthisis. The extent of physical signs is here of less moment than the symptoms. 15. Eapid waste of flesh, especially when occurring in persons rather above the average weight, is a bad prognostic; males are most subject to rapid reduction of weight. The following cases illustrate the marks on wavy inspiratory sound : — Sarah R. set. 15. Dark hair and eyes, well formed, cata- Case, inenia established some months, colour good, in good flesh, looks rather plump. This girl has been under my care p . for seven years. In 1856 she presented the physical signs physical of dulness, prolonged expiration, and rough inspiratory ^^8'"^ ^o^' ^ murmur under the clavicle, with much increase of vocal re- General sonance in the supraspinous fossa on the right side, and health had cough and expectoration with much loss of flesh. Her ^°'^'' " appetite and digestion were excellent, and she was well nourished and carefully attended to. There have been seve- ral cases of phthisis on the mother's side, and one sister died of the disease under my care. She now, July 1863 [seven years later), presents the physical signs of very markedly tuavy inspiration, persistent on cough, and great roughness of the inspiratory tone on the right side, with the same signs {less pronounced hut evident) on the left. The percussion note slightly didl on both sides. She has some cough but no expectoration, no dyspncea, and looks in all respects in perfect health. She took cod liver oil for five years, 3ij' three times a day. A. T. A pale anemic girl, aet. 17, without predisposition Persistem to phthisis, was examined by me in June 1858. She was out r ^* ^*^g^ of flesh but of spare habit ; no cough, expectoration, or passing in- fever. Catamenia irreg^ular : once in two months : always ^° second scanty. Phy. signs: — Chest rather flat, movements equal, sent dura- fair, no comparative dulness but general tone rather flat. ^^°^J 144 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. Slightly wavy inspiration which vanishes on cough in left ^^- subclavicular space. She was ordered iron, horse exercise, hip baths, and full meat diet. In May 1859, marked tvavy inspiration persistent after cough, from clavicle to Srd rib left ; general health improved ; catamenia still absent. Went to Eaux Bonnes in France at my request. In August same year examined on her return. Ctma. still absent; general health good ; has gained flesh. Phy. signs : Rough dry in- spiration still observable in left apex, the wavy character has ceased. December 1859, 'Cough without fever' is the report. In March 1860 she had caught cold, and had severe pain in left side with much hectic. Phy. signs : dul- ness with humid crepitation over nearly the whole of the left side, extending almost to the base posteriorly. She recovered from this almost fatal illness, and in the winter went to Algiers. In May 1861 she came back to England, had gained 5 lb. in weight and much in strength. She has had a liberal diet with wine, horse exercise, cough often troublesome, expectoration very slight, gij. in day. Cata- menia still absent. Has taken oil and steel constantly. Phy. signs : Slight dulness, impaired mobility, deficient respiration chiefly about the base, occasioned subcrepitant rale left side, in 1861 she went to Madeira for the winter, where Dr. Lund reports : 'Miss T. arrived here in a very favourable state, tolerably stout, fresh coloured, pulse 72 ; catamenia returned for two months. At the end of Decem- ber the pulse began to rise, the expectoration was white and flocculent, the cough became intractable. Subcrepitant rale well viarked at base of left lung. In March large rale in left with increase of expectoration.' In June 1862 I examined her, and found dulness, coarse dry crepitation under the clavicle, in the supraspinous fossa, and by the side of the scapula nearly to the base. The respiration is tubidar opposite the Tniddle of the scapula near to the spine, the axillary base clear, slight flattening of the chest walls in the subclavicular space. In October 1862 there was rather fine humid crepitus extending beloiv the scapida to the base ; manifest increase of cough, no fever, ctma. again absent three months. To go to Ventnor for the winter. She got on pretty well here, but the cough has become more constant with increased expectoration. Phy. signs. May CASES — FIRST STAGE. 145 1865, are crackling crepitation over the whole 'posterior chap. aspect of the lung, and to about the 4:th rib anteriorly, , ^ _. also in axilla. There is decided improvement in strength, and she is in fair flesh. No fever, app. good, has not taken oil lately; she is able to enjoy society and moves about a good deal in summer. Throughout the whole period from 1858 she has taken oil and iron pretty regularly, and counter- irritation has been freely used over the side. It is to be noted in this instructive case, that the disease was not here- ditary, that the earliest symptoms were those of anaemia, the earliest sign the wavy inspiration, and that but for the intervention of the acute attack in 1860 she might have remained in her former state for years. The gradual altera- tion in the physical signs is worthy of note. There has never been haemoptysis. E. H. set. 27, shopwoman. Brother and cousins d. of pht. 7 years. Hsemopty. seven years ago when 0. P. at this hospital, also two years ago, and occasionally ever since. Cough seven years, slight but constant. Spare and loses flesh lately, but not much. Chills and slight sweats. Ctma. reg. but scanty. App. poor, bowels rather loose, tenderness and pain in r. subclav. blowing resp. and vocal res. increased apex right, tvavy insp. left subclar. Improved much on oil. J. B. set. 32, tailor. No predisp. to pht., out of health six Waw R. or seven years, has habitual si. morning cough, no expec- Rheumatic toration, much nausea, acidity ; is a good deal out of flesh and looks much out of health; marked wavy respn. dry whiffing left subclav. ; pains in left side. By counter- irritation and saline treatment he lost his cough. In the winter he had rheumatic fever. Sign persistent after recovery. C. C. ast 19, f. No pred. to pht., hsemopt. a cupful six Wavy, years ago ; was In-Patient twice four years ago ; habitual cough, generally slight, but worse lately. Is now losing flesh and strength, but has done so on former occasions with re- Chronic covery. Rough dry blowing insp. and exp. right subclav. years. Rough wavy inspir. left. Has taken much oil. Discharged much improved in health three months later. A. W. set. 21, dressmaker. Mother and sister died of pht. Advancing Has had cough for years, no hsemopty., much hectic, profuse P^^t^^isis. expect,, t. coated, diarrhoea, thirst. Diminished mob. flattg. ^^"^^ bronchophony, humid crep. at apex, luavy insp. very Death. L 146 ELEMENTS OP PEOGNOSIS IN CONSUMPTION". CHAP. X. Wavy re- placed by other signs of stage of deposit. "Wavy re- placed by crepitus ; progress to cavities rapid. Limited cavity in one lung ; wavy in other; fair health. 11 years ; wavy in front, and softening at the back of leftlung; rapidly worse. Pirst stnge 7 years; re- placed by marked below this to the base right, rough wavy insp. subclav. left. Rapid increase of all symptoms, and death three months later. E. K. eet. 36, compositor. Mother and brothers d. of pht. ; dry cough and dyspnoea four months ; slight expect., loses flesh and strength, no fever, digestion impaired ; movements good, dulness and dry luavy resp., opp. Mh rib left, dulness and bronchophony, apex right. Improved much on qui- nine. Left town and took work in Bedfordshire ; returned three years later and was examined. The sounds ivere rough and blowing, resp. at the left, the vjaviness had disap- peared. His health was again bad, but he left London three months later much improved ; duration 4^ years. J. E. set. 25, clerk. Mother, uncle, and aunt d. of pht. ; slight cough for some years, no hsemopty., expect, lately more abundant, thick, is a good deal wasted, had sweats some weeks ago, no diarrh., app. fair, movements good, per- cussion even ; slightly wavy insp. and prolonged exp. left. Ordered oil, iodine solut. to the left, three glasses of wine in day. In January the ivavy sound was replaced by humid (n^epitus, and in July there was a cavity in each lung. C, G. set. 21, f. Aunt d. of pht.; complains of weakness for one year ; cough severe in autumn, again in spring, absent in summer ; hsemopty. slight, frequent ; no expect, for some time past, embonpoint good but has lost, app. fair, b. reg., no fever ; has taken oil one year ; gurgling and cavernous blowing, &c., for some inches subclav. left (^clear below this), dry rough ivavy resp., apex H^/t^, weighs 8*1^ ; went to Hastings, gained 12 lb., in six weeks. Seen one year later in fair health and flesh, scarcely any cough ; still taking oil. Gr. M. set. 35, carpenter. No predisp. hsemopty. mod. eleven years ago, five years ago, and last week ; cough habi- tual, remains spare but not much wasted, no present fever, digestion good. D. humid crepitus, extensive over front right : wavy inspir. and rough character of r. subcla. tuith humid crep. in the suprasp. fossa left ; has taken much oil ; repeated hasmoptysis occurred, and he left much worse. W, R. set. 30, painter. No predisp., has been an Out-P. here for seven years, he has habitual cough, slight dark expect., locks out of health but never loses flesh to any great WAVY INSPIRATORY SOUNDS. 147 extent. Piiy- signs : Dulness^ dry, tubular, wavy, inspi. CHAP. and exp. prolonged both apices. In the eighth year of his . / . attendance the wavy sound on the left was replaced by humid moist crepitus, but he^ rallied from this after a considerable reduc- !^" g.^j ^" tion of strength^ and his state again became chronic. year. 148 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAPTEE XI. CHRONIC FIRST STAGE : THE DEPOSIT TOLERATED. Two varie- ties. 1. Neither local nor systemic symptoms. 2. Slight irritation of lung with recur- rent febrile attacks. The conditions of this form are, that the deposit in the lung remains unchanged, and is tolerated for an indefinite time, the tubercle not causing any local irri- tation of importance, and the constitutional symptoms subsiding ; also, that no further deposit takes place. The patient, in such a state, has undergone an attack of tubercle, which has neither been absorbed nor altered in its chemical composition, nor has undergone soften- ing changes. There are two varieties to be observed. 1. In which the patient is as nearly as possible in his original state of health, with a tolerated deposit in the lung, there being neither systemic disorder nor symptoms of local disease, as cough, expectoration, dyspnoea ; but only generally a lowered state of vital powers, which indicates rather an illness undergone than present disease. The physical signs of deposit in the lung are permanent. 2. The second variety is rather one of long continued slight irritative disease in the lung ; which is reflected in the system, by reduced strength and subfebrile attacks, and is observable as lung disease by cough, expec- toration, dyspnoea, &c. The physical state of the lung shows phthisis (1), but indicates no advance or progres- sive destructive changes. There may be, and commonly is, a successive slight gradual increase in the amount of the morbid deposit, showing a continuance of the con- CHRONIC FIRST STAGE : THE DEPOSIT TOLERATED, 149 stitutional dyscrasis. This occurs during accesses of ill- chap. ness, with febrile disorder. ^ ^^- ^ Both these forms may end in softening and its con- comitant symptoms, and such is the result in a very large majority of the cases ; but it is possible for the patient to die of some non-tubercular disease. The first variety constitutes what has often been The first described as ' latent phthisis.' It may either commence ^^^^®*^' silently with the symptoms of emaciation, slowly pro- Maycom- gressive, and occasional febrile attacks, and digestion ^^^^'jj much disturbed ; or it may attack with symptoms of great severity, wasting, hectic, haemoptysis, irritative o^^tii cough, and all the physical signs of a deposit, generally toms^wS in the apex of the lung ; and, after proceeding so far, ^'^^^^'^^• every active disorder of health may cease, and the patient regain vigour and flesh up to a certain point, and lose his cough altogether. An occasional and rare ex- pectoration, chiefly of mucous matters, may mark a tendency to irritation of the lung. Such individuals vital are capable of performing most of the duties of active go™ hfe, and are often unconscious of any ailment for successive years. They are to be met with in the pulpit, and complain only of the after fatigue of pro- longed duties ; on the Exchange, where only extra hours, extra anxiety and excitement seem to tell on them more than on other men ; in our own active profes- sion, eager in the fight for fame and position, and only remembering a long-passed symptom of suspicious omen, when some overstrain has been apphed to the machine ; on the mountain side in Scotland and Swit- zerland, where they are occasionally pulled up by dyspnoea or hasmoptysis, and the cause has to be looked for in a forgotten ailment, dating years back. Some- times they run on to old age, when at sixty-five or ^ayiive seventy the lung exhibits signs of irritation once more, when if-' and a progressive emaciation is the first sign of mis- become^^ chief, to be followed by dyspnoea and cough. The more ^'^^i^^- 150 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, fortunate in worcUy means, who can select their homes v..^ ^^^ where they hke, and have no ties to country or chmate, are to be found on the Mle in boats, enjoying that dry and tranquil climate ; in Italy, among her ruins and galleries ; in Madeira, Africa, and Australia ; some in the far Pacific Islands ; others in Canada and Norway ; in the Hebrides and in India ; in the latest fashionable resorts of Mentone or Arcachon, or wherever enter- prise has undertaken to establish a sanitary home with agreeable surroundings ; on the long voyages to the Antipodes, and in our splendid steamers on the Mediter- ranean. And yet, wherever they are met with, they are sure to be in the right place, or on the way to it, and they worship an imaginary specific climate, which is to surpass the last forsaken, and reinstate the valetu- dinarian traveller. Withal, there is a consciousness that they are never quite well, and that the enemy has one foot in the citadel. Yet, with the invigorated nervous system, the improved digestion and nutrition which such changes and exercises imply, they are among the most agreeable of our travellers ; and althougli conscious of a flaw in the vital machine, this ' worn feeling has peopled many a page ' with rare narratives of scenery and ad- ventures in every remote and interesting corner of the globe. They are the condemned of the auscultators, having received a verdict from a fashionable physician fifteen or twenty years ago, and set to work like wise men to convert his faithful warning into a falsehood. One who seemed in perfect health and vigour, is a prosperous trader in a remote part of Africa, where he liad gone after an haemoptysis and an adverse opinion ; and having found his health south of the pillars of Hercules, has married and traded, and settled some twenty-five years ago, and bids fair to hve twenty more. Yet, when with stethoscope in hand I had detected feeble respiration, prolonged expiration, dull percussion, &c., under the right clavicle, and remembered that I was CHRONIC FIRST STAGE : THE DEPOSIT TOLERATED. 1 51 acting as referee for an insurance company, I had to pass chap. the inevitable condemnation, and dechne his payments - i,-^ - for my cUents. What tlien is the vahie of such a hfe ? and what its future ? Is there an inevitable fate attached to such a history and pliysical condition of the lung ? The truth must be told. These persons generally die of consumption, and sometimes break up most rapidly. The later stages of their disease are out of all propor- tion in speed to the middle period. An acute invasion if disease of tubercle may end in a tolerated first stage of years' nated^with duration ; but a renewal of irritation in the lung, when acutesymp- it does occur, is generally again acute. These two wk up facts are to be remembered in our prognosis. generaUy In this tolerated and prolonged first stage, without distinct lung symptoms, we have to remark : — 1. That the cause of the phenomena observed is to Cause of be sought for in the cessation of the tubercular blood fiJsJ°s°t?e disease, which seems to expand itself in the first violent attack on the lung. The further deposition of tubercle is arrested, and the deposit is tolerated because the temic"dTs- nutritive processes have resumed a healthy activity. It is the continuity of the morbid condition which pro- duced the original crop of tubercles, leading to succes- sive deposits in the lung, which stamps the fatal character on ordinary phthisis, and it is the cessation of this blood disorder which enables an individual to tolerate one attack of limited tubercular deposit. 2. The local irritation or inflammatory action in the Local im- lung tissue must have ceased in order to ensure this *^*^°° ^^^ tolerance. Hectic is the measure not of the amount of tubercle, but of the extent of irritation in the lung. These two conditions are essential to the form of phthisis now considered. 3. The digestive system must not only not have Digestion suffered in the early stasje of invasion of the disease ^^^^ ^^ . -, . „ . , '.^^^, unim- but must have remamed m fair order. This has been paired, the characteristic feature of every case of very ease has ceased. 152 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, prolonged life in all stages of phthisis which I have •_ ^ . witnessed. Description The actual State of such patients is generally this : °t^ [e *^^^'*^' ^^^'^ fever ceases, the health improves, the waste of flesh stops, but the patient never regains full flesh. Some error of sanguification has never been retrieved. A tolerable amount of vigour remains, but he is not able for extraordinary exertions. The pulse is quiet, but capable of excitement more than it should be. According to my observation in this and other countries, the patient (if such he can be called) is not so susceptible as others to epidemic diseases, or fevers of malarious origin. He generally escapes the maladies of his neighbours, and perhaps in this carries about with him a compensation for his primary illness, and therefore has cause for thankfulness.* But he cannot bear any extra strain on the vital machinery. Prolonged exertions of mind or body, or tampering with insalubrious habits, late hours over the desk, the excitement of political, fashionable, or professional life ; the struggle in which physical power commands suc- cess as much as intellectual superiority, are not for him, unless the heavy penalty of renewed blood disorder and relighted local mischief is paid for it ! The characteristics of such individuals are to be noted. They have no hereditary taint in general, although occasional instances of the transmitted disease may be found in this class. I have observed them of temjera- ^wo tcmpcramcnts. Either they have been originally ments. spare with high vitality, mental intelligence active or even brilliant, and the sanguine element strongly deve- loped ; or the lymphatic habit prevails, feeble pulse, slow cii^culation, inactive body, mental powers good but placid ; often intellectual vigour as contrasted with brilliancy. Of the two, I believe the latter tends most * Every misery that I miss is a new mercy. — The Complete Angler, by Izaac Walton. Lond. Ed., 1808. p. 330. CHRONIC FIRST STAGE : THE DEPOSIT TOLERATED. 153 to the prolonged first stage, while the former, if chap. attaining much chronicity in lung disease, will be found ■ — -^^ — - with tolerated cavity, the local disorder having reached a further stage in the outset, and then paused. The physical conditions should indicate a limited Double deposit in one lung. A double afiection rarely attains rarely chronicity in any stas^e of tubercle. By the term *^^*^^°®.^ ' limit ' is to be understood not only that the deposit is of slight extent, say to the second, or at most the Deposit third, rib, but that the physical signs stop abruptly there, and that pure vesicular breathing is heard to the base, both in the afiected and in the opposite lung. The second variety which I have described as one of The second long-continued slight irritation of the lung, the physical described, signs indicating unsoftened deposit, is attended neces- sarily with more disorder of health than the first. This class of persons are invalids of necessity, and are capable of far less active employment in life, and of much fewer of its pleasures from travel and variety, than the first. In truth, the constitutional disorder has never wholly ceased in them, and successive sUght Systemic deposits, possibly of a few tubercles at a time, keep up never a low irritative systemic disquiet, and never permit leased the original local disease to become wholly quiescent. There are frequent attacks of a febrile nature, partial Frequent sweatings which subside, a generally hot skin, and attacks. occasional accelerations of pulse. These symptoms are referred by the invahd to cold, but they are not of the nature of catarrh, nor yet of bronchitis. It is true that persons so afiected are Httle tolerant of cold, moist air ; they are habitually chiUy, and are very susceptible of atmospheric changes ; but their malaise is due to Their blood changes imperfectly performed, to a subfebrile ^^t^^®- state dependent on the tubercular diathesis, and to the local established disease in the lung, rather than to the phenomena of ordinary cold-catching. They are subject to congestion of the lung from these influences, 154 ELEMENTS OP PKOGNOSIS IN CONSUMPTION. CHAP. XI. Great liability to pass into the second stage. and their so-called attacks are referable to this cause. An occasional blood-spitting occurs, and at such times the physical signs become more intense, and some form of subcrepitant rale indicates the irritative action which has been set up. But quiet, local depletion or counter- irritation, and coohng sahne remedies, will "generally restore the patient to his former condition, and alter the physical signs to those proper to a quiescent deposit without softening changes. This is the more favour- able result of such attacks, but, in truth, such patients are in constant peril, and may at any moment pass into the second stage of phthisis. I subjoin some details regarding this class of cases, and first give a statement of the sex, age, and duration while under observation. Table showing the ages and sexes of 286 cases of phthisis in the first stage, which had already attained a dura- tion 0/ 18 months and upiuards. Ages No. of Cases. No. of Cases. Males Pemales From 10 to 15 4 6 „ 15 to 20 16 11 „ 20 to 25 31 31 „ 26 to 30 25 38 „ 30 to 35 22 27 „ 35 to 40 16 19 „ 40 to 45 14 16 „ 45 to 60 2 8 „ 60 to 55 „ 60 to 65 1 Totals . 131 155 CimONlC FIRST STAGE : THE DEPOSIT TOLERATED. 155 Table showing the duration to which 286 cases of phthisis in the first stage had already attained when last seen. CHAP XI. Duration already attained 1^ years 2" „ H „ 3 ,, 3^ „ 4 „ H „ 5 „ ' 6* „ 6 6 to 15 8 years 12 „ 20 „ Indefinite long periods Totals Males. Females. Total No. of No. of of both Cases Cases Sexes 5 3 8 11 7 18 16 23 39 11 . 7 18 13 18 31 6 9 15 10 6 16 8 8 16 5 10 15 3 7 10 7 10 17 2 7 9 1 1 2 33 39 72 131 155 286 The state on leaving was — Better * „ „ Worse „ „ Stationary 84 62 140 286 In the above, as in some other Tables given, I state the observed duration only. Each case had, in other words, already lasted the period named from the earhest symptoms of the illness which could be ascer- tained. None had died under observation, and all were seen and diagnosed by myself. Eeckoning from a former Table, f the average observed duration of each case of this class was 49*48 months. It is obvious, Average however, that this falls far short of the real duration ^^^^^°°- of such cases, reckoning up to the time of death. At the close of the period during which they remained under observation, 140, or about one half, were still in * i.e. after varying periods of treatment, from three months to some years. t See Chap, on 'Duration.' 156 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP. XI. Age, Duration equal in both sexes. Case. First stage lasting under ob- servation for 18 years. a stationary condition, that is, neither better nor worse, and therefore hkely to last for a still longer time ; and this class must, obviously, much raise the duration to be assigned to phthisis, all forms taken together. Eegarding age, it is observable that great chronicity of the first stage does not occur in very early hfe. About fifteen, the tendency to the latent form of the disease begins ; before that, our cases, especially those arising from acute or zymotic diseases, are more or less rapid, or terminate in ordinary phthisis, with only the customary tendency to prolongation. From twenty to forty-five years of age, this prolonged first stage notably prevails, and this tendency is pretty equally manifested in males and females. Of the frequent occurrence of the latent form of phthisis, no one can doubt who is familiar with practice, or with the best authorities who have written on the subject. Louis found that in 123 cases one-fifteenth were latent. Few die of the first attack of tubercle, and numbers remain with the morbid matter unchanged till a second or third attack results in a fresh deposit, at which time the first begins to soften. To the above Table must be added that composed of cases with the physical sign called ' wavy inspiration ; ' and to which, as it presents features somewhat pe- culiar, and which have been said to characterise 'slow' phthisis, I have directed particular attention. The following cases illustrate the forms of disease which we have been considering : — G-. H. B., in 1846, when aged 27, was seized with florid haemoptysis to the amount of some oz., having been previously out of health, and losing flesh for some months. He was a tall, well-made, large-chested man, with no hereditary taint. This attack was followed hy hectic, much sweating, rapid loss of flesh, and cough at first dry, but followed hy considerable mucous and partly purulent expectoration. He had pain in the right subclavicular region. At this spot, for about two CHRONIC FIEST STAGE : THE DEPOSIT TOLERATED. 157 inches, there was dulness, feeble respiration, expiration pro- CHAP. longed, and some amount of vocal resonance. Under the use , " - of counter-irritation, a generous diet, cod-liver oil, and horse exercise, he slowly regained health. In 1848 (two years later) he had again slight hsemoptysis, with a recurrence of the same . symptoms, which again subsided, and he felt for many years no uneasiness about his health, but continued to reside abroad. In 1855 (seven years later) he was again seen by me, and examined with a view to effecting an insurance on his life. This was nine years from the first attack. He was in excel- lent general health, and led an active life ; had no cough nor expectoration, and had gained flesh (though never emaciated) within the last year. The chest movements were perfect. The percussion note still dull under the right clavicle, with very deficient and rough inspiration, and marked vocal resonance. The life was declined by two London offices, with this history attached to it. In 1856, I again saw him; he had rapidly wasted, sweats at night, again coughs, has frequent slight hiemoptysis. A fine crepitus existed over the spot where formerly deposit in the lung was alone indicated. In 1864, however, he again appears in tolerable health, earnestly following business, spare, but looking wiry, able for any ordinary exertion, without cough or expectoration. The physical signs are the same as i7i 1855. 1 should remark that throughout his digestion has been good and his habits regular. Here is a case which has been under my own eye for eighteen years. Who shall assign a duration to it ? He is now 46 years of age. J. B., first under Dr. Quain in 1853, set. 34; cough from Chronic l. childhood, short breath, much slight hsemoptysis, dulness, 7years'dii- ' rough inspiration and expiration, righf In 1855 he ration. Oil came under my care ; the same signs more marked, slight loss ^""^ ^ y^-^a-t:^- of flesh, dyspnoea, cough worse ; has taken oil since 1853, which improved his appetite and digestion. He continued with variable conditions of health, but sometimes with great increase of cough, haemoptysis, and fever, till 1860, when he was tolerably well, in fair flesh, with the same physical signs and occasional distressing cough, He had taken oil for seven years. J. J. get. 28, light porter. June 1857. — No predisposition, Chronic i. couo-h for years ; now slight, and expect, lessening ; had severe Under ob- 158 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP. XI. servation 21 years ; duration indefinite. Very chronic. Chronic 1. 8^ years. sweats, which are better. Much marasmus (2). App. good, no diarrh. Chest emaciated, dulness marked, resp. of ivhif- fing character, and vocal resonance both apices ; has taken much oil, which begins to nauseate ; to take cit. ferri. ex infus. Calumbse ; sedatives for cough. Admitted In-P. in August ; gained 161b. in thirteen weeks ; took quinine and oil. Nov. — Dry tubular resp. whole left. Was once at the Convalescent Institution ; twice in the Victoria Hospital ; gained flesh, and when finally seen, in August 1859, was in tolerable flesh, but physical signs the same ; watched 2^ years ; duration very chronic. W. H. M., set. 24, compositor. No pred. ; ill some years ; cough and moderate expect. Severe sweats two ms. ago, less now ; loss of flesh and str. progressive, but rallies and gets stronger. Dulness, impaired mohiliiy, flattening, very feeble resp. subclav. left ; frequent slight haemoptysis ensued ; oil, and to go to country. Eeturned after some mths. No fever, less cough, and expectn. Eecommended sea voyage ; went to Black Sea and back ; returned in excellent health. Phy. signs as before ; no cough ; advised to emigrate to New Zealand, J. P., f., set. 19. 1857. No predisp. ; ctma. began at 11, stopped till 14, now regular; married at 17, no ch. ; cough 2^ yrs., haemoptysis at first, lately frequent ; losing flesh and str., chills, night sweats, p. rapid, app. bad, vomits, b. irreg., often loose ; o^esp. rough, tubular, exp. prolonged, voccd res. increased, dulness, slight flattening, mob. impaired at right apex. Has taken oil for 18 mths. ; ordered alkaline mixture, with gent. ; acid gall. ; emplast. lyttse. to right ; afterwards oil. Aug. 1858. — Had been much better, and lost cough, but symptoms returned, with dulness and feeble resp. at left (opposite) apex, about 4 mths. ago, when she became pregnant. Confined March 1859; very weak afterwards, much fever, cough, and haemoptysis. Lactation partial for some mths., but was obliged to give it up. Oct. 1859. — Wavy respiration left ; daily haemoptysis. Oil and quinine, with change to seaside, greatly improved her health ; she regained flesh. Feb. 1860. — Scarcely any cough, haemoptysis rare ; gains flesh. Oct. 1860. — Confined 6 weeks ago of a 6 months' stillborn child ; chest symptoms all worse, cough, fever, &c. ; moist crepitus left, replacing the fo'rmer wavy respiration. CHRONIC FIRST STAGE : THE DEPOSIT TOLERATED. 159 Dec. 1860. — Better, less cough, no fever, gains flesh. Jan. CHAP. 1861. — CalJed to see her child, set. 2, who had cough, large , -^^- •dbdoWien,diaxrh., crepitating sounds over left lung, child died convulsed 3 weeks later. May 1862. — Mother has been at Eamsgate, is much better, but looks delicate, rarely coughs, there is no crepitation at left, hid harsh resp., exp. long, and dulness as before. Has taken oil, and tr., ferri sesqui- chloride, for months. Oct. 1863. — Has gained flesh, cough oc- casional only, pain in left base, ctma. reg., digestion good ; phy. signs as last ; she is at Scarborough now. Duration up to 1863, 8-|- years. This is an instructive instance of the second variety of tubercle, viz., that in which the patient has frequent attacks, but rallies from time to time, the physical signs not passing permanently into the second stage. E. E., set. 27, male. Under Dr. Cotton two years ago ; chronic i. hsemoptysis slight, occasional, last 4 years ; expect, slight, Duration 5 occasional pain in left base ; moderate loss of flesh and str., digest, good, no predisp. to pht. ; dulness and very marked deficiency of resp., slight dry cracJde, left apex. Is at work (carpenter); continued to improve for one year under the use of oil and tonics, when attacked by pleu. of left. Duration five years. C. F. W., m., set. 25, smith. Hsemoptysis 7 years ago, and Chronic i. slight occasional ever since ; cough on lying down, and in ^"i^ition 7 morning with mod. easy expect., slightly wasted; rather gains flesh, digestion good. Rough dry inspiration, and exp. much prolonged, with dulness left sub. Lost 2 st. and 4 br. by pht. Duration 7 years. 160 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAPTEE Xn. CALCAEEOUS DEPOSITS IN THE LUNG. CHAP. XII. Calcareous transfor- mation of tubercle. Authori- ties. The frequency of the occurrence of calcareous deposits in the lung is sufficiently proved by competent ob- servers.* It is to be accepted as a proof that nature can absorb the animal portion of tubercle.f This con- version takes place most commonly in advanced life, when it is to be regarded as the residuum of a vital and prolonged struggle against consumption. Calcareous concretions of various degrees of hardness and black- ness occur in about one half of all the bodies examined at Chelsea Hospital. J Eogee, § in one hundred female bodies examined at Salpetriere over sixty years of age, found cretaceous concretions in the lung in fifty- one instances. Aret^us and Galen were the first to note the expectoration of calcareous matters. Aristotle often observed concretions in the lungs of victims. Bayle has described a particular species of consump- tion named '• plithisie calculeuse.' The fault of the older observers has been that the accompanying symptoms of phthisis were referred by them to the concretion, in- stead of regarding the latter as a natural attempt at cure, II and a result rather than a cause, Although very * Williams, op, cit. See also Stokes, op. cit. p. 456. f Tui-nbuU, An Enquiry into the Curability of Consumption, p. 87. Lond. 1859, X Maclacblan, op. cit. § Archives Gen. de Medecine, tome v. p, 183, II See also Cruveilliier's Transformations et Productions Organiques, voL ii. p. 112. CALCAREOUS DEPOSITS IN THE LUNG. 161 common in advanced life, the transformation may take place in the young. I have never seen it under twelve years of age. The proofs that these concretions are due to transfor- mation of tubercle, is to be found in the fact that they are sometimes found in the centre of a tuberculous mass ; occasionally in a cavity partially emptied, and by far most commonly at the apex of the lung, which is the ordinary seat of tubercle. This transformation is also found in glands. In the inferior animals it is a very common result of tubercle. It has been observed in the thymus by Cruveilhier. Of its occurrence in the peritoneum, there is a well-marked case by Dr. Dicken- son {2\ans. Path. Soc. vol. xiv. p. 163). The man died of scrofulous disease of the vertebra with psoas abscess. The mortar-hke deposits in certain cases of chronic abscess seem analogous. A remarkable case of cancer in the lung and mediastinum, with concretions and cicatrices, due apparently to tubercle, has been recorded by myself. (Trans. Path. Soc. of London, vol. xiv. p. 19.) Analysis of 10 cases of cretaceous , bony, or horny expectoration. Age No. of Cases Period of Occurrence 12 years 15 „ 20 „ 25 „ 30 „ 35 „ 2 1 2 2 1 2 6 months after illness commenced 1 year „ „ 2 years „ ,, 3 „ 4 „ Indefinite period One half had haemoptysis repeated several times. Witli signs of the 1st stage were found 1 case „ „ 2nd „ „ 6 cases •• «« ord. •■ la o .. CHAP. XJI. 10 These cases were characterised by the frequency of Characters hemoptysis, the extensive portion of the lung present- cases. ^ M 162 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, ing physical signs, the harshness of the respiratory <■ — ,-1— ' sounds, and the more advanced cases by considerable flattening of the chest waUs. The transformation of tubercle is, in fact, accompanied by considerable con- traction of the lung itself, and a lessened volume results, which is to be regarded as beneficial. These cases also tend to great prolongation. The longest living cases of tubercle in the lung, are probably those which have undergone the calcareous transformation. Who shall say at what period of life those chalky masses which we extract in our post-mortem examinations of the aged have been deposited ? The tubercle formed by a fault in sanguification at puberty, and which may have threatened the existence of the individual, may re- main in an altered form, and without any symptoms at eighty ! Of the ten cases of cretaceous expectoration whose history was accurately made out, six had presented the symptoms for three years, and one for six ; the average observed duration being 33*42 months. Two forms. Two forms of this peculiar class of cases may be observed. 1. In which after an attack of disordered health, a few cretified masses are expectorated, and the patient has no further chest symptoms. 2. The more ordinary cases, in which successive at- tacks of the tubercular disease occur, with expectoration of chalky matter, the disease advancing slowly, while the attempt at cure is being manifested. First Of the first variety, it is to be presumed that there variety. , i • i • i are many mstances to be met with m the experience of all of us. There is little doubt that numbers of individuals undergo slight attacks of tubercle with recovery ; and it is probable that this cretaceous or horny transformation is the most frequent mode of conversion for the purpose of toleration or expulsion of the morbid material. CALCAEEOUS DEPOSITS IN THE LUNG. 163 Gr. F. was, in 1839, attacked by slight cough, after unusual chap. application to study. He had previously lost strength, appe- ^ ^^ ^- tite, and flesh, and began to be slightly feverish. He had no predisposition to phthisis. After some increase of cough he Case. expectorated several small, hard cretaceous matters, which -^'^'^f*^'^* ' recovery, were examined by his brother, an eminent surgeon, and shown to me. He soon after regained flesh and health, and lost his cough. He is now (1865 — twenty-six years later) performing most arduous clerical duties, and is in very fair health, with a large healthy family. His parents died at an advanced age, and themselves inherited longevity. The only death in his generation was from typhus. The second form is the more common. The local Second disease is not eradicated nor arrested by the chemical imperfect alterations in the tubercle, but successive deposits take ^^^^'^^^J- place, much of which may continue to be cretified and expectorated, but a large part undergoes slow softening. The physical signs are diffused over a large space, and the affection is rarely single. The crepitant sounds are Defined harsh and crackling, and well-defined cavity is rare, ^^^^^y^^'^^- except in very aged persons. The following case has been under my eye for years, and is a fair example of this form of chronic phthisis : — M. H. set. 22, f. First seen March 1861; no predisp. to Case, pht. Has for years past occasionally expectorated chalky ^ y^'^^^- matters; cough slight and chiefly in morning; has lately lost flesh, but is always rather spare. Has had frequent slight haemoptysis. Much flattening of chest walls both sides, considerable dulness and crackling under both clavs. for sortie inches, no fever, digestion good, ctma. reg. ; has taken cod oil for three years. Improved much in summer by going to Scotland ; gained flesh, cough less, but expec- torated chalky matters about every three weeks; ordered liberal diet. There is much dyspnoea, yet the patient has for years taken an active part in a school, where much exer- cise of voice is required. Lately she has had an attack of diarrhoea, which much reduced her strength. I have advised perfect rest for some months. She has been ill more than six years. Dec. 1864. — I have examined her again ; she has gained flesh, the physical signs are dryer ; she brought me M 2 164 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XII. Case. 4|- years. Pht. 2. Case. Pht. 3 5i years. Case. Pht. 3. Case. Pht. 2. seven or eight calcareous matters coughed up. June 1865. — She is nearly in the same condition. M. A. W., f., set. 12. Ill four years, cough constant, expect, slight, has been much emaciated, is now slightly out of flesh, expect, hard gritty matters two years ago. Much flattening both sides, movements much hnpcdred, harsh res. and coarse crept, ivith exp. prolonged luhole right side, much dulness both, is growing fast ; ordered ol. morrhuse and vlnum ferri ; under treatment six ms., great gain of flesh and strength, digestion good, nearly lost her cough. Phy. signs persistent. Duration 4-| years. Gr. H., labourer, ast. 29. No predisp., hair and eyes dark, cough four years, absent in summer, worse this year, hsemopty. slight, frequent expect, abundant, thick, yellow ; sweats two months ago, more lately app. bad, t. white, b. reg., chest pains, expectorated cretaceous matters two years ago when under Dr. Peacock at London Hospital. Dulness, gurgling, flattening, impaired mobility luhole right side, expir. much prolonged, resp. very rough, vocal resonamce increased left side. Has taken much oil, continued under treatment 1^ year, and left much improved in health, cough moderate. He frequently expectorated chalky matters, which were ex- amined on various occasions. Treatment : Oil and quinine, sedatives, counterirritation. E. W., f., set. 19. Cough two years, no hsemoptysis, no predisposition, in good general health, has frequently spat up chalky matters, ctma. reg., gains flesh, digestion good. Cavernous blowing and gurgling to about the Mh rib left. This poor woman felt so well that she married a few months after this report was made, but six months later I find the following note : ' Cough severe, great dyspnoea, lips livid, sweats, gurgling extensive left, humid crepitation and ex. prolonged with harsh r. right.' I subjoin the following in contrast : — E. D. set. 32, joiner. No predisp., cough one year, cre- taceous expect, six iveeks ago, with hgemopty. (the first), pain in left base, si. sweats, has lost flesh, regains, app. poor, no diarrh. ; 7)iarked dulness upper -frds of left, ivith humid cre- pitus, cdso crepitus post base left. Six months later cheesy expectoration, health much improved, at work daily. Under CALCAREOUS DEPOSITS IN THE LUNG. 165 treatment nine months ; took oil and hydrochloric acid, with CHAP. iron. , _ ^^^- ^ The following summary may assist : — 1. Cases of cretaceous transformation occur generally in old age, but are also numerous in adult life. They are seldom met with before twelve years of age. 2. There is no early condition from which the change may be prognosticated with certainty ; but it appears most frequently in cases where tubercle has been scattered rather extensively through the lung, as indicated by the physical signs. 3. A general harshness of the respiratory tones, and a diffused sharp crepitation, often resembhng pleural sounds, with much impairment of the movements of the chest, and considerable flattening are the ordinary physical conditions. ^. A repetition of chalky, horny, or bony expecto- rations, with subsidence of the symptoms, frequent slight hemoptysis, dyspnoea, occasional severe exacer- "^ - bations of cough, with fever, alternated with periods of comparative cessation of the more distressing symptoms, form the chief features of the case. 5. The secondary disorders, as diarrhoea, are long delayed. 6. This form is generally non-hereditary, or acci- dental. 7. It is generally extremely prolonged, and a safe prognosis for duration may be offered, when once the condition is faudy recognised. 166 ELEMENTS OP TEOGNOSIS IN CONSUMPTION. CHAPTER Xni. CHEONIC SECOND STAGE. CHAP. XIII. Stage of softening. Capable of much pro- longation. Causes which in- fluence softening of tubercle. Nature of tubercle. G-rey— yellow. The stage of softening, implying as it does a process always destructive to the tubercle, and very frequently also to the structures in which it is imbedded, is not, at first view, very promising for duration ; and in truth, if it were simply a disintegration and breaking up of the morbid material and its surroundings, we should have little to note, excepting the greater or less rapidity of its course. That pecuhar and conservative law which interposes periods of remission to all chronic organic changes exerts its influence here, and it is practically proved that the softening period is capable of as great if not greater prolongation than either of the other stages of phthisis. The causes which influence the rapidity or slowness of the stage are referable to — 1. The nature of the tubercle, and the mode of its deposit. 2. The degree to which the lung tissue is engaged in irritative changes. 3. The cessation or continuity of the blood disease. The nature of the tubercle deposited influences the softening process directly. The grey variety has un- doubtedly less tendency to soften than the yellow, and some have behoved that the conversion of the former into the latter is a necessary condition to the chemical alterations undergone. That a form of tubercle analo- CHRONIC SECOND STAGE. 167 gous to, if not identical with, that deposited in the chap. external glands in strumous subjects, is met with in ^J^^:^ the lungs, and is characterised by the same slowness strumous to change, has long been evident from the observations ^'^po^it. of a large number of cases, without reference to merely theoretical views. A separate section is devoted to our analysis of this variety, which is often found combined or alternating with enlargements of the external glands. There is no certain method of recognising these f^^^^s^'' varieties in the living subject, but from a study of their these localisation, and the history of the attack with its con- ^^^^ties. comitants, a diagnosis not far removed from accuracy may be arrived at. The localisation of the physical signs is a material J^°^^^j'^^ _ help. The scattered grey tubercle is more diffused sicaisigna. throughout the king, and the signs of deposit, although more "concentrated at the apex, are spread over a larger surface of the chest, and shade off towards the base into pure vesicular respiration. The tubercle which is massed at one apex, giving rise to signs of great condensation of the lung, will be found in ex- perience to be more likely to undergo rapid soften- ing changes. Our hopes of chronicity must here be carried on to the third stage, when cavity has been formed. In the strumous variety, with external glan- strumous dular enlargements, the physical signs will often denote base° ^^ a diffused deposit, most obvious over the base of one or both lungs, and such cases are commonly very slow. In examining the history of cases of large cretified ^^f^f masses found in the lung after death, it will be ob- ^ ''^^^' served that they are almost invariably in the upper and back part of the apex ; but the whole apex is very rarely engaged and sohchfied. The cases given, of small masses of cretaceous expectoration, presented signs of diffused rather than of massed deposit. _ _ _ ^.^^^^^ In examining cases of retrogressive phthisis, it will be deposit. 168 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP. XIII. Integrity of the in- tervening portions of lung. Softening hastened by con- gestion. Changes in tubercle chiefly in- fluenced by parts in which it is deposited. Lung, its structure and functions. commonly found that the physical signs evidence a some- what diffused deposit. It may be presumed that the cause of this is to be found in the integrity of the intervening portions of lung. An amount of deposit sufficient wholly to obhterate any large portion of the pulmonary tissue, is necessarily accompanied by congestion of its capillaries, stasis of circulation, and inflammatory pro- ducts in the structural, serous, and bronchial tissues. These changes give a character to the physical signs, and are productive of the most important and urgent symptoms in this stage. Softening is undoubtedly hastened by such congestion, probably as a result of exalted chemical affinities developed in the tubercle. In the whole history of tubercle, there is perhaps no agent so important in hastening the destructive pro- gress of the disease as the surrounding irritation of the lung tissues. Were it not for this superadded con- dition, tubercle might remain inert for years, as is witnessed in the lower animals, the drying and absorb- tive processes would proceed in the vast majority of cases, and in the remainder, the deposit, if not excessive in extent, might be tolerated for a long hfetime. This fact is pregnant with meaning for diagnostic, prognostic, and for therapeutical purposes. Although tubercle has been proved to be unorgan- ised, and therefore stands as it were outside the system, yet the changes it is to undergo are chiefly under the influences of the parts in which it is ' deposited. If these are highly vascular, and play an active part in the economy, the proneness to irritation and inflam- matory actions is excessive. The lung, with its double circulation, itself the seat of the most active chemical changes in the body, in the immediate neighbourhood of the heart, from which the blood is rapidly propelled through it, undergoing constant motion, always exposed in its deepest recesses to the atmosphere, with a triple structure, combining the most sensitive and vitalised CIIEONIC SECOND STAGE. 1G9 tissues of the body, linked by its nervous supply alike chap. to the organic and cerebral nervous centres; accom- ^ ^ , -. plishing an exhalation of effete gaseous products, and of the watery waste of the blood, in addition to its own secretions, is, of all organs, that which necessarily suffers most from any foreign matter introduced into its structure. The mechanical effects of dust, as hi the phthisis of stone-masons and metal-workers, illustrates the diseased process which results from simple impac- tion, and such cases are usually slow. But when to the foreign body thus forced ui upon a machinery exquisitely dehcate and at full work, is superadded the congestion of inflammatory processes, we can see at a glance what mischief is inflicted on the organ. Tubercle in bone is, on the contrary, slow to destroy, and this Bone. because the part in which it is deposited is not highly vascular, remains inert, is not the seat of chemical alterations, and plays rather a mechanical than a vital part in the economy. The peritoneum investing vital Peri- organs, and itself a secreting surface, with movements *°''^'''^ incidental to its locahty, cannot long tolerate tubercle without suffering. A tubercle or two in the brain may Brain. long remain inert, unless it be placed in or near the serous hmug of the organ. The mesenteric glands will tolerate tubercle till they form distended masses, making up a large proportion of the weigh of the emaciated body ; and the cervical glands, playing no important part in the economy, often contain inert tubercle for years. From these considerations we may learn how important the integrity of the structm-e in which tubercle is developed, its moderate vascularity, and comparative immobihty, are to the continuance of the latter in an inert and nearly harmless form ; and how any inflammatory congestion hurries on the changes by which the destruction of the morbid pro- " duct is effected. The cessation or continuity of the blood disorder Cessation 170 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, has a powerful influence in retarding or promoting the . '^}-^' . softening of tubercle. An additional deposit in another or conti- P^rt of the luug, or on the opposite side, commonly ibf*d°^ accompanies the destructive change in the primary disorders, crop of tuberclc. It cannot be doubted also that irri- tation is kept up and increased by a supply of con- taminated blood constantly presented at the seat of the original disease. By whatever derangement of vital actions the ehmination of tubercle in the pulmonary tissue takes place, it is obvious that its continuance must prevent the primary mischief from becoming tolerated and inert. As remarked by Eokitansky, ' no local healing processes would be fraught with any value for the individual unless accompanied by the ex- tinction of the fundamental tubercle-producing crasis.' The greatest importance, then, is to be attached to the state of general health of the patient, and to the cessation of the cachexia in which the emaciation, fever, and chsorder of the secondary processes of assimilation have their origin. With an amendment in those func- tions which are performed in the penetraha of organic life, tubercle will not readily soften, and its inherent tendencies (if it have any) may be postponed inde- finitely. If there exist no certain means of ascertaining the species of tubercle which is deposited, there are at least unmistakable symptoms and physical signs of the constitutional disorder, and of the accompanying in- flammatory actions on which, more than on any other agents, depend the present security of the patient, and his chances of prolonged life, or even of ultimate cure. ChaT'^eters When phthisis in the second stage becomes chronic, "{^ff.^fted \)^^\^ jg^ when its duration extends beyond eighteen months, with some prospect of the life of the patient being still further prolonged, it exhibits certain features which are recognisable to the careftil observer. They may be classed as constitutional and local. The first is characterised by longer intervals between the attacks of hectic, during which the pulse subsides tional state. CHRONIC SECOND STAGE. 171 to a healthy standard, the skin is natural to the touch chap. and to the sensation of the patient, and the sweatmgs ^— 1-,— - have ceased. The tissues of the body are better Constitu- nourished ; there is gain of weight, and appreciable increase of plumpness of features, and the chest is better covered. The muscular system is invigorated, and there is more power of walking and of sitting, while the distressing lumbar weakness of the great longi- tudinal supports of the frame is not nearly so constant nor intense. The features no longer express exhaustion, the eye is less excited and briUiant, the cheek less sunken, the mouth more calm and less suggestive of dyspnoea. The sleep is more natural, the night cough subsides, and is represented by two fits only — that on lying down and rising. The appetite improves, the tongue is cleaner, irritative dyspepsia, shown by thirst, red and furred tongue, and occasional diarrhoea or re- laxation, ceases. The local signs improve as well as the local symptoms. Local signs An important change occurs in the crepitant moist ^ ^^^'^' sounds which characterise the second stage of phthisis. They become dryer, are crackhng rather than bubbhng. Moist, and occasionally pass into clicking and creaking sounds, comg^di-^' conveymg the impression that the consistence of the op- posing medium has become more glutinous and less fluid. The true humid crepitus, which might be compared to a stream of small bubbles, caused by air blown through gruel, is more of a crackle, and has fewer bubbles. This is a most favourable and important change, sibilant With this the sibilant r41es and rhonchi subside, and ^^l^^., -I . subside. the dulness may become a shade less. The meaning to be gathered from the alteration in the character of the sounds is that the inflammatory and irritative action in the lung tissues has subsided, and that active soften- ing has ceased : there is, in fact, no progression of the destructive process. With this concurrence of favourable conditions the patient may go on for years, presenting only occasional 172 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, exacerbations of disorder, and a persistence of tlie above ■ ■^^^' . physical signs. It is no longer doubtful that a complete disappear- ance of the crepitant sounds and a comparative restora- tion of the patient's health may occur in this stage, and of this instances will be given ; but there is no reason to suppose that tubercle is ever absorbed or re- moved (by other than cretifactive changes) in the Cessation sccoud stagc of phthisis. The cessation of the humid sounX^not souuds is duc uot to chmiuation of the deposit, but to due to a removal of the inflammatory action in the lunff, and tion of the to a drymg or retrogressive change m the tubercle. tubercle. There remain but two conditions to expect when once tubercle has in any degree softened, viz., its transfor- mation into horny or chalky matter, or its further softening to form a cavity. In all the instances which have been examined, when softening sounds ceased, there remained a permanent harsh inspkation, expira- tion prolonged, slight dulness, and other signs indicative of the phenomena of deposit. The persistence of these physical signs is, on the other hand, ' no proof that the patient is not progressing satisfactorily or that his disease is not arrested.'* Evidence ^^^ symptoms of arrcst of phthisis must be derived of arrest from the two sourccs of evidence at our command — taken from cessatiou of Constitutional disorder and alterations hi bothsymp- the phvsical sicrus. With the concurrence of these two toms and ^ n • • tit • c -\ signs, the fact IS unmistakably certified to us ; but by adopt- ing an opinion formed on one only we may be deceived. Increase of weight while taking cod-liver oil is occa- sionally attended by advance in the local disease, and although this is a rare occurrence — the rule being that while nutrition improves the lung disease remains at least stationary — the fact illustrates our proposition that an improvement, to be trustworthy, must be evidenced both by symptoms and by physical signs. * Phthisis and the Stethoscope. By Richard Payne Cotton, M.D. 3rd ed. Lond. 1864. CimONIC SECOND STAGE. 173 Table sJioiuinrj ar/e and sex of 2G6 cases of chronic phtJiisis in the second stage tuhlch had attained a duration of more than 18 months. CHAP. XIII. No. of No. of Ago Males Females Total Under 10 years 1 1 10 to 15 „ 3 3 6 15 „ 20 „ 12 15 27 20 „ 25 „ 29 18 47 25 „ 30 „ 26 26 52 30 „ 35 „ 23 20 43 35 „ 40 „ 22 19 41 40 „ 45 „ 15 12 27 45 „ 50 „ 8 3 11 50 „ 55 „ 7 2 9 55 „ 60 „ 1 1 2 Totals 147 119 266 The way to read this Table is that between ten and fifteen years of age six cases were observed, of whom tliree were males and three females, &c. Table of the observed duration of cases of chronic second stage, with the sex. Attained Duration Males Females Totals 2 years 7 8 15 2| „ 14 8 22 3 „ 8 7 15 H „ 15 10 25 4 „ 9 8 17 H „ 9 12 21 5 ,, 10 4 14 ^h „ 5 1 6 6 „ 5 2 7 7 „ 11 8 19 8 .. 4 3 7 9 „ 1 3 4 10 „ 3 5 8 10 to 12 years 5 4 9 12 „ 15 „ 3 3 6 15 „ 20 „ 2 2 4 Indefinite long periods 36 31 67 Totals 147 119 266 174 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XIII. The way to read this Table is that of cases which had attained a duration of two years in the second stage of phthisis, seven were males, eight were females — total, fifteen, &c. The average observed duration of 203 such cases * was 67'35 months, not allowing for those of indefinite periods. The state on leaving the hospital must be taken into consideration. Of 266 cases, 62 were better on leaving ; 72 were worse, of whom 7 died ; 132 remained stationary. We thus see that patients in this stage of disease, who have been ill more than eighteen months, may, if the disease be then quiescent, reasonably hope for a considerable prolongation of their lives ; and that the chances, at least, are that they will not die for forty- nine months, or something over four years, that being the expectation of hfe to be deduced from the above Table. The real expectation must be much higher than this, for of these 266 observed cases only seven had died. Of the seven deaths — 1 occurred at tlie end of 2 J years from the commencement of tlie disease 5 H 6 7 Case. Moist cre- pitus re- placed by From the above Tables have been ehmmated all cases of tubercle very sparsely diffused through the lung, or spreading over a large pulmonary space. This variety has seemed to be so important that I propose to con- sider it briefly in a separate section. The following cases are illustrative of the second stage of phthisis in its chronic form, and also of the possibility of its cure. July 1856. — T. D. set. 20, m., servant. No pred., parents living over 50 ; cougli 3 ms. ; no haemoptysis ; expect, thick, yellow, moderate, increasing, night sweats, marasmus 2, rapidly * See page 77. CHRONIC SECOND STAGE. 175 losing flesh, now 9 st, app. good, b. reg.,'t. hivved, flattening, CHAP. dulness, humid crepitus, and increased vocal resonance for . _^^ }^' .. sortie inches suhclav. right ; ordered oil, nil. acid sfall. c. morph. ., ij'11, m,-r.-?, orysounds. ij. om. nocte; solut. lod. dextro. lo go to Brighton. Eocorery December 1856. — Been at Brighton 4 ms., no cough, raises ofl^ealrh. no phlegm, no perspirations ; weight, 9st. Iflb ; app. good, eats meat three times a day ; does not feel weak nor languid, ' if he runs ever so fast does not feel his breath the least affected ;' dulness not great, hut decided ; flattening of chest ivalls on right; mobility manifestly impaired over ivhole suhclav. and four inches loiver; expiration equal to inspiration, and rough ; inspiration rough, and sensibly less than op- posite side ; no crepitant sounds, vocal resonance slightly in excess ; the lower anterior chest rough and slightly wavy inspiration ; the expiration at this part not so much pro- longed as above, hut still sensibly so. Maria S. set. 16. June 1856. — No predisp. ; ctma. not ap. ; Case, ill two years, with cough, and expect, lately severe at night ; ^^*- ^* profuse night sweats for some weeks, lessening ; app. mid. ; Moist no diarrh. Considerable dulness both suhclav. regions, sounds moist crepitation for some inches left, the same signs, but less marked, right. Ordered oil with ferr. cit. ex infus. Calumbee, and sedatives for cough. August. — Gained flesh, exp. less, but got worse in following winter, improved much in spring ; first catamenia in June 1857; dyspnoea; no cough, but physical signs as before (i.e. moist crepitus). Grained flesh in summer, and in March 1858 I find the following note: 'Chest carefully examined: prolonged expiration, the only abnormal sound, no crepitus, &c. ; scarcely ever coughs, great gain of flesh, looks in fair health, but rather pale ; is going to service ; has taken oil for 2 years. Duration 4 years.' (I am indebted to my colleague Dr. Quaiii for the greater part of the notes of the following most inter- esting case. For the last two years the patient was under my own care.) June 1851. — W. W. set. 18, bandsman. Life Gruards. No Case. predisp. ; played flute last 5 years, and feels no distress from 2nd sta<^f it ; subject to short cough last two winters, no hsemoptysis, Morbid'' is a little hoarse, sUght loss of flesh, no sweats, digestion good, disa^^^ear 176 ELEMEJfTS OF PROGNOSIS IN CONSUMPTION. CHAP, Dulness and crepitation under clavicle, left, breath clear ^ , J^^}^' . behind. Ordered cod oil ; iodine externally ; pil. conii c. morph. Oct. — Doing very well, only morning cough, dulness Oil taken tubular rcsp. and coarse crep. at second cartilage left. Feb. for 8 years i85i._Feels well ; no distress from blowing trumpet ; slight yellow expect, occasionally only, has gained flesh. March 1852. — Cough very little, continues his occupation; phy. signs as before, only voice sounds more resonant left, grows stout and tall. May. — Flattening of chest walls, heart beats high, a few large crepitant rales, breathing loud on inspiration and expiration; health good. Dec. 1852. — Dulness, creoJdng {not crepitation) left, feels well ; oil has been regularly taken throughout. July 1853. — At Chobham Camp, doing very well ; sounds much as last. April 1854. — Cough occasionally only in the morning, feels well, loud expiration, no crepitus, dulness slight, some flattening left, resp. right loud and clear. Oct. 1854. — Has coughed lately, much exposed to weather, rather free hasmoptysis, nausea, acidity. Ordered caustic sol. of iod. freely to chest ; he soon got better, but had lost flesh. Feb. 1855, — Rather weak inspiration left. May. — Doing well, scarcely any cough, gains flesh, app. good, continued occupation and oil. Feb. 1856. — Haemoptysis pro- fuse ; from this attack he recovered and resumed the treat- ment. May 1859. — He has taken cocoa-nut oil for some time, is in fair general health, and continues much the same as last report ; actual duration ten years ; under observation and treatment eight years. This case derives its interest from the fact of its having been under the observation of skilled observers for eight years ; from the continuous treatment by cod oil which was carried out, as well as from the remark- able physical changes in the lung, and concurrent im- provement in health. Case. July 1856. - — W. J. set. 47, gamekeeper. No predisp., Pht. 2, at cough for two years, now night and morning and on exer- Soxmds be- tion ; hsemopt. half pint nineteen years ago and last week ; come dry. ^10 sweats ; weight was 1 3 st. two years ago, is now 1 1 st. 2^ lb., app. good, b. reg., pain in right base, dyspnoea. Dulness, moist crepitus two inches subclav. right. Oil, solut. iod. to CimOXIC SECOND STAGE. 177 the right; pil. conii c. morph. Oct. 1856. — Expect, less, no night CITAP. cough, looks very well, gained 7 lbs., follows his occupation. , ^ } _. 01. 5iij. ter in die. April 1857. — Easier, a little phlegm in the morning only, cough only on exertion, and slight dyspnoea if he runs, looks very well, weight 11 st. 11;^ lb.; continues oil. JS^o moist sounds, hloiving expiration and inspiration, and voice rather resonant at apex rigid. To take oil. I have not seen him since ; duration about three years ; under observation nine months. Oct. 1852. — E. H. set. 24, carpenter. No predisp., cough Case, two ms , slight hsemopty. twice, loses flesh, dulness, harsh Passage dry inspiration, with sibilus left subclav. ; ordered oil, and 2nd stage. iodine externally. April 1853. — Much better, disease appeared l^^i^atiou, arrested, treatment continued till March 1854, when only ** sign luas very loud expiration left; cough rare. October same year even this sign was scarcely perceptible, but the right apex %v as almost crepitant. June 1855. — Dulness and deficiency both apices, marked humid crepitus left. At this time he went to the country in tolerable health with slight cough only, but occasional haemoptysis, no fever. Had taken oil under observation for 3^ years. {The notes are by Dr. Quain and myself.) J. Gr. set. 20, policeman. Maternal predisp., profuse hse- Case, mopty. six ms. ago, repeated two ms. ago, had sweats, weighed ^- ^■ 11 st. 3 lb., now 10 St. 11 lb., cough, dyspnoea, and mod. ex- improve?' pect., digestion good, dulness and humid crep. throughout ^^'^t. right side ; ordered oil, and solut. iod. dextro. Six ms. later phy. signs the same, very little cough, scarcely expectorates, general health good, face rosy, walks any distance without fatigue, weight list. J. E. set. 24, embroideress. Br. and sister died of phthisis, Case. cough two or three years, no hsemopty., abundant increasing p^^' ^\„^ expectoration, night sweats, rapid pulse, loses flesh, app. disappelir poor, t. red, no diarrh., palpitation, ctma. reg. ; dulness and ^^\^^^,' ^^'^ humid crepitus for two inches subclav. rigid', ordered gallic after i acid, citrate of iron, oil, iodine externally. March 1857. — Y'"^^^- In good flesh, no fever, cough slight, feels well ; rough resp., 5 yJars." exp. prolonged and harsh, no moist sounds right. March 1858. — Slightly humid crackle again at right apex, exp. prolonged, evening fever, urine deposits ; ordered efferves- cents, omit oil, iodine paint. July 1858. — Humid sounds N 178 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, are again replaced by rough insp., and exp. prolonged', XIII. health much improved. December 1858. — Has taken oil again for some months ; there are no abnormal physical signs in right apex, cough slight and occasional, in good flesh. Feb. 1860. — Cough again returned, some dyspnoea, but can run up-stairs ; has gained flesh, app. good, looks very well, has not taken oil since 1858; humid crepitus again under the clavicle right ; to resume oil. In March she was better. I have not heard of her since. Under observation over two years ; duration about five years. Case. March 1854. — E. T. set. 37, farmer, well to do, m., four the°pro^ ch. Dyspnoea, pain in right side and apex, little cough, gress no expect., breath sounds tolerably clear, feels weak. 01. theTtf ef^ morrhuse Jij. bis mist. gent, alkal. 5j. bis. Dec. — Doing 6| years, well, excepting a recent cold; still taking oil. April 1855. — Haemoptysis slight, occasional; cough more troublesome, ex- pect, increased, some sweats and chills, loses flesh, weight 10 st. 10 lb., dry crep., bronchophony right subclav. The hectic continued till July, when it increased, and all symp- toms began to improve ; weight 10 st. 2| lb. In August he weighed 10 st. 5 lb. ; oil _^ss. bis die. April, 1856. — Moist large crep. for six inches right, looks well, w. 1 st. 4^ lb. ; he improved till August, when app. failed, cough worse. He continued to reside in the country, and came to London for advice once a month. April 1857. — Cough worse, p. in left, expect, increased, no hectic, diarrh. began, extensive gurgling on both sides, w. 9 st. 11^ lb.; ol. and quinine; iodine sol. externally ; sedative mixture. August. — W. 9 st. 5^ lb., symptoms worse, slight hectic ; quinine in large doses, oil. — June 1858. — W. 8 st. 10^ lb., very weak ; rep. remedia. June 29, 1859, obiit. Total observed duration of case five years and three months. The premonitory stage in this case lasted more than one year ; the hectic, coinciding with the signs of softening, three months. After a rapid reduction of weight at this time he regained flesh, but not to his former standard. A second and considerable reduction occurred in 1856-7, when the opposite lung became rapidly attacked, and cavities were established. From this on he steadily but slowly lost, yet lived two years two months. The use of oil in prolonging life, by retarding the successive stages of the disease, is well seen. CHRONIC SECOND STAGE. 179 Chronic Diffused Tubercle. From numerous observations, I have ascertained chap. that tubercle when diffused or spread througliout a — ->— - large surface of one or both lungs undergoes its de- Diffused structive changes slowly, and in certain instances dries undergoes up. This condition indeed prevails in most cases of changes . . . slowly. cretified transformation. It is therefore to be re2;arded as, on the whole, a state tending to chronicity or pro- longation, and in certain cases to cure. It is more favourable then when the deposit is massed in one or both apices. Taking the average duration while under Average observation of aU cases of phthisis in the Tables given ^^^^t^^" as two years and six months, the dijSTused tubercle cases averaged thirty-seven months, while ordinary phthisis was as low as fifteen months. Doubtless this its chroni- slowness to destruction is mainly due to the integrity i^tegr%of of the intervening portions of lung being preserved, ^^^^^^e^^- for when inflammatory action is going on, the irrita- tions of tion of a large portion of pulmonary tissue would ^°^" necessitate excessive hectic, and rapid exhaustion of vital power. That scattered tubercle is more tolerated than that which is infiltrated into a large but limited portion of the lung, may be regarded as a rule. The latter condition softens more readily and tends to form Tubercles a cavity ; the former, so long as the separate masses of sofin^^^^ deposit do not coalesce, has little tendency to break up, cL^^ckiy- but for the maintenance of the quiescent state it is necessary that the lung should not undergo irritative or inflammatory changes. The reverse may be said of the third stage, for when tubercle has softened and formed a cavity, one of the chief conditions of temporary Eeversed safety for the patient is, that it should have been Fon_1-,_J_^ atmospheric pressure on one side or the other, and is, in fact, a differential puhiiometer of extreme delicacy. The flattemng of the chest walls is also an invariable Limited accompaniment of the shrinking of a cavity, and a 0?"^^ measure (when taken with the other compensatory 7^}^^ ^? -, . . \ „ , , . '- _ r indication conditions j oi the loss oi respiratory space. When it of ciironi- occurs it may, if limited in extent to the part of the sirmking lung presenting the physical signs of disease, be always of a cavity. taken as a sign of chronicity, and an indication of re- pair. Of already existing chronicity, for time must elapse before the walls of the chest lose a part of their elasticity ; and of repair, for the shrinking of a cavity is an approach to its diminution and ultimate oblitera- tion. The extensive flattening over a large surface of the chest, seen in all cases of chronic phthisis, is not here alluded to. Another compensating agent in filling up the lost Eniarge- respiratory space is the expansion of the opposite or healthy sound lung. Percussion will often indicate that such ^^'^^. extension of the space usually occupied by the healthy sating lung will take place even to the edge of the sternum on the opposite side. In all cases of puerile or com- pensatory respiration it may be presumed that a certain expansion of the air vesicles without impairment of their elasticity takes place, and that more breathing in such part of the lung is actually performed. The pre- servation of the elastic power of a lung so enlarged is its distinguishing character from the emphysematous condition, and is proved by the fact that when such dilatation of the cells occurs in acute inflammation of one side, the healthy lung returns to its normal state and size as soon as resolution of the diseased lung takes place. This puerility is, however, a rare occurrence in phthisis, and is only observed in chronic cases, where 202 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, the mischief in the diseased lung is hmited, and where ^•^^V ■ shrinking of that side has already taken place to some extent. The three compensating agents thus acting to fiU up the vacated respiratory space may then be enumerated as — displacement of the heart ; partial en- largement of the opposite lung, if healthy ; and flattening of the chest walls. At this flattened spot all or most of the phenomena of a cavity present. Below it we have the usual signs of consohdation more or less complete, — deficiency of respiratory tone, expiration prolonged, and very fre- quently wavy or interrupted respiration. These signs shade off towards the base. Prognosis Whcu, from the history and physical signs concur- favourabie. I'^ntly, wc cau diaguosc one of these cases, the progno- sis for time can be, and ought to be, favourable ; and the miserable error of condemning them to early death is entirely inadmissible. Such instances occur in the practice of all of us, and have led to much disrepute both of the profession and of individual practitioners, who having diagnosed a cavity, proceed to offer a prognosis fatal to the patient's hopes and to their own character for accuracy and practical experience. Condition The Condition, of patients who have outlived the formation of a cavity, and in whom the constitutional disorder has ceased, and the local deposit of tubercle been nearly or entirely limited to one apex, is highly interesting. In their appearance there is scarcely any evidence of the almost fatal attack which they have undergone. There is both colour and roundness of feature and of limb. Very frequently the chest is of the anti-phthisical build : so that there is nothing to catch even the skilled medical eye in their appearance, excepting the flattening above alluded to. Such persons are frequently known to follow the active pursuits of life with abihty and vigour. One of my patients in this state, and who has had a large of such patients. CHRONIC THIED STAGE. 203 cavity in the left lung for ten years, is now conducting a chap. National School single-handed. She gives her lessons _?,^Z_. in an audible tone, and sings occasionally. Another for years was an energetic preacher and a zealous parochial clergyman. The absolute symptoms of re- Permanent maining disease are, however, evident enough. There ®y"P*°°^^- is always a certain amount of dyspnoea on exertion. Unless the cavity be absolutely ' dry,' which is very rare, there is always a morning expectoration, although this may be very shght ; and there is ever a danger of Danger of sudden and possibly profuse haamoptysis. If the di- L^™"" gestion be good (and this appears to be an essential element in the case), sanguification is well performed, and there is a much greater tolerance of cold, and generally less of the chilly state than is common in the consumptive. There is less tolerance of fatigue, and less power of endurance, than in a state of health. The patient lives, in fact, at a lower par than formerly. As his dangers consist in over-exertion of mind or of Dangers body, or in any reduction of vital powers, so his safety ql^fre^r can alone be insured by leading a tranquil life ; by ments. covering the surface with woollen or silk ; by living in well- ventilated rooms both by day and night ; by daily exercise, on horseback if possible, in pure, dry air ; by an abundant supply of good food, and, if possible, by obtaining that mental and bodily invigoration which frequent change of quarters, and travelling in agreeable society, over interesting countries or on long sea- voyages, seldom fail to confer. It would be a mistake to shut up such persons in hot rooms or in a relaxing climate, or to imprison the mouth in a respirator, or the body in a close carriage, as we daily see practised. Their require- ments consist in dry, bracing air, and a life free from anxiety; and the more they are kept moving about and agreeably occupied the better. I am not prepared to say that a large use of stimu- stimu- lants is always advisable ; but I have observed that these ^^°*^' 204 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, cases generally do best on a liberal allowance of wine . ■^^^' . or beer, which, however, should always be stopped if the pulse gets excited or the skin hot, or if any amount of hsemorrhage threatens. (See the chapter on ' Treat- ment.') Termina- The possibility of a cure in these cases, and their tiiTse°^ termination by extension of disease, remain to be con- cases— sidered. extension. The curc of cavity in the lung has long been a vexed Possible question. I presume there is now no doubt on the minds cavity. of the most experienced observers that cavities close and heal up. If the cessation of all the physical signs of such a lesion, and the perfect restoration of health, be considered evidence sufficient, there are cases enough of this kind on record by good authorities to justify the opinion that this form of cure is possible. But all agree that it is not frequent; and its infrequency must be apparent from the fact, that out of an experience of 4530 cases, most carefully noted at the Hospital for Consumption by myself personally, I can only place on record sixty-eight cases of well circumscribed cavity, with thirteen presenting the characters of ' retracted cavity ' — in all, eighty-one instances in which the patients seemed progressing towards a cure of cavity ! For it is quite certain that in order to the closing of a cavity, the conditions which I have assigned to the class called 'circumscribed ' must be present ; viz., a limit of the de- posit to one apex, and a cessation of the constitutional disorder. Eyidence The cvidencc derived from dissection must be re- Sction.^' garded as of the highest importance ; and the numerous cicatrices found in the lungs of persons who have died of other diseases can be referred to no other cause than the heahng of small cavities. Such direct evidence as I can myself supply is here given in the history of certain of my own cases, and others, from Bennett and Quain, are added. In practice it is of much more import- CHRONIC THIRD STAGE. 205 ance tliat our knowledge of tlie history and progress of chap. the disease should enable us to select with something of ^-^ accuracy the cases which are susceptible of prolonga- More im- . 1 i o portant to tion and improvement, than that we should offer hopes select cases of a cure which at the best, and under the most favour- of^proio^l^ able circumstances, is an occurrence so rare as to be gation. exceptional. It is of the highest value to a patient to be assured by competent authority, and as a fact founded on most careful observations, that his chances of hfe are not the nine or eighteen months formerly assigned to phthisis ; and it is of the highest value to the physician that the knowledge of the possibility of great prolongation of life in certain forms of consumption should be one of his own assured facts, and should not be thrust upon him as a taunting contradiction of some former ill- omened prophecy of his, but be delivered by him as a prognosis founded on scientific observation. With such knowledge at hand, and a ready tact in selecting his case, he may send many a patient away — not, indeed, with the hope of healing up a cavity in his lung, but with the assurance that life can support such an injury for years, if certain conditions of health be observed. By conduct on the part of the profession directed by such knowledge, and governed by good sense, we shall cease to regard the healing of the cavity as the object to be accomplished, the chances being so largely against its occurrence ; and shall best counteract the empiricism of the day, and most readily put a stop to such practices as are entered on to promote cicatrisation.* The dangers incident to this class of cases consist in Dangers haemorrhages from the cavity, in the possible occurrence "^"'^'^i^*' * Sucli are^' supposed 'healing/ but really irritating inhalations, tlie forced blowing of a pipe, supposed to assist the closing of the cavity by causing the distended air-vesicles surrounding it to press its walls to- gether ; the inventor forgetting that the forced distention of the lung acts equally on the cavity ! ! &c. &c. 206 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XIV. Fatal haemor- rhage most rare. Breaking lap of the cavity rarely a single process. New de- posit. of pneumothorax,* and in an extension of disease to the parts surrounding it, or to other portions of the same or of the opposite lung. I have never known haemorrhage to prove fatal from a single cavity ; but it is often profuse. Its occurrence may be due to a rupture of some large vessel included in the injured part, or to a breaking up of tlie cavity with extension of the softening process. A pliysical examination when the hsemorrhage has subsided will decide the question. If made during the oozing of blood, the soft crepitant sound caused by its effusion into the minute tubes wiU be a source of error. The breaking up of such a cavity is very often ex- tremely rapid when it begins, and is rarely, if ever, a single process. There is always a renewal of the blood disease and constitutional disorder evidenced by fresh deposit of tubercle. The seat of this deposit is rarely immediately beneath the cavity, but most commonly at the base of the same lung or in the opposite apex. The second deposit for a long time evidences the same tendency to slowness as the first; and repeated slight attacks of hectic may be the only systemic indication of its ex- istence, till the recurrence of these leads to a careful examination of the chest, and slight softening is detected. Sometimes a more acute attack ushers in an extensive deposit in the opposite lung, which undergoes its changes with rapidity, and a cavity is speedily formed, the patient's health breaking up. It is singular how long the original cavity will remain intact as it were, presenting its defined features, and maintaining, with regard to the surrounding tissues of the lung, its insulated character. The patient, in fact, * In 20 cases of pneumothorax occm-ring at the hospital, the cavity was single in only three instances. The patients survived the injury respectively 6 hours, 10 days, and 14 days. (See further the chapter on 'Pneumothorax.') CHRONIC THIRD STAGE. 207 does not die of this original cavity, nor of disease chap. directly extending from it ; but from a renewal of the ■ — -.^__ blood disorder, from fresh deposits, and from secondary attacks, as ulcerated bowels, laryngitis, &c. The following Tables give the most interesting infor- Analysis mation regarding 68 cases of this form of disease, cases of which came under my own observation at the hospital. ii^^'Jed 'J J- eavitv. caTity. Tahle showing the ages and sex of 68 cases of single dry cavity, or ' limited cavity ' in one lung. Age Males Females Total Under 10 years 10 to 15 „ 15 to 20 „ 20 to 25 „ 25 to 30 „ 30 to 35 „ 35 to 40 „ 40 to 45 „ 45 to 50 „ 50 to 55 „ Totals 2 5 8 9 8 6 5 1 1 1 1 4 9 3 2 2 1 1 3 9 17 12 10 8 6 1 1 45 23 68 Table showing the duration, while under observation, of 68 cases of ' dry cavity,^ or ' limited ' cavity in one lung, in both sexes. Duration No. of Cases Duration No. of Cases 1 year 2 years ^ „ 9 11 9 7 5 4 6 years 8 „ . . 9 „ 13i „ . . Indefinite long periods 2 1 1 3 1 6 4 „ 2 — 5 „ 7 Total 68 The average duration (while under observation) of each of these cases was 38 "90 months ; that of ordinary phthisis being 15-22 months. Of course these figures are only approximative ; but they convey the fact that this form of disease affords more than double the 208 ELEMENTS OF PROGNOSIS IN CONSUMPTION. chance of prolongation given by phthisis in its common manifestation. Analysis of Of the abovc 68 cases, 50 had the cavity on the 'Hmked right side, and 18 on the left — a very remarkable pre- cavity.' ponderance. Nearly two-thirds were males. The greatest number of cases in males occurred between 20 and 45 years of age ; and in females be- tween 20 and 25. In 6 only was any hereditary predisposition to phthisis clearly made out. Thirty-four had dry cavity, and an equal number had cavity exhibiting the usual moist sounds ; but both classes had it in the ' circumscribed ' or ' limited ' form. The opposite lung had the physical signs of pht. 1 in 17 instances, and in 1 only the signs of pht. 2. The preceding affections were few, and had existed in 5 instances only. Two had typhus ; rheumatism, gout, and recent rubeola occurred, each in one in- stance. One case only died while under observation — a male, at 25, who had been ill for an indefinite period. The cause of death was diarrhoea. No post-mortem exami- nation allowed. On leaving the hospital 55 were better or stationary; 13 were worse. In 3 the disease in the lung extended while under observation. In 6 instances only of females within the menstrual age were the catamenia wholly absent ; viz. — in 2 for three months, in 2 for six months, and in 2 for years. Analysis The foUowiug is an analysis of 18 cases given by BeiSett's Bennett* of the arrest or cure of phthisis. C3iS6S 01 arrested 1. ^t. 50, m. Cicatrised cavity; first attack, set. 22; cre- phthisis. taceous concretions opposite apex. 2. ^t. 28, m. Two contracted cavities in left; cretaceous concretions in right ; puckering ; emphysema at base. * Tlie Pathology and Treatment of Pulmonary Consumption, by J. H. Bennett, M.D. Edin. 1859. CimONIC TIIIED STAGE BENNETT'S CASES OF ARREST. 209 3. Jilt. 19, m. Left lung contracted to size of fist; filled CHAP. with small cavities lined by a membrane ; no recent XI II. tubercle ; cretaceous concretions at right apex. 4. ^t. 20, m. Cavity right apex, 1842, with pht. 1 at left apex; arrest and complete recovery, 1846; health remains good, 1859. 5. Mt. 15, m. Scrofulous; necrosis of femur; cavity right apex ; condensation left apex, cardiac disease, 1849; cicatrisation, 1851; health good, 1853; ca- vernous blowing, gurgle, &c. were replaced by dry, rather rough respiration, with slight dulness. 6. Hereditary consumption. Mt. 17, m. Softening right apex, consolidation left apex, 1843; complete re- covery, 1850; good health, 1859; cretaceous ex- pectoration. 7. ^t. 35, m. Softening right apex, 1843 ; arrest, 1844 ; slight emphysema; complete recovery, 1859; dul- ness and harsh inspiration only remaining. 8. JEt 22, m. Cavity right apex, 1844; recovery; slight emphysema, 1846 ; gurgle, pectoriloquy, &c. replaced by dulness ; feeble respiration ; occasional friction sounds at apex ; occasional dyspnoea only symptom. 9. ^t. 22, f. Dulness, mucous rales, bronchophony left apex, 1844; recovery, 1845; no dulness, expiration prolonged (only). 10. Male, set. — . Cavity left apex, 1840; recovery in 14 months; good health, 1859; no signs of cavity; wore a seton for 9 months. {This case is well worth studying in detail.) 11. ^t. 21, m. In 1853 dulness, crepitus, bronchophony right apex; 1857, flattening, dulness, healthy respi- ration, slight vocal resonance; 1859, good health, active exercise, living in Australia. 12. ^t. 33, m. In 1849, cavity right, cavity also left, (apices); well in 1859; both sides flattened, re- tracted, dry blowing, harsh sounds, friction murmur, ' lungs cicatrising.'' 13. M. set. 27. 1854, dulness, crepitus right apex; dul- ness, bronchophony only, 1859 ; excellent health. 14. F. set. 24. Cavity right apex, 1855; dry cavity, con- tracting, 1859 ; excellent health. 210 ELEMENTS OF PROGNOSIS IN CONSUMPTION, CHAP. xin. Analysis of Dr. Quain's cases of arrested phthisis. Case 1. Arrest of phthisis in the 3rd stage. 15. F. set. 45. Cavity left apex, 1844 ; deposit in right apex; ill 4 years; cavity became dry, 1848. 16. F. set. 30. Cavity left apex, 1842 ; became dry, health much improved, 1847. 17. M. set. 24. In 1836 had pht. ; remained an-ested 19 years, but died of phthisis in 1855 (a drunkard). 18. M. set. 17. In 1855, cavity right apex ; deposit in upper third of left lung; great marasmus. In 1856 cavity became dry, health greatly improved; died in 1859. It will be remarked that of these eighteen cases, fourteen were males ; nine of whom had cavity in the right Imig, and three in the left. Only four females are in the list, of whom three had the left lung most affected. The following analysis of twelve cases of arrested phthisis, which occurred in the practice of my colleague Dr. Quain, is of the highest interest; the authenticity and accuracy of the reports being insured by the well- known ability of the observer.* The first case is of D-reat importance, as the physical conditions were re- cognised during life, and traced after death. It furnishes perhaps the most complete history of a case of arrested phthisis which has ever been placed on record : — M. B., a female, in May 1848, when set. 13, admitted an out-patient at the Hospital for Consumption. She was suf- fering from severe cough, wasting, and dyspnoea. She had no predisposition to phthisis, and had not then had hsemo- ptysis. Her illness began after influenza in the preceding winter. Decided dulness, bronchophony and bronchial breathing left apex; feeble inspiration, expiration pro- longed right apex. She was treated by oil, small doses of morphia ; iodine solution externally. In August she had lost 4 lbs. in weight. Crepitation over left apex. In September she had profuse hsemoptysis, followed by large purulent ex- pectoration. A large cavity then formed with the usual * Condensed from the reports in the Lancet, 1852, p. 487 et seq. The first case appeared also in the Trans. Path. Society Loncl., vol. for 1850-1, p. 50, the specimen having been exhibited at the Society. CHRONIC THIRD STAGE — QUAIN'S CASES OF ARREST. 211 physical signs. In June 1849 she had not lost ground. CHAT. Loud 'pectoriloquy, cavernous breathing, gurgling left apex, , ^^^^\ . loud expiratory murmur right. In Augvist flattening over left apex; cavernous respiration, hut less loud; respira- tion puerile over right apex; health began to improve. During the winter 1849-50 she continued the remedies. In October she had scarcely any cough : she is free from suffering of any kind, and has considerably gained in weight. Chest examination shows remarkable flattening and con^ traction over left apex, evident dulness and diminished mobility ; respiration of a sharp, whiffung character, luith slight crepitus. At the opposite side respiration is loudly puerile, and percussion shows the right lung extending across the sternum to the left side. At the summit of the left lung posteriorly, the respiration is scarcely audible; the dulness here is more decided than in front. The heart is seen to heat from between the 2nd to the 4d,h left costal cartilages. At the beginning of March she was attacked by influenza, then epidemic ; and, singularly enough, had the gastric, and not the pulmonary complication of the disease. After bilious vomiting and diarrhoea for four days, she died. PoST-MOETEM. — Body well proportioned, a fair amount of pogt.mor- fat. Eight lung very voluminous, and extending across tem. nearly as far as left margin of the sternum. There was no appearance of the left lung in front, but its place was occupied by the heart and pericardium, drawn upwards and to the left side, and by the walls of the apex of the chest falling in- wards and downwards. Heart healthy, rather large. Left lung much diminished in size behind the heart ; this lung was adherent, especially at the apex, which was covered pos- teriorly by a mass of solid fibrinous tissue, corresponding to the seat of dulness mentioned. Very nearly the whole of what had been the upper lobe of this lung was occupied by the remains of a cavity irregularly divided into two by a band. The excavation was the size of a walnut : it contained about half a drachm of a whey-like fluid. The walls were formed by condensed pulmonary tissue, in thickness from a line to a quarter of an inch, and in parts puckered and contracted. The air cells and bronchi were distinctly visible, under the microscope, in this tissue, which was separated from the contents of the cavity by a wall or membrane of firm fila- p2 212 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. QUAP. mentous tissue and granular cells. The cavity communicated • . with the left bronchus by an orifice the size of a crow-quill, situated midway between the top and bottom of the cavity. Lower part of this lung nearly healthy. The right lung large ; displaced a quantity of water measuring 23 ounces, whilst the left displaced only 9 ounces. The apex was re- markably puckered ; on cutting through which the tissue of the lung was found to be traversed by short fibrous bands, between which appeared points of yellow tubercle. A little lower down, in the centre of the upper lobe, a mass of soft tubercle, about the size of a hazel nut, was found. In the other lobes two spots of firm yellow tubercle, and in other two calcareous particles. The remaining organs were healthy. No disease of the intestines ; no recent deposit of tubercle any^vhere. Eemark- TliG leading features of the above case consist in the toes^of' observed progression of the physical signs, and the this case, corresponding symptoms ; the post-mortem appearances confirming every step of the diagnosis and every phase of the history of the case. The increased and com- pensatory vokime of the right lung, the great contrac- tion of the left, the displacement upwards of the heart, and the flattening of the chest walls, are remarkable instances of the mechanical alterations which are ne- cessitated when any amount of pulmonary space has been lost. As a cure of phthisis, both of its local manifestations and of the constitutional disorder, it is a very instructive example. I presume that the tubercle was of the yellow massed variety, which has been described in the chapter on ' Strumous Phthisis.' The following cases of arrest of phthisis occurred in my own practice. They were chiefly in the third stage, those of the first and second being inserted here to illustrate the nature of the changes in the physical signs :— 2nd stage, X., engine-maker, set. 35. January 1849. No predisp., arrest. g months ill, no hsemopty., cough, dyspnoea, wasting, dul- ness, coarse crep., hronchial voice and resp., left ajjex. CHRONIC THIRD STAGE— CASES OP ARREST. 213 Weight 10.5|. Ordered oil, iod. solut. extern., morphia. In 6 months no cough, health improved, weight 11^, dulness, flattening, bronchial voice, no crep. left In 1852, flatten- ing, and ex'piration long, only ; cough very slight, health ' good. A. B., female, ast. 26. Mother and brother died of pht. 3rd staga arrest. Ill 9 months. July 1848, frequent hsemopty., expect, copious, sweats, rapid pulse, ctma. irreg., digestion good, cavernous resp., coarse crepitus, bronchial voice, right apex. January 1851, flattening, dulness, long expiration, vocal resonance, no crepitus, scarcely coughs, quite well in health. S. C, female, school-assistant, set. 20. No predisposition. Cavity 3 years ill, cough, sweats, hsemopty., ctma. irreg., dulness, ^^^^^?^P' flattening, cavernous breathing, pectoriloquy, gurgling, left placed; suhclav. After 1 year began to improve (on oil, &c.), loud '^^^^ creahing, some crepitus, left apex. In two years, looking well, flattening left subclav., heart beating to left side at the 2nd intercostal space, no crepitus, a loud creaking sound, chiefly with expiration. One year later, slight cough, no expectoration, weight increased, health good, left subcla- vian space more fcdlen in, dulness, ^ bruit de pot fele,^ heart as before, respiration puerile in right. W. S., tailor, get. 22. Oct. 1848. 1 uncle, 1 sister, died ist stage, of pht. Ill 3 months. Cough, hsemopty., wasting, dulness, a^'^'est. bronchial voice, expiration long, right apex. January 1850, feels quite well, flattening, no dulness, rather tubular ex- piration, r. apex. (I should have classed this among the chronic first stage cases, but the arrest was manifest.) R. H., waiter, set. 26. May 1849. Ill 1 year, worse 4 2ud stage, months. No hsemopty., cough, expectoration, wasting, did- arrest. ness, crepitus luell marked, right subclav. After 2 months become no cough : perfectly well in 1852, when the signs were slight ^■ dulness, iveak inspiratory sound only. T. W., lad, set. 14. June 1849. Mother and 2 sisters died 3rd stage, of pht. Ill 1 year ; much debility, wasting, purulent expec- arrest. toration, pulse rapid, dyspnoea, cavernous resp., coarse moist signs dis- rhonchus, left apex, harsh resp. and exp. prolonged, right appear. apex. Sept. 1849, feels well, increased in weight, no crepita- tion. May 1852, flattening both, most left ; inspiratory 214 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, murmur seems to want penetration, expiratory ivhijffing. >_ , ' -^ In excellent health, hard worked in open air. 2nd stage, F. T., male, set. 25. August 1850. Uncle and aunt died arrest, ^f pj^thisis. No hsemopty. ; ill 6 months ; dulness, bronchial resp., coarse crepitus, left apex. In two months the moist sounds disappeared. Health improved. 1st stage, arrest. Cavity contract- ing ; health restored. T. W., male, set. 40. July 1850. Father died of pht. Ill 4 months; loss of flesh, hsemopty., severe cough, dul- ness, feeble resp. right apex, wavy inspiration and dul- ness left apex. In 1852 perfectly well, no cough, puerile resp. both apices, right subclav. region flatter. M. P., set. 25, female. June 1848. 1 sister died of pht. Ill nine months ; cough, hsemopty., liver enlarged. Dulness, bronchial resp. right apex. In October, gurgling in same space. July 1859, little cough, scarcely any expectoration, cavity contracting, dulness, flattening, creaking sounds, some coarse crepitus occasionally, right subclav. Posteriorly cavernous blowing; left, puerile. March 1852, in perfect health; weight was 7.12, is now 10.8. Whispered pectori- loquy over a smcdl spot, right apex, flattening under the clavicle ; no cough, no symptoms. 2nd stage, M. A. B., Jet. 9. Sept. 1848. 1 aunt died of pht. Ill 3 arrest. months ; cough, wasting, hectic, dulness and coarse cre- restoration pitus, left apex. June 1852, quite well, grown tall and of health, gtout ; spine curved, the convexity of curve being towards left scapula ; loud puerility left apex, posteriorly, dulness and harsh respiration at extreme apex. This dulness is most likely the result of ' puckering ' of the lung. Hereditary phthisis. 2nd stage, arrest. Numerical analysis. Gr. C, carpenter, set. 31. Dec. 1849. His mother and seven brothers and sisters died of phthisis. Ill 1 year; cough, hsemoptysis, wasting, dulness and coarse crepitus right apex. May 1852, free from cough, no symptom of illness ; flattening {no crepitus), inspiratory sound weak, expiration long right apex, left puerile. A numerical analysis of these cases is not of miicli value. Of the twelve, seven were males. The left side was affected in six instances, or one half. But in CrmONIC THIRD STAGE — CASES OF AREEST. 215 all wliicli passed beyond tlie stage of deposit, the affec- tion was confined to one lung. Eight out of twelve had a family predisposition to phthisis. Taking Bennett's and Quain's cases together, we shall CHAP. xjir. find the following figures ': Total; Males . „ Females „ Right hing „ Left lung . 21 9 15 9 The preponderance of males over females, and of the Males and right side affection over the left, is here very marked, alirion^ The following tables give particulars of the age, sex, preponde- and duration of 206 cases of chronic cavity, which occurred in my own practice: — rate. Table showing the Sex and Age in 206 Cases of Chronic '^3rd Stage. Sex and age, pht. 3. Age No. of males No. of females Totals Under 10 years 10 to 15 „ 15 to 20 „ 20 to 25 „ 25 to 30 „ 30 to 85 „ 35 to 40 „ 40 to 45 „ 45 to 50 „ 50 to 55 „ 55 to GO „ Total . 1 11 • 28 25 27 15 12 2 1 2 1 20 16 13 15 9 5 3 2 2 31 44 38 42 24 17 5 1 122 84 206 216 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XIII. Duration, Pht. 3. State on leaving hospital. Average duration of Pht. 3. Table showing the Duration, while under Observation, of 206 Cases of Chronic Cavity in the Lung in both Sexes ; those which lasted under 18 months not included. Duration Males Females Totals 2 years ■^2 }) 2 6 1 1 3 7 3 » 15 5 20 4 „ 14 6 7 7 21 13 10 9 19 5 „ 7 2 9 5^ „ 6 „ 6 7 2 8 8 15 7 10 3 13 8 „ 3 2 5 9 „ 10 „ 4 1 2 1 6 10 to 12 yeai s . 1 4 5 12 to 15 „ 3 3 15 to 20 „ 1 1 2 21 1 1 1 Indefinite Ic mg periods Totals . . 26 28 55 122 84 206 Of tlie above only five died wMle under observation. All were males. Two had been ill for indefinite Ions: periods ; one for tliree years ; one for four and a half years ; and one for seven years. The state on leaving the hospital was as foUows ; Better 40 Worse, including five dead . . .73 Stationary ...... 93 Total 206 The average duration of the disease in this stage from its commencement, and reckoned from the above obser- vations, excluding the 55 ill for indefinite periods, was 66-66 months.* The grand average of all cases of * An insurance office with large invalid business is in the habit of assig-ning tivo years as the average expectation of life in cases of limited cavity in one lung. CHRONIC THIRD STAGE — CASES. 217 plitliisis being 30 months and three-fifths, this form and stage of disease is seen to attain more than donble the duration of ordinary consumption. In other words, wlien a patient with cavity has passed 18 months, there remains still a reasonable expectation of hfe,- which may be extended for more than four years. For it is to be remembered that these tables do not represent the actual duration of each case to its termination, but only while under observation. I subjoin particulars of some of the more remarkable cases, selected from a great number of notes, taken in all instances in the presence of the pa- tient. The various forms of the third stage of chronic phthisis will thus be sufiiciently illustrated: — B. T., set 23, dark hair and eyes, mother died of morbus Case. cordis ; one sister d. of haemoptysis (phthisis). Had under- -^°?'P^*^*l^ gone much mental harass from altered circumstances and cavity, domestic . affliction for some months early in 1862. Lost severe hec- flesh rapidly in February and March, when cough, preceded cov'ery of by a rather profuse hgemoptysis, commenced. In May 1862 health, had much hectic, pulse hard, 120, excessive chills, and mahisdrv copious morning sweats. Anorexia complete, much nausea, thirst, tongue furred, bowels costive, sleep disturbed by almost continuous cough. In June she began to expectorate copiously, and all the symptoms were at a maximum. Chest well formed, much dulness to 3rd rib, with gurgle, blowing on inspiration a,nd expiration, increased vocal resonance. The same signs in the supraclavicular and supraspinous regions, right. Beloiv this anteriorly great roughness of inspiratory tone, and expiration prolonged. Remaining parts of both lungs clear. This poor girl had been going out in all weathers as a daily governess. Through the kindness of friends she was relieved from this necessity, and all necessary comforts were secured for her, together with perfect rest. During June and July she continued to emaciate with rapidity, and was reduced to a state of extreme weakness ; but the physical ' signs did not extend to the base of the lung, and the opposite lung was clear. The treatment adopted was active counter-irritation over the right apex ; and the hydrocyanic acid, in effervescence with carbonate of ammonia : morphia 218 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP, for cough. Small quantities of nourishment at short in- , -^™- , tervals. Her exhaustion became so great that wine was ordered about June, and she took three glasses of sherry daily, a quantity which had soon to be doubled. In August she was with great difficulty moved to the country. Her diet, under nay directions, consisted at this time of the most concentrated nourishment, given every two hours. Turtle and other soups, eggs, jelly, meat pounded, milk. She took two glasses of brandy and a pint of port daily. I received cheering reports. In May 1863 she called on me in London; and I have rarely been more surprised or gratified. She ap- peared in perfect health, embonpoint considerable, colour excellent ; has had no fever for months, no cough nor ex- pectoration ; app. excellent, b. reg., ctm. reg. Chest signs : flattening of subclavian space, dulness well marked, dry cavernous blowing, impeo-fect pectoriloquy {no moist sounds), right subclav. as far as third rib, slightly blowing respira- tion, suprasp. fossa; lung perfectly clear anteriorly and posteriorly below this. The following case has been under my own care since 1856, and has been examined repeatedly by the most competent observers : — Chronic June, 1856. E. M., set 15, assists her mother as national circiiin- schoolmistress, no predisposition, dark hair and eyes. Ill cavity in ^ years, constant cough, lately worse, no hsemopty. Ctma. left;liealt]i established at 13^, absent one year, returned lately; is treatmenr growing fast. No present fever, had sweats; app. lately by oil for fails ; t. dry, whitish. Lately been in-patient ; gained 5 lb. in ten years, g niths. Much dulncss, gurgling, pectoriloquy, flattening slight, cardiac impulse communicated for 3 inches sub- clav. left; base clear. Has taken much oil and iron, with sedatives, for cough. This treatment continued with solut. iod. to the left side. From June to August had slight hsemopty, and frequent diarrhoea, with sweats ; but by No- vember had mach improved, these symptoms having been checked by acet. plumbi c. opio. At this time the signs became dryer, and the expectoration less. She looked well, weight 8.13^. In December expiration prolonged right apex, cough rather more troublesome. LIMITED CAVITY IN LEFT APEX FOR TEN YEARS; MUCH FLATTENING OF SUBCLAVICULAR SPACE ; HEALTH EXCELLENT. iDrawn from Life.) tSee pase 218. i CHRONIC THIRD STAGE — CASES. 219 April, 1857: during winter got on well, expectoration CHAP, moderate, rather gains flesh, and has the aspect of excellent . "^^/^" . - health. Lately appetite fails, and has occasional slight diarrhoea, with thirst. Haemoptysis 3 weeks ago. Ourgling for 3 inches, left. June 1857: has reduced in weight to S.5 ; the physical signs have extended to the jjosterior part of the apex; cough increased; vomits. Omit oil. Mist, acid hydrocyanici. August : improved, but occasional diar- rhoea, requiring astringents and opium; takes oil pretty constantly. November 1857: improved; weight, 8.13^; looks well, diarrhoea rarely ; a dry form of crepitation over dull space, right. With the exception of occasional hsemo- ptysis, there is not much to record, excepting a gradual improvement in health, a persistence in the physical signs of cavity in the left apex, and a marked sinking of the chest walls over this spot. The heart is also drawn up, and there is pulsation in the 3rd intercostal space. In October 1863 I made the following note: — Couarh very slight, scanty morning expectoration, is in good flesh, colour good. Ctma. regular, digestion excellent, no diarrhoea for months. Has had occasional haemoptysis when over- worked. Has the entire management of a National School for the last two years. She comes to the hospital once a month, and has now taken oil for nine years, with only a rare interval when it disagreed. Great sinking of chest walls left suhclav., dulness and dry crackling on cough to 4th rib, faint dry crepitus below this to the anterior base. Blowing and dry crackle in supraspinous fossa, roughness of respiration in base posteriorly. Slight occasioned dry crepitation, and some blowing sounds opposite spine of scapula, right. In July, 1865, she remains in all respects in the same state. W. P., set. 36, clerk, no predisp. 13 years ago had has- Well de- moptysis, and was under treatment for ' tubercle in right ^^^^ '^^- lung.' Is subject to dyspnoea ever since on exertion. Slight dhronie'^^ occasional cough with slight expectoration. Complains of 13 years deficient circulation in extremities. Is in fair flesh, digestion healthy. Much dulness, cavernous bloiving, very distinct pectoriloquy, bruit de pot fele under right clavicle to 2nd rib ; below this wavy inspn. still loiuer deficient resp. (as compared with opposite lung). 220 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP. XIII. Defined cavity, frequent sliglit hsemopty., 8 years. Limited cavity, greatly improved health. SmaU _ cavity in apex, pro- fuse hse- mopty., not ex- tended after 8 years. Limited cavity be- fore pu- J. H., set. 42, tailor, no predisp. Hsemoptysis 8 years ago, and frequent, slight ever since. Cough slight, spare but not losing, app. good, b. reg., no fever, diffused chest-pains ; dulness, nearly pectoriloquy, cav. bloiving (no moist scls.), suhclav. right, rest of lungs clear. Treated with gallic acid, oil, quinine, and iodine externally. Much improved after 1 year. W. H., get. 33, coachman, no predisp. Ill 7 mths. Apho- nia some mths., slight cough, hard gristly expectoration, no hsemoptys. In good flesh, but lost ^ stone last month, now 13.2. Digestion good, embonpoint, colour and muscular development excellent, as in perfect health. Dyspnoea lately, dulness and large gurgle, marked 'pectoriloquy, apex right side. Ordered oil, gallic acid, iodine externally. Two months later I find the following note: — Grreat improvement in health and strength ; no sweats, cough better, only when hungry ; breath much better ; marked vocal resonance, clicking, and occasional bubble, right subclav. circumscribed. May 1856. H. L., set. 38, painter (mother d. of phthisis). Ill 1 year, cough slight, increasing expectoration, sweats, dyspnoea, losing flesh. Heemoptysis i pint a day for 3 days, 5 weeks ago. Cavernous cough and pectoriloquy supra- clav. dexto., beloiu this dry and tubular character of resp. Pil. conii c. morph., oil, gallic acid, iodine externally. Eeport six months later : looks very well, cough night and morning only, tolerated cavity right. One year later : appearance of excellent health, slight morning cough only; weight 10.2. Pectoriloquy above clavicle and cavernous blowing, expira- tion prolonged and insp. rough 2 inches below clavicle, right. Oct. 1864. While writing out his case, singularly enough this patient calls at my house. I find a ivell-defined cavity in right apex, extending as far as 3rd rib anteriorly, and suprasp. fossa, base clear, tubular bloiving left sup-sp. fossa. General health somewhat impaired, much dyspnoea. Has slight dilatation cordis, hepatic enlargement, no fever, is not wasted, has slight cough and daily moderate expecto- ration. I can thus verify the existence of a cavity for seven years. Jane H., set. 16, no predisp.- Ctma. not appeared. Grow- ing fast, rather gains flesh. Ill 2 years with cough, slight CHEONIC THIRD STAGE — CASES. 221 expectoration. Hsemopty. teacupful 4 months ago ; app. CHAP, good, b. loose, t. clean. Grained in weight, and improved . ^^ ^^'_. in health at the Bournemouth Convalescent Institution. Has berty ; im- taken oil 8 mths. Very marked dulness and superficial proving. gurgling for 3 inches sub. clav. right, dry wavy inspiration ^^'^^' loiver down, much improved under treatment for 4 months. A. v., set. 22 (male). Tenor singer. No predisp. Hse- Small' mopty. 3 quarts suddenly 3 years ago while singing, and fre- *^^J'^y; cpient ever since. Cough, but lately very slight, scarcely hEemopty. expectorates, some sweating 3 months ago, and slight ^'^'^^^^ ^1 diarrhoea occasionally, slightly out of flesh, small cavity right apex. Maria M., set. 24, black hair, eyes dark grey, had typhus 2 Cavity in years ago, cough ever since, no hsemopty. ; expectoration typhus ^^ abundant, thick, yellow, teacupful daily; digestion good, improve- b. reg., ctma. reg., no hectic, embonpoint good, gains flesh, ^'^^ ' movements very good, no flattening, very superficial caver- nous blowing and pectoriloquy with extreme dulness for 5 inches left. Improved on oil for 6 mths. H. C, set. 25, butcher. Profuse hsemopty. 1 year ago, and Large frequent since. Cough and abundant expectoration in morn- ^p-^i^' ^ ° '- right apex; ing, sweats some mths. ago, no present hectic; app. good, arcus lives well, meat twice a day, 3|- pints of beer, oil taken for ^^™^yt 2 mths. Is in good flesh. Slight arcus senilis. Signs of large cavity in right apex. A. D., set. 21, gardener, no predisp. Slight hsemoptysis 18 Cavity months ago, after a strain, cough severe for last 4 mths. , ^°i^i ° . ' ° . health im- Expectoration thick, abundant, increasing, losing flesh, proved; sweats, thirst, white tongue, acidity, vomits, anorexia, bowels ^ years. costive. Dulness very WMrked, gurgling, blowing, pecto- riloquy right, dulness and feeble respiration apex left. Ordered oil, alkaline mixture, pil. conii c. morphise. He gradually improved, and the note 6 months later was, * much better, looks in excellent health, works a little, no dyspnoea except on great exertion, a little clear spittle only daily.' Pectoriloquy as before, a crumpling sound {not gurgling), considerable retractation of chest ivalls left. To continue the oil. W. E., set. 35, engine-driver, no predisposition, still at work, Chi-onic but not on the line. Eight years ago had an attack on the •^^^'?|™" o J a scribed right lung. Hsemoptysis 2 quarts 3 years ago. Cough con- cavity for 222 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, tinuoiis, but not severe, with, slight expectoration ; weighs XIII. ^ iQ^4^^ ^as 12.4. No present fever, app. good, b. reg., im- years. proves in health, hoarseness and soreness of larynx last year. Cavity Dulness, vectoriloquy, cavernous blowing to Srd rib, riciht, breaking . %{ . k i -n i .j • 7 -P up. Dis- Signs weii circumscribed. Beloiv tins, roughness of resp. ease in ^nd exp. prolonged. Still loiuer, wavy respn., base clear. lun°^8i Rough r. and exp. long apjex left. Has taken 1 gallon years. of oil. Ordered iod. potassii, gr. iii. ex. decoct, sarsse. ter in die, linctiis opii, solut. argent, nit. to larynx. One month later humid crepitus replaced the wavy respn. below the cavity. Six months later, friction sounds left base, with extension of disease in right lung, and symptoms much worse. Cireum- Thomas B., get. 32, comedian ; no predisp. ; presented Feb. scribed • 1857. A spare, low-sized, intelligent man, chest well deve- cavity, leit. ^ ' ° Eemark- loped, arms muscular ; was accustomed to gymnastic exercises ablephysi- -^-^ ^j^g circus (as clown) till 9 months ago, where he lost his ability to ' voice, and with it his engagement at Astley's. Ill for 5 siiig- years, with cough and frequent haemoptysis, and certain Diiration amount of dyspncea on exertion, which, however, did not 10 years, prevent his extraordinary exertions before the public. Has no present fever ; digestion good, app. excellent, leads a strictly temperate life. Dulness, cavernous blowing, pec- toriloquy well marked and circumscribed, left subclavian region. Ordered oil, linctus opii, solut. iod. to the larynx externall}^ The uvula was shortened, and a tannin gargle directed. May. — Voice as strong as it ever was; has re- sumed his occupation as clown, can sing, but by my advice avoids the more violent exercises of the circus (as somersaults). In October went to the north of England, and filled many engagements. In August 1858 I was telegraphed that he was seized with profuse haemoptysis on the stage at H . I directed, in reply, frequent doses of acet. plumbi c. opio, and rest, and he resumed his occupation within a month. In May 1859 this well- walled cavity gave way, and a coarse crepitant sound was evident over the luhole left front, while dry bloiving respiratory sounds were heard at the right apex. Yet, in spite of many warnings, he persisted in his professional exertions, only greatly moderating the mus- cular exercises, and confining himself to the jesting depart- ment. In August he was so weak that he fainted more than CHEONIC THIRD STAGE — CASES. 223 once ; but at the end of the month he again accepted a pro- CHAP, vincial eno-agement. In the summer of 1860 he had much , J^^^^- _ improved, and still acted and sung. The expectoration had much increased, and diarrhoea at intervals reduced his strength. Yet, with a full knowledge of his danger, he con- tinued at his occupation. Finally, in 1862, his weakness became extreme, and although in nightly attendance at a theatre in the north, he was so ill as to be scarcely able to stand. Alarmed, at length, by repeated faintings, he hurried up to London by train, and died in my presence two hours after his arrival.* I am indebted to the kindness of my colleague, Dr. Quain, for the abridged notes of the following case : — May 1850. Mary W., set. 45; married, 5 children; ill Dr. _ ^ 2 years ; cough continuous, and frequent haemoptysis ; dul- Q^^™ ^ ness, less mobility, dry creaking and loud voice, right Signs of subclav. Mist. gent, alk., pil. acid. gall. ol. morrhuse. July : ^^'^■^^j^^^ better, coughs up calcareous particles. Oct. : irritative disappeur, fever, with pain in side. March 1851 : some flattening, °i|_'^,^'^ rigid, very loud expiration, still dulness, expectoration taken for abundant. April 1852 : is doing well, but has consider- seven able anxiety ; ctma. quite regular, not taking oil for some ^^^^gj, ob- time, but continues mist. gent. ; flattening, much less did- servation. ness, markedly tuhidar resp. ctnd bronchophony, nearly pectoriloquy {if not absolutely), right apex. Oct. 1852 : uncommonly well, menst. regular, little, if any, cough, regular bowels ; resp. noiu less loud, right. Still taking oil and mist. gent. alk. The solution of iodine has been fre- quently applied. April 1853 : doing well, mens, getting less, but regular; breath rather short, merely loud expira- tion, now in right, no undue resonance of voice. April 1854: some return of cough, but general health good; signs same as last year. In 1856-6 her health was not so good. At this time menstruation began to be irregular (her age then was 50-51). In July 1857 I find a final * I cannot forbear from dwelling on tie heroic fortitude of this re- markable man, and can testify to his self-denial and its object. He had a ynh and aged mother much dependent on his exertions. I have wit- nessed his performances at Her Majesty's Theatre, when few would have credited the physical weakness against which he struggled. 224 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP. ' XIII. Case. Phthisis, 3rd stage. Eecovery of health after for- mation of cavity in one year; tolerance for seven years ; oil for seven years. report that she was ' doing well.' The treatment with oil, mist. gent. alk. and sedatives, as also the external application of iodine, had been carried out under Dr. Quain's observa- tion (and occasionally under my own) for seven years. The following case was under my care for eiglit years : — June 1855. L. B., set. 13 ; mother died of rapid pht. under my care ; father died of phagedenic ulceration of pharynx, ex- tending to the carotid artery. Cough, expect, mod., extreme sweatings for 6 ms. Anemia, and considerable emaciation ; di- gestion good. Dulness all over anterior and posterior ajpex, luith moist crepitus right. Dulness and slight crepitus suh- clav. left. Cod-oil, gallic acid, iodine externally, vinegar sponging. She improved much, but in Decemb. a cavity formed in right apex. She greatly regained health after this, and was in good flesh. The cavity was well circum- scribed, the base of the lung having cleared up and presenting no crepitant sounds. The moist sounds at the left apex also disappeared. The shape of the chest good, movements ex- cellent, a slight flattening only at right subclav. In Feb. 1857 ctma. appeared. She has had no fever for months, her health is excellent, app. good, has grown much, height 5 feet, weight 7 stone. March 1859 : looks in perfect health ; weight, 8.2. Phy. signs : dulness, gurgling, for 3 inches, suhclav.^ marked wavy inspiration below this, and expiration pro- longed, left. Dulness, gurgle, bronchial resp. and bronchicd voice in the superior scapular region for 6 inches right side, post, base clear. At this period this poor girl's life seemed capable of indefinite prolongation. She proposed to marry, but I dissuaded her from this step. She was appren- ticed to a dressmaker, contrary to my advice. Her chest symptoms were limited to dyspnoea on exertion, and slight morning cough, and she appeared to be in perfect health. She continued to take oil constantly. In 1862, towards winter, she began to break up. In January 1863, vomiting, diarrhoea, and sweats set in. The barrier below the cavity broke up, and crepitant sounds replaced the wavy. The opposite apex also again became crepitant. She emaciated rapidly, and died in March 1863. Duration of case, eight years and three months. CHRONIC THIRD STAGE CASES. 225 This case is a good example of the improvement chap. in health which often occurs after the formation of ^.JE^L^ cavity. The blood disease appeared exhausted for the Remarks. time, and a remarkable toleration of the local mischief occurred. The evidence of circumscription of the cavity was well marked, and the alteration of the moist sounds in the opposite lung to respiration, only harsh, was very remarkable. At the break up this lung became again crepitant, showing a renewal of the destructive process. We cannot doubt that had the constitutional disorder not been reinduced by the close confinement and other pernicious influences to which she was exposed, this patient might have lived for many years. As it was, the prolongation for more than eight years was remarkable, and the conditions under which it occurred most worthy of note. March 1859. Ch. H., aet. 26, m., shopkeeper. No predisp. ; Case. cough for three years; no hgemopty. ; expect, slight ; no present Origiii ^^ fever ; marasmus 2, not losing ; digestion fair ; had inflam- attack, mation of right side in Nov. last. Great dulness and de- 2nd stage, ficiency of vesp. from scapula down; also in axilla and CavitylS' from 5th rib to base anteriorly. Humid crackle subclav. 5th year. and much vocal resonance sup-sp. fossa right: measure- retrTctTin ments equcd. Ordered oil, quinine and iron, linctus opii, two years, iodine externally to right. Improved much by going out of ■^'^^^^ °^- town, and was in tolerable health till Dec. 1861, at which time a cavity formed in right apex, and a pleuritic attack same side induced considerable effusion. This was treated by iodine, cod-liver oil, and counter-irritation, and was par- tially absorbed, but dulness and absolute nullity of respira- tion remained at the base cdl round. In March 1862 the base anteriorly presented crepitation, but he was in o-ood general health ; no cough, app. excellent, walks long distances daily, lives well, still taking oil, able to follow his employ- ment. Oct. 1863. Dry, wavy, bloiving inspircdio7i and exp. for some inches under clavicle. No moist sounds {tohere for- merly gurgling), retraction of chest ivalls, dulness for some Q 226 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. XIII. Case. Passage from 1st to 3rd stage, with signs of cavity- disappear- ing. Oil for four years. Chronic cavity, left ; good health ; ' 5. I years. Tolerated cavity ; ability for hard work ; robust health ; duration 21 months, inches suhclav. The base is dull, and respn. deft, as formerly, right. Scarcely ever expectorates ; no cough ; leads an active life; gain of weight. In December 1863 some pain in left base, tvith very slight dry wavy sound (probably pleural). Health unimpaired. Duration 7 years ; under observation 4 years. Oil was taken for nearly the whole period, and counter-irritation repeatedly used. He goes annually out of town in summer, and lives well, carrying on a large business. M. W., f., set. 45, married, 5 eh. No predisp. May 1850. Ill 2 years ; cough ; frequent si. hsemopty. ; dulness, less mobility, dry, creaHng, loud voice, right. Ordered oil and mist, alkal. gent. — March 1851. Some flattening, very loud expiration, dulness. — August. Rough crepitation, loud expiration ; some cough ; general health fair.— April 1852. Doing well ; ctma. reg. ; in fair flesh. Flattening, much less dulness, resp. very tubular ; cavernous blowing and pectoriloquy, right. — Oct. 1852. Uncommonly well; little cough, if any. — April 1853. Doing well; mens, ceasing ; more dyspnoea ; merely loud expiration, now in right front ; no vocal resonance. — April 1854. Still doing well ; taking oil ; ctma. irregular ; occasional dyspnoea the only symptom. Phy. signs as last. Emily K., set. 22. No predisposition. Hair and eyes dark. Cough for 5 years, constant, but slight, with mode- rate expectoration. One slight hsemopty. some mths. ago. Is in good flesh; weight, 8.1. App. and digestion good. Ctma. reg. Small superficial cavity in left apex. Under treatment for 9 mths. ; took oil for that period. Had scarcely any cough ; very slight expectoration. Greneral health ex- cellent. W. B., labourer, set. 28. No predisp. Cough, 14 months ; expectoration abundant, green, dark. Hsemoptysis slight, 9 weeks ago. Sweats lately ; loses flesh ; reduced from 14 stone to 13. Dulness, coarse crepitus, pectoriloquy, left apex. Rest of both lungs clear. Oil and solut. iod. ex- ternally. Seven months later, in November, I find the following note : — ' No cough nor expectoration since July. No hsemoptysis. Is now in perfect health ; works hard, chiefly at sewers, and is much exposed to wet. Lives well ; drinks plenty of ale, rarely spirits. Has no fever, is robust CHRONIC THIED STAGE CASES. 22T in appearance, weighs 11. 8|. Phy. signs: marked crepitus CHAP. and loud vocal resonance over left apex.'' ^^^^\^ I am permitted to mention the following cases on very high medical authority : — A. B., 8Bt. 72. Her mother, two brothers, and one sister Single died of phthisis. In 1837 Dr. Williams and others ascer- ^f^j^^'"^ tained that she had a well-marked single cavity in the right 27 years apex. She has now no cough, is in very good general ^g°'' P^^" health, and lately made a long journey without discomfort, living. There are no existing signs of cavity (December 1864). C. D., f., set. 15. Ill 2 years. No predisp. Large dry Cavity; cavity in left apex. Heart heating in left axilla. Health heart^°^ improving ; gained 5 lbs. in 3 mths. {Dr. Cotton, Ward K, t^o years, p. 423, Case Book.) C. T., f., set. 27. No predisp. Dark hair ; fingers clubbed. Cavity 111 about 5 years with cough and dyspnoea, much increased Heart last 3 years, with pain in right. Cavity right apex. Cardiac displaced pulsations evident to sight and touch between 2nd and ^° ^^i\. Zrd ribs of right side. Clear sound on percussion over the tercostal usual cardiac region. Circumscribed crepitation at angle, space. Six right scapula. Six months later right base became cre- pitant. Right 6. measures aboid half an inch less at the nipple. Eventually a cavity formed at left apex, when she sunk in the 6th year of her illness. This patient was long under observation in the hospital, having been three times an in-patient. Post-mortem examination confirmed the relative position of parts as above stated. [Dr. Cur sham, Montgomery Ward, p. 220, Case Book.) M. A. H., female, set. 8, small precocious child ; f. died of Cavity pht. Ill 2 years since a severe attack of measles. Right side placed much shrunken. Cavity in apex. Heart dislocated, apex heart. beating betiueen 5th and 6th ribs to right of sternum. Death from heemoptysis. [Dr. Cursham, Montgomery Ward, Case Book, p.S7.) The following case, for which I am indebted to my colleague, Dr. Cotton, is a good example of the cure of tubercle, resulting in obliteration of cavity and pucker- ing of the lung : — J. N., set. 36, a Greenwich fisherman, admitted to Ward q2 228 ELEMENTS OF PROGNOSIS IN CONSUMPTION. . CHAP. XIII. Evidence of healed- Tip cavity; death from diseased heart and kidney. Summary of good prognos- tics. No. 5, Sept. 5, 1864, complaining of dyspnosa, short cough, and wasting. A systolic inurviuT ivas present at the ensi- forni cartilage. Slight creaHng sounds ivere noticed at the apex of the right side. Excessive albuminuria, with large and small granular casts. Extreme anasarca ; prostration. The mother of the patient volunteered the information that he had been reported to be in a consumption by the doctors 7 or 8 years ago ; that he had spat blood, and been much out of flesh, but -that ' he had got well again.' He died on Sept. 16th. Post-mortem appearances : — Lungs : right almost universally adherent ; adhesions old and flrin, especially at apex. This lung is very dense at the summit for about the size of a large walnut, ivith much puckering at the top and hack. On cutting into it, there are dense, white, fibrous- looking cicatrices, and one cheesy mass the size of a split pea. The left lung presents similar appearances to the right, excepting that the thickening and contraction at apex are much more marked. The cicatrix of former cavity, the size of a chestnut, is well seen. There is much old tubercle around it, and a few grey miliary tubercles rather lower down in the lung. In the heart was observed insufficiency of the aortic and tricuspid valves and dilatation of the right ventricle. Atheromatous degeneration of the aorta. The prognostics in the third stage of phthisis are to be derived from a most careful study of the history and symptoms of our patient, always in conjunction with the physical signs. The following summary may •assist : — Good prognostics derived from personal history. 1. Family antecedents not phtliisicaL 2.' The male sex. 3. Age not under 20. Good prognostics derived from the physical state of the lungs. Supposing a cavity to have formed, to afford a rea- sonable hope of its becoming tolerated it should be — 1. Confined to one lung- — the apex. 2. The right lung is more favourable, especially in males CHRONIC THIRD STAGE — PROGNOSTICS. 229 3. The physical signs should be accumulated in chap. one spot of limited extent. • ,_ - 4. The physical signs should be well marked and well defined ; that is, the more evidence there is of a perfect excavation, from percussion, breath, cough, and voice sounds, the better ; and there should be an abrupt limit of these signs at the lower edge of the cavity. 5. The cavity should be of moderate size, with the physical signs included m 3 and 4, and not ex- tending to other parts of the lung ; while fever is continuous, and the constitutional disturb- ance intense, a very guarded prognosis should be offered, always, however, holding in reserve the possibility of such a case becoming one of limited and tolerated cavity. On the cessation of the constitutional disturbance, the further favourable prognostics are — 6. A gradual flattening of the subclavicular space, the other parts of the chest retaining their mobility. 7. Alteration of the heart's position. 8. An expansion of the opposite lung to fill up the pulmonary space lost by the shrinking cavity. 9. The absolute immunity from disease of other parts of the same lung, or of the opposite. 10. The cavity sounds become more dry. 11. The absolute cessation of gurghng. 12. The substitution of leathery creaking sounds. 13. A diminution of the area over which the phe- nomena of cavity are heard. 14. The ultimate permanence of duhiess, fixity, retractation of chest walls, and blowing sounds with prolonged expiration, as the only pheno- mena. The favourable prognostics derivable from symptoms are inseparable from those furnished by the physical 230 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP, signs, and by the progressive character of these latter. • , -■> They consist in — 1. The subsidence of all the constitutional symp- toms — hectic, waste, and secondary gastric disorder — soon after the formation of a cavity in the lung. 2. A quiet pulse. 3. Diminished cough, and lessened expectoration, moderated dyspnoea, absence of local pain. 4. The absence of the secondary comphcations of phthisis, diarrhoea, laryngitis, &c. 5. The gradual restoration of the processes of nu- trition, improved appetite, gain of flesh, im- proved colour of face, hps and tongue, and nails. 6. Improved nervous power, evidenced in subsi- dence of irritability, more tranquil sleep, less anxiety, and revived hopes. 7. The restoration or gradually improved regu- larity of the catamenial functions in females. The continuance of the stage of toleration is evi- denced by — 1. An habitually quiet pulse. 2. The absence of sweating. 3. No hgemoptysis (or its rare occurrence). 4. The integrity of the digestive system, in its primary and secondary processes. 5. A maintained average of weight, lower than the mean of health, but never rapidly suiking. The possibility of obtaining the requirements for a maintenance of this state of toleration, viz. : — 1. Freedom from anxiety, whether that due to precariousness of the means of providing the necessaries of hfe, or to grave concerns for the patient or his dependents. CHRONIC THIKD STAGE — PROGNOSTICS. 231 2. Abundance of the comforts of life. chap. 3. Pure air, well-ventilated apartments, exercise, s..^ ,_^_ 4. The absence of the sedentary occupations, or of those of a generally unhealthy character, and especially of tiiat which appeared to act as a promoting cause of the disease in its beginning. It is not pretended that a considerable decree of ^^^^"^ , -■ . . , , . . ^ forms 01 chromcity may not be, m certain mstances, attained by chronic individuals with other forms of cavity in the lung than '^^^'^^y- that above described as of the limited or circumscribed variety. The irregular or (as it has been called) the anfractuous cavity, while its very character indicates a The an- small amount of surrounding healthy lung tissue, may '^^'^^^^°^^^- differ from the circumscribed form only in its configura- tion, and in its history and progress may possess many of the features above designated. But, on the other hand, it must be acknowledged that the ordinary form or type of continuous and destructive phthisis is that which, from a breaking up of contiguous masses of tubercle thickly scattered through the lung, forms a chain of irregularly con- nected cavities, which burrow deeply into the pulmo- nary tissues, and present all the symptoms due to congestion and irritation of the lung itself. The an- fractuous cavity, or chain of cavities, stands interme- diate between the two leading varieties of phthisis, which we have designated as ' diffused tubercle ' and 'limited cavity;' and as it is eminently destructive in its progress, so is it opposed to the probability of a maintenance of any considerable residual portion of healthy lung to permit of the processes of respiration being sufficiently carried on to support life. There are, however, a number of cases of the third stage of phthisis, met with in practice, which last an incredible time, although not belonging to the class of limited excavations in one lung. 232 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XIII, Double cavities. Hare. Eequire- ments. Prognosis. Irregular cavities, with dis- ease of opposite lung. Descrip- tion of. Observations made on. large numbers of these cases seem to warrant their division into two classes. 1. Cases of two pretty well defined cavities, one in each lung, the bases remaining clear. 2. A series of irregular cavities in one lung, often extending to the very base ; the opposite lung presenting only the signs of a limited deposit in the first or second stage. Of the fact of persons with two * cavities often surviving such disease for years there can be no doubt. Two periods of excessive danger have been passed ; and the assumption must be that, when the hectic and constitutional disorder attending the forma- tion of the second cavity have subsided, the joatient is left even then with sufficient respiratory space for the lowered requirements of the system. Ihese cases are so rare as to be almost anomalous ; and they evidence a more than usual vitality, a great power of sangui- fication ; and are never found coexisting with any permanent and serious derangement of the digestive processes. I have only met with instances of much prolongation of life in cases of this kind among the higher classes, Avhere every requirement of health, abundant and varied nourishment, frequent changes of air, and prompt medical help when comphcations arose, afford the fairest chances of assisting in the struggle for existence made against great odds. With these requirements fulfiUed, a fair prognosis for time may be offered. A series of irregular cavities in one lung, with a slight amount of disease in the opposite, and much prolongation of hfe, is not uncommonly met with. In these patients * Dr. Copland mentions a case of phthisis which ' had evidently been of forty -four years' duration' — death from haemorrhage. Several lined cavities in both lungs, with fibro-cartilaginous walls, and two so much reduced as to be almost cicatrised. — Copland on Consumption. Jjond. 1861. p. 67. CHRONIC THIRD STAGE TWO CAVITIES. 233 life is sustained at the lowest possible level. The ema- chap. ciation is very great ; but the patient never loses much - '^^]^' _. flesh, and never gains any. The respiratory require- ments of the system are at their lowest ; and badly- aerated blood is constantly circulating, as shown by the peach-like colour of the cheeks, the partial lividity of lips, and the colour of the nails. There is no better test of the state of the capillary circulation than the nail and the parts surrounding its root. If pressure does not give a rosy colour, or effect much alteration in that already existing, there is much capillary stagnation; and the nutritive processes, and chemical vital changes carried on in the terminal part of the circulation, may be presumed to be very feeble and imperfect. The condition of the luno; is shown by the tubular Piiysicai , T . , -. . ° -. .,. . conditions. blowing breath and voice sounds prevaiung irregu- larly over large portions of it ; and we know from dissection that a chain of irregular cavities is often formed from apex to base. The opposite side may present crepitant sounds over a third or a half of its extent, and all this local mischief may coexist with ditfons!"' quiet pulse, and a tolerable integrity of digestion and of the functions of life continued till the break-up occurs suddenly. A great fixity of the chest and great flattening of the anterior walls is always mani- fest. The side most affected will appear scarcely to move. The flattening; is not limited to one subclavicu- lar space, as in the former variety ; but is diffused. It is due to atrophy and contraction of the lung, and loss of respiratory space. In these cases the heart is rarely displaced ; and the opposite lung, being diseased, is incapable of expansion. The threatened atmospheric vacuum is therefore compensated by sinking of the chest walls above. The decubitus of the patient is commonly on the back, or with the head inchned towards the least affected side ; the occurrence of cough and dyspnoea preventing any other posture. 234 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XIII. Dangers. Clubbed fingers most com- mon in 3rd stage. Authori- ties. Eigaud. Trousseau. The dangers incident to this condition are — 1. Congestion of the remaining portion of sound lung, which annihilates the remaining respira- tory space. 2. Sudden haemoptysis, which, if profuse, fills up the tubes, and causes instant death. But the termination may be by slow emaciation, and exhaustion painfully prolonged. It is obvious that this class of cases owes its continu- ous character to the small requirements of the system for respiration, and to the possibility of sustaining the patient with the fewest possible demands on his strength. Digital Clubbing.^ The peculiar condition of the ends of the fingers which occurs in many cases of advanced phthisis may be best considered here, as it undoubtedly is attached more to the third than to either of the other two stages of tubercular disease. Such authorities as have recorded their observations on this subject have agreed that the condition termed clubbing is found almost exclusively associated with phthisis. M. Eigaud f finds that this sign was present in many non-phthisical cases ; and those which he cites are instances in which certain peculiar trades caused the appearance, as burnishers, polishers, workers at sewing machines, &c. ; but these instances have so obviously a mechanical origin that they may be dis- missed at once from all consideration. More worthy of notice is his statement that this sign was absent in 135 out of 179 cases of phthisis. The opinions of Trousseau J are of more value. He * See Frontispiece. t Gazette Heldom. de 3Ied. et Chir., April 11, 1862. X Journal de Med. et Chir., Nov. 16, 1862. CHRONIC THIED STAGE DIGITAL CLUBBING. 235 considers this condition to be due to liypertrophy of chap. the bone and fibroceUiikr tissue ; and ascribes it to the . '^ second and third stages of phthisis, and to chronic pleurisy in young subjects. According to this autho- rity it is not found in scrofula. He has noticed it in cyanosis occasionally, in which cases it is referable to non-arterialisation of blood. My colleague. Dr. Quain, informs me that he has seen a most marked instance of clubbed fingers in a case which occurred at University College Hospital, and in which the only abnormal con- dition found after death was universal adhesion of the pericardium. The lungs were free from tubercle. My own experience would nearly limit this condition Author's to phthisis of a very chronic character ; and generally encT^ to the second and third stages of phthisis, with a large preponderance of the latter. There may be exceptional instances of its occurrence in other affections ; but they are very rare, and the clubbed shape is generally not perfect. A few cardiac cases and chronic pleurisy form these sign exceptions. The condition is not only almost pecuhar valuable to phthisis, but, what is infinitely more important, to for prog- very chronic phthisis : and it is as an element of prog- nosis rather than of diagnosis that the sign becomes of value. Wherever this tendency is well marked, long duration and toleration of disease may be looked for ; and wherever the condition is thoroughly developed, phthisis, possibly in a latent form, has been present for years. I have further observed that the condition is almost is assod- peculiar to the species of tubercular disease in which cavities, cavities are formed, as distinguished from that in which there is a deposit diffused throughout the lungs with- out tendency to aggregation. In forty-six cases under my care which presented this peculiarity, only four had ' diffused tubercle.' On the other hand, it is scarcely ever seen in cases of circumscribed single cavity. 236 ELEMENTS OF PROGNOSIS IN CONSUMPTION. Sex has slight in- fluence. Age. In thirty instances the patients were in the third stage (cavity), fifteen were in the second, and only one in the first stage. Sex appeared to have httle influence, as the numbers were 24 males to 22 females ; but females exhibited the conditions at an earlier aare than males. The following table shows these observations : — Age Males . Females Total Under 10 yrs. 1 3 4 . 15 „ 1 2 3 V 20 ,, 4 3 7 « 2.5 „ 3 4 7 V 30 „ 6 5 11 „ 35 „ 2 2 4 „ 40 „ 5 3 8 ,, 45 „ 1 1 „ 55 „ 1 1 24 22 46 tions. In endeavouring Compiica- r^\^Q nou-phtliisical comphcations'in these cases were few ; Fistula . External struma Morbus cordis Rheumatism . Pleurisy , More important is the duration, to ascertain this, we were met by the difficulty which in very chronic affections attends on an investigation of the earliest symptoms. The cases which remained thus obscure as to their early history were among the most prolonged of all, and have a value in estimating the character of disease. They are marked 'indefinite periods ' in the following table : — Duration. No. of cases. Buration. No. of cases. 1 year . 2 7 years . 1 2 years . 6 9 „ . . .V 1 3 „ . . . 11 12 „ . 1 4 „ . . . . 4 Chronic indefinite . 15 5 „ . . . 3 6 „ . . . 2 46 CHRONIC THIRD STAGE DIGITAL CLUBBING. 237 3 22 21 The average duration to be assigned to each case from the above table is 45*67 months (not including indefinites). It will thus be seen that digital clubbing implies prolonged toleration of disease. These cases, when ex- amined on leaving, were found as follows : — Better .... Worse , . . ' . Stationary It is to be remembered that, as the tables are calcu- lated from the duration while under observation, a much longer term than that marked must really be assigned to them. Through the kindness of Mr. Edwards, the valuable Eesident Medical Officer of the Hospital for Consump- tion, and whose experience extends now over many years, I am enabled to give the following table of observations, which is formed from probably the largest numbers ever collected : — CHAP. XIII. Average duration. State on leaving hospital. Mr. Ed- wards' tables. Clubbed Per cent. Not clubbed Per cent. Males Females Totals . 404 250 29-12 23-96 Males Females 983 793 70-87 76-03 654 26-91 1,776 73-08 Notes as to clubbed fingers were made in males 1,387, females 1,043 ; total 2,430. Patients whose fingers were decidedly ' clubbed ' are a little above 29 per cent, in males, and not quite 24 per cent, in females ; a difference on the male side of a trifle over 5 per cent. ' The total ' clubbed ' of both sexes was nearly 27 per clubbing cent, against those 'not clubbed' of 73 per cent. belongs to o , _ , f^ chronic In reviewing such -facts, and studying the cases, we phthisis. are led to the conclusion that this peculiar condition, which has been noticed in all ages from Hippocrates, attaches itself very exclusively to chronic phthisis. 238 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XIII. Its cause. Appear- ances. Evidence of non- art erialisa- tion and imperfect nutrition. It is never seen in incipient stages of tubercular disease, nor does it occur in the more acute forms of phthisis. To what then is it due ? We believe that its cause will be found in an altered and much lowered condition of nutrition, evidenced at the terminal parts of the circulation. The appearances are due to two conditions : hyper- trophy, causing expansion both of the bone and of the fibrocellular soft parts, and also to absorption of the pulpy parts underlying the nail ; for incurvation of the nails is always conjoined with the former condition. A great stagnation of the circulation may be noticed, and is evidenced by the lividity of these parts. Under the influence of great venosity, the result of imperfect arterialisation in the lungs, the capillary changes are imperfectly performed, the nutrition of the part is impaired, and a loose, spongy, and ill- compacted tissue is produced, instead of healthy struc- ture. That the whole capillary circulation of the body is in a similar state in very chronic phthisis, with great destruction of respiratory space, is highly probable ; and we can have no better evidence of the condition of the terminal portion of the vascular system than in the parts underlying and surrounding the nails. The phthisical patient, in very advanced stages of the disease, is hving at a lower respiratory average than would be consistent with health. As in hybernating animals, his production of heat and the activity of the capillary circulation are greatly diminished ; the nu- tritive processes are proportionately lowered ; and, if the individual is at the growing age, normal growth is stopped. When new tissues are to be formed, or old ones sustained in the daily loss and renewal of struc- ture, the processes of nutrition are scantily performed, and their products are of lower vitality. In a word, we believe that this abnormal tissue about the bone is only one specimen of what is going on all over the CHEONIC THIRD STAGE — DIGITAL CLUBBING. 239 body, and illustrates the formation of a low quality chap. of tissue out of partially arterialised blood. In such .J^'_. individuals the colour of the face and of the lips is generally dusky, and evidences the admixture of venous blood in the circulation. The cases, apparently exceptional, in which I have witnessed clubbing in even a shght degree without manifest phthisis, have been instances of chronic pleurisy, empyema undergoing absorption, and chronic cardiac affections. In phthisis combined with diseases of the heart (ob- Found iu structive — valvular affections chiefly) it occurs very ^ith^^^^ fi^equently. valvular filSGRSG The following instance of cancer in the lung and mediastinum, Avith old calcareous concretions in the lung, and puckering at the apex, was accompanied by very marked digital clubbing ; but the signs of old tubercle wiU probably, to many readers, account for the state of the fingers : — C. L.,* set. 54, admitted into the Hosp. for Consumption, c^se. under Dr. Pollock's care, August 8, 1862. No known predis-. Cancerous position to tubercular or cancerous disease. Had gout four years ly^o- and ago, and has been out of health ever since. Hsemoptysis mediasti- 16 weeks ago, since then persistent cough and increasing olcTcica- dyspnoea, with latterly severe lancinating pain through the trices and left chest. ^Expectoration moderate, viscid, prune colour, tilj^jj'g^in Slight loss of flesh. He is a stout, well-built man. Face the lung, congested, bloated, of a dark venous colour. The fingers are /"t^^j markedly clubbed. Decubitus partially on the left side, with head low. Right pupil is larger than the left ; the right radial pulse fuller than the left. Chest movevients on left nea.rly lost; external chest veins enlarged, and more so on the left. Left absolutely dull all over front to the base, dulness extending across the iipper two- thirds of the sternum and the lower third. Com- plete absence of respiration over the dull part. Pos- * Abridged from tlie Path. Transactions, vol. xiy. p. 19. 240 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, teriorly in supraspinous fossa bronchial respiration and ^_"^ ^^^'_- bronchial voice. Very tubular res'piration along spine, with increase of vocal fremitus. Slight moist crepitation, extreme base, posteriorly. Respiration puerile on right, and very rough. His natural voice had been a deep bass ; he now spoke in a high treble. No dyspnoea ; excessive ten- derness over left chest. In about a week slight prominence of the chest walls was manifest at the 2 rid and 3rd ribs. This was hard and exquisitely tender, and the centre of the lancinating pains from which he suffered. The diagnosis of a cancerous mass, occupying the mediastinum and encroach- ing on the left lung, was recorded at the first visit, and the progress of the case only verified this opinion. He died exhausted on October 15. There had never been ex- cessive dyspnoea. The left radial pulse became imper- ceptible before the right. Post-mortem appearances 30 hours after death : — Left pleura contains a large quantity of fluid; it is firmly adherent to the lung. A cancerous growth is seen in the posterior mediastinum, adherent to the vertebrae, as low down as the last dorsal, and extending up- wards along the neck. It presses on the left lung, and sur- rounds the various structures at the root of the lung, and is continuous anteriorly with the external tumour. Left lung compressed to the size of an orange, is infiltrated in its upper third with cancerous matter. Left bronchus nearly oblite- rated ; left pulmonary artery much narrowed ; arch of the aorta not pressed upon. The right lung is of average size. In the lower lobe are two cancerous deposits, white, cerebriform, and possessing the usual microscopical appearances of cancer. A puckering of the lung is seen on its surface in the lower lobe, and on cutting into it there is a small cretified mass. There are two cicatrices at the apex of this lung ; no recent tubercle. One of the bronchial glands at the root of this lung is converted into a cretaceous mass. Heart, liver, and kidneys healthy. The external tumour, when microscopically examined, appears to be cancerous. In the above case the two diseases of cancer and tubercle were undoubtedly combined ; and the tuber- cular seems to have been superseded by the malignant disease. DIGITAL CLUBBING — GASES. 241 James S., ret. 39, keeps a beer-shop. No predisposition _ CHAP, to phthisis. Eheiimatic fever some years ago. Cough many -^^^^•_^ months; hard, dry, till last month, when he expectorated m. Cordis. matter mixed with blood. Night-sweats. Weighed 12.6; is Phthisis i. now 1 1 stone. Digestion impaired, urine loaded, t. furred, flngers colour sallow ; has probably drunk much beer. The fingers are much clubbed. Rough aortic systolic murmur. Ex- <]piration long, cough ir)ipulsive, wavy rough inspiration, with dulness on percussion for some inches right. Im- proved at first on taraxacum and nitric acid, with the ext. acet. colchici and aloes. Later on, the cardiac symptoms in- creased, and he was confined to the house. Catherine H., set. 18. One aunt died of phthisis. Ill 12 Verychro- years, ever since an attack of pertussis. Has constant cough, pj^^^l^s^gs streaky haemoptysis. Digestion good. Ctma. not appeared. No 1 2 years. fever present. Hair and eyes dark ; colour rosy ; not much out of flesh. The usual signs of irregular cavities in both lungs. She cannot take oil ; improved on effervescents with hydrocyanic acid and light wines. The catamenia appeared some months later, and continued regular. She became an in-patient for three months, but did not gain weight. Her fingers are much clubbed. Eliza L., set. 30, widow. No predisposition. A profuse Phthisis 2. haemoptysis 8^ years ago, followed by a cough, which has been ^^ continuous ever since. The haemoptysis has frequently been repeated, the last three weeks ago. The cough is now only on lying down and on rising, with slight expectoration ; on some days none at all. She had much hectic at the begin- ning of her illness, marked by profuse sweating. Pulse now quiet. She is only slightly wasted. Her fingers are very markedly clubbed. Digestion fair ; no diarrhoea ; ctma. absent 2 months. Dulness very marked, ruith coarse, dry, crackling crepitation over the tvhole left front. The expira- tion is long and rough at right apex. About a year ago she took oil with much advantage. After five months of treatment she gained 10 lbs. in weight, and was in very fair health, with scarcely any cough. Sarah S., aet. 26, housemaid. No predisposition to phthisis, phthisis 3 Haemoptysis 6 years ago, and cough with expectoration ever double, since, till about 2 months ago, when by removal to the y^^^®- country she lost her cough altogether. Ctma. regular, but cluWs^d. E 242 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP. XIII. Tolerable health. Struma. Phthisis 3, very chro- nic. Chronic stationary phthisis 3 6 years. scanty ; app. poor ; bowels reg. No fever. The fingers are much clubbed. There are two cavities of irregular shape, presenting a very dry character of the sounds. She im- proved considerably on oil and bismuth. Louisa S., set. 11. Grandfather and aunt died of phthisis. Chronic suppuration of cervical glands; healed up recently. Cough for some years, with occasional streaky haemoptysis. JSTo present fever ; bowels reg. Is much wasted. For the last year the fingers have gradually become clubbed, and now exhibit that condition in a very marked degree. Gurgling and blowing sounds over the whole right front. Humid crepitus at the base posteriorly, left. This child improved much on syrup, ferri. iod. John D., set. 9, dark hair and eyes. 2 aunts and 2 cousins died of phthisis. Ill for 5 years. Cough, expectoration, and streaky, frequent haemoptysis. Is not losing flesh, and only slightly wasted. The fingers much clubbed, and nails in- curvated. Gurgling and dulness over the whole left. Click- ing on right side. Improved much on oil. STRUMOUS niTIIISIS. 243 CHAPTEE XIV.* STRUMOUS PHTHISIS. The formation of tubercle before the age of puberty chap. possesses features which deserve a separate and careful . ^^^- . consideration. The possibility of organs other than Formation the lungs being the seat of its development while the before^e^ latter remain free, has attracted the attention of all ^s^^f pathologists, and has been implied by Louis in the ^^ ^^^' proposition that after the age of fifteen tubercle, if Louis. present in any tissue of the body, is always found in the lungs. The converse remains true — tubercular disease may invade every organ before that age without engaging the pulmonary structure. The fact has been proved by many observations, and may be accepted as a pathological axiom. The universality of the deposit in so many various tissues at this early age argues a cause intensely productive of a uniform morbid ■ result, consentaneous influences helping its elaboration, and a high degree of blood contamination ; while it is obvious that either the lungs are in many instances at this period able to throw off the morbid material, or are in their structures and functions less capable of submitting to the infiltration. The activity of the lacteal and lymphatic systems in early life is doubtless a potential cause in directing the tubercular deposit to the involuted structures which we distmguish as glands, and hence the extensive alterations in the mesenteric, bronchial and cervical B 2 244 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP. XIV. Influence of growth. Puberty. Strumous tubercle. glands, so common in tlie infancy and childhood of the children of tubercidous parents. Growth, or the act of nutrition which produces new tissues, renders these latest organisations most hable to become the seat of tubercle. Thus bone is attacked, or rather becomes built up of such materials as render its permanence impossible, and its early destruction inevitable. The more complex and elaborate tissues, as the brain, with large vascular supply and most rapid growi^h, are very prone to tubercular degeneration, as attested by the great frequency of hydrocephalus in strumous subjects. But while these various structures are in process of formation by an impure plasma, the lung enjoys a comparative immunity. A period of extreme peril arises when the formative activity of the blood has been partly expended, and the highly organised being has to be furnished with a power of reproduction. Puberty in some of these subjects is never reached ; others, when attained, vital powers fail, and the m organism is irreparably damaged; and some survive to mature age with the seeds of decline then sown, of which the fruit is only to appear when the whole body has reached its natural period of decline. Then, in advanced age, the latent tubercle of early manhood will often reappear, though with altered features. It is stiU, however, the destroyer ; and the habits of living and easy circumstances of the individuals may have warded off the attack throughout years of active hfe, only to lead to senile phthisis in the end. On the other hand, tubercular consumption of the lunc is by no means uncommon in early life, and at the strumous age. It is then only one and a most important manifestation of the strumous habit. In treating of the possible absorption of tubercle in the lung, some arguments were advanced to show the identity of the deposit as seen in the external glands STRUMOUS PHTHISIS. ' 245 with that in the pulmonary structure. This seemed to chap. be proved by the sameness of the deposit ; by the one- ._3-^__^ ness of the hereditary tendencies some children of Tho depo- phthisical parents exhibited, pulmonary and other ex- luug and ternal strumous disease ; by the unity of the processes ^^^^^® witnessed in the deposit, whether tending to resolution identical. or to destructive softening and ehmination ; and by the general constitutional features exhibited by the indi- viduals of the strumous diathesis as compared with the phthisical. The position here assumed is not purely theoretical, but has a decided use in assisting our recognition of the true nature of many of our cases and our prognosis of the results. It will be now our duty to examine whether there are any special characters in the phtliisis of early life, and whether these are derived from its association with the so-called strumous habit. As usual, the following statements are to be regarded only as observed facts, for which in every instance reference to cases is or can be made. Tubercle in the lung may be found in the youngest Tubercle children, from the infant at the breast. Its most IJIider'^i? common form at tliis time consists in a general infil- tration. It is often acute, that is, rapidly developed, and the child may perish in the first stage with ex- tensive marasmus and diseased mesenteric glands, or in the second with numerous softened tubercles, or more rarely when the third stage of excavation is reached. Out of 285 cases observed under the age of fifteen, 17 were affected from birth, 126 were in the first stage, 125 m the second, and 34 were in the third stage of phthisis. While under observation 13 observa- died, and the stage was ascertained ui 11 of them — 90^ °^ viz. 2 in the first, 7 in the second, and 2 in the third stage. Of the whole number, 155 were males and 130 More females. f ^^^^ than females. From the following table it will appear that the 246 ELEMENTS OF PEOGNOSTS IN CONSUMPTION. ten years from 5 to 15 are those in which the affection is most common, and that the male sex begins to show higher numbers than the female from 5 years of age up to 10, when the number are nearly equal. Fifteen is an age of great peril in females. Table showing the Ages and Sex in 285 Cases of Phthisis under Fifteen Years of Age. Age Males Females Total Under 3 yrs. 5-10 „ 10-15 „ 8 24 64 59 8 14 52 56 16 38 116 115 155 130 285 The deaths occurred as follows. Total 13. Males 3 to 5 years of age, 3 deaths. 5 to 10 „ 3 „ „ 10 to 15 „ 2 „ Females under 3 years of age, 2 deaths, 3 to 5 „ 1 „ 10 to 15 „ 2 „ External The rarity of a combination of external suppurating suppura- strumous glands with an active state of tubercle in the tion rare i i i r* n i • ^ -i^j- ^^^^'^ in phthisis, lung has been beiore dwelt on m the chapter on the premonitory stage of phthisis. It is there shown that out of 300 cases of phthisis occurring in persons of marked strumous habit, only 5 had external suppiu-a- tion, although 33 had enlargement of glands of the chronic kind. The following table gives the observed duration of 300 cases of this form of the disease, of whom the 285 already quoted were the portion under 15 years of age, the small remainder (fifteen) having shown the strumous habit, but being aged from 15 to 40. STRUMOUS PHTHISIS. 247 Table showing the observed Duration of the Disease in 300 Cases of Phthisis, in the Strumous Habit, of luhich 285 were under the Age of Fifteen. [This table does not express the duration up to the time of death.] CHAP. XI v. Duration. No. of cases. Had been ill 6 mouths 30 „ 1 year . 51 ;; IJyear . 24 „ 2 years 23 n 11 }i 3 „ 8 „ 3 to 4 „ 10 }> ■* >7 " )> 9 )) 5 „ 6 „ 6 >f ^ >} ' n 4 )j ' }> ° }j 1 )j 8 j> 9 „ 1 V 12 1 (ac „ from birth 17 „ indefinite long periods 104 To tal 300 State on leaving hospital : — Better, 87. Worse, 65 (of whom 13 died). Stationary, 158. =300. The average duration of each of these cases is 23-61 months, without reckoning those ill for ' indefinite periods.' The locahsation of the tubercular deposit in these cases is sometimes peculiar, and deserves attentive consideration. It is found most commonly either in the diffused form, i. e, scattered throughout one or both lungs without much coalescence or grouping ; or by no means unfrequently at the base of one or both lungs, the apices remaining clear for lengthened periods. The latter condition is to be regarded as favourable both for cure and for chronicity, and bears out tlie view already advocated, that tubercle at the base of the lung generally makes a slower destructive progress than when it is first developed in the ordinary mode at the apex. In 46 instances out of the 300 given this condition was observed ; and several examples of the removal of the deposit, when in this part of the lung, will be found in the cases at the end of this section. Average duration of stru- mous phtliisis. Localisa- tion of the deposit. DiSlised, or at base. 248 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. XIV. Absorp- tion may- take place. It must be held as no longer doubtful, that complete absorption of the deposit may take place ; nor can the argument, that in cases where a cessation of the phy- sical signs and of the constitutional disturbance occurs, the seat of the disease is in the bronchial glands at the root of the lung, be considered valid. The locahsation of the physical signs, either diffused over the lung or at its base, forbids such a supposition ; for however difficult the diagnosis of deposit in the glands may be, it is certain that when the disease is limited to them, the sounds of crepitus, dulness, &c., cannot be heard over the pulmonary space, and especially at the base. The truth is, that in these cases of bronchial phthisis the lung is itself almost always engaged. The ordinary history of phthisis in the strumous habit may be studied in its two forms of acute and chronic. The acute variety has been already sketched in the chapter on ' Acute Phthisis,' and may be regarded as an invasion of the whole system by the tubercular disease, as after death nearly every organ in the body will be found engaged. The fever is high and without remissions, the pulse sustained at a rapid number, the digestive disorder urgent and extreme, the local disease rapidly progressive. With these symptoms the disease is often fatal in from three to seven weeks. Not unfrequently some of the zymotic diseases of children occur, and precipitate the tubercular disease. Case. J. Gr.j eet. 2. Mother out-patient now with pht. 2. Eubeola and pertussis within the year; cough 3 months; night-fever, wasting, sweating, extreme; app. bad, b. cos- tive; abdomen large, knotty; urine high-coloured, offen- sive. Chest pigeon-shaped; rough murmur with first sound ; diffused crepitus both lungs ; large, knotted, hard swelling in parotid region ; umbilical hernia, &c. &c. Ordinary history of strumous phthisis. Acute variety. Chronic form. This case needs no comment. It is when the disease is slow and becomes clu"onic that it possesses higher STRUMOUS PHTHISIS. 249 interest. In such instances it begins insidiously, and chap. seems a disorder of growth. The frame is not hardy, ^^Il_ the complexion is pale, the expression delicate, the skin fine in texture and does not freckle easily. Some amount of dyspnoea may precede the cough, which is commonly dry, or even absent, and expectoration rare ; in very young subjects absent. An haemoptysis may Profuse occur in very early life. I have seen it at eighteen t>^S°Sot months, two years, three years, five years of age, re- ^^^^^ ^ peatedly; but never profuse under five years.* The amount of wasting is not great, and is rather referred by the parent to arrest of development. Febrile ac- ^^'^er. cesses will be noted, more or less acute, but in the chronic variety they always subside. Their continuity means continuous phthisis ; their absence is a sign of niiprovement, and a prognostic for chronicity better than all other evidence put together. With their ces- sation the little patient partially regains flesh, may lose his cough, and, especially after a residence at the sea, presents an aspect which will satisfy any but a medical eye. Nay, perfect recovery may take place, and no evidence of past mischief can in certain cases be found. The physical signs indicate one of these conditions : — Physical 1. A diffused deposit in one or both lungs, evi- cateV" ^' denced by dulness of the percussion tone, harsh and "^^^eties. occasionally wavy inspiration, expiration long and ^i^^sed. rough, and a crepitus of any shade of intensity, from the very dry to the actually humid. 2. Physical signs entirely confined to the base of one At base, or both lungs, consisting of dulness, and a crepitus as above described. 3. The ordinary locahsation at the apex of one or At apex, both lungs, where marked and defined dulness, bron- chial voice, and tubular blowing, with varying harsh tones of the respiratory murmur, and prolonged ex- * In 351 cases of profuse liajmoptysis, only 43 occurred in persons under twenty. 250 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP, piration, with or without crepitus, indicate a pretty ■ -^^J' . extensive deposit. In this last condition there is seldom the decided limit to the disease often met with in adults. The signs shade off towards the base of the lung- DifFused Tlic difFuscd dcposit in the child, as in the adult, ^^°^^*" can exist with but little active disturbance of the general health, provided the signs due to inflammatory action are absent. A very fine crepitant sound, with much dulness, extending over a large pulmonary space, is frequently found coexisting with a tolerable state of health. There may be little dyspnoea, no pain, scarcely any cough, and no expectoration, with a complete absence of fever, while the physical signs denote the existence of softening. Were we here to measure the actual gravity of the case by percussion and the stethoscope, and to deliver a prognosis of rapidly in- creasing danger, we should greatly err. Such cases may go on for years in a scarcely varying condition of tolerable health, so long as the hygienic requirements . of warm clothing, abundant food, and fresh air are forthcoming. They are among the successful cases which leave our hospital with ' arrest' after their names, but they die when shut into the wretched garrets and courts from whence we have taken them to the purer air and abundant healthy food of our wards. It is especially to be noted in the class of cliildren here Growth described, that growth is stopped, and the development fe oppe . ^^. ^1^^ body beyond a certain point is never attained. If puberty is reached, an unexpanded figure and re- tarded menstruation in the female, and a stunted growth in the male, with a persistent childish voice often up to the age of sixteen or seventeen, show the incompleteness of the maturity which nature scarcely seems to promise. They are dwarfed in figure, and sometimes (though not always) in intellect, and the arrest of development strikes us before a more minute STKUMOUS PHTHISIS. 251 ])hysical examination reveals tlie cause. Growth is at chap. a standstill, and though the body does not waste, it .-_l^ilL_. ceases to increase. The liistory of the disease presenting physical signs Signs at at tlie base does not differ from that of diffused deposit. Both belong to the chronic, slow variety, with occa- • sional exacerbation of symptoms. The secondary dis- orders, diarrhoea, &c., may occur, but are commonly delayed to a later period of the disease,. or if present, are slight. The influence of remedies is very marked. Good diet and wholesome sanitary influences, mostly increase the muscular system, and the patient may even fatten. Cod-hver oil much assists the nutrition of the body ; and many of these patients seem well nourished, till, on examination, it is found that the tissues are flabby, and permit of rapid variations in weight. April 1855. EHen P., get. 9. No predisp. ; rubeola 18 Case, months ago ; pertussis 1 year ago ; slight cough ever since ; after'^^^ ' hsemopty. slight 3 weeks ago ; lately sweats ; wasting 2 measles months ; app. had ; t. clean ; h. reg. ; dulness, prolonged fiJ^^c^X expiration, hronchial voice, right. — Nov. No cough ; sartie Eecove^. 'pky. signs. — Feb. 1856. Resp. very tubular ; health im- Oilfor2| proves. — July 1857. Very slightly prolonged expiration only ; in excellent health ; much grown ; has taken oil and V. ferri 2^ years. Maria M., set. 16 (looks 13). No predisp. ; habitual cough Diffiised for years ; worse in summer ; no h^mopty. ; dyspnoea ; pain tubercle. in right ; moderate expectoration ; is moderately wasted ; chest develop- flat ; mammae not developed ; has never menstruated ; app. ^^^*- fair; b. reg.; diffused double crepitus over both sides, most clu-omc. ^marked at right base, dulness most marked at right apex. Ordered chloric sether mixture, croton liniment, &c. She improved much and gained flesh. A. P., f., set. 1|-, still at breast. Strumous inflammation struma of eyelids ; purulent discharges ; impetigo of lips ; enlarged ^^^ .^^!^*'^- cervical glands ; much wasting ; bowels loose ; severe cough ; Hfemopty.' hcemoptysis last week ; aphthae on mouth ; dulness and ■^S^ 14- extensive crepitus, left. (Once seen.) Oct. 1860. C. L., set. 7^, f. Grraudfather (only) died Case, 25! ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP. XIV. Phthisis 2. Mesenteric disease. Lumbar abscess. Eecovery. 5 years. Case. Softening sounds at base ; cleared up. of phthisis. Strumous aspect, light hair, blue eyes, &c. ; others of family have enlarged glands ; out of health since 4 years of age; great enlargement of mesenteric glands, hard, painless ; lumbar abscess opened 3 months now, dis- charged 3 pints, now closed; constant cough some months ; one streaky hsemopt. ; no expectoration ; diarrhsea 3 m. in day; app. good; crepitation diffused, ivith dulness over whole left lung. To take oil, syrup, ferri iod. and sedative mixtm-e. She rapidly improved, regained flesh and strength. — July 1861. Profuse haemoptysis; pfiy. signs cleared up ; soon after crepitation replaced by cooing sounds with dulness; looks hearty. — Dec. 1861. Another profuse hsemopty. after a fall, but rapidly recovered; and in Ja- nuary 1862 presented no physical signs. Had lost her cough, diarrhoea, &c., and regained the appearance of good health. Under treatment 15 months. Duration about 5 years. January 1861. E. C, set. 14, m. No predisp. ; cough only 3 weeks ; hgemopty. florid, mixed, last week ; expectn. thick ; moderate night-sweats ; loses flesh ; app. bad ; b. reg. ; dul- ness and moist crepitus, whole base, right. Oil, quinine, counter-irritation to base. In July he was quite ivell ; no physical signs whatever. AGE A MODIFIER OF PHTHISIS. 253 CHAPTER XV. AGE A MODIFIER OP PHTHISIS. The first Medical Eeport (1849) of the Hospital for chap. Consumption states, that the age most affected by .-\ ' ^ phtliisis in all its forms is the decade from 25 to 35 ^^^ years. The second Eeport (1863) 'exhibits a large phthisis preponderance of cases between the ages of 20 and pr^aiLt. 30. On either side of this decade the numbers diminish in about an equal ratio.' * From 10 to 20 tliere occurred 1,331 cases. „ 20 „ 30 „ 2,708 „ „ 30 „ 40 „ 1,444 „ „ 40 „ 60 „ 551 „ This was out of a total of 6,134 cases. The age at which the disease is most prevalent is thus sufficiently marked. But of the forms and varieties in which the affection presented, the Report takes no notice. It has indeed been the fashion to regard phthisis as a single affection, as a class without varieties, instead of studying it as it really is — a family of tuber- cular affections composed of many groups, offering much variety in its manifestations, and requhing, not only for the purpose of study, but as a requisite in practice, many important subdivisions. It is also to be remarked, that very young and very old cases are not commonly found among the in- patients at the hospital, from whom the Report was * p. 5. 254 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. XV. Phthisis attaches itself to the ages of growth and decay. The age of growth ; forms of phthisis in. Age of dechne. Authori- ties quoted. prepared ; and without doubt, age is a regulator of the type and progress of the disease to a very considerable extent. Phthisis, notwithstanding its prevalence at all periods of life, appears to attach itself remarkably to the age of growth and to the age of decay. In the former period are found its most formidable manifestations. Acute phthisis, strumous phthisis, the ordinary continuous form of the disease — that in wliich cavity is quickly formed — and the large class which arise out of acute disorders. Marked hereditary pre- disposition also exhibits its influence at the time of Hfe at which growth is most rapid, and rarely delays to strike its victim till the period of decay. Even then its influence has not died out, for numbers who are hereditarily predisposed to phthisis survive the age at which it is most destructive, to perisli m very advanced hfe of the same malady.* It is common for insurance companies f to regard the proclivity to phthisis acquired by hereditary ten- dencies to have died out at 45 ; but although the greatest amount of danger is past at this age, many cases occur and much mortality prevails in more ad- vanced life. Authorities are quite agreed on this point. Mac- lachlan says, ' At Chelsea Hospital, tubercles, tubercular concretions, chronic diffused grey consohdation, ex- cavations or traces of recent and ancient cicatrised * A table carefully constructed by Dr. Fuller, from the Registrar- General's Reports, shows that ^ the mortality from consumption does not vary materially between the ages of fifteen and seventy, but is actually somewhat less between the ages of ten and fortj^ than it is between the ages of forty and seventy.' — On Diseases of the Chest : Dr. Fuller. Lond, 1862, p. 351. t The rule of many offices is to decline a life if two members of the family have died of consumption, unless the applicant is past the age of forty, and personally free from any siispicion of disease. Even then an advanced premiimi is demanded. AGE A MODIFIER OF PHTHISIS. 255 cavities occur . in the luno;s of about one-lialf tlic chap; number of the men examined, whose age varies from .-_1,__ 60 to 80 and upwards.' * Williams found tubercles in half the cases of post- mortems of persons past middle life, dying from various diseases in London and Paris. f Eoger,J in one hundred females examined at Sal- petriere over sixty, found in fifty-one cretaceous or calcareous concretions in the lungs, and other signs of cured or existing phthisis. Beau,§ in 160 aged females dying of other affections than consumption, found in all, with three exceptions only, indications of former phthisical disease. Brinton || considers that at 40 half the danger from phthisis is over, and at 50 three-fourths of the danger in males, and four-fifths in females. Christison^ gives the number of deaths from phthisis in persons selected for insurance in the Scottish Widows' ofiice as 48 per cent, between 30 and 40, and 22 per cent, between 40 and 50 years of age. In the Edinburgh Eoyal Infirmary, out of 852 cases of deaths from phthisis in males, 25 per cent, were above 40, and 8 per cent, above 50, In London, in 1845, 3,624 males died of phthisis, of which 36 per cent, were above 40, and 15 per cent, were above 50. In the ' Standard ' ofiice, of lives accepted when over 40 years of age, 5 per cent, died of phthisis, and of those accepted after 50, 2 per cent. ; after 55, 1 per cent. ; and after 60 none died of consumption. These were, of course, selected lives — that is, the hereditary element was not present. * Op. cit. p. 333. t Lib. Tract. Med. vol. iii. p. 183. X Archives Gen. de Med. t. v. p. 183. § Etudes Clin, sur Med. des Viellards, p. 19. II Brinton, On Life Assurmice. *j[ Edinb, Monthly Journal, vol. xvii. 1853. 256 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP. XV. Phthisis of advanced age most common in males. Stage. In a later report from the same office (1860), out of 582 deaths among the assured, phthisis was the cause in 10 per cent. These were mostly persons in ad- vanced life. There is therefore abundant evidence of the existence of the disease in advanced life. In hospital out-patient practice, I have collected 174 cases which were over the age of 45. Of these one- third only were females. The stage of the disease was ascertained in 146 in- stances, as follows : — Age. Tendency to form cavity. Age at modifier of duration. After 45 disease is slow. Average duration. First stage Second „ Third „ Between 45 and 50 years of age At 52 years of age „ 54 „ 56 „ 58 ,, 60 Over 60 33 cases. 71 „ 42 „ 54 6 9 7 7 7 10 Females. 30 6 3 4 2 3 The physical signs were confined to the base of the lung in 8 instances. There were 9 cases of diffused tubercle. The tendency to form cavity seems rather marked. Viewed from the side of duration, phthisis has a new aspect ; and it is in this sense, as well as in the form of the disease, that age is a great modifier. It has already been seen that the hereditary form of the disease and its most acute manifestations are found during the years when the frame is being built up and completed. It is in advanced life that the slowest variety of the disease is often seen ; but very chronic phthisis (as has been abundantly shown) may prevail at any age. StiU it holds good as an axiom that after 45 the disease is slow to advance. The average observed duration of my cases was 33*76 months, as compared AGE A MODIFIER OF niTHISIS. 257 with ordinary phthisis (all ages), which stands at 15-22 months ; and at the time of leaving the hospital the condition of the majority was favourable, as shown in the following table :- Better on leaving Worse Stationary- Si 34 (4 died) 81 The following shows the observed duration of the 146 cases of phthisis, in individuals over 45 : — Cases. 1 for 6 months . . .13 „ 1 year z' 21 Jf -'•2 V 23 „ 2 years 11 „ 2i „ 13 „ 3 „ 11 „ ^ ,, 4 „ 4 „ 4 „ H „ 8 „ 5 . „ 1 111 for 5^ years V 6 „ V 8 „ „ 10 „ " ^? " „ indefinite long periods Total . 2 2 1 1 2 1 20 14G The succeeding table shows the different forms of phthisis, and the numbers of each variety, at the dif- ferent ages : — Table shoiuing the Number of Cases of the Different Varie- ties of Phthisis which occurred at the Different Ages. [Both Sexes.) CHAP. XV. State on leaving hospital. Observed duration after 45 years of Ages in Yeaes of Phthisis 3 5 10 15 20 25! 30 35 40 45 60 55 60 1 65 70 76 Ordinary phthisis 3 1 18 125 172'l56 126 94 57 20 2 2 1 Chronic 1st stage 9 28 62 63 49 35 30 10 1 „ 2nd „ 1 6 27 47 52 43 41 27 11 9 2 „ 3rd „ 2 2 31 44 38 42 24 17 5 1 Strumous phthisis 16 38 116;il5 5 e; 8 1 3 1 Rapid phthisis 1 2 45 48 54 32 22 12 1 Rapid waste 2 5 8 8 2 8 1 Origin in acute 1 diseases J 16 12 7 7 7 5 6 8 4 3 1 Dry cavity "I Tolerated cavity J 1 3 10 21 16 11 9 8 1 1 Pregnancy Lactation J 5 41 87 61 35 5 j Carried fonoard 19 58 130 162|285'453'487 379273 163 52.14 5 2 258 ELEMENTS OF PROGNOSIS IN CONSUMPTION. Table — Continued The va- rieties of phthisis modified by age. Varieties of Plitliisis BroiujU fonmrd 19 58 130 162;285 Clubbed fingers > a qi >? Rheumatism \ M. cordis pht. J Bronchitis Emphys. pht. SigTis at base ■ Age over 45 Fistula-phthisis Sypbilis-phthisis Profuse t^ h£e-l moptysis J Oil very useful Totals Viewing the disease as a whole, its greatest pre- valence is -undoubtedly to be found between 20 and 45 years of age ; but it will be observed how large a num- ber of cases occiu^ after this age. In early hfe, a great wave as it were, sweeps off most of those hereditarily predisposed, and nearly aU the strumous. The zymotic diseases and acute fevers incident to early life leave behind them germs of disease in which, or from which, are developed some of the most formidable varieties of the disorder. Among these rheumatism is very marked as exhibiting a cause predisposing to tuberculosis, or identical mth it. The vascular system being at its fiille^^t and in its most active condition, congestions ot the lung and haemorrhages are prevalent. Pregnancy is found to complicate, to develop, or to precipitate phthisis remarkably, and exerts a powerful influence from 20 to 40 years of age, culmmatmg at 30. While the nutrition of the body is most vigorous, and san- * The strmnous cases presenting this V<^ff^^\^'lZ^^-%'inems t These numbers are differently grouped from the others . 20 means from 10 years of age to 20 years, &c. AGE A MODIFIER OF PHTHISIS. 259 guification most active, extreme alterations of weight chap. are most likely to occur. The dry cavity and tolerated > ^J' _■ cavity are not often found at the strumous period, the nature of the deposit in the latter being generally diffused, and often involving the bases of the lungs, seeming to interfere with the formation of circumscribed excavations. Eistula is found ordinarily in the middle periods, as is also the comphcation with syphihs. For the same reasons as those which influence growth, the use of oil is found most beneficial during the years devoted to perfecting the frame. In advanced hfe there is much less benefit to be derived from its use. It is thus, in regarding phthisis as a single manifesta- Processes tion of constitutional disorder, we are compelled to anfdJa' recognise as influential on its course all that is con- considered. cerned in the processes of growth, of maintenance, and of decay, as emanations from a cause common both to the healthy action and the diseased product. Tubercle is possibly the perversion of normal material, and may represent alterations in the quahty of that which was destined to the formation of healthy tissue at the period of growth. In the acceleration which the tubercular disease receives during early hfe, in the formative period of pregnancy, and again in the dechne of vigour and decay of tissues, we may recognise a sameness of producing cause. Intimately associated with the pro- duction and the disintegration of the body, the age in which it is found may possibly become the guide to a discovery of the nature of the error in which it originates. The phthisis of early life is acute and rapid, involves Phthisis of many organs simultaneously, and is a blood crasis of ^^^^^^ ''"'^ manifest severity from its commencement. The phthisis tested!" of more advanced age is often latent in its beginnings, slow in its advance, tending to the destruction of limited portions of the lung, and is found with few secondary s 2 260 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, derangements accompanying. Destruction of pulmonary ■_ '^, • ^ tissue without limit, by inflammatory or irritative actions almost continuous, characterises the phthisis of puberty : concentration of disease in one part, moderated and remittent inflammatory attacks, but excessive tendency to degeneration, mark the phthisis of age. The cal- careous transformation is most frequent in the elderly adult ; the broken-up chain of cavities, with scarcely any healthy lung intervening, is the too frequent history of the disease in the young. A retrograde action is evident in the morbid matter deposited in the aged, Avith httle tendency to irritation of the surrounding tissues ; in the young, the vital or chemical changes causing softening of the tubercle and irritative ulcera- tion of the lung in which it is imbedded are character- istic features. In the aged, systemic disorder, rarely veiy high, does not find a machine working at extreme pressure, but rather at slackened speed ; in the young, the whole energy of the animal is being devoted to nutritive action when the disturbance occurs, and the resulting disarrangement is proportionate to the im- portance of the operations interfered with. It is thus that, when a cure cannot be looked for, chronicity rises to be an important feature in a disease ultimately, but not uniformly, destructive in its progress, and that a careful estimate of all which retards morbid action becomes a study worthy of the scientific phy- sician. In this fight, age, as a modifier of disease, is an agent deserving our most careful investigation. Second The sccoud great access of disease in the phthisical d?sease°at habit may be observed at the period of the dechne of the decline j^fe^ but with modified characters. That a latent con- stitutional affection should resume active conditions when vital processes are lessening, and the office of the nutritive powers is rather to sustain the old than to build up new tissues, is puzzhng, but not contradictory. A diminished vitality may oppose fewer obstacles to AGE A MODIFIER OF PHTHISIS. 261 the development of disease than when the system is at chap. its highest power. A disorder incident to nutrition v_ ,_:_. (if this theory be accorded), and whose essence consists in the elaboration and deposit of a morbid material, may find its earliest pabulum in an overabundant and newly formed plasma ; but in the activity of the respira- tory, secretory, and circulatory processes, an exit may present to get rid of the offending material. The glandu- lar apparatus of the body (if the identity of the strumous and tubercular habits be granted) may serve as a diver- ticuliun for morbid matter in early hfe, and the lungs be saved till the glandular system reach its period of decadence, when the respiratory becomes the seat of the deposit. Old deposits in the lunsrs, themselves the result of oiddepo- Sits from low inflammatory actions in early adult hfe, which have inflamma- never been absorbed nor wholly organised, often be- ^p^i^ aT-^ come the seat of tubercular changes when age ad- vancediife. vances. Doubtless some of the cases in which the base of the lung is found to be the seat of tubercle in elderly persons are thus to be accounted for, and are only old results of inflammation which have become the nidus of tubercle, or take on the ulcerative actions of tubercle without being identical with its composi- tion. The examination of the aged proves that con- sumption may exist independently of tubercular deve- lopment, contrary to the opinions of Louis and Laennec. ' Senile * phthisis is often the sequence of chronic bron- Phthisis in chitis, ending in indolent inflammation or partial in- these-^^ duration; the induration breaks down into cavities, }^^^^^^_ non-tubercular, dark, sloughy, without membranous tion, of lining.' Such appears also to have been the opinion and^may^' of Armstrong", Graves, Stokes — of Bayle, who calls it ®^®* y^*'^- ' ulcerative phthisis,' and of Addison, who named it cie. * See Maclaclilan: op. cit. Grave's Clinical Lectures. Armstrong: Lectures Pract. Physic. 262 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. ' pneumonic phthisis.' ' The pneumonic species of con- XV, sumption is a truly scrofulous form.' Phthisis Age, then, is a modifier of the type, and exercises descnbed. ^ Controlling influence over the progress of the disease. Should phthisis invade the system after forty-five, we are to expect a slow form, moderate febrile action, and tardy advance of pulmonary mischief. Emacia- A long period of emaciation generally precedes Sest^ the positive evidence to be derived from physical symptom, glgus. Tlic systcm as a whole degenerates, and the nutritive powers decay before structural mischief an- - nounces itself A steadily progressive emaciation, therefore, without evident organic alterations, is to be regarded with great suspicion in the elderly. In this respect, phthisis remains true to its type, and verifies the name which all countries have bestowed on it, '■wasting.' As in earher fife, so in latest, an altered nutrition is the first evidence of the invasion of the disease. The pulmonary symptoms are most commonly ushered in by cough, which passes for bronchitis in its insidious and more chronic form. The case, indeed, may retain this name till its observed continuity, the absence of the summer remissions, and the progressive weakness of the patient, stamp it with its real cha- racters. Profuse Hsemoptysis, which many regard as so characteristic of the disease, is generally absent. In its profuse form it is especially rare. Out of 351 cases of copious haemorrhage from the lungs, in my practice, only 40 occurred after the age of forty. Pidse often The pulsc, in senile phthisis, is often very quiet, of^h?'^'^^ unless a great amount of structural disease exist; so extent of ^2il it is, lu a scusc, the measure of the extent of local local dis- ease, disease. Pain is of rare occurrence, the passive character of the afiection being here again manifest, the pleuritic haemo- ptysis rare, AGE A MODIFIER OF PHTHISIS. 263 attacks so common in the phthisis of adults being chap. seldom observed. Febrile symptoms of severity are - ■^^- . also absent as a rule ; nor is dyspnoea so pressing a cause of distress as in ordinary phthisis. Serious errors of digestion, as vomiting and nausea, Gastric are rare; nor is the cough of that character which rare!'^^'^ brings up food, and proves so distressing in earlier life. Simple anorexia is, however, a very common symptom. Secondary diarrhoea is also less frequent, and is often delayed till a late period of the disease, or even absent altoo-ether. Other secondary affections, not belonging to tlie Secondary phthisical class, are, however, often found combined rS*^°"^ with the disease in advanced hfe. Those which ori- Degenera- ginate in degeneration, as might be expected, are com- *^°^ °^ mon : such are fatty conversion of organic tissues, the may be heart and arteries, or in the cornea, where the arcus ^th^^ senilis is found at an earher age than is usual in non- p^^t^^sis. phthisical cases. With more or less of these symptoms the patient Helps to may hnger on for years, especially if provided with the ^ ^"'^^^^^^y- comforts of life, warmth, food adapted to his require- ments and appetite, and a fair allowance of stimulants. Mental quiet, and all that ' should accompany old age,' when permitted to surround the patient, infinitely tend to the prolongation of his life. He should not travel about, nor seek the delusion of climatic cures, if he is past sixty. At such an age the fatigues of removal, and the absence of habitual comforts, of the well accustomed chair, and of the bodily requirements which time and tender care may have accumidated about him, are poorly compensated for by change of air. With such care the case may be indefinitely pro- longed, and life may be even tolerably easy to the last. And when the end comes, it is often due to some of the secondary accompanying and non-phthisical concur- I'ents, as cardiac or aiteiial degeneration, affecting the 264 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XV. Numbers in males. Signs at base. Confined to one lung. Post- mortem appear- ances. Acute phthisis may occur in ad- vanced life. Case of acute phthisis, set. 60. _ Cavity in central or distal seats of circulation at tlie heart or in the brain. It has been remarked already that this form of the disease is much more common in males than females. My tables give 100 of the former to 21 of the latter. In many cases the physical signs are at the base of the lung. Out of 72 instances of this locahsation of the disease, there were 35 males and 6 females over the age of 40, and 8 of the males were over 45 years. The disease is generally confined to one lung, and the apex is its most common seat. The tendency to form cavity has been remarked, the tubercle being massed in one part, and the other portions of the lung being ordinarily healthy. Authorities have remarked on the tendency to contraction and cicatrisation of excavations in advanced hfe, and on the frequency of calcareous transformations of the tubercle. The appearances of such lungs after death are com- posed of aggregated tubercular masses, seldom exceed- ing the size of a pigeon's egg, of iron-grey colour, black from pigment admixture. The pleurse are generally adherent over the cavity or deposit. The ordinary appearances of cicatrices of old standing are very com- mon. It has been remarked that the cavities are more frequently lined than in adult cases. Although the tendency to slowness in the advance of disease is marked after the age of 45, yet cases of acute phthisis occasionally occur. At Chelsea, a case £et. 73 died m less than three months, and within six weeks of cavity forming. I subjoin an interesting case which . occurred in my own practice. Hasse (quoted by Mac- lachlan) gives a case of rapid phthisis est. 89, and Blakiston a case set. 73, which died in six weeks. X. Y., a gentleman set. 60, without hereditary tendency to phthisis, and having previously enjoyed good health, con- sulted me in January 1860. He had been suffering from cough for six weeks, and felt rather out of health. Percus- Post-mor- tem. AGE A MODIFIER OP PHTHISIS. ' 265 sion good, slight sonorous rales di fused chiefly over right cHAP. side. Ordered pil. liyd, c. ipecac, linimentum ol. crot., X V. mist, ipecacuan. I sent him to Hastings, with a request to . , place himself under Dr. Blakiston's care. — May 3. Dr. B. death in 6 writes, ' Dry harassing cough, expectoration often reddish, is extremely weak, liver much out of order, clayey stools, little or no dulness, mucous clicks, expiration prolonged over upper third anterior right chest, also bronchophony.^ Dr. Lionel Beale examined the sputa microscopically, and reported ' tubercle corpuscles, portions of pulmonary tissue, granular cells from bronchial tubes, mucus with carbon;' pulse weak, 120 ; kept up while health improved, expec- toration nearly ceased, legs began to swell, action of heart more feeble, a threatening of gangrene on one foot, and on the other a blister formed and broke. Dr. Blakiston's diagnosis was, 'tuberculosis of right lung, whether in the common form or existing as tubercular pneumonia ; heart with feeble walls and tendency to degenerate. Prognosis unfavourable.' Treated by small repeated doses of brandy, mixt. of acid, nitro-mur. and taraxacum, pepsine ; nitro-mur. acid applied externally; cod-liver oil. — May 4, 1860. I again saw him with Mr. Brown, of Brixton. Cachectic appearance ; colour sallow ; has lost flesh considerably ; com- plains of gasping and a sudden short catch in the breath; scarcely any cough ; raises one or two- fragments of rusty- coloured expectoration daily ; no fever ; pulse 80 ; both legs oedematous, and thighs (less) ; an unhealthy, glassy-looking ulcer on dorsal aspect of left toes ; a dark-coloured vesicle on the toes of the other foot ; warmth of feet fair ; femoral pulsation felt to be equal and full ; chest emaciated, much flattened in right subclavicular space, ivith mobility much impaired ; dulness for about 3 inches from the clavicle ; bron- chicd voice, and respiration over this space ; lower than this a fine crepitus ; same signs in superior scapular region for sortie inches ; the hepatic dulness is increased anteriorly and posteriorly, and comes beloiu the ribs ; the liver feels irre- gular and hard at this spot ; hearfs sounds lueak, distinct, impidse lost, no murtnur ; tongue red, moist, ragged, stripped ; bowels open by medicine ; urine abundant, pale, not albuminous ; the ulcer on the foot slightly extended and grew nearly black ; the slough never separated. Dr. 266 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP Watsou saw him with Mr. Brown and myself at the end ^ J' . of May ; and Dr. Blakiston being .in London for a day or two, favoured us with a visit. There was a doubt whether some malignant formation or deposit occupied the right lung; the age of the patient and rapid progress of the case somewhat favouring this supposition. Treatment of a supporting kind was directed ; but, in spite of all our efforts, the patient daily lost strength, and died exhausted, with symptoms of effusion into the pleura, on June 12, 1860, being within six months of the time of the earliest symptoms. Post-mortem examination 36 hours after death (with the assistance of Mr. Brown) : — About 4 quarts of fluid in the pleurae, chiefly the right ; right lung pressed upwards and backwards ; no adhesions excepting at apex of left lung; right lung dark, solid, hard, non-crepitant upper two-thirds ; this portion was infiltrated with granular tubercle com- mencing to soften; a small cavity existed at the posterior part of the apex ; the deposit appeared to be a form of tubercle with an exudation of inflammatory products of a white fibrinous appearance ; under the microscope there was a large amount of fat and tubercle corpuscles ; left lung at its apex was slightly infiltrated with the same ; heart large, flabby, dilated, valves and lining membrane of vessels healthy; the femoral vessels healthy ; liver enlarged, very hard, stud- ded with yellow granular deposit. Dr. Lionel Beale, and my colleague Dr. Scott Alison, agreed with me that the deposit in the lung was tubercle, modified by inflammatory action. This was a very rapid case, ending within six months. When examined in January, he had no signs of con- solidation of the lung, and only the symptoms of bronchitis. The invasion of tubercle was inflammatory, and the consolidation such as, if placed at the base instead of at the apex of the lung, would certainly have passed for a pneumonia during life, accompanied as it was by a rusty-coloured expectoration. The post- mortem appearances and microscopical evidence loft no doubt as to its being tubercle. The invasion was acute and expended itself The pulse was latterly tranquil, the pulmonary symptoms qidte in abeyance. The AGE A MODIFIER OF PHTHISIS. 267 anasarca was accounted for by the disease of the liver. The cause of the gangrenous ulcer was not very evident, and we were not able to explore the vascular system sufficiently to clear up this point. As regards the tubercular disease, the case illustrates many features of rapid senile phthisis. Chas. M., set. 63. Cough for 10 years; slight difficult Clirouic expectoration ; dyspnoea ; no hsemopty. ; digestion impaired ; ^ ' ' dulness and marked humid crejoitus for some inches right apex ; much improved by sedatives and counter-irritation. Thos. P., set. 52, bricklayer. Winter cough and dyspnoea 4 Phthisis years ; hsemopty. some years ago ; difficult frothy expec- "^*'l bron- toration ; no fever ; much out of flesh ; decubitus on left ; Dilated sinking and fixity under both cavicles; dry bronchial rales l^ronchus. hoth sides ; tubular respiration and voice right apex. He improved on mist, scillse c. lobelia, pil. conii c. morphia, and was under treatment 18 months with the same physical signs. The diagnosis appeared at the time to lie between dilated bronchus and tubercular deposit with bronchitis. July 1855. — Eobert D., set. 56, clerk. Ill 5 months; dry Acute for- cough in Feb. ; slight hsemoptysis twice 6 weeks ago ; ^^\\°^ °^ moderate but increasing expectoration, yellow, easy, chiefly at night ; had sweats and much fever in Feb. ; none now ; app. good ; b. reg. ; weight 10 st. 2|lb. ; dulness, immo- bility, flattening, gurgling for 3 inches apex right. Im- proved on oil. January 1857. — James M., labourer, set. 61. No pre- Chronic disposition; cough for 10 years in winter, constant last 2 ^^"^^^J years ; no haemoptysis ; morning expectoration abundant, thick, easy ; is slightly out of flesh ; app. poor ; b. regular ; no fever ; didness, gurgling, subclav. ; bronchial resp. and voice posteriorly right. Improved on sedatives with counter-irritation. Frank E., tea-dealer, set. 76 (looks 66). No predisp. to inherited phth. His father died at 76, mother at 87, his aunt at 97. longevity. Has suffered from dyspnoea for 10 or 12 years ; nights broken base, by this distress ; cough moderate ; expectoration slight ; app. good; bowels regular; didness and very marked crepitation over anterior inferior portion of left lung ; decubitus on right. 268 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XV. Strumous phthisis ; cavity ; set. 50. Chronic slow phthisis with bron- chitis. Diffused tubercle, set. 59. Rob. A., set. 50, clerk, height 6 feet 3 inches. No pre- disposition; suppuration of cervical glands 18 months ago; cough ever since ; thick white expectoration ; no hsemopty. ; fistula in ano, operation years ago, but discharge remains ; tongue very red, cracked ; nausea ; night-sweats ; dulness, coarse crepitus, nearly pectoriloquy right apex; occasional click on cough, left. Grot rapidly worse, the gastric symptoms increasing in severity. Thos. S., set. 62, lodge-keeper in Kensington Gardens. Winter cough for 3 years; slight, difficult, frothy expectora- tion ; no hsemoptysis ; no loss of flesh ; app. good ; bowels irregular ; percussion note low throughout both sides ; coarse crepitation and much resonance of voice supraclav. only, right. Was doing well at the end of 12 months (the fourth year). Thos. H., set. 59, labourer. Ill 1 year with cough and expectoration ; occasl. hsemopty. with relief; night-cough ; cold sweats; loss of flesh ; walks from Norwood to the hos- pital ; dulness, flattening, crepitation moist diffused over left. Improved much on oil and sedatives, with iodine solution externally. Prognostics of Phthisis in the Aged. 1. Phthisis occurring in advanced life is commonly slow. Gradual emaciation is generally the ear- liest symptom. 2. The more advanced the age, the more likely s it that the form of the disease will be the laten in development, and the chronic in form. 3. Acute phthisis may arise in age, and either termi- nate in rapid and extensive deposit, or in loca- lised and massed deposit in the apex which forms a cavity. 4. A quiet pulse is one of the most favourable of the good symptoms. A permanently accele- rated pulse indicates extensive and advancing deposit in the aged. 5. A long-continued and progressive emaciation is a bad symptom, even while the pulmonary symptoms are moderate. AGE A MODIFIER OF PHTHISIS. 269 The complications common to plitliisis in the chap. ordinary form (diarrhoea, laryngitis, profuse « — ^ . hasmoptysis) are not ordinarily present in the tuberculosis of advanced life. Their absence does not imply safety, although their presence is of evil import. Old deposits in the lung, the result of low in- flammatory action, often at the base, commonly break up in old age, and assume the tubercular form. These cases are often very slow. The disease may be confined to one lung in the aged, and yet prove fatal ; a fact which, as it is the reverse of the ordinary events of phthisis, should be borne in mind in offering a prognosis. 270 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAPTEE XVL RHEUMATISM, GOUT, DISEASE OF THE HEART. CHAP. XVI. The rheu- matic diathesis a cause of phthisis. Kheuma- tism in the course of phthisis. Its cha- racter. In tlie section on the premonitory stage of phthisis, the rheumatic and gouty constitution was considered as a causative agent in the production of tubercle. In many instances rheumatism is the du-ect forerunner of phthisis, and in very many the two affections are asso- ciated in the same individual, attacks of rheumatism or gout occurring in the course of ordinary consumption. The tubercular and the rheumatic diatheses are doubtless very intimately allied.. The hereditary in- fluences may be the same in both. Eheumatic parents often have phthisical children, or one child of such parentage will exhibit the rheumatic, and another the tubercular affection. That rheumatism is frequently propagated by descent is undoubted, and with such hereditary antecedents it is not uncommon to see strumous affections in earlier, and pulmonary in later life, while some of the children may only have the muscular form of rheumatism, or the acute attack on joints. Some again may have cardiac disease without preceding rheumatism. In the course of phthisis rheu- matic affections are frequent, oftentimes alternating with the more active chest symptoms, and for the time suspending the progress of the lung disease. The rheumatic attacks in phthisis are not of the extreme severity which we witness in uncompli- cated rheumatism. Acute inflammatory affections of RHEUMATISM, GOUT, DISEASE OF THE HEART. 271 CHAP. XVI. the heart are also rare, and the case generally yields in a shorter time than usual to ordinary treatment. At the close of such an attack, or shortly after, the chest symptoms resume their activity, and the case its ordinary aspect. After a time repetitions of the rheumatic attacks may occur, and much enfeeble the patient. But the progress of the pulmonary affection is on Tubercular the whole slow, and the distress great. A prognosis sioS^^ for long duration may therefore be generally offered. The age at which this complication with phthisis is Age. most common is from 20 to 35, and the male sex is Sex. more likely to be its subject than the female ; for out of 142 instances, 92 were males. I have thrown the leading features of these cases into a tabular form, showing the nature of the affections present, and the predisposition. Of cases of rheumatism, disease of the heart, or gout, combined with phthisis, I observed 142 examples occurring in a total of 4,530 cases. No. of No. of cases. cases. Rheumatism before phthisis 49 Hypertrophy ... 3 „ after „ 18 Intermittent pulse . . 5 Disease of heart only, with- Valve not stated ... 3 out rheumatism . 54 Gout . . . . ■ . 7 „ Mitral valve 38 Predisposition to phthisis . 20 „ Aortic „ 35 „ to rheumatism . 3 Dilatation and Degeneration 23 „ to disease of heart 1 The ages of the seven cases of gout with phthisis were two aged 40, and five between 40 and 50. It will be seen from this statement that, as a disease preceding phthisis, rheumatism holds a prominent place ; and remembering tliat all affections of an acute nature are very rarely seen in the course of consump- tion, it is impossible to avoid the conclusion that the two diatheses are closely allied. Theoretical considera- tions, and especially that winch points to an excess of 272 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XVI. Disease of the heart. Influence on phthisis. Hereditary- tendencies. Gout. fibrin as a cliaracteristiG of both disorders, corroborate this view. Disease of the heart, whether of the walls or valves, is by no means an unfrequent concomitant of phthisis ; it is often found where acute rheumatic inflammation has been the exciting cause ; and it may fairly be doubted whether the rheumatic constitution does not often induce thickening of the valves as a slow chronic result of the diathetic temperament called rheumatism. In 54 in- stances of disease of the heart with phthisis, there had been no previous rheumatic attack. The disorders of the mitral valve were shghtly in excess of those of the aortic. Dilatation of the cavities of the heart was far more frequent than simple hypertrophy. The antagonism of both of these conditions of the heart to phthisis has been repeatedly stated; and in the case of dilatation, the assumption is, that whatever tends to induce venosity of the blood opposes the deve- lopment of tubercle. Hypertrophy has been often asserted to be equally antagonistic, but the reasons have not been thrown into the form of a theory to account for the result. Experience proves that both of these conditions retard the progress of tubercle, and a prognosis for length of duration may safely be offered. Almost aU the cases of this combination which I have witnessed have been slow, and the tubercular disease has not advanced to that extreme disorganisation of botlj lungs which is the common end of ordinary phthisis. Death has generally taken place rather from the cardiac than from the pulmonary disease. It is to be remarked that in these mixed cases the hereditary predisposition is rather to phthisis than to rheumatism, and that the parent may have one disease and transmit the other. Gout and rheumatism are so allied to each other in their pathological development, that they may well be RHEUMATISM, GOUT, DISEASE OP THE HEART. 273 considered together in tlieir inflaence on phthisis. The chap. children of gouty parents, especially if the latter be ' - aged, are often phthisical ; and not a few consumptive patients have attacks of gout. The above table gives only seven instances out of 92, but this table was con- structed from out-patient cases. Since I have had charge of in-patients, I have met with many more in- stances of gout occurring in the phthisical, and of the alliance of the gouty with the tubercular habit. The identity of the arthritic with the tubercular constitution has been often argued, and lately views possessing much interest have been put forward by Dr. Gueneau de Mussy in favour of this hypothesis. He considers DeMussy's that, in many instances where gout is said to ' over- the arthri- leap ' one generation and exhibit its effects in the next, ^J^ ^}^' the intermediate one is not free from gouty attacks, which are exhibited in scrofulous and tubercular diseases, and that females (supposed to be much ex- empt from gout) illustrate the inherited diathesis in various forms of tubercular disease. The same author doubts whether the calcareous transformations under- gone in certain cases of tubercle do not belong to the gouty class of affections. Such theoretical considerations are worth attention, but the practical point remains, that gout, Hke rheu- matism, when the specific attack of the disease is de- veloped in a case of tubercle, retards the latter. During the gouty fit, the chest symptoms are mitigated, and a pause is gained in the advance of pulmonary disease. As in rheumatism, so in gout, when fever has subsided, and the urine is clear, an interval of ' con- valescence ' often occurs, after which a renewal of chest irritation may take place. On the whole, the character of these cases is long ; but it is to be observed that they are not very amenable to remedies, and that cod oil often disagrees. 274 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. XVI. Duration, Table showing the Ages and Sex of 14:2 Cases of Phthisis, with Bheumatism, Disease of the Heart, or Gout. Males Females Total Age 5 years " i " " f, " „ 40 „ » 45 „ „ 50 „ w 55 „ „ 60 „ „ 65 „ „ 69 „ Totals 3 2 17 15 15 12 11 7 3 3 2 1 1 2 3 2 12 9 9 1 5 2 2 1 1 1 2 6 4 29 24 24 13 16 9 5 4 3 2 1 92 50 142 Thus, at the age of 5 years, 2 cases occurred, both of which were females, &c. &c. As before stated, the cases of gout were in individuals at or over 40. The duration of these cases, while under observation, was as follows : 25 cases lasted for . 6 montlis 1 case lasted for . 5 years 20 , . 1 year 4 cases „ . 5i ,, 22 , 11 • ^2 V >, . 6 „ 10 , . 2 years „ ,, ■ 6i „ 4 , . ^ „ „ „ ■ 7 „ 4 , . 3 „ 1 „ „ . 10 „ 7 , • 3^ „ 1 „ „ ■ 12 „ 2 , . 4 „ 39 „ lasted for indefinite long 2 , • 41 „ periods. The average duration of these cases, while under observation, was 23-30 months, the mdefinite period cases not considered. On leaving the hospital, there were : — Better Worse Stationary 47 36 of wliom 11 died. 59 EHEUMATISM, GOUT, DISEASE OF THE HEART. 275 Of tliesc cases, 51 were in the first stage, 60 in the chap. second, and 31 in the third stage of phthisis. Of the - '^^^' - deaths, 1 occurred in the first stage, 5 in the second, and 5 in the third stage. The cases which unite the features of rheumatic Characters heart disease, and tubercle in the lung, present several casL!^^ peculiarities. A rather profuse hasmoptysis frequently is the first Hgemo- symptom of lung disease, and throughout its whole ^^'^^^^^ course recurrence of haemorrhage is common. Nor is it always dependent on the pulmonary congestion secondary to mitral narrowing, for it is witnessed in aortic thickening and in simple dilatation. So common is this, that the haemorrhage diathesis has been supposed to attach itself especially to this combination. The left ^^^^ ^™g lung is most frequently affected, and the exudation is affected. massed and somewhat circumscribed at the apex. A Diffused cavity is generally formed, this form of tubercle being rare rarely disposed in the sparse diffused variety which we have described. The exudation is probably more fibrinous, and possesses more of the rheumatic element than ordinary tubercle. Laycock * asserts that it breaks down into a less regular excavation than is common. The infiltration of inflammatory products around the tubercular deposit is undoubtedly greater than in ordinary phthisis. The contractility of such products, and possibly the tendency of the tubercle itself (which is more commonly of the grey variety) to retrograde changes, gives rise to great flattening and retractation of the chest walls in cases which become somewhat chronic. For the same reason the heart is Flattening frequently displaced upwards, the pulsation being very waUs.^^*^ manifest to the eye and touch in the third or even in the second intercostal space. We have thus a succession * ' Lectures on the Physiognomical Diagnosis of Disease : ' Med. Times and Gazette, May 3, 1862. T 2 276 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. XVI. Life pro- longed. Clubbing. Extreme wasting absent. of physical signs from above downwards, very cliaracter- istic — a cavity under the clavicle on the left, with retractation of the chest walls and the heart immediately underlying it, with such murmur as belongs to the pecuhar lesion of which it may be the seat.* On examining such cases after death, the irregular, con- tracted cavity, with much inflammatory infiltration of the lung surrounding it, as well as in other parts, will be found to form a characteristic morbid state. Very often there is almost no tubercle, the lung being con- tracted by fibrinous products which diminish its bulk, and render its tissue dense and unyielding. Cretifac- tions are not uncommonly found. Practically, there is found to be a great tendency to longevity and prolongation of hfe in these cases. When the first severity of mischief is over and softening has occurred, the patient regains a certain amount of vigour and of flesh, the cough subsides, the secretion from the cavity lessens, and the pulse, although excitable, is commonly tranquil, often, however, possessing the thrill of mitral disease. The hand generally becomes most characteristic, and 'clubbing' of the fingers is almost invariable. The patient often remains free from all secondary disorder, as diarrhoea, for an unusual period. In some instances, this symptom never occurs. Eepeated heemorrhages are very apt to distress and to lower the strength, but they have their use, and relief to dyspnoea is very com- monly the effect. Death may occur from the pulmonary or the cardiac lesion, but the ordinary extreme Avasting of phthisis is not common. With extension of the deposit to the opposite lung, the breathing becomes much distressed, and the hvid lip and nails of the sufferer evidence imperfect aeration of the blood. This symptom is very marked, and occurs long before the See diagram pag-e 199. RHEUMATISM, GOUT, DISEASE OF THE HEART. 277 final break up. I have frequently seen death take chap. place from cardiac obstruction, secondary anasarca, . — ,.1^ and oedema of the lung, but slowly and with much suffering. Great prolongation is the character of this singular comphcation of pulmonary and cardiac disease. Such are the symptoms, but their explanation is not so easy. Why should the left lung be the seat of tubercle more commonly than the right, when cardiac disease is also present ? That peculiarity of nervous power which governs the distribution and locahty of disease has been assigned as the agent directly influential in such in- stances as this ; but while attributing this action to the sympathetic and par vagum, we are rather eluding than answering the question. The neighbourhood of organs (apart from their function), and even where their nervous supply is derived from different sources, often determines their imphcation in diseased action.^ Thus when structural hepatic disease is combined with pul- monary, it is the right lung which is commonly engaged. Professor Laycock has stated his opinion that the reason may be found in the anatomical relations of the left pulmonary veins, which he so closely together that pressure upon one could hardly be made without involving the others, and ' conceives that this pressure may be made by enlarged bronchial glands.' But he is finally compelled to take refuge in the vagueness of a ' defect in the innervation of the nutrient and motor nerves.' V. C- get. 23, Nov. 1860. Mother, two maternal uncles, phthisis 3. and one paternal uncle died of phthisis. Ten years ago had Mitml^^ profuse hsemopytsis, which has been repeated frequently since, hypertr'o-' She has also been subject for the same period to cough, with phy^^^ moderate expectoration. Is slightly wasted, and not losing Jvities. flesh lately. Has had attacks of hectic, but there is no pre- U years, sent fever. The pulse has a characteristic thrill. There is a chronic abscess connected with the hip joint, from which she has suffered from infancy. The limb is shortened; the discharge now very slight. Ctma. regular and sufficient. 278 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. The hsemoptysis, which at times amounts to half-a-pint, is J^^^- most common at the menstrual period. Urine natural. No oedema. Digestion good. Her principal distress arises from dyspnoea on exertion. She has never had rheumatism. A loud systolic soufflet over the mitral region, and a distinct murmur, rough, systolic at the base. The heart is drawn up to the left side, and the cardAac dulness is extensive, the impulse increased. Very marked dulness, 7)iuch retraction of the chest walls, and diminished mobility; gurgling, pec- toriloquy, under the clavicle for three inches, and in the supraspinous fossa. Slight humid craxMe over the base, posterimdy left. On the right side there is diffused humid crepitus over the upper third of the lung. The posterior- inferior of the right lung is the only part ivhere vesicular respiration is heard. She was treated by tinct. ferri sesquichlorid. ; gallic acid, 3 grains twice a day, sedative mixture. She improved very much, was able to walk some distance, took a part in teaching at a Sunday- school, and looked well. At intervals till January 1863 I attended her, gene- rally on the occasion of a profuse haemoptysis. At other times when she was much distressed by dyspnoea, without spitting of blood. On these last occasions I generally ordered a few leeches to the sternum, which caused immediate relief, a sense of giddiness under which she suffered being at once removed by this treatment. At this time a well-defined cavity formed in the opposite lung. So that ive had thus physical signs of two cavities and crepitation in all the other portions of the lung excepting in the right base, in addition to the cardiac disease. It was only in the summer of 1864 that she gave up walking out, and was obliged to confine herself to the house. From the commencement of this year she had no further hsemoptysis, and her dyspnoea daily increased. She had to be carried up-stairs, but could walk down. Her digestion remained good to the last. She never had any of the secondary effects of tubercle, as diarrhoea. In November she was seized with agonising dyspnoea. I found her gasping for breath, face livid, lips purple, pulse nearly imperceptible and very rapid ; a coarse crepitus over the hitherto healthy right base. Brandy in re- peated small doses, alternated with ammonia and chloric ether, large turpentine fomentatioDS to the chest and back, and RHEUMATISM, GOUT, DISEASE OP THE HEART. 279 warmth with frictions to the extremities somewhat relieved CHAP, her. At nights she was delirious, had no sleep, an intolerable -^^- orthopnoea rendering her sufferings very great. Notwith- standing the most unfavourable prognosis formed at this time, she again rallied. Tlte right base became clear, the colour of the face much improved, and she became calmer and more collected. Slight anasarca of the lower limbs appeared to relieve the terminal part of the circulation. In this revived condition, which from the medical ivmiiing given did not restore the hopes of her friends, she lingered a fortnight longer, and died on De- cember 26, 1864, without any paroxysm of dyspnoea, and without suffering. The heart's power had failed, and death was due to the cardiac rather than the pul- monary disease. The case thus lasted fourteen years, and during the last two she had double cavities in the lung, as well as the cardiac aff^ection. The following points are worthy of remark : — 1. The marked predisposition to phtliisis. 2. The modification of the tubercular by the cardiac disease. The latter consisted in valvular thick- ening and consecutive hypertrophy, a condition especially antagonistic to phthisis. 3. The completeness of the processes of sanguifica- tion, owing to integrity of the digestion. 4. The frequent rehef from copious haemoptysis, an indication which was followed with advantage by the local abstraction of blood. 5. FinaUy, the persistent vitality, which should never be forgotten in offering a prognosis as to time in cases of this nature. 280 ELEMENTS OF PROGNOSIS IN CONSUMPTIOK CHAPTER XVII. EMPHYSEMA OF THE LUNG WITH PHTHISIS. ASTHMA. CHRONIC BRONCHITIS. CHAP. XVII. Emphy- sema an ele- ment of chronicity. Two forms: compen- satory dilatation of air- Tesicles and true emphy- iBema. Compen- satory di- latation. The complication of phthisis with emphysema of the lung or with asthma is uncommon. These affections mask the tubercular disease as well as comphcate it. It has been shown that emphysema of the lung is to a certain extent antagonistic to tubercle. When coex- istent it is found in middle life most commonly ; but their concurrence is extremely rare. In many cases it bears a very small proportion to the total number ex- amined. In all it seemed to form an element of chronicity. Two forms of the affection are to be recognised. Pirst, that partial distention of the remaining sound air vesicles which occurs in certain cases of very chronic phthisis ; and next, the true emphysema, which may have been a pre-existent or a concurrent affection with tubercle. These two varieties are often confounded; but they bear a different interpretation, both in their results on the lung, and on the case. We shall first consider the compensatory dilatation of the cells which occurs as a sequence to chronic phthisis. It is only in the most prolonged forms of phthisis that the air-vesicles become dilated, and then the in- creased respiratory spaces gained by amphfication of the ultimate cells of the lung is only won after long- continued resistance of the system to a limited form of EMrilYSEMA — PHTHISIS. 281 the tubercular affection. Cavities in the luno; lonff tole- chap. XVJI rated, and extensive deposit of the diffused character, .__,__. on one side, are the conditions most Hkely to induce Physical dilatation of the cells in the remaining and healthy- portions of the lungs. In sucli instances the process of Not mor- enlargement of the cells is scarcely a morbid action; ^^ " but is, in its nature and results, in the breathing efforts which have caused it, and in the resulting defect in elasticity, a purely compensatory arrangement. The effort is toward prolongation. The system, to require such respiratory space, is of necessity not in the im- paired position as regards circulating and oxygenating requirements, which is witnessed in the ordinary course of progressive phthisis. If much blood be circulating, and if that fluid be so well formed as to demand a fre- quent renewal from the atmosphere, the diminution suffered from an extensive deposit of tubercle is severely felt and lung space must be gained. A structure capable of dilatation to twice or three times its original volume, is distended to afford the necessary respiration ; and the act is in its nature curative and restorative. The dilated air vesicles, in such cases, do not lose No loss of their elasticity to the same extent which is found in L'^ceUs!'^ ordinary emphysema. The new space gained in the lung is, on the whole, good for respiration ; and the exit and entrance of air is free. When this condition is found at the basis of the lungs, the tubercular conco- mitant affection has invariably been of long standing. The physical phenomena are not those of ordinary emphysema, viz., loud percussion note and deficient respiratory murmur ; but while the resonance is preter- naturaUy clear, the respiratory sounds are unusually loud and long. The prognosis in such cases is always Prognosis good for time, the conditions being, in fact, such as in- duration, dicate a tendency to rectify local mischief by increasing the remaining respiratory space, as well as affording evidence of the still- existing requirements of the system 282 CHAP, XVII. Contrast with con- tinuous phthisis. Practical indica- , tions. ELEMENTS OF PEOGNOSIS IN CONSUMPTION. for air and circulation. The converse of this state is - weU seen in ordinary continuous phthisis, where the , portions of hing, not the seat of the deposit, are con- gested, as indicated by the rough tone of respiration and occasional rales heard ; and where the ultimate tendency, if the case be at aU prolonged, is to con- traction and shrinking of the lung tissue, and consequent diminution of the respiratory space. It may be weU to notice here the practical indications which may be gathered from these considerations. To enlarge the remaining respiratory space if, in such in- creased distention, it can be made to maintain its respiratory powers, is a very manifest way to remedy the mechanical inconvenience resulting from an obhte- ration of a portion of the pulmonary area. To enlarge without securing the integrity of the newly-expanded respiratory membrane would be to add a new source of embarrassment to the patient. If we could at will cause true emphysema of the base of the lungs in a case of ordinary phthisis, we should doubtless giVe rise to infinite distress. ^ In the few instances in which nature enlarges the aur-vesicles, while maintaining their respiratory inte- grity, the process is one of extreme slowness, and it argues a hmit to the deposit of tubercle, and compa- rative healthiness of the remainmg portions of lung, as weU as a cessation (temporary at least) in the consti- tutional tubercular disorder. It may therefore be fairly deduced, from a study of the natural processes, that a fair exercise of the lungs is not to be forbidden to patients in the above con- dition ; and that where we find a limited amount of local disease, with physical evidence of the integrity of the remaining portions of lung, and a manifest sub- sidence of the systemic disorder, we shaU do well to enjoin a due exercise of the lungs, as by reading aloud occasionaUy even by singing, but, above all, by the EMPHYSEMA — PHTHISIS. 283 most beneficial mode of all, horse-exercise at a rapid chap. pace. The instances in which I have seen the dilata- - — r— ^ tion of the healthy cells occur, with increased respira- tory powers to the patient, have occurred in persons Horse ex- taking daily active horse-exercise in the open air, and ^^°^^^ ^^^' I have often witnessed the greatest relief to dyspnoea obtained by a gallop. The dangers incurred are not to be forgotten. Hse- Danger,?. moptysis and pneumothorax are possible occurrences. We have all seen these disastrous events fatal. I have Avitnessed the latter in a young lady from combing her back hair, when a small superficial cavity gave way ! But if our cases be properly selected, the contingencies Hkely to occur will be found as one to a thousand com- pared with the gain by a moderate daily exercise of the lungs, promoting circulation, respiration, muscular vigoiu", and a gradual extension of the remaining healthy respiratory space. The true emphysema of the lung, that in which the True em- air-vesicles have lost their elastic power, is a rare com- ^ y^^™^- bination with tubercle. It has been considered anta- gonistic* The condition of the pulmonary circulation, Antag;nis- and the general venosity of the system, have been sup- phthisis, posed to be agencies opposed to the tubercular diathesis. With the theory we have not here to deal. The practical point of the rarity of the combination with existing phthisis is undoubted. The contrasts are remarkable : — Emijhysema. Large rounded chest. Antero-posterior measurements deep. Distension of respiratory space. Hsemorrliage rare, and of venous Llood. Stasis of pulmonary circulation reacting on the heart and caus- ing dilatation of its chambers. Phthms. Flat long chest. Antero-posterior measurements shallow. Contraction of respiratory space. Haemorrhage frequent, of aerated blood. Hyper-activity in the pulmonary circulation, heart feeble from atrophy. Contrasts. * ' n 3'- a une sorte d'antagonisme entre ces deux maladies (I'asthme et la tuberculisation pulmonaire) qu'elles paraissent s'exclure mutuellement 284 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP. XVII. Emphy- sema the earliest aifection. Asthmatic fits. Physical signs. Cardiac dilatation. Symptoms. Alterna- tion of the two affec- tions. True emphysema, when coexisting Avith phthisis, will generally be found to have been the earher affec- tion. The occurrence of asthmatic fits from childhood, with recurring attacks of bronchitis and ultimate de- position of tubercle, is the ordinary history of such cases. On examination, the ordinary build of emphy- sema will be evident, and the ordinary physical signs of fixity of the chest walls. Loud percussion note, and feeble respiratory murmurs will be present. One apex, or both, may also furnish the signs of deposit in the lung in the first stage, or in that of softening or cavity. The asthmatic paroxysm is present, often to an extreme degree of distress, such, indeed, as is rarely seen paralleled in any pulmonary affection. The lung disease is slow to advance, but the cardiac dilatation, inevitable in prolonged cases of emphysema, increases with time, and finally rises to be the most destructive element in the case. As these cases of conjoined asthma and tubercle develop themselves, there is a curious mixture of the symptoms peculiar to both. Should the asthmatic affection have preceded the other, the seizures no longer remit, but the dyspncea becomes, as it were, continuous, while the physical signs of deposit in the lung supply sufficient evidence of the cause. The pauses which are so common in the tubercular disease are often occupied by the asthmatic paroxysm, and the two affections seem almost to alternate. Should tubercle have been the earher affection, its advance is steadily retarded from the moment that fits of dyspnoea occur. ISTot only is phthisis thus held in check, as it were, but dans certaines races predisposees a leiir double atteinte : que, cliez le meme sujet, le developpement de I'une semble enrayer ou afFaiblir la marche de I'autre.' (De I'lnfluence reciproque de I'Asthme et de la Tuberculisation pulmonaire. Par Dr. N. Gueueau de Mussy, Medecin de I'Hotel-Dieu : Arch. Gen. de Medecine, Nov. 1864, p. 513). See also Williams {Prin. of Med?), Eoliitansky, and otliers. EMPHYSEMA — niTIIlSIS. 285 the various secondary disorders, as well as the more chap. ordinary manifestations of disease, are interfered with. v-^_,__. The physical signs require to be studied with great Sources of care. The emphysematous state of the lung may mask the dulness on percussion, the sonorous rales so com- mon in asthma disguise the fluid gurgle or soft crepi- tant sounds of tubercle, and the ordinary loud harsh and prolonged expiration of the former may wholly overcome the same phenomenon referable to a deposit in the lung. A careful comparative estimate of the sounds at the two sides is highl}'- necessary, and an equally careful investigation of the patient's history and family antecedents can alone save us from error. The conjoined aiFection is greatly prolonged. The Proionga- body wastes often to an extreme, but hectic is not *^°^' severe, and secondary diarrhoea is rare, and does not kill as in ordinary phthisis. We are often surprised to witness the length to which these cases are prolonged, and as the suffering from dyspnoea is extreme, there is, perhaps, in the whole range of disease no affection more painful to witness. Unfortunately a prognosis for prolongation may be given. Death finally occurs Death from failure of the heart's action. The respiratory u^Ti? death is rare. These cases appear to he on the limits ^leart's of bronchitis and phthisis, and to partake of the aspects of both. The age at which the comphcation presents Age that is more that of bronchitis of the chronic form than of troncidS phthisis. The predisposition may be either to tubercle or to asthma, but rather to the former. In the dyspnoea, and its recurrence in fits, in the shape of the chest, and in the nature of the expectoration, we recognise rather emphysema than phthisis, and in treatment the cases respond to the remedies for the former affection. On the other hand, the hemoptysis (when present, as it gene- rally is), and the progressive wasting, lend an unmis- takeable character, even without physical signs, of tubercle. In viewing the chronicity which is often 286 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. XVII. Phthisis retarded. duration. Chronic bronchitis with tubercle. Diagnosis obscure. accorded to these cases, we are tempted to ask whether the emphysema does not compensate for the respiratory space lost by the tubercular deposit ? It is certam that the phthisis does not advance as in other cases. Cavities do not form and extend, nor does the disease develop itself with activity and rapidity in the opposite lung, nor do secondary ajQfections intervene. That terrible monopoly which consumption appears to exercise over the system, excluding all diseases but itself, is interfered with, and although an additional cause of distress be added to the patient, he does not so rapidly sink under the double as he would have done from the single ailment. The average observed duration of the comphcation of phthisis with emphysema and bronchitis, was found to be 49-24 months, which is more than three times that of ordinary phthisis. Bronchitis has been grouped with emphysema in this section, from the frequent combination of the two affections, whether with or without phthisis, but it need scarcely be said that bronchitis is often found as the companion of tubercle without any amount of existmg emphysema. It is chiefly in aged persons that bron- chitis is found as the direct forerunner of the tuber- cular disease. In them it often masks the latter for months or years. In a sense, bronchitis is never absent from any case of phthisis at any age, but it is especially the concomitant of the senile form. But there are also cases in which the cough, the expectoration, and the febrile remittent character of the symptoms, combined with very considerable loss of flesh, lend a character to the disease which is scarcely distinguishable from phthisis. The physical condition of the chest may also be not so absolutely decided as to warrant an authoritative opinion. On the supposi- tion that it is phthisis, the chest signs are of too diffused a character to permit of the locahsation so character- EMPHYSEMA — PHTHISIS. 287 istic of tubercle. Viewed from the side of bronchitis chap. the signs are too condensed, and the presence of some - -,— - duhiess on percussion may, without tubercular disease, lead an unskilled observer to believe in consolidation rather than inflammation. And when we come to re- gard closely the history and signs of such cases, when we remember that there is but a step between capillary bronchitis and pneumonia, and often a doubtful divi- sion between pneumonia and tubercle in the lung, we shall see cause to view our most approved tact with diffidence. In truth, these are what they appear, cases of a very mixed character, and accuracy is alone to be ensured by remembering that our differences in no- menclature are not always borne out by the structural varieties which our names represent. In the following cases, selected from large numbers, as presenting a distinct combination of bronchitis or emphysema with phthisis, careful observations were made. Emphysema well marked existed in nineteen cases, Predispo- In these the predisposition was ascertained in fifteen tubercle cases, and it was found that twelve had inherited more tendencies * to phthisis, and only three to asthma. As regards bronchitis combined (in its severer forms) with phthisis, there were 77 cases observed. Of these stage. 27 were in the first stage, 49 in the second, and 1 in the third stage of consumption. Forty-four had bron- chitis before phthisis, two had unmistakeable symptoms of phthisis first ; and in 31 it appeared doubtful which of the two affections had the priority in point of date. The following table shows the ages and the stage of phthisis : — * This would seem to contradict the experience of Dr. de Mussy (o}). cit. sup.), who considers that the predisposition to asthma is always most marked. 288 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP. XVII. Ages and stage. Law of tubercle exempli- fied. Nos. stage 1. stage 2. stage 3. Age 25 "i „ 40 „ 45 „ 50 „ 60 Totals 9 11 10 15 11 9 5 7 6 5 3 6 3 3 1 3 6 7 9 8 6 4 6 1 77 27 49 1 The table reads thus : at 25 years of age 9 in- stances presented, of which 6 were in the first stage, and 3 were in the second, &c. Duration. The duration while under observation was as follows : Cases. Cases. For indefinite long periods . 29 For 5 years . . 4 „ 6 montlis . 1 „ 6 )} . 6 „ lyear . . 5 „ 7 V • • . 3 V -'■2 V . 2 „ 8 V . 1 „ 2 years . . 3 „10 7; . 6 91 • . 5 » -'2 .?; )j 3 „ • . . 5 — )) 4 ,, . 7 77 It will be remarked in the above table how great was the duration of this class of case. In fact, scarcely any of them fall within the category of ordinary phthisis, which runs its course in eighteen months. The age is rather that of bronchitis in its chronic form, than of phthisis ; and the cases partaking of a mixed character observed that law of tubercle that every agent capable of converting it from its usual course, adds prolongation to its term. The state of health of 59 patients was observed when they passed from under observation, with the following result : — Improved .... 22 Stationary . ... 18 Worse ..... 19 Total 59 EMPHYSEMA, BRONCHITIS, PHTHISIS, CASES. 289 Oct. 1857. — Mrs. 0. set. 35 ; no known predisposition to CHAP, either asthma or phthisis ; has 3 healthy children, youngest ^^JJ- 13. Has been subject to cough for four or five winters, now q^^^ continuous cough for one year, with frothy, difficult expec- Bronchitis, toration. One slight haemoptysis three weeks ago. Very ^^P^y* considerable loss of flesh and strength lately. Dyspnoea on phthisis, exertion. Pain in left side and scapula. Digestion pretty ™- cordis, c) 1 ./ under ob- fair. Ctma. regular. Chest emaciated, movements impaired servation both, flattening left anteriorly ; dulness and hum.id ere- '^ years. jpitus over whole left. December.- — An acute attack of asthma, with excessive dyspnoea, sonorous rales over both chests ; pulse not affected in the attack. Extremities were cold ; chills excessive ; no sweats. The following summer she rallied, but the winter brought exacerbations, chiefly of the asthmatic form, which increased in severity year by year. A cardiac, mitral, systolic _ murmur, faint hut 'pro- nounced, with heart sounds diffused over a wide extent, and the same pulmonary signs as before, were noted in June 1860. At this time she became much emaciated, with- out any advance in the physical signs, and without any fever. Her attacks of dyspnoea increased both in frequency and severity. The greatest relief from these paroxysms was now experienced from the use of morphia in doses of one- eighth of a grain. In July 1862 she was much emaciated, the physical state of the chest, as regarded the tubercle, had not advanced, but much emphysema of the bases of both lungs was mccnifest. Her life had been one of greatest suffering. In her paroxysms of dyspnoea she has lain for three weeks in a prone position, without the possibility of moving, and with all the accumulated miseries which such a state of things involved. The slightest movement brought on the most distressing dyspnoea. Her cough at this time was chiefly in morning and evening houi's, and was followed by a considerable expectoration of muco-purulent matter. Her nourishment was taken chiefly in the fluid form, and in small quantities. Stimulants often relieved her, and up to the time of her death in June 1864 she never left off taking- morphia, of which she generally consumed 3 grains in the day. Eemedies of the antispasmodic kind were on the whole the most efficacious, next to morphia. She died after much suffering, and without any advance in the physical signs. U 290 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XVII. Case. Emphy- sema with subsequent tubercle : 6 years. Case. Asthma from child- hood, phthisis in adult life. Case. Emphy- sema, bronchitis, phthisis. Her intellects were unimpaired to the last. Death took place from gradual atrophy, and failure of the heart's action, without diarrhoea, or suffocative effusion into the tubes. In this case tlie predominance of empliysema over the tubercular affection, the gradual supervention of dilatation of the cells, and the complication of dilated heart, together with the excessive dyspnoea and final result from failure of the powers of circulation, are very remarkable and typical features of this combination of disease. • J. M'C. set. 41, shipwright, (kindly sent to me by Dr. M'Donough, of Sheerness). No predisposition to pht. ; cough for 6 years ; worse and continuous last 2 years ; with lately haemoptysis ; loss of flesh and strength ; considerable expec- toration and night sweats ; dulness and flattening, humid crepitus left apex for some inches, %viih emphysema of both bases ; tvorse at night ; feeble action of heart. Improved much on sedatives and anti-spasmodics, with counter-irritation. E. C. set. 27, mother of 3 children. Fits of dyspnoea once a week since childhood; more frequent lately and at cata- menial period. The dyspnoea lasts one day, when it is ended by a prolonged fit of coughing, with moderate yel- lowish white expectoration. On these occasions she has hsemoptysis, florid, mixed ; lately there is loss of flesh, with night sweats ; bowels flatulent always before the attack ; dulness, with tubular respiration of a dry character and crepitus at left apex for some inches. The case was under my care for 2\ years. The treatment found to be most efiBcacious was an emetic of ipecacuan when the attack was impending, and full doses of quinine in the interval. Asafoe- tida and aloes in the form of pills was also found useful. The phthisical symptoms did not advance, nor did the signs change. E. E. leadshot maker, set. 36, sister died of phthisis. Ill 3 years, and was in-patient 2 years ago, when he gained 21 lbs. in 3 months. Lately his cough and expectoration much increased ; no hsemoptysis ; much wasting ; didness and moist crepitus right apex; rest of lungs emphyse- r)%atous and with bronchial rales. Improved much on mist, sether. chlor. and pil. stramonii, with acetic acid lini- ment externally, and afterwards on mist, senegse. EMPHYSEMA, BRONCHITIS, PHTHISIS, PROGNOSIS. 291 Sarab 0. set. 42, housemaid. Subject to fits of dyspnoea CHAP, for 18 years, followed by cough and expectoration ; no . ^^^^^' . haemoptysis ; has lately begun to lose flesh and strength ; Case. ctma. regular ; digestion bad ; dulness and clicking at both Asthma apices ivell ^narked. Improved on stramonium and chloric deposit^i'n aether with counter-irritation. lung. Charles A. set. 23, clerk, 2 brothers and 1 sister died Bronchitis, of phthisis. Ill 2 years with cough of bronchitic character ; jJ^^^^^J^^^ for the last 6 weeks haemoptysis, with increase of cough, and difficult expectoration ; dulness, flattening, impaired mobi- lity, rough and blowing resp., tvith exp. prolonged right apex; diffused bronchial rales both bases. Treated for 1 year by oil and sedatives, with external application of iodine ; got worse slowly. Mrs. T. get. 56, Feb. 1862. Ill for some months; no Case. predisposition ; no haemoptysis ; excessive dyspnoea on exer- ^^^^^^^^^t tion ; constant cough and expectoration ; moderately wasted, first ; no present hectic; digestion unimpaired; dulness, flatten- ^ardiac i/ng, gurgling ; subclav. diffused ; humid crepitus to the base death. anteriorly and posteriorly left ; humid crepitus anterior and posterior parts of apex right ; systolic murmur at base. This lady's dyspnoea increased, but the tubercular affection remained stationary. There was neither fever nor diarrhoea, and she died in the spring of 1864, of gradual dilatation of the heart. Prognosis. The prognosis in the class of cases presenting com- Cases of pensatory respiration, and the evidence of enlargement tory^diia-' of the healthy portions of the lung in phthisis, must tationiong. be invariably good for duration. Nature has already made a vigorous resistance to disease, and the battle will be a long one, even if the fight be severe. In phthisis, when found combmed with the asth- Asthma matic paroxysm and true emphysema of the hmg, the bereie case is certain to be a long one, and an opinion favour- ^""S- able for time may with confidence be delivered, if no cardiac afiection be present. If dilatation of the cardiac chambers be present, the distress will be great, but the • case will still exceed the ordinary limits of phthisis. v2 292 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. In the case of compensatory dilatation of the cells, V- . • . the tubercular is the primary affection ; in emphysema the asthma almost always precedes the phthisis. The Chronic former is hkely to be the longest in duration. Bron- phthisis. ' chitis of the chronic form, combined with tubercle in the lung, tends to the chronicity of both affections, and the case will be a long one. MENSTRUATION — PEEGNANCY — LACTATION. 293 CHAPTEE XVni. MENSTRUATION PREGNANCY LACTATION. The influence of the catamenial function on phthisis in chap. XVIII its development and progress, has been held by many , — '-- authorities to be considerable. The commencement of influence phthisis at the age of puberty, and its association with struation the absence or incompleteness of the uterine function °^^ ^ ^^^^^ at that time, have appeared to stand in the relation of cause and effect, and amennorrhoea has been re- garded and treated remedially as the exciting cause of the tubercular affection. It has often been attempted to restore uterine activity, in order to cure or prevent the consumption. It seems, however, far more reasonable to attribute Arrest of the suppression of the catamenia to the constitutional ^^*"*^°°- disorder of nutrition, which is alike the cause of the suppressed secretion and of the phthisis. The earhest features of tuberculosis are arrest of development and emaciation, and the uterus only shares in the general want of functional activity undergone by all the organs. Were the suppression due to a local congestion of the generative organs, the symptoms would be different, as a general state of plethora is known to prevail in such cases. But the nature of the amennorrhoea is manifest. There is want of nervous Organic power, and deficiency of circulation. Neither the quantity nor the quality of blood are equal to the requu-ements of the system at the age when the frame should expand. 294 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP, when growth takes a new impulse, and various im- X VIII. portant functions dependent on full organic develop- ment have to assume a new activity. The causation should here be reversed, it is tuberculosis which gives rise to the suppression of the uterine secretion, and not the amennorrhoea which causes the phthisis. The age of puberty is perilous to growth if organic hfe be not in full activity, and in those hereditarily pre- disposed to tubercular disease is the second great period when an invasion of the latter is to be appre- hended. During childhood, mesenteric, cerebral, and external glandular affections predominate, at puberty pulmonary disease is threatened ; and although, as has been shown, consumption does not necessarily attack the predisposed at this time, yet many fall victims to its ravages at this critical age. The great wave of tubercular disease doubtless attains its greatest intensity at from 25 to 35, but the grave error of nutrition of which tubercle is the expression, finds an impulse of development when bodily growth should be in the highest degree of activity. At puberty not only is growth active and rapid, but nervous power is inten- sified, and organic life becomes very susceptible of derangement. At the moment of greatest activity in blood-making and tissue-formation, errors in the quality of the plasma are speedily felt by the respiratory Amennor- systcm. Wc cauuot for a moment believe, that the rhcea not retention in the blood of that which s;oes to form the a cause oi . . <^ phthisis, healthy uterine secretion, has anything to say to the formation of tubercle, but the error in nutrition of which the latter is the expression, is doubtless ex- tended to the uterus and ovaries in common with the other organs of the body. That an improvement in health should occur, or an arrest in the tubercular disease take place coincidently with the establishment or reappearance of menstruation, is only in accordance with this view. In all instances in which we have MENSTRUATION PEEGNANCY LACTATION. 295 seen such coincidences, an amelioration of the chief chap. symptoms, an arrest of the emaciation, and a pause in - ^^^^^- . the febrile action, has preceded the restoration of the catamenia. That a large number of cases of phthisis commence at the age of puberty is a well-ascertained fact. To prove that the estabhshment of the uterine function has a direct relation to phthisis, it would be necessary to show that more females than males are affected by pulmonary consumption at the age of puberty. Out More of 300 cases of strumous phtliisis, I had 59 males and T.tllf^'' 56 females between the ages of 10 and 15. In 59 piithisicai instances of incipient phthisis (all ages), there ■ were ofpubCTtj. 19 males and only 4 females between the ages of 15 and 20. In phthisis occurring in the rheumatic dia- thesis between the ages of 15 and 20, there were 19 males and 14 females. In 179 cases of acute phthisis, 26 males and 16 females were attacked between the ages of 15 and 20. From the above observations it would appear that there is a large prej)onderance of males over females (123 of the former to 90 of the latter). The more rapid and acute form of phthisis also shows a majority of males at this age. It is then the age and not the sex, and the general functions of growth and increased activity of the nutritive processes, to which we are to look for the exciting causes which render the period of puberty perilous. Passing to other considerations connected with this The pro- subject, it will be asked in what respect does the cessa- phtM^s tion or continuance of the catamenial function influence influenced the progress of phthisis when estabhshed ? struation. The following statement gives the result of observa- tions on 99 cases in which the menstrual function was irregular, absent, or excessive. The stage of phthisis is also given in relation to these points : — 296 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. No. of XVIII. Stage 1. cases. ■ r ' Catamenia, irregular or deficient, m . 1 jj absent „ ; 14 V excessive Stage 2. }> 2 Catamenia, irregular or deficient, m . 2 » absent „ • • 16 V excessive Stage 3, )} 1 Catamenia, irregular or deficient. m . 7 j> absent 28 )> excessive Total 1 . 72 Average' observed duration. Ill 27 cases examined the catamenia had never appeared. They are arranged below according to age, and the stage of disease : — Phtliisis 1 2 „ 3 Totals . Age. 13 14 15 16 17 18 20 1 1 2 3 2 4 3 2 5 1 1 1 1 2 2 9 10 1 1 2 The above table reads thus : At the age of 13 the catamenia had never appeared in two instances, one of which was in the first and the other in the second sta^e of phthisis. On leaving off treatment at the hospital the following results were noted in 76 cases : — Catamenia abseni.- -Improved or stationary "Worse No. of cases. . 46 . 14 Catamenia deficient or irregular. — Improved or stationary 7 ?> ;, Worse ... 1 Catamenia in excess. — Improved or stationary . . 3 „ „ Worse 5 Total . . 76 The average duration while under observation of this class of cases in which the catamenial function was MENSTRUATION — PREGNANCY — LACTATION. 297 much interfered with in the course of the phthisical chap. disease was ascertained to be 21*71 months, which is a > , L- low figure. The above figures are taken from cases selected as presenting catamenial irregularities, and do not repre- sent average occurrences in phthisis. They are, there- fore, illustrative rather than demonstrative. It would appear from them that the uterine function is most commonly absent altogether, or simply regular ; and that its absence is, in many instances, consistent with much improvement in the disease, and very frequently with the stationary aspect of phthisis. But on the whole amennorrhoea is a bad symptom, which is rarely absent in the advanced stages of the disease. From general experience, difficult to state in a tabular form, I should offer the following Prognostics. 1. A rapid invasion of phthisis may be dreaded Progno- when the disease is hereditary, and attacks at the age of puberty in either sex. 2. Tuberculosis delays or wholly puts a stop to uterine regularity at the age of puberty in females. 3. The establishment of this function is often attended by relief to the tubercular disease, and its per- sistent regularity is a good sign. 4. The permanent arrest of menstruation in phthisis is a very common occurrence. This event is preceded by much exhaustion of the system and vital powers, and is a bad prognostic. 5. When menstruation is pretty regular in a phthi- sical patient, all the symptoms are hable to undergo an increase at the monthly period. 6. When menstruation is suddenly checked, a hsemoptysis is a frequent event, and may be regarded as vicarious, and with less import of 298 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XVIII. Pregnancy, danger at this period of here- ditary- tendencies. The phthi- sical age nearly that of preg- nancy. Disease commonly quiescent pulmonary misGhief tlian under other circum- stances. 7. In very chronic first or second stage cases, with- out fever, the catamenia are often absent altogether. In such cases a resumption of the uterine function is preceded by a higher sangui- fication, and is a good prognostic. 8. In very chronic cavity cases of the anaemic variety the absence of the catamenia is not a sign of bad omen, the system living, as it were, at a low average, and all vital functions being econo- mised. 9. In chronic cavity cases, where the system has recovered to a considerable extent the injury suffered, the regularity of this function is a positive sign of vigour, and an essential element in a favourable prognosis for time. Pregnancy. — Lactation. — Phthisis. In the chapter on the premonitory stage of phthisis are given some details showing the influence of preg- nancy and lactation as proximate causes of the disease. If the hereditary taint be present, these events of female life are fraught with peril. The age at which trans- mitted phthisis develops itself is either at the strumous period, or from 20 to 30, and in females wlio pass through the first epoch, the disease is rarely delayed beyond the second. If strumous children are not swept off before 20, the generative period is most likely to bring pulmonary consumption. Apart from sexual considerations, this is also the age at which phthisis, in both males and females, begins to be most prevalent. Phthisis may either be present before pregnancy, or commence during gestation, or at the time of delivery, or soon after. From a careful examination of a large number of cases (234), it is concluded that the disease was in a MENSTRUATION — PREGNANCY — LACTATION. 299 latent form during or shortly before pregnancy in the chap. great majority, and that it received an acceleration . ^^^^i- . from the time of confinement. The period of gestation during is comparatively one of latency, or rather of quiescence p^'^S'^^'^'^^- of the symptoms. However rapid the form of phthisis Patient which is present, the patient survives to the time of fg^Je-^^'^ labour, and the instances are quite exceptional in which livered. the mother dies undelivered.* The ordinary course is that all the symptoms assume Symptoms increased uro-ency from the time of labour. The hectic ^^^"°^^^ o >) _ urgent becomes severe, diarrhoea or laryngeal disease begins after and rapidly exhausts the patient. Sudden death may occur from the shock of delivery, or even an ordinary The shock amount of hemorrhage may prove fatal by causing h^'J^oJ-^'^^' collapse. Of course, any great loss is additionally ^'^^g^- perilous. In such cases the patient, blanched, anemic, and exhausted, may succumb within a week or two from diarrhoea and hectic. The disease is in almost every instance increased, and the danger incident to the time of labour must never be overlooked in our prognosis. Old cases of cavity in the lung, or chronic oid cases long-tolerated disease, will also often break up at this ^^y^^*^^^ period, but it does not follow that this will be the in- variable sequence, for in numerous instances these patients survive many confinements. The truth, how- ever, remains that the actual period of delivery is one of unusual peril, and that very prolonged cases of con- sumption often break up at this time. The danger. The form however, attaches itself eminently to the rapid con- ofte^l^ute tinuous form of the disease. And it is for such cases o^ continu-- that an invariable prognosis of peril must be offered by the attendant. In 232 cases of phthisis comphcated by pregnancy, * One of these most painful events occurred in one of my wards, and in my presence ; but both Mr. Edwards our Resident Surgeon, my clinical assistants, and myself, were satisfied that there had been no evidence of life in the foetus for twenty-fom* hours previously. oiis. 300 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XVIII. Average duration. Hsemor- rhage a cause. Lactation a cause. Lactation accelerates the disease. Consump- tive mo- thers should not nurse. 79 cases were in the 1st stage of phthisis. 74 „ „ 2nd „ 79 „ „ 3rd Six died while under my care, all in the third stage, of whom one had been ill for 6 months, 3 for 18 months, 1 for 2 years, and 1 for 5 years. Taking all the cases together, the average duration to be assigned to each case was 19-39 months, which is exceedingly low (see table of duration). In 5 instances, the cause of the invasion of the disease appeared traceable to excessive hasmorrhage at labour. The influence of lactation as an exciting cause of phthisis has been noticed before (p. 85), and a table has been given of the number of cases which com- menced at this period. As a causative agent there can be little doubt of its influence, and its effect on the progress of consumption already declared must be con- sidered as prejudicial in a marked degree. If pregnancy retard the course of phthisis, lactation accelerates it. Out of 189 cases, the disease was manifestly increased in 92 instances, and only in one or two could it be fairly said that the pulmonary disease remained stationary ! Nor can it be said that excessive lactation is the chief danger in persons of the phthisical habit, but lactation at all. Out of the above 189 cases, only 14 had nursed longer than 1 year. It is manifest, there- fore, that the drain caused by even a few months' nursing is highly dangerous in those predisposed to consumption. The preceding confinement has already reduced the system, and left it, as we have seen, most liable to an invasion of tubercle ; and if at this time a new function which draws heavily on the nutritive powers be undertaken, the chances are that a rapid form of disease will be induced. The rule, therefore, ought to be imperative that mothers already in con- sumption, or threatened with that affection, should not MENSTRUATION — PEEGNANCY — LACTATION. CHAP. XVIII. nurse. The health of the child is also concerned in the question ; for, although the mother may have an abundant supply of milk, it is seldom of a nutritive quality, and the infant wastes from want of proper food. That the germs of tubercular disease (already hereditary in this case) may thus be increased is self-evident, as children such children generally die early. ^^® ®^^^y- Many consumptive mothers date the commencement of their illness from the weaning period. In the above cases, 16 out of 189 did so, and doubtless this is a time of grave peril. In such cases, the catamenia never Catamenia return, or one or two changes only may take place, r^tum The prognosis is bad, the disease is generally of the Prognosis rapid, intractable form, the fever continuous, and the ^^^' local disease without limit. There is, perhaps, more severe hectic in this class of patients than in any other. The ages of persons affected by pregnancy or lacta- Age. tion are given below. From 25 to 40 is the prevalent period ; but, as a large number of marriages are con- tracted in this country between those ages, the table has not much value as bearing on phthisis. No. of No. of Ages. cases. Ages. cases. 18 . 1 40 . . • . 35 20 . 4 45 . . • . 5 25 . 41 30 . 87 35 . 61 Total . . 234 302 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAPTEE XIX. HEMOPTYSIS. Cannot be regarded alone. CHAP. To assign a special value to each individual sjTiiptoni • r— ' of consumption would be to adopt rather an empuical Symptoms, than a rational view of the disease. Eegarding the affection as a constitutional disorder, rather than the manifestation of a merely local alteration in the organs in which it is seated, we must look further than to such symptoms as are dependent on structural disar- rangement. All the knowledge which can be gathered from physical changes is to be added to and compared with the evidence of systemic variations from the standard of health. The sum of the two sets of ob- servations is an indication of the present state of the patient, and an apphcation of om- acquaintance with the higher problems of the laws of vital phenomena to this ascertained condition, forms the basis on which we are to construct a rational prognosis. But there is also a certain knowledge of the nature and bearing of particular symptoms, always demanded by the patient, which is of real importance in the formation of a True value proguosls. Wc cauuot scvcr thcsc symptoms from general vital conditions, but we can assign to them a pecuhar value, and are often enabled, if truly informed as to their meaning, to relieve apprehensions on the part of the sick, or to strengthen our own views as to the nature and probable course of the affection. Ee- membering that these hold a position of subordinate relative. IS most common in HEMOPTYSIS. 60 importance to the signs which are of a more general chap. character and have their chief value as interpreters of -^ — .^ systemic disorder, their study will be found valuable in practice, and a perfect knowledge of their meaning will greatly assist us in estimating the progress of any given case. In this relation, an examination of the most prominent will be found interesting. It is pro- posed to record, the result of many observations on liEemoptysis, and on alterations in the digestive system, as among the chief of this class of symptoms. Haemoptysis is common to aU stages of phthisis, but Hjemo- especially remarkable in two. In a great number of ^^^ cases it marks the very beginning of tubercular disease i^t and 3rd in the lung, and it is a very ordinary symptom of the third or stage of cavity. Again, in many instances it is present in a slight form throughout the whole course of the affection, or it marks the period when softening begins, indicating the passage of the disease from the first to the second stage. Its coin^se, and therefore its import, is different in in first each of these instances. In the first or earhest stage, to^fonges- when a deposit of tubercle is taking place, and before ^^°^- local injury to either blood-vessels or the bronchial membrane, it seems to be a congestion resembling local pulmonary apoplexy, and generally consists in a sudden rather profuse effusion, to the amount of some ounces of pure florid blood, and is accompanied by flushing, dyspnoea, pain in the chest, and hard rapid pulse. A carefid observer will be able to detect dul- ness of the percussion note of the clavicular region of one side, while much harshness of the respiration murmur, and a fine crepitus caused by blood in the smaller air-tubes will be manifest.* The hgemoptysis caused by excavation of the lung is * Much physical examination of the chest at this period is inadmis- sible. It will be well to abstain from percussion. 304 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP, also not unfrequently profuse, and of all the forms is v, "^ , ' .,. alone ever fatal ' per se,' an event which is due partly In 3rd to the cffusion proceeding directly from a tolerably ^ ^^^* large vessel, and also from the already exhausted con- dition of the patient, whose general strength is much less tolerant of the loss of blood, owing to the impo- verishment of the system from the blood disease, and to the emaciation of all the tissues, including the mus- cular structure of the heart itself It is manifest that these two cases of loss of blood differ materially. The first is, or resembles, a congestion, occurring before the constitution has suffered from the wasting effects of disease, and is felt by the system as a relief, evi- denced by the subsidence of dyspnoea, and of pain, which commonly follows its appearance ; the latter is a hsemorrhage mainly due to mechanical local causes, and is only a further drain on a system already weak- ened by profuse expectoration, sweating, and altera- tions in the nutritive qualities of the blood itself. The import of the first is the invasion of a formidable local disease, accompanied by congestion ; of the latter, the already advanced stage of an affection which has ulcerated large vessels, and, it may be, impaired the coagulability of the vital fluid, and certainly the con- Treatment tractility of the arterial and venous structures. The indicated, treatment indicated by these considerations is manifest. The occurrence of heemoptysis in the early stage must be met by local depletion, of which the best form is leeching, after which a cupping-glass may be apphed ; and further, by coohng, sahne medicines, the most perfect quiet, abstiuence from all mental or physical excitants, and by the use of iced drinks. The haemo- ptysis of the later period demands styptics of the stimulant kind, as turpentine, as the system will not tolerate the loss of an additional ounce of blood ; on the contrary, support must be given ; and while rest is enjoined, a diet of an invigorating kind may be ii^MorxYSis. 305 given with advantage. Many lives have been short- chap. ened by the opposite or depleting method carried out ^^^.^^ with vigour, when the patient was already in the ad- vanced stage of an exhausting malady. The condition to be combated is a hasmorrhage from open vessels permeating a diseased and ill-vitalised portion of a highly vascular organ, the system already reduced, the blood itself vitiated and altered, and the vital con- tractility of the vessels lowered. If this state be contrasted with that of a congestive hasmorrhage from an organ irritated by the early inva- sion of disease, with a system, vascular and nervous, working at nearly full powers, the mode of its occur- rence will be more readily appreciated, while its treat- ment will be conducted on the rational principle of meeting the actual requirements of each case. The third case of hgemorrhage from the lungs in Frequent tubercle is that of frequently repeated shght losses. It £or- is due to causes partly mechanical, partly vital. The Phages, vessels are themselves weak and impaired in structure, and the smaller branches frequently give way ; the cir- culating fluid has been impoverished and altered, and the force of the general circulation weakened. The import of this form of hemoptysis is not important ; it is never dangerous, often indicative of some slight and temporary congestion of the diseased portion- of the lung, or of simple slow extension of the softening process. The prognostic import of the two former cases demands attention, and our tables furnish evidence that indications of value may be derived from the period of the disease in which the hasmoptysis occurs, its amount, and the frequency of its recurrence. " Those who rely on this symptom as pathognomonic Hsemo- of phthisis must often, however, be greatly deceived in ^Sut their diagnosis, and their prognosis may be found not tubercle. unfrequently in error. Out of 446 cases occurring in X 306 ELEMENTS OP PEOGXOSIS IN CONSUMPTION. CHAP. XIX.' Phthisis. Rare in acute phthisis. Profuse haemo- ptysis, its prognostic Talue. Not fatal at com- mencement of phthisis. my hospital practice of non-tuberculous disorders re- sembling consumption, a very large proportion liad hsemoptysis, and in addition to these there were care- fully noted 191 instances of spitting of blood without consumption, depending on cardiac disease, bronchitis, &c. In many of these, the blood coughed up had all the characters of phthisical haemorrhage, being florid, frothy, &c. Even deducting the cases of vicarious origin, and all those in wliich the symptom was feigned, there remains a large number to contradict many of our diagnostic maxims. The rule must, therefore, be laid down that, without the evidence of physical signs and the concurrence of other symptoms, the diagnosis of tubercle in the lung cannot be made from haemopty- sis alone, no matter what its characters may be. I have witnessed the most profuse pulmonary hgemorrhages repeated again and again without any physical signs in the lung of either tubercle or congestion, without any of the history of consumption, and without cardiac disease. In the section on the first stage of phthisis, the value of heemoptysis as a prognostic has been considered. The acute j)hthisis is not commonly accompanied by this symptom and, if present, it is rarely in the profuse form. Ordinary continuous phthisis is not infrequently characterised by a moderate heemoptysis at the outset, and by streaks of blood in the expectoration in the later periods of the disease. Profuse hemoptysis at the commencement of phthi- sis argues a rapid passage of the disease from the first into the second stage, but the ultimate duration of such cases as a whole does not appear to be as short as that of several other varieties of tubercle. Profuse hsemoptysis is not fatal at ' the commence- ment of phthisis, nor does a first attack commonly prove so in any stage of the disease. It is most com- iiiEMOPTysis. 307 moil ill the third stage, then in the second, and most chap. rare in the first stage of phthisis ; but a large proper- -^ijli^ tioii with tliis symptom were found within the first three Relative months of tlie invasion of the disease, which is to be irsteg^f accounted for by the fact that such cases rapidly pass from tlie first into the stage of softening or cavity. It Residual is probable that in certain instances the residual fibrin- ous deposit in the lung is capable of becoming the nidus of tubercle, and that, when infiltrated into the pulmon- ary tissue, it readily enters into the destructive changes which accompany softening. For this reason, among indicates others, an early profuse haemoptysis indicates rapidity passage in the progress of disease during its primary stages. ^^^° ^nd The congestion, also, of which it is the indication, evidences a condition of the pulmonary tissue the most unfavourable for toleration of the deposited tubercle, and that most fitted to induce in it destructive changes. Profuse hasmoptysis is very apt to be repeated, and Apt to be due caution is to be observed when it has once oc- ^^p^^^*^*^- curred. The hemorrhagic diathesis * is well marked in many individuals and even in whole families. The present danger of a large hemoptysis is to be Danger of, estimated by the amount of lung ah-eady diseased ; by casTs^^' the single or double nature of the affection, and by the frequency of its repetition. Such an event is very rarely fatal when the blood proceeds from a single f cavity ; the remaining parts of the lung being clear. Double disease is the condition fraught v/ith most danger, as the remaining respiratory space is blocked up, and the patient may die instantly from sufibcation. * I have seen fatal liaemorrliage occur from tlie use of the scarificator aroimd the knee-joiut. A patient under my charge nearly bled to death from a slight cut in the head, but he survived to die the foUowiug year from profuse htemoptysis. t In 21 cases of fatal haemoptysis occurring in the Hospital, and which were examined after death, all had disease in both lungs. See 2nd Medical Report, p. 20. X 2 308 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. XIX. A. v., a gentleman's coachman, Lad Leen under my care for years, and having all the comforts of life, and very few Fatal case, demands on his strength by his kind employers, he managed to tolerate a large amount of local disease, and looked in very fair health. There was a large cavity in the left apex, with diffused crepitation over the remaining part of that lung. Softening, of a slow character, had commenced in the opposite lung at the apex. He was attacked by profuse hsemoptysis while driving the carriage, and dropped dead off the box. He had had haemoptysis some years before. Mode of death. Ptilse. Weak heart. Moderate haemo- ptysis. Immediate effects salutary. The patient may also die from, tlie repetition of the liasmoptysis in such quantities and at sucli short in- tervals, as to exhaust all vital power. A good many- such cases are lost in our wards in spite of the most active treatment. The pulse is the best indication, as until it loses the hgemorrhagic character there is no safety for the patient. When it resumes its natural action, a prognosis of recovery from that attack may be safely offered, provided the patient is not already much exhausted by the hsemorrhage, by cliarrhcEa, or by the various events of orchnary phthisis. A moderate single haemorrhage will often end the case in patients previously much reduced. The heart, thinned and enfeebled, is unable to continue its contractions, and, supplied by a less stimulating blood deficient in red corpuscules, yields at once when, in addition to these deficiencies, a sudden diminution in quantity occurs. A moderate hasmoptysis, in the course of ordinary phthisis, is to be considered as an event with present and remote results. The immediate effect is salutary. The cough is relieved, the sense of dyspnoea lessened, expectoration becomes easier, and the patient, who had before been clistressed by night cough, can often lie down and sleep. Hectic becomes less and the pulse more moderate, while the daily exacerbation is gene- rally lessened or may even cease altogether. This result may be observed from the time when the sputa HAEMOPTYSIS. 309 cease to be coloured, which may be about the third chap. • XIX or fourth day from the expectoration of fluid blood. .1— - Who can avoid seeing in this evidence of the fact that congestion of the lung, and not the mere presence of tubercle, gives rise to the more grave symptoms of phthisis ? The more remote effects of a moderate liEemoptysis Eemote are undoubtedly lowering, if the disease have been i Jeering. already much advanced, and the system reduced by hectic. If to this state a diarrhoea be added, we have a condition very perilous indeed. Supposing the di- gestion to be sound, and sanguification active, the loss may be repaired, and recovery up to the former average of strength and flesh be attained. But it is otherwise when the vital powers have been already reduced, and the heart's action weakened, for under such circumstances the circulation never recovers its Heart does tone or volume, and the patient is in a permanently cover'its lowered condition. The value of the integrity of the ^o^^- digestive system is here strikingly exhibited. If blood- making be not equal to restore blood loss, the balance is against the patient. A critical examination of the heart and tongue will therefore much assist our prognosis. If the first sound of the heart be very feeble or nearly lost, and the impulse be weak ; and if the tongue be much and permanently furred, or stripped red, and morbidly clean, or aphthous, the prognosis must be bad, after even a moderate (^vi. to ^vii.) hsemoptysis. The phenomena of reaction after great losses of Eeaction blood are very rarely observed in phthisis after pro- mSrhage fuse hasmoptysis. Thus we seldom witness the bound- ^^'"'e in ing pulse, increased colour, giddiness, noise in the ^ head, cardiac distress, amaurosis or delirium, jactitation and restlessness, which are well known in cases of vascular reaction after great ha3morrhages. The system appears to have less resilience and power of resistance, 310 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, and when once reduced it remains at tlie lower level. v_£H^ The weakness and thinning of the walls of the heart must also have an influence, and prevent reaction to any considerable extent. Finally, it is not to be forgotten that patients weakened by a great loss of blood occurring in the course of an Syncope, exhaustiug disease, are liable to sudden syncope. Death often takes place long after hemoptysis has ceased, and such an event may be precipitated by any exertion or even by a sudden change of position. The most perfect rest should therefore be enjoined in such cases. Analysis of rj^i^Q following tables sliow somc of the most inte- 351 cases . -i-ok-i !• /-y of profuse rcstmg particulars m ool cases oi pro/use licBmoptysis. p^^g' Of these 50 had this symptom in a very marked degree, and they are separately grouped. Influence From tlicsc it vdU appear that males are much more of sex ; the •iii-i •• i n i4& profuse subject to spit blooQ m large quantities than lemales.* form m q^ ^^ coiitrary, in the more moderate degree of hsemo- ptysis females predominate. In aU Taking both sexes and all forms of hsemoptysis to- lorms more P pit females, gethci", it lias becii found that many more females than males had this symptom. Very pro- The followiug table presents an analysis of 50 cases ptysis: of vevy pvofusG ha3mo]3tysis in which the quantity a^T-^ 'dura- i'"^^g^^ from oiic pint to several quarts : — tion of case. 4 cases were in tlie 1st stage of pTitliisis. 26 , jj 2nd V 20 , jy 3rd V 6 , were under 20 years of age 28 , were between 20 and 30 jj 12 , j; 30 and 40 V 4 , were over 40 J> 18 hf id been ill for 1 year. 16 j> >? 2 years 10 }j V 3 „ . 2 » V 4 „ 4 5) „ ovei 4 „ See also p. 16 of 2nd Medical Heport of the Hospital for Consumption. HAEMOPTYSIS. 311 sis of 351 Cases of Prof use HoB'mo'ptysis occurring in CHAP. the author'i ? practic e. No. of cases. . 267 XIX. Males .... Profuse hfemo- Females . 84 ptysis : 351 cases Age under 20 . 43 „ between 20 and 30 . 168 analysed. „ „ 30 and 40 . 100 „ over 40 . 40 In tHe 1st stage of plitMsis . 45 „ 2nd „ 143 „ 8rd „ 163 Had symptoms of phtHisis for 1 year 95 r » 2 years 102 ,V )) 3 „ 77 }> }> 4 „ . 33 „ „ ovei '^. " ; 32 „ „ for < m indefini te period . 12 The youngest patient exhibiting this symptom was eleven years of age, a girl in the second stage of phthisis who had been ill one year, and had the haemorrhage to the amount of two pints within three months of the commencement of her iUness. The largest quantity recorded was eight quarts by a man aged twenty in the second stage of phthisis, oc- curring within the first three months of illness, and whose case was under observation for three years, during which time the hasmorrhage was frequently renewed. The duration of these cases of profuse hemoptysis while under observation, taken as a whole, was found to average 30 '35 months, which is a higher range than might have been expected from theory, or rather from the popular estimate of the destructive character of this symptom. It will be seen that many of these patients had been affected with symptoms of phthisis for two years, three years, and four years, and some few for a much longer period. 312 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAPTEE XX. GASTEIC SYMPTOMS DIAERHCEA, FISTULA. CHAP. We are not inclined to adopt tlie term gastric phthisis _ . as denoting a distinct variety of the disease. In very few instances does any consumptive patient escape without irritation, and even ulceration, of the mucous tract. There are cases, chiefly of the continuous, rapid variety, in which the gastric symptoms form the leading features, and impress, from the very first, a specific character on the disease. But experience has not shown us that in any instance in adults has the evidence of pulmonary tubercle been wanting, although the prominence and urgency of the gastric disorder may have thrown the lung affection into the shade. Affections of the gastro-intestinal mucous membrane in phthisis exercise a powerful influence on the pro- gress of the disease. As an actual and proximate cause of death, they are probably more fatal than the lung disease itself. The early stages of acute phthisis are in many instances more marked by gastric than by pulmonary symptoms, and certainly the former cause more distress, and depress the vital powers more ra- pidly and to a greater extent, than the latter. The thirst, anorexia, red tongue, nausea or vomiting, and irritative diarrhoea which accompany the continuously progressive phthisis, are as characteristic of the disease as are hectic, cough, and hsemoptysis. In the latter stages of all forms of phthisis, the GASTEIC SYMPTOMS — DIAREIICEA, FISTULA. 313 breaking up period of old deposits, and in the intervals chap. or pauses of the lung affection, this irritation of the mucous surfaces is often found as a most destructive agent, which in its milder forms keeps the patient at an habitually low average of strength, and in its more severe precipitates a fatal issue, which but for this comphcation might have been long delayed. Like the other features of phthisis in the more chronic form, it is intermittent, and seldom assumes continuity till ulceration of some portion of the mem- brane occurs. In the early attacks it is purely an irritative symp- tom, but in the later there are invariably lesions of the mucous structure. All authorities are agreed as to its prevalence in phthisis. Laennec found the stomach sound only in one-fifth of all his dissections of phthisical cases. Louis gives the same figure, and records ' softening ' of the gastric membrane in ' one-tenth,' and ulceration of the large and small intestines in ' five-sixths ' of the cases examined after death. Our own experience would give even a higher proportion than this. As an element in prognosis, therefore, all forms of gastro-intestinal irritation are of bad import, their present effect on the patient being exhausting, and their occurrence indicating at least a commencement of one of the most unmanageable complications of phthisis. Whether tubercular disease falls with greater severity on those who have previously suffered from irritation of the gastro-intestinal membrane, is a question on which we have no direct observations to offer ; but we are inclined to think that such a condition pre- viously existing leads the way to a more rapid form of phthisis, should the latter disease be acquired. To the views of Bennett and others that phthisis originates in acidity of the prima3 vi^, we cannot wholly give our adhesion, and some observations have XX. 314 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. Gastric symptoms earliest. CHAP, been given wliich do not entirely bear out the con- ^ . ' ^ elusions alluded to, but of the frequent concurrence of such disorder with some of the acute forms of tuber- cular disease, there can be no question. It is well to consider separately the purely gastric and the intestinal symptoms. The former, in rapid phthisis, are the earhest to appear. In the most acute form of tuberculosis they may even be the first symptoms of departure from health. Out of 113 cases of rapid phthisis, it was found that 97 presented gastric symptoms, of more or less severity, within the first three months. In the same class of cases diarrhoea appeared in the following periods : viz., within the first three months, 27 cases ; within six months, 12 cases ; and within nine months, 2 cases. The gastric symptoms were nausea, vomiting, thirst, red, and often dry tongue, and in certain rarer in- stances severe gastralgia. The appearance of the tongue is often very characteristic. In the earher stages furred, it becomes red, preternaturaUy clean, stripped, smooth, and shining. Aphtha succeed to this state, as the vital powers decay. These successive changes in the tongue are more commonly seen in cases where the purely gastric symptoms predominate over the intestinal. The vomiting may occur in two ways. As the result of such irritation of the lining membrane as causes re- jection of food soon after it has been taken ; or as the result, more mechanical than irritative, of the act of coughing. By a reflex action when food is taken, a fit of cough is induced, and the straining of the dia- phragm and of the abdominal muscles, empties the stomach of its contents. The recognition of these two Treatment. Varieties of vomiting is highly useful in practice. The former is best allayed by sedatives, as morphia ; the latter by brandy. Irritation of the pneumogastric Vomiting, two varieties. GASTRIC SYMPTOMS — DIARRHCEA, FISTULA. 315 nerve is doubtless mucli concerned in the production ciiap. of this symptom, ■ — -^<—^ Vomiting and other gastric symptoms, however common in the more acute and rapid forms of phthisis, are not limited to these varieties, but are present in a large majority of chronic cases towards their termina- tion, and accompany the final stage of consumption. So invariably present are these symptoms, and so cha- racteristic of the final break-up, that if a new divi- sion of phthisis could assist either in diagnosis or in treatment, the last stage miglit well be called the gastric. Viewed as prognostics, it may be said that when Progno- these symptoms usher in phthisis, they denote a rapid ^*^°^' form of the affection ; and when they appear in the progress of chronic cases, they are indicative of great danger ; when present in intensity and with the aphthous state, death is generally near. A great and often sud- den change comes over the patient. A sense of extreme weakness and exhaustion, which he endeavours to de- scribe in the most forcible language, but which is better gathered from his prostrate appearance than from his words, prevents sleep, and engenders an ex- cessive restlessness which no change of posture can reheve ; a rapid small pulse betokens sinking of the vital powers ; and often there are no intercurrent affections, as pneumonia or diarrhoea ; or great losses, as copious hasmoptysis or expectoration, to account for the rapid alteration in the patient, Avho, only the day before, may have been walking about the ward. The tongue and pulse in these cases are characteristic : red and stripped and aphthous, or rough with elevated papilla3, and spotted all over (like snow-flakes on red flannel), the tongue seems to have lost its vitahty. The prognosis of such a state need not be dwelt on. On the whole, it would appear that continued irrita- tion of the intestinal mucous surface can be longer 316 ELEMENTS OF PROGNOSIS IN CONSUMPTION. 'chap, tolerated than a similar state of the gastric membrane. ■ -^^- . DiarrhcEa does not often accompany the earliest stages. Diarrhoea. q£ ^^^ ^f ^]^g Varieties of phthisis, and in its first attacks is not the result of ulceration ; but its frequent renewals, although each access is productive of much weakness to the patient, are wonderfully tolerated. Even months may elapse before extreme prostration occurs, and the measure of the danger is in many instances rather to be estimated by the concurrence of other symptoms, as severe hectic, than by the frequency of the attacks of bowel disorder. The 'persistence of diarrhoea is, however, always a grave symptom. inSrd In 39 cases observed with regard to stage, it was stage. found to cocxist with cavity m the lung in 22 instances; w;ith softening in 12; and with the stage of deposit in only 5 cases. In the persistent form it is, therefore, chiefly associated with the third stage of phthisis. In some exceptional cases we have seen extensive ulcera- tion of the ileum and caecum in which diarrhoea had not occurred during life. When this symptom resists all remedies, but is steadily persistent, its prognostic import is of the worst character. In spite of the non-extension of lung disease, and of the absence of hectic, such patients pro- gressively lose flesh and strength, and die of exhaustion. In these instances, the tongue may not for a long time denote any mischief, but anorexia is an early feature. The diarrhoea may nearly cease a day or two before the fatal event. Fistula in Ano : Phthisis. Fistula. The coincidence of abscess by the side of the rectum with phthisis, has been regarded by most authorities on this subject as conducive to prolongation of the tuber- cular disease. The observations which we have been able to make with accuracy confirm the opinion. The GASTRIC SYMPTOMS — DIARRHOEA, FISTULA. 317 tendency of such collections of matter to burrow and chap. form sinuous communication with the bowel and with -^^' _ . each other is well known. Whether in phthisis such tendency is greater than where no such disease of the lung exists, belongs rather to the province of surgery than of medicine to decide, but we are inclined to believe that such is the case. It would still further appear that in tubercular cases these sinuses are diffi- cult to heal, and that although operation be had recourse to, a chronic discharge from an imperfectly healed fistula most commonly remains. It is matter of observation that irritation of a portion of the gastro-intestinal canal is often manifested at the extremities of the mucous tract. Of this, aphthae co- incident in the mouth and fauces and also at the anus, and irritation of the nostrils in children the subject of intestinal worms, are familiar examples. The exciting cause of fistulse in phthisis may thus be accounted for. These cases of phthisis with fistula are certainly not ordinarily accompanied by diarrhoea, and the dis- charge from the neighbourhood, of the rectum is, there- fore, not due to mere extension of irritation from the ileum and csecum. More probably it is due to the cause alluded to, and is properly a reflection at the extremity of the mucous tract of an irritation existing near its other extremity. The result of such cases as we have witnessed is Operation that the operation is not ordinarily successful in heal- cessfiJ ' ing the fistula ; that if successful for a time the dis- charge almost invariably returns ; that the phthisical symptoms always increase after the healing of the sinus ; and that the discharge itself is a condition favourable to the quiescence of the irritation in the lung. In very frequent instances, the aggravation of all the symptoms of phthisis has occurred almost im- mediately after the suppression of the discharge. The converse is also true. The long continuance 318 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, of fistula in cases of consumption has been found very > ,-1— . constantly where the lung affection is much prolonged, ' and presents the features so often alluded to as in- dicating very chronic consumption. More com- The coincidcncc of the two affections (tubercle in Temuies. tlic lung and fistula in ano) is much more common in males than females. It is rarely found in early hfe, and is uncommon under twenty, the age at which it most prevails being from thirty-five to forty-five, and in senile phthisis the combination is by no means rare. In the larger proportion of cases it is found in the third stage of phthisis, next to this in the second, and in but few instances in the first stage. The phthisis is the earhest affection, but it occasionally happens that the fistula precedes all symptoms of consumption. When the chest disease precedes the fistula, the latter is rarely found within six months of the access of the lung disease, and most commonly is observed only when the patient is in the second or third year of pulmonary consumption. Bad results Wlicn the Operation is successful the patient is com- tion?*^^^" monly, as regards the phthisis, in a quiescent state ; but generally within one or two months the lung disease assumes activity — the symptoms being dyspnoea, sense of tightness across the chest, haamoptysis, or in cases already chronic a great increase of cough and expec- toration. With these an access of hectic, more or less severe, is very common.' Should the discharge return, these symptoms commonly subside. Symptoms The symptouis of abscess by the side of the rectum subacute, in phthisical cases are ordinarily of a subacute cha- racter. In many instances the patient cannot state with accuracy when the local affection began, and is only led to investigate the matter on discovering a discharge from the part. The average duration of these cases of phthisis is GASTRIC SYMPTOMS DIAERHCEA, FISTULA. 319 CHAP. XX. undoubtedly long. And as an element in prognosis it is a valuable symptom. This will be apparent from the consideration that fistula is never found associated J^^'^'^*'°'^ with acute phthisis : that it is extremely rare at the age when that disease exhibits its most rapid forms, and that it is most common m the stage of cavity and associated with a non-febrile state of system. It has been remarked above that fistula is not commonly co- existent with diarrhoea, and it is possible that the latter symptom may be intercepted as it were by the chronic discharge from the terminal portion of the mucous canal. The following table gives some details of about thirty- one cases of phthisis with fistula. And although the number be small, the leading features of the associated affections are sufficiently marked to make it worthy of insertion here. Analysis of Cases of Phthisis with Fistula in Ano. 20 25 30 35 40 45 60 55 60 27 The average duration of each case in males was, 29*05 months (omitting the indefinite periods) : — Stage 1 .... 4 cases. „ 2 .... 7 „ „ 3 .... 20 „ Of these ten were operated on with the following- result : — Fistula healed and chest symptoms became worse in 3 cases. Phthisis commenced after the operation in . 2 „ The fistula returned in .... 3 „ Result douhtful 2 .. E AND SEX Males. Females. . 3 . . 4 . 1 . 3 . . 5 . 1 . 6 . 2 2 '. 2 '. . 1 . . 1 . 27 4 DUKATION WHILE TJNDEB, DBSEE YATION. Indefinite, very chronic Had been ill 6 months Nos. 8 1 „ 1 year . „ 1^ year . ,, 2 years . ;; 3',, . 3 3 4 3 4 1 320 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP. In twenty-one cases no operation was performed : — " ■ ^ Fistula persistent, ctest symptoms remained ciironic in 14 cases. ,, ,, „ became worse „ 4 „ „ had existed long before pbtbisis, the latter being in a quiescent form „ 3 ,, PNEUMOTHORAX. 321 CHAPTER XXI. PNEUMOTHORAX. There are three modes of death after this lesion. chap. 1. The shock to the system causing rapid collapse. ^^^' 2. The supervention of effusion into the pleura, with Three .T • • 'x J.' r J t modes of the accompanying irritative lever and subse- death. quent exhaustion. 3. The new lesion not having proved immediately fatal, the case becomes chronic, and the patient sinks in the ordinary course of the tubercular disease, the termination not being directly due to the pneumothorax. 1. The shock proves fatal. Shock This result I have witnessed within twenty-four hours, and within one week after the accident. Who- ever has seen the effects shortly after its occurrence, cannot fail to be struck with the general depression of the nervous and circulating systems. The patient is conscious of an alarming alteration. He is pale, gasps for breath, and is mtolerably restless. The respkatory efforts are immense, but the rehef from the deepest inhalation is trifling. There is a consciousness of diminished space for breath, and many sufferers have exclaimed that tlie air does not enter. An acute local pain aggravates the distress. Position frequently changed fails to reheve, and if the opposite lung be unsound (as often happens), there is a constant struggle to retain a posture on either side, very painful to wit- T fatal. 322 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. ness. Orthopnoea supervenes. The pulse is at once — — r-^ greatly reduced in volume, and increased in frequency. The systemic circulation cannot fail to be embarrassed, from two causes. 1. The volume of blood in the pulmonary circula- tion is diminished by one half (if the collapse of the lung be complete), and the balance between the right and left cavities of the heart is interfered with. As a question of quantity alone, this altered distribution of the circulation must be a trial to the system, and venous engorgement be the immediate result. 2. The diminished aerification of the blood, from deprivation of nearly half of the respiratory space for- merly available. The great nervous centres are sup- phed with impure blood, and all ultimate capillary changes, whether for secretion or for decarbonisation, are imperfectly performed. The respiratory process, which is spread over all the tissues, resulting in mole- cular, heat-producing changes, the oxydising of effete material, and the removal of carbonaceous impurity, is disordered, and the patient is reduced somewhat to the condition of an animal with communication between the right and left cavities of the heart. The intense nervous exhaustion, dyspnoea, pallor, loss of animal heat, thready and rapid pulse, indicating feeble ven- tricular contraction, form a group of symptoms which often results in speedy death, and the prognosis re- quired immediately after the occurrence of perforation of the lung, being formed with regard to these altered physiological relations, cannot be other than a grave anticipation of the worst result. Should the shock prove fatal in from twelve to twenty-four hours, there is no pause in the increase and progress of these symptoms ; but it not uncommonly happens that a week or more may elapse before the system seems to have realised the injury to its chief vital functions. The fatal result is not, however, less attributable to PNEUMOTHORAX. 323 the primary effects of the accident, than if death had char occurred within a few hours ; and I have had occasion .JE^L__ to remark that so long as the patient is kept perfectly quiet, and no demands are made on the nervous or circulating powers, life may be continued, although at a low par, and valuable time be gained for the economy to readjust its requirements to the alterations which have taken place in the respiratory system. The fol- lowing case well exemphfies this. T. C. set. 18, had been for some months under my care, Case. and had a cavity in the apex of the left lung, evidenced by l^™ite(i the usual signs. Her general health was very slightly im- pneumo- paired, the fever which had attended the softening and exca- thorax, vation stages having subsided some months previously, and lodays. the opposite lung affording no abnormal sounds. She was in pretty good flesh, had a moderate, daily expectoration, and her appetite was excellent. She was able to attend to her business as barmaid in a hotel. One morning, while dressing, and in the act of combing her back hair, she was seized with sudden pain in the left shoulder, with faintness and dyspnoea. On arriving, I detected the occurrence of pneu- mothorax. The left side was loudly resonant on percussion, vesicular respiration absent, metallic sounds accompanied the inspiration, and amphoric blowing was heard just below the spine of the scapula. Perfect rest and stimulants re- stored her, and she was comparatively comfortable on the next day, and improved daily for a week. When calling to pay my usual visit on the tenth evening, on passing by the bar of the hotel, I was surprised to see her sitting in a small room inside it, and enclosed by glass partitions in the usual fashion. On entering, I found her eating bread and cheese, and drinking ale, and several persons were smoking, so that the atmosphere was, even to me, intolerable. I at once suggested her removal to her bedroom, and she was carried up in a chair as she had come down. She was in good spirits, but said that she had felt a strong desire to 'have her supper again in the old place.' She was put to bed, and did not seem to be much exhausted, but she was found dead in bed at 2 a.m. that night. No post-mortem was allowed, but there can be no doubt that she died of collapse, just as might T 2 324 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP. XXI. Prognosis to include a tempo- rary rally. Effusion into pleura. have occurred within the first day, and that the exertions made had demanded more from the system than its im- paired nervous, respiratory, and circulating powers could meet. Ill all cases of pneumotliorax, therefore, the pro- gnosis is to include the likelihood of death occurring within the first week, even although, the other lung be sound, and the general health previously but slightly impaired in proportion to the local mischief which has given rise to the lesion in question. It is not out of place here to recur to the observation previously made — that acute attacks occurring in the course of chronic disease are not tolerated in proportion to the strength and robust condition of the patient, but are frequently seen to be best borne by a system which has been already reduced (of course within certain limits) ; the respiratory requirements being small, and the necessity for aerification of a large quantity of blood being les- sened by previous emaciation. This is especially true of pneumothorax, the most prolonged cases of which lesion I have had occasion to witness in individuals who had been emaciated in the ordinary course of phthisis. The persistent vitality of many of our chronic cases of consumption manifested throughout the various secondary complications is here exhibited occasionally in an extraordinary degree, and that which would kill a more robust is tolerated for months by a weakened, and often almost exhausted patient. The opinion offered to friends immediately after the occurrence of pneumothorax arising from a tubercular perforation of the lung is therefore to in- clude the chance of the case becoming chronic, and the possibility of a raUy, even from very unfavourable symptoms. 2. The supervention of effusion into the pleura. Should the immediate shock not prove fatal, there is PNEUMOTHOEAX. 325 most commonly a pause in the progression of all the chap. symptoms. And unless the contents of a cavity have . ^^^'_ - been emptied by a large opening into the pleura, the pleuritis is slow to develop itself. The medical attend- ant should be prepared for this state of things, and neither build too much on this temporary lull, nor reckon on the certainty of a great increase in the local mischief within a short period. He is to regard his patient as in the utmost hazard of an acute pleurisy — ■ but to suspend his judgment, as to the result, till efiu- sion takes place. Is the secondary effusion an inevitable result ? We may safely say that it is not. The actual physical condition consists in a collapsed lung, more or less bound down by adhesions, and a pleural cavity partly filled with air. Should the purulent matter from the tubercular cavity not be present in the pleura, there is nothing to forbid a partial recovery from the accident which has taken place. That air can be absorbed from the pleura is proved beyond a doubt by the result of operations for empyema, which, performed in the usual manner, inva- riably permit its entrance through the trocar. A boy under my care in the Hospital for Consump- Case. tion, who had a copious effusion into the left pleura, ^p"?'^^™*' was operated on by Mr. Fergusson, and air was per- yation, air mitted to enter freely into the cavity of the pleura, recovery.' About three pints of serum were drawn off, and he recovered after some weeks, the lung returning nearly to the base of the chest, but being evidently bound down by adhesions which prevented its complete ex- pansion. I do not advocate this mode of operating, as air must be regarded as an extraneous body hinder- ing the desired descent of the lung quite as much as serum. The valvular syphon of Dr. Eussell seems pre- ferable to the ordinary trocar. The physical conditions required to produce an emp- tying of the contents of the cavity into the pleura are 326 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP, to be remembered. They are : a large opening, espe- ^ '^"^^' - daily in a part where the exudations previously thrown out to protect the lung from this very lesion, do not form the thick impervious covering which Ave find so difficult to break down in our autopsies of tubercular cases. The opening in pneumothorax is generally very small, it is also often fistulous or valvular, and with difficulty gives issue to the contents of the cavity. Pulmonary resilience is partially lost, owing to the col- lapse of the lung, and it is wonderful how little fluid will escape into the pleura unless the rent be large, dependent and direct. The period at which the efilision due to acute pleu- risy supervenmg may be expected, will vary with the case ; but there is commonly a lull in all the symptoms if the immediate shock be survived, and the case has already lasted a week. When it does occur, it is rarely of that passive kind which we occasionally wit- Symptoms ucss in idiopathic pleurisy. The symptoms of pain, very acute, jygpjioea, with shiveriug, hard and rapid pulse, and heat of the surface, are present, and the subsequent exhaustion is more rapid and urgent. Should the op- posite lung be affected with tubercle to any consider- able extent, the case is very hopeless, and the patient sinks with symptoms of respiratory difficulty of the most painful nature. Even in such an extremity as this, however, nature has occasionally proved capable of a rally, and life has been prolonged for months. In- stances are on record where external fistula has given exit to the matter, the patient slowly sinking after months of hectic, until an extreme degree of marasmus has been reached. We have not yet accurate records of many cases of pleuritic effusion which owe their origin to perforation of the lung involving pneumo- Perfora- tllOraX. comi^n^^ There can be little doubt that perforation is a more than sup- common result of phtliisis than has at aU been supposed ; PXEUMOTHOEAX. 327 and without 2:oin(y the entire lengths to which some chap. " observers have carried their views,* it must be remem- - bered that the cases which are recognised and diagnosed are few comparatively to those which pass before even competent observers. To explain this, it is to be re- membered that both the phenomena and physical signs of perforation often pass away before the case presents, especially at public institutions. The extravasated air may have been absorbed, or has been succeeded by the effusion of fluid ; the metallic, amphoric, and tympan- itic sounds which have primarily distinguished the lesion have therefore ceased with the physical conditions which gave rise to them, and even to a careful observer there will remain only the signs of effusion with a compressed lung. To detect the presence of a rent in the apex of a lung so forced upwards and backwards by fluid in the pleura is sometimes possible ; but far more commonly the physical signs only indicate, by a pecuhar crepita- tion (which is to be carefully distinguished from the ordinary humid crepitus of softening tubercle), a com- pressed state of the pulmonary tissue. The pre-existing cavity will in most cases be found collapsed, the per- foration permitting its walls to approach so that all signs of excavation cease, and, indeed, are very com- monly absent from the moment the perforation has taken place. In cases of pleurisy with effusion presenting for the first time, in the tubercular habit, where the constitu- tional symptoms and history of the case point to the existence of a cavity, but where the signs only mdicate * Dr. Scott Alison divides phthisis into four stages, perforation forming the fourth. 'The progression of excavation/ he says, 'naturally tends to the penetration or perforation of the pleura ; ' and he adds : ' 1 am satis- fied that perforation actually occurs in a very considerable proportion of advanced or old standing cases of phthisis.' — The Physical Examination of the Chest in Ptdmmiary Consumption, ^'c. By S. Scott Alison, M.D. Lond. 1862. p. 270. 328 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. efTusion, it is quite possible that the history may have ' — r-^ been that of tubercle, cavity, perforation, pneumothorax, and effusion in consecutive order, of the last of which, lesions we can alone find existing physical evidence — the actual signs of air in the pleura communicating with the bronchial tubes having been replaced by those of effusion. The real nature of many of such cases no doubt often escapes detection ; and it thus happens that pneumothorax is actually of more frequent occur- rence than has been supposed. Other When the other causes of pleurisy in the tubercular pleurisy, habit are considered, it will be found that this one (previous pneumothorax) has a right to be classed with them ; but more frequent annotations of such cases have yet to furnish us with numerical data of accuracy as regards its relative frequency. These other causes would appear to be — 1. Extension of irritation from the lung outwards. 2. A deposit of tubercle in the pleura itself The ordinary pleuritic attacks which occur in the progress of all cases of phthisis are of a subinflamma- tory nature, and in the vast majority of instances termi- nate in a slight effusion of lymph, which unites the pulmonary to the costal pleura. They are plainly the natural means of limiting, circumscribing, and walling up the disease in the lung. They are the safeguard against perforation ; and if, as stated by Dr. Alison, 'the progress of a cavity be to the surface,' these barriers interpose in a most effectual manner an obstacle to such advances of local mischief If we can conceive for a moment a lung in an advanced stage of tubercle, riddled by excavations of various size, and lined only by a thin pellucid membrane like the pleura when healthy, we can readily imagine how every minute spot of tubercle on the surface must, in softening, imperil the hfe of the patient, from the danger of rupturing so PNEUMOTHORAX. 329 frail a barrier. Louis and others have recorded cases chap. of fatal pneumothorax from the softening of a mass of ^^J^' tubercle the size of a pea before thickening of the pleural covering had taken place. It is rare, however, to find fluid effusion taking place from these attacks, v^hich have for their object only a thickening of tissues. Such cases do occur, but they stand in a very small proportion to the numbers of ' dry ' attacks, which every tubercular patient undergoes. 2. A "deposit of tubercle in the pleura itself is fre- quently seen in our autopsies. It is not invariably accompanied by effusion, but is its occasional cause. We certainly find fluid in the pleural sac in a number of cases where no such deposit in the membrane exists. From observation and a careful consideration of the reasoning above given, I am inclined to class these causes of effiision in the following order of frequency : 1. Extension from within outwards — from the lung to the pleura. 2. Pneumothorax. 3. Tubercle in the pleura itself 3. The patient, having escaped the dangers of sudden Third con- collapse and of secondary effusion, may remain in a of'^pneu- somewhat stationary condition for an unlimited period, motiiorax, eventually sinking from the primary tubercular disease. The following facts must be remembered in forming state of a prognosis : — The cavity in the lung is rather improved In^thr^*^^ in condition than deteriorated by the perforation. It is i^ng. the pleural not the pulmonary mischief, and the shock to the system which prove fatal. A vital part which has remained in an injured state connected with ever-con- tinuous respiratory movements, is nearly removed from the influence of the incessant influx and exit of air. From the time that the pleura is filled with air the cavity be- comes flaccid, and its secretion seems in most cases to be considerably lessened; not, as has been supposed, by being 330 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP. XXI. Case. Cavity, pneumo- thorax, rally for 18 months. thrown into the pleura instead of into a bronchial tube, but by being absolutely diminished in quantity, the lung becoming collapsed, compressed, and comparatively at rest. There is little doubt that under certain circum- stances the walls of a cavity, under such conditions, may adhere and cicatrise ; although any calculations founded on the possibility of such an occurrence must be erro- neous from the extreme rarity of the case.* As regards the cavity in the lung in cases of pneu- mothorax, therefore, the case is no worse than it was, and is, perhaps, in better circumstances ; and, should pleuritis not occur, or in the interval before the period of its occurrence, the tubercular mischief is, to say the least, at a standstill. This consideration may perhaps account for the pause w.hich often occurs in cases of per- foration after the first shock has been recovered from. The rarity of the cases in which the primary results of perforation are tolerated by the patient, renders it necessary to scrutinise each with peculiar care. The following has occurred under my own eye, and every physical phenomenon has been repeatedly verified by most careful examinations. Miss A. set. 28 years, is of a phthisical family, her mother having died (under my care) of consumption, and one brother being at present in the second stage of tubercle. It is to be remarked that her mother's case was extremely chronic, having lasted for many years, and her brother exhibits the * Here, indeed, we have the very condition quoad the cavity in the lung, for ciu'e, and it has heen doubted by some whether it would not be well to produce an analogous condition artificially, by puncturing the chest walls and the cavity in the lung. If we could be sure that this operation would not afford an entrance for air into the pleura, there would remain arguments in favour of thus removing an irritated ulcerated por- tion of the lung from the air current, and causing its partial collapse ; and if the tubercular excavation could be proved to be single, and the local mischief not to extend to the lower parts of the lung, we should then have a right to begin to calculate on possibilities of doing good by such an opening ; but after satisfying ourselves of the existence of these favourable conditions we should find but a small residue of phthisical cases affording even a remote chance of recovery from such a procedure. PNEUMOTHORAX. 331 same tendency to prolongation of the disease. In the spring CHAP, of last year she presented the physical signs extremely well . ^ marked of a cavity in the apex of the left lung. The base of the same side was slightly crepitant, and the right apex was rather dull, the expiration prolonged, and the respiratory sound roucfh. She was much emaciated, and suffered from hectic sweating. The digestion was in pretty fair order ; the larynx unaffected. Her expectoration was considerable. In the month of March she was seized with sudden acute pain in the left chest, accompanied by dyspnoea, excessive distress, rapid almost imperceptible pulse, clammy sweats, and ex- haustion. I saw her after some hours, and found the physi- cal signs to be those of pneumothorax. There was a iyrapa- nitic sound on 'percussion over the lower two-thirds of the left chest ; vesicular breathing absent ever this region, and replaced by a metallic sound on both inspiration and expiration ; metallic voice ; and amphoric bloiving. The metallic phenomena were most apparent (as is usual) oppo- site the spine of the scapula. The physical signs of cavity formerly evident (pectoriloquy and cavernous blowing) were replaced by a peculiar crepitant sound, resembling that heard in a lung compressed by fluid. The decubitus was on the back, the patient inclining slightly to the affected side. Under the free use of stimulants, with camphor and opium, she rallied from the immediate shock ; the pain ceased ; the distress moderated ; and after eight weeks she was in a fairly comfortable state, having as yet never left her bedroom, but being able to talk and receive visitors ; and decidedly free from pain and marked dyspnoea, unless exertions were made. In this case I noted that the metallic sounds and amphoric blowing occasionally entirely disappeared, and were replaced by the dry crepitant lung sound for some inches below the scapula, over which space at the same time the tympanitic percussion note was also absent, and on these days she was better. But the old physical conditions invariably returned after a day or two with increase of dyspnoea. This would appear to arise from the lung being as yet free from adhe- sions in its lower part, and thus occasionally able to expand and partly occupy its old position. The only obstacle to its entire expansion is the air in the pleural sac. The opening is probably small and valvular, or fistulous. I have verified 332 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, this alternation of the physical condition by careful examina- ^^^' ^^'^^ °^ ^^ °^ eight occasions. She went out repeatedly during the winter, was able to walk half a mile, and go to church. She could talk with ease and in a clear voice, and with sustained power of con- versation. She was entirely without fever, and remained so for months. She had regained flesh up to a standard far above what she stood at before the perforation occurred. Expectoration for many months was scarcely anything ; but from taking cold it again increased. Over the whole left lung there is heard, one year later, moist crepitation, 'most intense at the apex ; but the foriner signs of cavity have entirely disappeared, viz., cavernous blowing, pectoriloquy, and gurgling. The dulness on percussion remained. The opposite lung tolerably free. There can be little doubt that in this case, which has been carefully watched and honestly recorded, the pneumothorax had a curative tendency, and that the patient having escaped the early result of inflammation and effusion into the pleura, had profited by the state of comparative inactivity into which the diseased lung was thrown, and for many months remained actually in a better state than she was before the occurrence of pneumothorax. She survived the occurrence for eighteen months, and died while still under my obser- vation with the ordinary symptoms of slow phthisis. Perforation of the lung, pneumothorax, and effusion into the pleura from the bursting of a tuberculous cavity, in a child 3^ years of age. Case. ^* ^- ^ male child, aged 3^- years, had been staying at Very small a friend's house for a fortnight, and returned home appa- chn?''' '' gently in pretty good health on October 23, 1862. He had get. 3^, however slight cough, and brought up a spot of blood on thorax°" some phlegm the day after his arrival; but he played and death,' ate as usual. On the 29th he was seen by the late Mr. tem"™°^' Sawyer, of Park Street, and was found to be suffering from great dyspnoea and restlessness, with almost imperceptible pulse and suppression of all the secretions ; the respiratory PNEUMOTHORAX. 333 sounds were very feelale over the right side. He was treated CHAP. by calomel and ipecacuanha and a blister to the right side ; -^^^- on the next day he had rallied, the pulse rose, but the child was evidently in great distress and screaming violently. On the 31st, Mr. Sawyer asked me to see the case; I found the child much exhausted ; respirations 64 ; pulse 140, very thready; great restlessness, and a very collapsed expression of countenance. On examining the chest the existence of pneumothorax on the right side was evident : anteriorly from the nipple doivn there were tympanitic percussion note, and very marked metallic sounds both on inspiration and expiration ; a very feeble respiratory murmur was heard over the upper part of the lung; the base posteriorly ivas dull; no respiration heard; puerile respiration in the opposite lung. Some oedema of the integuments existed on the seventh and eighth ribs at the right side, but no fracture was detected. The diagnosis of perforation of tht lung, pneumothorax, and subsequent effusion into the pleura was offered at the time. The cause of the perforation of the lung remained to be seen. There was no evidence of injury having been received ; while, on the other hand, the tolerably good state of health of the child, and the absence of pre- disposition to tubercle in the family (for which careful enquiry was made), rendered it unlikely to have resulted from the bursting of a tuberculous cavity. The child died the same evening (31st). On November 2, the post-mortem examination was made by Mr. Sawyer and myself. The body appeared to be fairly nourished. On opening the right pleura air escaped through the incision ; the lung, collapsed, lay in the upper and back part of the pleural cavity. Both the costal and pulmonary pleurae were rough and lined with fresh lymph, and flakes of lymph floated about in a thin turbid fluid of which there were twelve ounces in the pleura ; a single band of adhesion connected the base of the right lung to the diaphragm ; another band stretched across to the seventh rib. There was no fracture of the ribs. The lung was removed and a blow- pipe tied into the bronchus. On immersing the lung in water and blowing through the tube, air issued freely from a point in the interlobular fissure, and from another in the posterior edge of the lung. The lung itself was collapsed. 334 ELEMENTS OF PROGNOSIS IN" CONSUMPTION.' CHAP, sunk in water, and was coated all over with a thick layer ^^^- of lymph. A probe passed easily from the ruptured part into a small cavity in the middle lobe. It is of irregular shape, and about half an inch across its widest measurement. The opposite lung and pleurae healthy. From these appear- ances it was evident that a small unsuspected cavity had been * formed in the lung very near the interlobular fissure, and that it had ruptured the pleura and given rise to the usual phenomena of pneumothorax, followed by liquid effusion, and terminating in death. Author!- In reviewing well-known authorities on this affection, I find that Laennec says, ' the effusion of air cannot exist for any length of time without giving rise to severe symptoms, and even death. I have never seen pneumothorax in any person who was not confined to bed.' In upwards of 20 cases by Dr. Townsend, ' none lasted more than 5 months.' In 7 cases by Louis, 36 days was the longest period of survival. Dr. Stokes gives, as an exception, one case only which survived 1 year : the rest perished within a few weeks, excepting one, which survived 5 months. My colleague, Dr. Alison, gives 8 cases, of which 6 died within 6 weeks, 1 at 2 Hospital months, and 1 lived 18 months. An analysis of 20 cases which occurred at the hospital presents the follow- ing results : — 12 males ; 8 females. 14 under 25 years ; 45 greatest age. 9 under 1 year duration (previous). 12 under 18 months' duration ; 2 unknown duration ; 6 very chronic ; double cavities in 18 cases ; single in 2. Duration of life after accident : All but one died under 1 month ; the one (4 months) had enormous but gradual effusion into the pleura; 15 died under a fortnight, in from 15 minutes, 1 hour, 8 hours, 48 hours, 3 days, &c<, 13 cases occurred on right, 7 on left ; in 8 the per- foration was at or above the level of the second rib ; in cases. PNEUMOTHORAX. 385 one were 2 perforations ; in another, several ; the scat chap. of rupture not found in the remaining 9. > J^^^' . - Effusion occurred in 12 cases ; none in 8. Death ensued from sudden collapse, or from more gradual sinking, and asphyxia in all cases. The prognostics in pneumothorax must almost always Progno- be unfavourable. The possibility of such a recovery as ^^^^'^' we have described must not, however, be forgotten, as those who meet with phthiscal cases in large numbers are now aware of the fact that occasionally a rally may be made for an indefinite period. The conditions of temporary recovery fi:'om the lesion of the lung and pleura imphed in pneumothorax are various, and must all be reaHsed, 1. A tolerably well-defined cavity. 2. A well- thickened and protective pleura. 3. A small and fistulous opening into the pleura, large enough to admit the passage of air, and small enough to forbid the passage of Hquid matters. Its position in the lung must also favour this condition. 4. The persistent absence of effusion. 5. A tolerably sound condition of the opposite lung. 336 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAPTER XXII. HEREDITARY INFLUENCE. CHAP. The influences which tend to precipitate an attack of ^.35^1^ tubercle in the lung in any individual are remote and proximate. Causes The rcmotc causes are found in the hereditary pre- pr^^mate. disposition to tuberculosis, which, although not present Hereditary ^^ ^hc parcuts, may have an ancestral origin generations taints. back. Occupa- In the occupations of life which prepare the field for tions. ^-j^g seeds of disease to be sown by other influences, but which are not of themselves direct producers of tubercle. Privations. In the privations of life, which are in most instances necessitated, but in some voluntarily assumed, as in the conventual system. Errors. In the crrors of hfe — those sins against natural laws, some of which we are aU committing, with impunity or to destruction. To this class belong all excesses which waste vital powers, undue carefulness and anxiety, over-watching, sexual excesses, the excited race after wealth or distinction, and the ineffectual struggle against poverty. The over- nursed in close and luxurious cham- bers, and the student outstepping his powers on a short Alpine hohday ; the sorely-taxed governess, toihng aU day and sitting up half the night to enj oy the luxury of solitude, and converse with books and absent friends ; the under-dressed lady undergoing in ill-ventilated rooms the dangerous excitement of the ball : all these and many others are labouring thoughtlessly to prepare HEEEDITAEY INFLUENCE. 337 the field in wliicli the seeds of death may be sown, and be- chap. come productive or not as other agencies shall determine. > ^^^^J- , Of all of these, doubtless the most important is here- Hereditary ditary predisposition ; for, in its absence, how many StIon^^°' struggle through influences and errors which destroy ^o^Y^iflu- others in early life, and attain a considerable longevity .^ Not all the predisposing causes united could, in a Something given instance, induce consumption with certainty, ^o^ethan without some subtle agent to precipitate, concentrate, causes ne- and shape those elements of disease into tubercle. '^^^^'^^' 'What can be more obvious,' says Louis, 'than that the first step towards the real and not the fancied knowledge of the remote causes of phthisis must be to ascertain whether the same causes would not entail the development of any other equally chronic disease ? ' We can take the plant in full health, place it in Analogies. darkness and cold, and with certainty prevent the de- -^^^°*^- velopment of its groAvth, and its fructification. It has even been stated that external struma may with much struma, certainty be induced by placing under-clothed children in low and damp situations, by restricting their food to the lower farinaceous materials, and by depriving them of milk. In certain malarious districts at seasons of the year Malaria. when the marsh poison is most concentrated, exposure under ascertained circumstances is almost certain to be followed by some form of intermittent. Thus we have known four young and healthy men cross the Pontine marshes in September, and sleep in their carriage with windows open. Of these, three had pernicious fever, of whom two died. In all epidemics of contagious diseases, as rubeola Contagious and variola, exposure is not certain to induce the affec- *'p^'^^^^'^^- tion in those unprotected by a previous attack or by vaccination. There exists on the one hand a degree of certainty that some will undergo an attack if exposed, which far sur- z 338 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, passes any likelihood that phthisis shall be induced by an vi^H:^ intense combination of the influences which are supposed to lead to it ; and on the other even in these eminently contagious and epidemic affections, there is recognisable a certain immunity of individuals which points strongly to the fact that something more than exposure and in- tensity of the diseased element is wanting to complete the vital phenomena of imparted disease. We know also that where chiklren so escape the con- tagious influence, the same individuals may at some future time, when they are apparently more susceptible (as we call it), undergo an attack of the disease from a similar exposure. Certain Wc also know that there are some constitutions ap- nVIis-^ ^ parently insusceptible of certain poisons at any time, as ceptibie. jj^ ^|-^g instauccs of vaccination repeatedly unsuccessful in certain individuals, however often it may be tried, or however varied may be the source from which we obtain the lymph. Those familiar in hospital practice with the phenomena of typhus are also aware how some escape the contagious influence wholly, whilst others have a Eever. repetition of fevers. Among the students in the fever wards the slightest exposure will in certain instances ensure an attack, whilst others even more dihgent in their clinical attention to the sick escape altogether. There is even in famihes a certain proclivity to fever of which we have known remarkable examples, whilst other families escape from even the closest exposure to Failures couceutratcd contagion. So again on some sunny slope well drained and well exposed to wind and rain, equally well cultivated, manured, and sown with the same seed on the same day by the same machine, we shall find, not uniformity of produce, but almost invariably (in the case of turnips) a spot where the crop is dwarfed, insuf- ficient, or altogether absent, which the farmer cannot account for, and where on former years, he has, out of the same materials of labour and seed, found an abun- in seed crops IIEEEDITARY INFLUENCE. 339 clant result, nay more, where next year, or two or more chap. years later, under identical circumstances, lie may pro- ^ ^^^^' ■ duce an excellent crop. From considering these facts it will be evident that something more than a prepared soil and healthy seed ; something more than an intense contagion and direct exposure to its influence ; some- thing more than actual inoculation of morbid matter into healthy blood, is necessary to induce the well-grown crop, or the specific fever, or the peculiar disease which should in ordinary course follow the processes which we have described.* This additional something may be called ' suscepti- Suscepti- bility ; ' but this is an expression of the fact, and not an ^]^lt2 explanation of the result, be it failure or success. We want to know why some individuals, some families, some fields, are ' susceptible,' and not others. What is the residual element which is wanting in the non- susceptible, although greatly exposed, and present in the susceptible, when even slightly exposed ? Why do not the same remote causes produce other diseases equally chronic, as phthisis ? or are there diseases as common dependent on the same causes ? It is evident that the remote causes are not ' per se ' sufficient for the production of tubercular disease, and our questions cannot be intelligibly or satisfactorily answered by referring the influence desired to be de- * M. Trovisseau, when commentino- on the spread of puerperal fever, says : — ' These germs will not he developed as readily in all patients, because the conditions of their reception vary infinitely. Some patients, like certain earths, may not receive certain germs. The wind may spread the same seed widely over a country, and yet the grain will not spring up everywhere alike. Here, the soil may be too wet ; there, too dry : here, otlier germs have grown up, and stifled the new seed. Just so it ig with morbid germs and ferments. They individually require conditions favourable to their development.' This argument is pursued, and the necessity of a ' productive soil ' insisted on, by Mr. Spencer Wells, in his interesting communication. Some Causes of Excessive Mortality after Sur- gical Operations, read before the British Medical Association iu August, 1864. z 2 340 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, fined to the other class of causes which have been ■ ^^"- . called the ' proximate.' Hereditary In tlic abscncc of morc accurate knowledge than babiy^th°e' scicuce jct posscsscs, wc are inclined to refer the actual preeipitat- prccipitation of the disease which we call tubercle to mg agent, -ri _, _, the influence of hereditary predisposition acting m con- junction with, or occasionally even in the absence of, all or any of the other remote agents which give rise to phthisis. It is true that privation, excess, errors in habits of life, the sedentary occupations, the pernicious influence of certain trades, grief, anxiety, and the other wasters of vital powers, will not suflice to induce consumption in all, or even in the greater proportion of, individuals ; for these agents so universally prevalent are part of the daily lot, or of the daily errors, of many more than fall victims to consumption. But it is also true that, if to any or all of these conditions that of inherited tendency to phthisis be superadded, very few indeed escape the disease. And if to these circumstances we add age, the great modifier of this class of afiections, we can almost surely predicate, even of individuals, how and when they shall begin to exhibit symptoms of the malady. Proportion I^ wiU bc, and ought to be, asked, for what propor- so mflu- ^j^Qjj of the cases of consumption this process of reason- enced. . .,, i p ing Will account ? and we answer for two out of three : for such is the proportion of hereditary disease whicli may be gathered from the observations of the most informed and trustworthy observers. And how to account for the remaining third of consumption cases : those which have been called accidental .^ Accidental The cascs of accidental phthisis stand alone to phthisis, represent the non-hereditary form of the disease, and, as has been elsewhere shown, possess characters peculiar to themselves. They illustrate the fact of the possibility HEREDITARY INFLUENCE. 341 of tuberculosis arising out of external agencies, and, re- chap. presenting so small a proportion of the whole, may ^^L^ fairly be said to be exceptional ; and when from these are deducted the instances which are fairly referable in their origin to acute affections, as fever and the exanthemata, and when the rheumatic diathesis is also eliminated as a cause, we shall find that they are numerically very few. Indeed, before allowing that Great ex- the hereditary cases are only two-thirds, we shall do hereditary well to consider what is the real meaning of the ii^fi^i^iee. term, when we shall be inclined to extend its influ- ence much further than it at present stands in our calculations. Hereditary predisposition is commonly taken to mean Transmis- the occurrence of the same disease in parents. And it JJJiJteTto is true that such inheritance is sufiicient to stamp the parents, case as belonging to this class. But this is only the terminal link of a chain ; and of the higher and pre- ceding links we are generally only informed to the second degree, while to ascertain even this is considered unusual accuracy of research. Yet no fact is more certainly known than that fea- Moral and tures, form, frame, pecuKarity of constitution, suscepti- toS'of''^ bility to certain agents, not to speak of character remotean- mental and moral, the passions, and the intellect, are origin, often derived from progenitors many steps upwards in the ancestral tree. Mr. Sedgwick gives many instances of this in his work and papers on hereditary trans- mission, and the daily experience of all of us cor- roborates its truth. Individually, we are combinations of many ancestors. The actual traits of our parents may or may not be seen in their offspring ; and it is more common to find that one or two only are found in each child, and that in a whole family the members represent, eacli individually, only some single feature of mind or body of one or other parent. Whence, then, are derived the remain- 342 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, ing? Doubtless from some ancestor long forgotten, v' , _- whose intellectual powers or defects, infirmities or vigour of body, whose faults and follies, whose brilliant powers or miserable failings, may be reflected in a remote descendant, as he had himself derived them from some distant ancestor. This question of transmission, then, is a larger one than we had supposed. We are accustomed to say that ' gout may skip a generation ! ' Why may not it skip four or five ? Those intimate vital processes on which organization depends are of far more remote origin than is commonly supposed, and reflect the ten- dencies of untold numbers who have preceded us in the family tree. The children of a drunkard or of a very old man are notoriously short-lived, and fall victims to organic disease (chiefly tubercular). But should they marry, their children ahke possess the taint, only it is modified by the new blood of the second parent, whose pecuHar- ities. become engrafted in the ofispring. This new influence may be more or less powerful as the child resembles one or other parent, but the dregs of the taint on the father's side may still remain ; and, although the individual may himself escape, owing to the stronger admixture of the maternal element, he may in turn beget children who shall reflect the grand- father's peculiarities, and be the representatives of his weakness and decay. And the process may go on for generations, until sufiiciently diluted by intermarriages. After a long interval, however, a lineal descendent may be born who shall represent, out of due proportion, the physical infirmities which his immediate predecessors had escaped, but which he personally derives from the feeble frame or exhausted powers of the forgotten founder of the family. Should his disease be tuber- cular, tlie case would be called ' accidental ' if induced by the personal errors of the individual affected, but HEKEDITARY INFLUENCE. 343 ancestral predisposition would have determined the chap. diathesis. -, — , — L- It is rather a fearful matter thus to look back on the Analogy sins of our forefathers, and to recognise the transmitted ^l^^i punishment ; but it is not out of accordance with other properties, facts of moral origin, and of highest dictation. The mystery of original sin, the punishment to 'the third and fourth generation,' are paralleled and vindicated by the observations of the physiologist. ' JSTor can the fact be disputed,' says Guizot, ' though appreciable with diffi- Guizot. culty, that the natural and special dispositions of the in- dividual descend to him in a certain measure from his origin, and that parents transmit to their children such or such moral propensities, just as they do such or such physical temperament, or such or such features. Here- ditary transmission enters into the moral as well as mto the physical order of the world.' * In considering the subject of hereditary transmission, Organic ■ it has not escaped observation, that the pecuharities of ckiiy m- oreranic life are transmitted quite as much, or even flwencedby more, than likeness of features, build, &c., and this is sion. quite in accordance with a pinori reasoning. Diseases of constitutional origin thus find a ready method of propagation and development. The ultimate processes of sanguification, of vitahsation of alimentary matters, and the formation and nutrition of tissues, are thus directly affected, and here are located the primary errors which become developed into organic disease. Indi- viduals thus placed, as it were, on the chain of inhe- rited disease, may personally escape its influence by avoiding the other agents which concentrate and pre- cipitate any special disorder. They are not, however, the less transmitters of peculiar constitutions, if they are not individually sufferers. The electric current on * Meditations on the ^Essence of Cliristianity, Sec. By M. Guizot, p. 50. London: 1864. 344 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XXII. Forms of disease especially trans- mitted. Accidental may be added to ancestral causes of phthisis. Converg- ence of ancestral liability. the wire passes on its errand, and leaves no trace of its transit. It would appear, however, that when by the access of external influences they fall victims to the inherited disease, they become intensifiers as well as propagators, and that their children become more hable to the disease in an aggravated form than were the parents. Finally, the forms of disease, those modifications on which depend its rapidity, development, and duration, are most distinctly reflected in families. How often do we witness child after child carried ofl" at the same age, by the same variety of tubercular disease, and with almost identical symptoms. In some families this de- structive agent attacks the mesenteric glands in earhest infancy ; in others, the brain in early boyhood ; in a third, the bones at the age of puberty ; in a fourtli, the lungs in manliood ; or in a fifth, when age is de- clining, the long-suspended blow is Avitnessed in senile phthisis, while each family comes to recognise a dreaded period of danger, when its successive members drop ofl*, and an age which, when reached, is fraught with almost unavoidable peril ! But hereditary tendency to disease may be intensi- fied in two Avays. First, by the personal errors of any individual on the chain, who by inducing an attack of the constitutional afiection which might have continued latent, becomes, as it were, a new focus of disease to his progeny. Like the ganghon on the nerve, this con- centration is attended with increased activity. Thus may an ' accidental,' superadded to a ' transmitted ' cause, intensify the product to his successors. Secondly, a convergence of ancestral liability to dis- ease may be obtained by the intermarriage of persons hereditarily predisposed. No method is so sure as this to ensure a precipitation of tuberculosis. The children of such unions rarely escape. Marriages of near consanguinity have been supposed HEEEDITARY INFLUENCE. 345 to lead to the same result, whether there exist any chap. hereditary taint or not, and the question has been of v '^^^^ L- late much discussed. This is not the place to enter on Marriages its consideration, but we are inclined to believe that guinitjf^" phthisis is not directly produced in this manner. But ^^iy|oi>e Till • • 1 1 • avoided, we hold the opinion that such intermarriages do not, as a rule, produce as vigorous an offspring as those of non-relations, and that such degeneracy of vital power as is due to this cause may in its turn become a pre- disposing though not a direct agent in the production of consumption. Eemembering, also, that peculiarities of organic life are especially those which seem most capable of transmis- sion ; that such are closely connected with the seat of constitutional diseases, and that any weakness is sure to be increased by such intermarriages, we can easily re- cognise an element of weakness, which, although not itself morbid, may readily be developed into disease. Should both parents inherit a weakness of the. vital organism from a common ancestor, the ordinary risks of hfe are almost sure to seize upon the vulnerable pohit of the system. The converse condition is true also. Intermarriages of individuals remote from each other in ancestry, in social condition, in constitution, and in what is called ' temperament,' but above all, the unions of persons of different race and country (if direct taint of disease be absent on both sides), are very generally free from resulting afiections of constitutional origin m their chil- dren. It is perhaps true that marriages between indi- viduals of different races are not very prolific ; and if this be the case, it is another reason for the greater vigour of their offspring, for the members of large families are generally not so individually strong as those of small ones. This question of large families is also of interest. Parents weakly from any inherited or personal disease, 346 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP. XXII. The phthisical prohfic. Sexual transmis- sion of disease. Indications for pre- vention of phthisis. are frequently very prolific, and become the pro- pagators of constitutional and organic disorders. We have known as many as seventeen brothers and sisters die of consumption. As a matter of experience, there is no doubt that the phthisical are prolific, and endless instances occur in practice of a mother conceiving when in an advanced stage of tubercular disease, and having* a child which survives only a few months. Nor is the generative power confined to the mother. Men in much advanced phthisis often marry and have children. The question of the sexual transmission of disease is one of much interest, and we have long adopted the belief founded on observation, that the father transmits to sons, and the mothers to daughters, their respective peculiarities of organisation in greater intensity and with more frequency than the converse. It frequently occurs to us to observe, that daughters personally re- sembling a consumptive mother, as in colour of hair, eyes, and in general build, become the victims of the same disease, whilst the sons resembling the father who is not the subject of phthisis, escape. It is doubtless occasionally true that fathers will transmit their personal pecuharities of organisation to daughters rather than to sons. But such instances would appear to be rather the exception than the rule. There can be no question as to the practical bearing of these considerations on the hereditary transmission of phthisis.'^ If this great scourge of our race is to be materially lessened, we must go to the source whence it flows. No mstitution for the special treatment of individual cases, no success achieved in prolonging the duration of such cases, can check the march and progress of a malady at once universally prevalent and destructive, so long as a constantly reproducing agent is at work originating fresh cases, and imprinting at their very conception the elements of certain destruction on thousands of children. It is as HEREDITARY INFLUENCE. 347 if we were to expect purity of the Thames by inter- chap. cepting the drainage of London, while we permit the • — V— ' direct access of the sweepings of numerous towns and villages to its streams higher up. In the prevention of phthisis, this becomes a pri- mary element. So long as the consumptive marry and transmit a tendency to the same disease, which is not escaped by more than one out of every three of their descendants, so long shall we have the same malady confronting us in successive generations. It is not to be expected, however, that the warnings of medical men will have much effect in checking this source of disease, for marriages are entered on without any regard for such considerations. But it is not less our duty to act as faithful watchmen, and warn of the fatal consequences of such imprudence. To the phthisical father, there is an almost certainty of his having un- healthy, short-lived children ; and to the phthisical mother there is a double danger, first, that her own health may break up at or after the time of her confine- ment ; and next, that her offspring shall be short-lived. Marriages of near consanguinity should be strictly Marriages forbidden if there be a phthisical taint in the family, as guinity. the disease is almost certain to be precipitated on the children. Marriages of consanguinity also, even when there is no consumptive tendency, should not be lightly entered on. Whether or not it be conceded that such unions generally produce puny and unhealthy offspring, it is certain that organic peculiarities are thereby concen- trated, and organic weakness engendered, and the door is thus opened to ^ome of the most fatal maladies to which the frame is incident. Medical men have this duty to perform, and how- ever unpalatable the advice to be offered, they should not shrink from plainly declaring their knowledge, for it is no mere question of opinion on the points we 348 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP. XXII. Marriage of the phthisical. Marriage as a sup- posed remedy. have named. The phthisical should not marry ; those strongly predisposed by family inheritance of disease should not marry ; near relations so predisposed should not marry ; and unions of individuals of near consan- guinity, even although personally healthy, should be m''ged to consider well the possible consequences of such a step. That properties should be consohdated and family interests preserved, is but a poor compen- sation for the dreadful results of early death, and such grief as no money considerations can lessen, but which they are more hkely to embitter when the fatal event has occurred. And here it may be fitting to say a word on the fallacy so prevalent amongst all classes of society, that marriage tends to ward off, and even to cure, consump- tion in young females. This erroneous opinion has obviously arisen from the fact that in phthisis the ca- tamenial function is often suspended, and it is supposed that if uterine regularity be restored, the impending disease may be averted. But here is a gross mistake. Amenorrhoea is not a cause, but a consequence of con- sumption. It arises out of the same error of nutrition and lowering of vital power, and deficient sanguifica- tion, which have given rise to the tubercular disease. Stoppage of the menstrual secretion is a symptom of constitutional disorder, excepting in the few instances m which it arises from hyper-congestion of the uterus and general plethora, or from mechanical occlusion. Its restoration, indeed, evidences an improved nutrition of the whole body, and increased vital powers, but can have no influence in arresting estabhshed, or prevent- ing threatened deposit of tubercle- in the lung. We doubt if a single case of true consumption was ever cured or warded off by restoring the uterine function. We equally doubt if any such case was ever caused by its suspension. What can be more cruel than to propose marriage, with its probable consequences, as a HEREDITARY INFLUENCE. 349 cure or mode of prevention ? The feeble girl is to be chap. made a mother, in order that her child may die, and ~ ^ . 1> that a fearful time of danger for herself may be in- curred at or soon after its birth ! or even under the most hopeful circumstances, that the child may grow up to a feeble youth and immature womanhood, and find herself without the care of a mother when early decay is manifesting itself! While such advice as leads to early marriage of the phthisical girl can only come through or directly from medical sources, we are our- selves alone to blame if we permit or countenance such a violation of good sense and of physiological laws. Let any one inclined to act on these views turn to the instances which are presented in the chapter on preg- nancy, or examine the cases of married women in our wards, and he cannot fail to perceive in these inex- orable facts sufficient evidence to contradict any theory formed on such fallacious grounds. 350 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAPTEE XXIII. PEEVENTIVE TEEATMENT OF PHTHISIS — INFANCY- CHILDHOOD. CHAR XXIII. Manage- ment of children heredi- tarily pre- disposed to phthisis. Food. The management of children hereditarily predisposed to phthisis must naturally engage our attention in con- sidering the modes of preventing consumption. Infants should be provided with a v^^et-nurse if the mother be dehcate, and a thoroughly healthy woman, free from all taint, should be selected for this ofEce. Lactation is to the mother a certain source of ill health, and is a ready mode of developing the tubercular disease, while the child is sure to be imperfectly nourished, and draws with the supply from its mother's breast an addi- tional element of danger to that which it derives from its parentage. It should be kept to this kind of nou- rishment for a long time, and a too early addition of farinaceous and animal matters to its diet is to be avoided. The most robust children are brought up on milk alone, and the admixture of other matters before dentition has commenced is fraught with danger. We have even seen children judiciously brought up by hand under these circumstances, if the food be not mixed, and the supply derived from one healthy cow. Dentition is generaUy late, and the appearance of teeth is the signal for an advance in the kind of food, and should be waited for. Everything which irritates the delicate mucous membrane, and causes diarrhoea, should be avoided, and the more active drugs, such as calomel. PREVENTIVE TREATMENT OP PHTHISIS. 351 should never be administered to these children. On -chap. the appearance of thrush, which is very common, the -JE^^^ mildest antacids, as fluid magnesia, should alone be injurious given. Should bronchitis occur, depressing agents, as drugs!" tartar emetic, should be carefully avoided. On the occurrence of measles, the simplest management should be adopted ; no medicine is necessary in an ordinary attack, but an even and moderate temperature and di- luent drinks will be found suflicient. If pneumonia . supervene, these children are not to be subjected to lowering treatment. Pneumonia will resolve itself, and even the double affection will not always prove fatal, if vital power be not too much depressed. Early ex- Air. posure to fresh air soon after birth is highly necessary, or the infant will be peculiarly liable to attacks of bronchitis. When the weather permits, the pure air of the parks or the country will be found the best of tonics. Sometimes, even with the most judicious diet, iron, infants will be found pale and ansemic, with feeble pulse and circulation, and the best results attend the use of the vinum ferri, in doses of ten drops three times a day. We have administered this as early as the fourth month for many weeks continuously, with most satisfactory effects, the child acquiring colour and firmness of flesh. We have tried many experiments to ascertain how early it is advisable to give cod-liver oil. oil, and have found it unsuitable before the ninth month, and in some cases till after the child has at- tained one year. It is possible to digest cream earlier, and it may often be given with good effect. Daily bathing of the surface is a valuable habit. At Bath, first the bath is to be tepid, but very soon may be used cold. The best method is simple and rapid immersion, which is better than the slower process of sponging ; the object being to obtain quick reaction. The clothing of Clothing. such children should be from birth warm and suflicient. More harm is done from insufliciency than from thin 352 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, material. The whole body should be covered with XXIII. woollen, and the upper part of the chest should on no account be left uncovered ; neither, as the child grows older, should any evening stripping be permitted. This covering, once assumed, should not be left off. In the summer of this climate a somewhat hghter material may be adopted next the skin ; but such changes as are necessary in very hot weather should be of the outer, and not affect the under clothing, which it is best to maintain of the same warmth summer and Open-air winter. Opcu-air exercise is to be sedulously culti- exercise. y^^Q^^ There is no possibility of safety without it. No plea for education, no false theories about taking of cold, are to be allowed to stand in the way of it. Sedentary occupations in childhood and close rooms sow the seeds of death, when predisposition to phthisis exists. Even on a damp day, or in frost, the child had better be out running and using out-of-door toys, unless a very cold wind prevail at the same time. Light. Neither should sun be avoided. Light is an essential agent in healthy blood changes, and plays a powerful part in animal chemistry, although we may not be able to define its action. A freckled child is rarely consumptive — a singular fact, but one which we have verified in very many instances. There is not only mental invigoration in sunlight, but there are doubtless vital agents assisted, and possibly developed by it. The child's day-room should also be exposed to hght, having a full southern or south-western aspect ; and while there should not be a suspicion of uncleanliness, the air should have full access to it by a window open at top during some portion of every winter day, and almost always in summer, while it should be open every night in the year. Ventilation The vcntilatioii of sleeping-rooms demands even of sleeping more carc. In winter there may be a fire, and a louvre ventilator two feet square in the door, with access rooms. MANAGEMENT OP CHILDHOOD : VENTILATION. 353 of fresli air from an open window on the adioining chap. XXIII staircase. This should be open day and night, but less -- \ " - open in severe cold weather in winter. The above plan is far better than warming the whole house by a heating apparatus, for it insures change of the respired air, which the latter plan does not. This method of obtaining fresh air in the sleeping floors of our modern houses by an open window summer and winter, has several advantages. The air so entering is derived from the upper stratum and not from that on a level with the streets. It also prevents the access of mias- mata, and of the fermentation and products of foul drainage, which are derived from the basement. Where the kitchens are below the level of the ground, (as in London,) a door should shut off the whole of that floor, and with it all entrance of air from drains If a house be shut up at aU points at night, the air which must enter wiU find its way from the drains, and down the chimneys, in both cases foul and impure. Let us then get rid of prejudice and let in that portion of the atmosphere which is the purest that is possible to obtain, and this can alone be had from a free opening on the higher floors of the house, and best of all from a window. Temperature in the bed-room is to be main- tained by fire in an open fire-place, which is in itself the best of ventilators. Having thus provided for warmth and pure air in the sleeping-room in winter, we can secure it equally in summer, by leaving the bedroom window open at the top. Delicate children cannot be too soon accustomed to sleep in fresh air. With warm bed clothing, (a very important matter,) this is not only safe, but necessary, and remembering that the organs of respiration are those threatened by the disease we are considering, their vital processes cannot too early be accustomed to pure unvitiated air, and this should not be scanty or filtered though warming machinery, but unrestricted in quantity, and as pure as is obtainable. AA 354 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP. The points to remember about open windows in sleep- > . L- ing-rooms, are that the bed-clothing be sufficient, and that no current of air be directed on the body. Education. As the child grows ' up his education should be physical rather than intellectual, calculated rather to stimulate the growth of healthy tissue, than the often premature development of a weakly brain. The accomplishments of early life are forced beauties wliich fade while still in their period of promise, unless sup- ported and strengthened into maturity by a healthy organisation. The precocity which dehghts the thoughtless because of its present beauty, cannot but pain the informed who see in it only evidence of early decay. The brain is, indeed, one of the first organs to fall before the invasion of tubercle, and long before lungs are even threatened becomes the seat of disease. Cerebral tubercle and cerebral meningitis are rare in the phthisis of adidts, but common enough before puberty. The other parts of the body most prone to become attacked by tubercle at this period are also not to be forgotten, bone and glands. These and the brain have to stand the first shock, as it were, of those fatal errors of nutrition which often only attack the lungs when puberty approaches. Puberty. At this important period of development, if glands and bone and brain have still remained sound, the first -great afflux of danger to the lungs arrives — although many sink before this time of pulmonary disease. If the natural expansion of the frame, and especially of the bony walls of the chest, does not take place, the respiratory function is cramped, and even by the eye we can foretell the threatened invasion of tubercle; whilst in the female, unless the generative functions attain the healthy degree of development, and the nutrition of the body be largely increased, should the — , — '-' modus operandi, but we are too well acquainted with the results. The frightful effects of impure air have been witnessed in the army to an extent which is scarcely credible. That the diseases so caused are preventible, is an additional proof of the insalubrity of crowded apartments. The following statement by Miss Night- ingale exhibits remarkable facts in powerful language : Preyenti- ' After the Crimean war, it was found that the death- army. I'ate among soldiers from consumption alone and its cognate diseases (the monstrous products of breathing foul air), exceeded the total death-rate from all causes among the civil population of the corresponding ages. The total mortality in the army was nearly double — in the Guards more than double— that of the civil community. It is now actually less than in civil life. Only half as many of our soldiers die now as formerly ; and in some cases half, in others two-thirds, of the mortality from consumption, has disappeared.' * In-door Confinement within doors seems to be in itself a pre- disposing cause of phthisis, which, judging by figures, is one of the most powerful. Among 3,214 men at the hospital (who composed all the cases of decided phthisis which were registered as in-patients in 10 years), more than one-half (1,812) had followed in-door occupations; and the 2,413 females may be said to have been almost all so engaged. The following table includes sufficient numbers to show this fact. Were it necessary, it could be much enlarged by adding the occupations of out-patients, but with the same result. * Miss Niglitingale : Paper On Army Sanitary Meform under the late Lord Herhe)-t, read at the Cougres International de Bienfaisance/ June 13, 1862. occupation. PEEVENTIVE TEEATMENT OP PHTHISIS : OCCUPATION. 367 Table shoiving the Occupations of 5,627 persons of both Sexes affected by Phthisis.* Males. Bakers 64 Bookbinders 17 Bricklayers Butchers . . 109 3 Carpenters Clerks and Shopmen . Coachmen . 295 394 211 Gardeners . . 82 Labourers . . , 539 Mechanics . 176 Painters . 105 Printers 103 Publicans . 46 Railway . Sailors and Watermen 38 74 Servants . 285 Shoemakers . 171 Soldiers and Police . 103 Smiths Teachers Tailors "Weavers At home Various Total Females. 89 42 145 11 63 49 3,214 Servants . . 984 Domestic . . 447 Milliners . . 397 Laundresses . 77 Governesses, &c. . 80 Oth-fer trades . 150 At home . . 278 Total 2,413 CHAR XXIV. The deductions from the above table are so obvious, as to strike even a superficial observer. If disease of a given form be so associated v^ith certain conditions, that in two-thirds of the instances which present them- selves to our notice, these conditions be present, v^e cannot avoid referring the diseased result to the ante- cedent error. In other words, deficient ventilation and crowded apartments are eminently productive of tubercular disease. The effects of posture are chiefly observed in boot- Posture, makers, tailors, handweavers, and others whose work necessitates the stooping posture. The results are mechanical hindrance to the free entramse of air to the chest, restricted expansion of the bony walls, and an imperfect respiration. In the case of bootmakers, there is the addition of pressure on the epigastrium, which gives rise to the well-known neurosis. But on * Second Medical Report of the Hospital for Consumption and Diseases of the Chest. Churchill ; 1863. pp. 6-7. 368 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, the whole, all of the errors of this class are to be re- . , L. ferred to insufficient expansion of the chest. What- ever tends to lessen the quantity of air which enters the chest, impedes respiratory changes, interferes with the nutrition of the tissues, and helps to induce those secondary disorders in which organic diseases originate. The first hnk in this chain may be considered to be an interference with the mechanism of breathing, and it would be difficult to say where and how soon the phenomena of vital disorder supersede or follow on those simply referable to interference with the chemical changes due to respiration. Either from stooping, pressure on the chest-walls, or simply from continuous sedentary position, the respiratory act is shortened, and the blood- changes in the lung imperfectly performed. The nutrition of the pulmonary tissue is also directly impaired. Just in proportion to the healthy activity is the nutrition of an organ, and it is more than likely that when the constitutional disorder has acquired a certain degree of intensity, the localisation of the tuber- cular deposit may be determined by the weakened nutrition and impaired vitality of the lung tissue which is to receive it. That lessened breath-motion leads to the deposition of tubercle, has been advocated with ability by my late colleague. Dr. E. Smith,* and although the theory of the epithelial origin of tubercle is at- tached to this statement, and may not readily be assented to, yet of the fact there can be no doubt, that imperfect pulmonary expansion is an exciting cause of tubercle. We here speak only of the elementary prin- ciples which should guide our preventive treatment ; and when the sedentary so frequently become the sub- jects of phthisis, we cannot doubt the influence of diminished respiratory movements. The singular exemption of butchers from consump- * Consumption, its Early and Remediahle Stages. By Dr. E, Smitli. London : 1862. p. 202. PREVENTIVE TREATMENT OP PHTHISIS: OCCUPATION. 369 tion is to be remarked. There are found but three chap. instances out of 3,214 which iiichide almost all trades JE^ and occupations. The statistics of the out-patients lingular who came under my notice amply confirm the view oJSt" that this occupation is specially non-consumptive. If ^^'*- we remember that their shops are of necessity airy and open, that they are abundantly fed on animal food, and that from early morning they are rapidly driving about m the open air, taking much exercise, and living well, we shall be able to understand the influences which prevent the access of tubercular disease. These con- ditions of open-air exercise and high feeding are in fact antagonistic to consumption. If, however, we wish to make a practical appHcation of this knowledge, we must prescribe all of these influences united— for what would the feeding be without the fresh air, and what would the exposure be without the exercise.? We are well satisfied, however, that if this mode of life were carried out to the fuU by those threatened with phthisis, many a life might be saved. A full action of the skin as ensured by exercise is FuUac so nnportant to the preservation of health, that in the ^^^^^^ ^^^ consideration of the influence of sedentary occupations '^'''' It cannot be omitted. The skin is directly a purifier of the blood, and is associated with the lungs and kidneys in this oflice. The reactions of the skin are chiefly felt by the lungs. An extensive burn of the surface often proves fatal by a pneumonia. In India where the air is rarefied by high temperature, the' action of the skin is much increased, while the work of the lungs is materiaUy lessened. The blood-changes which necessitate the evolution of carbon and of other products of secondary assimilation, employ these two organs sometimes together, often alternately. The decarbonising and the exhalant functions are shared by both. In aU the stages of tubercular disease ex- cessive sweating is a very constant symptom. It is B B 370 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, difficult, in studying the connection of tliese morbid XXIV. ^ pj-ocesses, to avoid regarding the profuse perspirations of advanced phthisis as not only an eifort to throw off morbid matters from the blood, but also as represent- ing vicariously the exhalation of watery matters from the system.* Cleanhness, therefore, which seems almost forbidden by certain occupations which clog the pores, and by close and crowded dwelhngs which in- terfere with personal purity, is a necessary condition in all measures preventive of phthisis. Dust. The number of persons who suffer from the inhala- tion of dust in their various occupations is almost incredible. By a calculation made by Dr. Greenhow, it would appear that the preventible deaths in England and Wales from consumption amount to 45,000 ; or, in, other words, if the mortality from phthisis could be reduced to what is presumed to be its normal rate, (3 in 1,000), the saving of life would amount to this ; for in many manufacturing districts the rate is 8, 9, or even 10 to 1,000 ! It is true that ' dust ' is not the only exciting cause at work in the production of pulmonary disease ; but it is the chief and most deadly of several deleterious influences to which the workman is exposed. The following have been enumerated as among the most pernicious forms of this mechanical irritant. The dust in hackhng flax, in carding cotton, in grinding steel, porcelain, pearl for buttons, in potteries, among mat- tress makers and cleaners, among chaff-cutters, stone- masons, needle-polishers, and in mines where the exposure to metallic dust is a fertile cause of phthisis. ' Few men who enter certain rooms in cotton factories ever hve to attain 38.' ' Out of 27 men in a flax- * The improvement in certain cases of phthisis which have resulted from the use of the Turkish Bath is curious as bearing- on this point. In several instances we have witnessed a remarkable cessation of hectic sweatings after a few baths, PREVENTIVE TREATMENT OF PHTHISIS : OCCUPATION. 371 hackling factory, 23 had puhnonary disease,' are the chap. statements made. xxiv. Fortunately their capabiHty of prevention has been Preventive equally proved. In certain well-ventilated mines the °^^'^^^'^^- mortahty is one-third less than in others, and the simple use of the fan in workshops has materially lessened the quantity of disease among the grinders of Sheffield. Dr. Greenhow points out that the potter's consump- tion is chiefly caused by portions of clay being allowed to be trampled into dust on the floors of the work- rooms. Inventions to prevent the entrance of dust into the air-passages have often been devised, and many of them have been sufficiently tried to warrant their adoption. Such are the use of a veil over the nostrils and mouth, and in men the growth of the beard. A perfect ventilation and extreme cleanhness are, however, the best modes of prevention. The metaUic dust in mines, the floating particles of flax, cotton, and straw, are all possible to remove, rather let us say impossible to con- tinue, in the presence of a good system of ventilation. Nor is it necessary, in the opinion of the most compe- tent observers, to subject the inmates of these mines and factories to a current either of roasted dry, or of cold and damp air. Many experiments have failed because of the injurious effects of these currents, which are intolerable to persons exposed to them. It is per- fectly possible to obtain warmth and freshness of the air suppHed without a draught, and without over dryness and rarefaction. It it notorious that such workmen are very sensitive to sudden changes of temperature, as their mucous membrane has been already rendered irritable by contact with atmospheric dirt. But it is quite certain that a steady current of warm and mode- rately dry air may be obtained without causing chill. Such at least is the united testimony of the best observers. B B 2 372 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. Over work means exhaustion of organic life. The ^ XXIV. ^ jji^igcular apparatus of the body has a hmit set to its Orerwork. excrcise, bcyond which any strain is a breaking power. Like all the rest of the animal mechanism, it has a reserve of force for occasions outside and beyond the ordinary requirements made upon it. A. man may walk, under extraordinary circumstances of pressure, say five miles an hour ; but no necessity or reward could make him walk seven. The final spirt in the boat- race can be got up by a hardy crew determined to win, even when well nigh exhausted ; but the continuance of such effort would be impossible. But to what is called organic life there is no such direct hmit. It is capable of sustaining gradually mcreased pressure, under which its resisting powers at first increase, then lessen, but continue to tolerate with increasing feebleness the op- pressing agents. The victory is finaUy against the organs, but the struggle is prolonged, and in its first period of resistance it is amazing what an amount of latent vital vigour is called into activity. The reducing process is, however, progressive and certain. Over strain of mind and body ; hours given to intellectual and bodily labour which should be devoted to rest, di- rectly waste cerebral vitality and impair the nutrition of organs. There is one part of the machinery which never sleeps — the spinal centre ; but finally it loses power, and the organic movements over which it pre- sides become impaired, lowered, and exhausted. The blood-changes necessary to the formation and support of healthy tissue soon yield after this, and tubercular degradation is one of the results. But we cannot leave this part of our subject without calling loudly on employers and philanthropists, and all who are connected with labour in every form, to amend the conditions on which work must be now performed. The amount of preventible disease is astonishing, TEEVENTIVE TEEATMENT OF riTTIIISIS : OCCUPATION. 373 and we are almost compelled to cry out, ' Wliy will chap, ye die?' JE^ Labour is fairly paid for now-a-days ; that is, skill and time are rewarded ; but no wages can compensate for disease and death. Why should tailors work in steaming hot rooms, the very an* of which is deadly, crowding m together, with not one hundredth part of the respiratory space neces- sary to support life — the skin clogged, and the lungs gorged by their own foul exhalations ? Why should young and delicate girls be crowded into hot rooms, given insufficient time for food, and but half time for repose — rooms which dare not be venti- lated, we are told, for fear that atmospheric impurities should stain the costly dress which is being worked at, while the deadly impurities with which the lungs of these workers are continually infected are never con- sidered for ? Why should stone-masons, potters, and others inhale a deadly dust, and so certainly induce a disease whose mortality can be easily reckoned in the fearfid per- centage which their insurance societies record in their reports ? Why should compositors work in a deadly atmo- sphere of heat and foul air, crowded up into the garrets which we may see glowing into the night air as we pass the offices of our jom-nals ? Why should men be put in cellars, where no day- hght ever reaches, to perform work which would be better done in the face of the sun, and at less expense ? These conditions are all preventible causes of disease. There is great outcry about drainage, and fi^om Windsor Castle to St. Giles's some would profess to trace the origin of typhus and other animal poisons to foul matters retained within our dwelhngs ; and considering the amount of impurity underlying most of the best of 374 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. London houses, it is wonderful that we do not all die V . , 1- of typhus, or some other form of blood-poisoning. But the amount of such diseases and the resulting mor- tahty is as nothing compared to the work of death done by crowding, heat, and exhalations from living bodies. The preventible causes of chronic disease are, in other words, a hundred times more prevalent every- where than those of acute. There is actually no reason why such conditions as we have named should not be swept away, and with them the inevitable amount of death and disease which now is dependent on them. Work would be better done, and more labour got out of the workman, if he were to do it in spacious, airy, and light halls, instead of in dark, confined, and poisonous back rooms. But for this capital is required. True ; but capital can be found. At present it is outlaid on that which meets the eye ; on the reception-room for the customer, and not on the workshop for the men. Eeverse the pro- ceeding, and a remedy is applied which will repay both masters and men ; a higher class of work will be produced, and the producing powers and duration of life of the skilled labourer be vastly increased. Some- thing is being done in this direction, but much more is needed, and the improvement of the dwellings of the working classes is as much demanded as that of the unwholesome apartments in which they are crowded during business hours. Privations Qf the otlicr remotc causes of phthisis, the privations and errors of hfe in individuals, it is not necessary to treat at length. All that exhausts vital power prepares the soil, and leads the way to diseases of degeneration. But something more than this is necessary, and it seems probable that the additional element is hereditary taint, near or remote. It is very remarkable how much misery of mind and body, how long a continuance of exhausting vices may be persevered in, without the TREVENTIVE TREATMENT OF PHTHISIS : OCCUPATION. 375 indications of tubercular disease. Yet, on the other chap. hand, it occurs to us all to witness daily how the JE^^ pressure of mental distress, anxiety for the provision for daily wants, and the harass of business, breaks down the finest constitution. In so far as these causes are preventible, all would gladly avoid them. When present, they are rarely susceptible of removal ; and when absent from the favoured condition of the few, the enemy is apt to creep in through some other door. We need not dwell on them longer in the light of pre- vention, but a warning must be held out to those who embark everything in the great life struggle, instead of allowing only a certain and limited stake to depend on the issue. Against the vices of hfe — the preventible, fruitful causes of organic disease which depend on our own passions — the moralist and the physician take common ground. A large experience has persuaded us of the deadly influence of youthful vices, and of the excesses which go by the name of pleasure. These are pre- ventible causes of disease ; but it is to be feared that medical warnings can do Httle towards their eradication. 376 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAPTEE XXV. THE SPECIFIC TEEATMENT OF PHTHISIS. CHAP. XXV. Specific treatment. The specific treatment of phthisis has naturally received much attention, and very many remedies have been in turn proposed, tiied, and abandoned, which have been supposed to possess a direct antagonistic power over tubercle. An enumeration of these means would show the various theories which have induced their trial, but could not add much to our knowledge of the disease or to our faith in drugs. To some, indeed, no theory whatever has been attached, and such are merely the jresult of a blind empiricism. Even down to the latest date, however, are to be found men educated in patho- logical science who uphold that certain substances possess the required power, and that, if their adminis- tration be only timely and sufficient in quantity, a cure may be effected. That these articles include the most widely-differing agents, every form of chemical opposite ■ — acids and alkalies, every variety of vital alteratives, sedatives, and stimulants ; promoters of absorption, as mercury and iodine ; direct nutritives of the blood, as oils and iron ; and feeders of special tissues, as phospho- rus — is well known. To us the question remains, not from which of these classes we shall select a remedy, T^ut whether any specific is likely to be found which shall possess the required powers. The above have been tried again and again with THE SPECIFIC TREATMENT OF PHTHISIS. 377 only disastrous results where cure is regarded, and with chap. no certified specific action in any case. This may seem >- . ' - a bold assertion, but its truth is recorded in many a failure, and it can only be denied by the ignorant or interested. It is, indeed, curious to observe how specific medicine is declining. Even syphilis, for which we seemed to possess a formula of undoubted power, and of such universal application that the practice of all countries had agreed on its use, has ceased to be treated with mercury, and we have lived to see able observers and good pathologists recommend that this powerfid. drug should in no case be resorted to. Nor has the iodine treatment more advocates, while such remedies as sarsaparilla and nitric acid are almost obsolete. Perhaps no drug has held its place and sustained its character like quinine, and doubtless with reason, but its antiperiodic powers are lately much less believed in. Certain remedies of short-lived fame, like the Sarra- cenia purpurea for variola, have been heralded as possessing great powers, tried, and abandoned. That the philosophic spirit of the day is opposed to the doctrine of specifics is very evident ; yet, with an experience that there are fashions in medical practice as in all other things, we shall do well to content our- selves with a modest and moderate adhesion to the doctrines of this or of any time. We are apparently in a transition period of unbelief, and it is possible that we are not looking at or for remedies with anything hke the earnestness with which our ancestors sought them. The foundations of medical science are, in fact, undergoing rearrangement. Our knowledge of structure, of function, and of vital changes, was found to be partial or incorrect, and, doubtless for sufficient reasons, the attention of the profession is being directed with all its keenness of observation to a 378 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, rectification of these important ground-works of all . ■^^^^' . medical science. Diseases have changed their names as different struc- tural alterations have been discovered, and we are no longer led by nomenclature as we have been, knowing that it is doubtful how long the most approved can stand the test of observation. The individuality of disease is getting to be doubted also. Formerly it was the organ affected, or the de- posit in tissues, or frequently only the secondary effects of deeper causes, which gave a name to the disease. ISTow, as a higher research ascends the vital chain of causation, we detect earlier deviations from health than those which become manifest in the more active symp- toms of disorders, or even in the post-mortem examina- tion ; and we are compelled to doubt the accuracy of the title which more superficial observers, with lower powers than our own to assist them, may have given to the disease we have to treat. Nothing can more shake our confidence in specifics than this shifting of the seat or primary cause of disease as an accommodation to the views of later investigators, for the essential condition required for the action of a specific is that it shall address itself to an individualised and perfectly certified affection. If the disease be not really what was supposed, but some aberration higher up in vital changes, our specific loses its application ; and just in proportion as the powers of the remedial • agent are defined, so does it necessitate for its success- ful use a definite and certified malady. Thus it would appear that the changes in pathologi- cal definitions, which are necessary results of increased knowledge, have interfered with our faith in specifics. But something higher still in our recent advances opposes the doctrines of specific medicines. Vital changes are not single, but multiform. There is, per- haps, no isolated and perfectly unassociated morbid THE SPECIFIC TREATMENT OF PHTHISIS. 379 phenomenon in the whole history of disease ; and chap. probably there exists no single cause to which, as to — r— a fountain-head, we can refer any deviation from health. This is certainly true of organic changes, if less apparent in those which we call functional. How, then, shall remedies of single operation address them- selves to a multiform origin of disease ? Nor is the seat of morbid actions so defined as to afford an iso- lated mark to the best directed specific remedy. To take pulmonary tubercle as an illustration. It is a compound body, imbedded in a complex structure (the lung) whose vital relations and reactions supply the real events of its history in the economy. Suppos- ing the deposited ^tubercle to constitute the disease (which it does not), its reactions on the system are to be represented by pulmonary irritation involving all the tissues of that complex organ, and reflected on its nervous and vascular relations, which are extremely complicated and exceptional. But supposing the de- posited tubercle to be, as it really is (and not as it seems to be), not the disease itself, but a secondary, or it may be a tertiary, result of pre- existent systemic disorder, of grave alterations in the assimilating pro- cesses whereby blood becomes structure ; or, higher stiU, of blood-making in its vital sources, in which are implied sound innervation, perfection of various secre- tions, and vitahsation of many constituents ; we are lost in the attempt so to define the fontem et originem of disease as to adapt the most cunningly-devised remedy to the condition to be altered, assisted, or reversed. From considerations such as these, the philosophic mind of the day will not readily assent to any proposi- tion implying a direct assault on the supposed seat of any constitutional malady — and all organic alterations originate in constitutional disorder. We may seem to some to narrow the limits of action of our remedies ; 380 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, but the first step in such an enquiry as the present is v_ ,-J_ to define what it is possible to do, and that which clearly hes without the domain and province of art. Our next is, doubtless, to ascertain whether, if com- bined vital actions in their aberrations from healthy unison cannot as a whole be changed by any remedy, we may not be able to modify single and well-recognised deviations by certain well-selected agents. And here, if anywhere, are to be found the hopeful indications for treatment in a constitutional disorder like phthisis. That medicinal agents have certain special powers is not to be denied. It is their capabihty of remedying certain diseases in their nature complex, and not their abihty to efiect alterations in. given conditions of vital actions, against which we contend. Thus, a deficiency of red corpuscules can doubtless be remedied by iron, and the fatty tissues can be nourished and a richer chyme prepared by the use of fish oils, and old deposits of inactive character can be rendered more susceptible of organisation and therefore of removal, and absorp- tion of the plastic exudations of inflammation can be stimulated and hastened, and excessive secretions can be restrained and so waste prevented ; well-selected tonics may be addressed to and will reach the muscular apparatus of the hollow viscera, and the nervous system be strengthened by the same remedies. Or by a nu- merous and valuable class of agents, the direct seda- tives, we can lower nervous susceptibihty to reflex impressions, lessen the respiratory requirements of the system, diminish nervous waste, and vastly assist in restoring our patient to a condition favourable for the resumption of the vital actions which constitute health. By the use of these various agents pain may be reheved, nutrition reinforced, the blood may be fed, and the nervous system invigorated, excessive secre- tions and muscular waste may be arrested ; and if any .'THE SPECIFIC TREATMENT OP PHTHISIS. 881 of these indications be fulfilled by our remedies, we chap. shall not have been engaged in a vain struggle with . ^^' . disease. A large number of organic affections derive their leading features from local inflammatory actions. In combating these by local depletion and repeated coun- ter-irritation, we are ministering to the arrest of the disease itself; for if the inflammatory element could be deducted from these constitutional disorders, a most important advance would be made towards their cure. 382 ELEMENTS OF PKOGI^OSIS IN CONSUMPTION. CHAPTEE XXVI. THE DIRECT TREATMENT OF PHTHISIS. The Premonitory Stage. CHAP. This has to be considered with reajard to the different XXVI. o" varieties of the disease, and its various stages. Direct jjj considering the ' premonitory stage ' of phthisis stage The pre- ' "^6 cannot consent to a definition which includes any monitory manifest changes in the physical condition of the chest. It has been argued that feebleness of respiration, and slight general dulness of the percussion-note, prolonged expiration, with some impairment of the mobihty of the chest walls, are characters which accompany the ' pre- tubercular stage.' But these are some of the actual features by which we recognise an already established deposit. Where, then, shall we draw the line.^ or, can we, to suit a theory, presume that with these altered physical conditions there does not already exist some amount of structural disease ? But when to the above physical signs we add the symptoms which are said to distinguish such ' premonitory stage,' viz., haemoptysis, cough, and progressive emaciation, we find ourselves at once in the presence of the history of established tubercular disease. Short of actual demonstration by post-mortem examination, there can be no proof of this group of physical signs and of symptoms being present without any deposit in the lung. This early period of threatened or established tuber- cular disease has also been designated ' the remediable THE DIEECT TKEATMENT OF PHTHISIS. 383 stage of consumption.' If remedy mean cure, it becomes a matter of experience whether this stage of estabhshed disease (as we beheve it to be) is more capable of entire removal than any of those later in the history of the affection. When tubercle is once estabhshed as a deposit, its absorption, or cretifaction, or softening and removal, with ultimate cicatrisation of the cavity, are possible events, as we have seen. But these occurrences are rare, and cannot be reck- oned on in ordinary practice. In the preceding pages cases have been given illustrative of each of these events; but the whole experience of the writer goes to prove that every stage of phthisis is ' remediable ' in the common and true sense of the word, and that to apply the term to one early and, necessarily, limited period of the affection, is to contradict the daily testimony of expe- rience. Let us boldly say ' curable ' when cure is meant, and the expression cannot be confined to any stage of the disease. But, while all that is helpful by restoring the weakened processes of nutrition, by abating the congestion of the lung surrounding the seat of deposit, by lessening and controlhng every drain on the system, and by exalting the nervous vitality of organs, is at our command in every stage of phthisis, and is found serviceable in arresting the destructive progress of tubercle, whether as a deposit in the process of softening, or in the achieved mischief of cavity, we cannot consent to limit the term ' remediable ' to any stage of the disease. In a former chapter we have dwelt on the features which distinguish the period preceding deposit in the lung, and it has been argued that alterations in the nutrition of the body are in every instance, excepting in acute phthisis, the forerunners of tubercle. We cannot draw the hue, nor say with certainty when local disease has taken place ; but the earliest appreciable occurrences in the history of the disease are emaciation 384 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, and a subfebrile state. This statement is not offered as > — , — '^ a theory, but as the simple result of unprejudiced ob- servation. It has not appeared that appetite is much impaired at this period, or that the loss of flesh can be attributed directly to diminution of the quantity of food taken. Men grow thin and fall into phthisis, who are partaking daily and largely of food of the best quality, containing every element necessary for its con- version into healthy blood. It is not usual to find appetite impaired in this earhest stage, at least to an amount which could at all account for the emaciation. The primary changes of digestion are generally suffi- ciently complete, but the secondary and higher vital- ising actions by which food is made into blood, and blood becomes tissue, are not performed efficiently. It has not appeared that ' ehmination ' is, as a rule, so excessive as to account for this early emaciation. There is generally an access of severe sweating, a febrile access, such as occurs in the later stages as the result of irri- tative action, but this subsides. The skin is not always moist, on the contrary it is often dry, and the pores seem closed, and dry heat is very commonly complained of. Guiding The principles which should guide us in treating this principles, constitutional disorder appear to be the following : — 1. To promote healthy blood-changes. 2. To maintain full respiratory action. 3. To eliminate morbid matters from the system. 4. To supply the largest amount of the most nutri- tive food which can be digested. Topromote 1. The promotiou of healthy blood-changes is best biood^"'' accomplished by exercise. The active renewal of tissues changes, ig , Stimulated by their waste in a normal exercise of their functions. The intimate changes between blood and tissue, in which the former is raised into a higher grade of vitality, are constantly going on. But their rapidity and perfection is dependent above all else on a due exercise of the vital functions which are appro- DIKECT TKEATMENT OF PHTHISIS. 385 priate to the tissue. Should muscle be employed, we chap. are aware that its circulation is increased, its growth JE^ accelerated, its bulk enlarged, and its innervation raised by the very fact of its activity. Thus the arm of the blacksmith, the legs of the runner, and the chest muscles of the athlete, increase in size and in power. A more rapid conversion of the nutritive material is effected, and a more rapid waste takes place. If these processes are balanced, the system is no gainer, but an excess of the nutritive over the expending actions is so invariable, that greater volume of tissue is an almost constant result. This increase of bulk is, however, but the end to which a series of vital actions lead. 'tIio final step by which the corpuscule deposited is assimi- lated to the actual form of the tissue to which it is applied, is only the terminal and culminating event in a series of nutritive actions. Backwards in the chain we can recognise increased innervation, stimulated cir- culation, improvement in the quality of blood formed to meet enlarged requirements, secretions increased from hver and pancreas, respiratory movements and results augmented, till tJie stimulus reaches the organs devoted to the supply of the primary elements necessary to nutrition. Here the purely gastric and preparatory processes are stirred into activity, and chyle and chyme are prepared of a higher quality, while the demand for food is exalted. These results of bodily exercise are far from theoretical. Let anyone accustomed to the sedentary occupations of town life take an autumn holiday in mountain scenery, and mark the results as he daily increases his muscular activity. At first there is fatigue, because he has drawn on his ordinary powers supplied by his ordinary recruiting forces. But back- wards in the chain we have traced, his innervation, sanguification, and appetite increase, till every vital process is quickened, and with enlarged demands, his system is stimulated to produce a greater quantity c c 386 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, and a much improved quality of nutritive blood. . XXVI. Temperature rises, the colour of the surface becomes ruddy, respiratory changes are increased. He is throw- ing off more water from the skin and lungs, and more carbonic acid. The bowels become inactive, on account of such diminution of water. But voluntary and or- ganic muscles alike improve in tone and in vigour, and the heart's action is strengthened, at the same time that the muscles of the limbs become fuller and firmer. By daily exercise pushed to the verge of fatigue, every vital action is stimulated. Such changes have been attributed to the absence of city habits and of city cares, but no one who has tried these experiments on himself can doubt the improvement in vital powers, nor that it is due both to the removal of unhealthy influences, and to the organic changes being stimulated into activity by abundant exercise in fresh air. In this so-called ' premonitory stage ' of phthisis, where the symptoms we have to combat are diminished activity of vital processes, leading to "the formation of an imperfect blood plasma, and secondarily to all the phenomena of lessened nutrition, we say let the patient take daily exercise of an active kind in the purest and most bracing air, and let muscular waste be stimulated, in order that muscular enlargement and nutrition may be increased, and that all the vital processes concerned, eliminative and reparative, may be alike roused into activity. For this purpose exercise in the open air is impera- tive. The atmosphere respired should be pure, dry, and bracing. If the season be summer or autumn, an elevated locahty with the perfect drainage natural to a sandy soil or a greatly inclined surface should be selected, and in order to encourage increased respi- ratory effort and expansion, a hilly or mountainous neighbourhood is the best. Dryness of air, promoting perspiration and pulmonary exhalation, is also most DIRECT TREATMENT OF PHTHISIS : PREMONITORY STAGE, 387 desirable, and within certain limits, a lessened bare- chap. metric pressure is desirable. It will at once be seen ■ ^^^^- . that these requirements cannot be met by a residence in a very hot climate, for here we have increased rare- faction of air, with no diminution of atmospheric pressure. Even in India and Jamaica, however, the relief obtainable in consumption by rarefaction is great, although temporary. Happily, we can find nearer home localities well adapted for the ends proposed. In summer the Pyrenees and Switzerland offer exactly the conditions required, and of these the former is pre- ferable, for the climate is more uniform, and, excepting in the lowest and most sheltered valleys, the tempera- ture is not excessive. But Scotland, Wales, and our Lake District afford almost all that is necessary. High mountain ascents are not only unnecessary, but would be injudicious, as taxing both muscular and respiratory powers excessively. But wherever there is a high, sunny slope, and bracing air to be got at, let our threatened consumptive ascend it, slowly at first, but with a daily increase of the time and labour spent in the achievement. The exercise of the upper extremities and of the chest muscles is also most advisable. Walking, which is the mode proposed, and happily is within the reach of every one, implies a certain activity of arms, but it is not sufficient, and exercises of a gymnastic kind, gradually increased, are to be diligently used. It is well known that such muscular movements of the upper half of the body will more rapidly and effectually strengthen the digestive processes, than an equivalent amount of walking. Eowing, if practised in moderation, is an excellent mode of improving the arm and chest muscles. Should the season of the year not permit of out- of-door amusements of this kind, dumb-bells at home, and some of the well-contrived apparatus for arm c c 2 action. 388 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP, and back exercise should be daily made use of in the -— T — l-- house, and with open windows, even in winter. We shall thus promote muscular and respiratory changes together. 2. To maintain full respiratory action. To main- This is the second indication, and it seems almost ratory ^^^" part of the first. Although, however certain means may be adapted to answer both requirements, respiration having different ends to fulfil from any merely muscu- lar part of the animal frame, must be considered and provided for separately. Within certain limits the vital and chemical changes due to respiration are increased in proportion to the frequency and fidness of the pulmonary expansion. This is explicable without adopting the doctrine that there is partial collapse of the Inng-cells, and impaired elasticity before the deposit of tubercle. The broad fact is most evident to all enquirers, that the sedentary occupations which imply a shallow and imperfect respira- tion are those which most readily induce consumption. Whatever be the nature of the disease, its most fre- quent seat is the lung, and the physiological law is true here, that the full and healthy exercise of an organ is the condition best calculated to maintain its struc- tural integrity. Even were there no chemical or vital phenomena dependent on respiration, the entire activity of the lung viewed merely as a tissue would be thus best preserved, that is, its circulation and nutrition would be at their highest. But when, in addition, the impor- tant changes of which it is the seat are considered, this necessity will be doubly manifest. The air-cells are capable of expansion to twice their ordinary volume, without injury to their elasticity, and we may presume that their respiratory capacity in a vital sense is raised in proportion. The undoubted fact noticed elsewhere, and confirmed by many observations of different authorities, that general emphysema of the lung is a rare combination DIRECT TREATMENT OF PHTHISIS : TREMONITORY STAGE. 389 with phthisis, may perhaps be taken to confirm this view, chap. or at least may be allowed as evidence that increased - " . ' - size of the vesicular cells of the lung is antagonistic to the deposit of tubercle. The modes of increasing the expansion of the lung are various. None is better than walking briskly ; climbing a hill may be next attempted ; rowing, run- ning, and horse exercise, if not carried to excess, are highly useful ; and for feeble persons the first attempts may be made at home, by reading aloud, singing, and the practice of sustaining a note preceded by a deep inspiration, and of course followed by one. The practice of making deep and forced expansions of the chest, which can be taught to most persons, has been highly recommended by Dr. E. Smith, Piorry, and others, and fulfils the same indications ; but this ought to be an addition to, and not a substitute for, brisk exercise in the open air. The playing of wind instru- ments has been advised, with the same view. We have had some cases at the hospital which seemed to favour their use, but the impression left was that the practice was often productive of hsemoptysis, thus evidencing a tendency to induce congestion of the lung. We should hesitate to recommend it, believing that the same amount of benefit may be obtained by some of the other modes mentioned. Various instruments have been proposed to promote expansion of the lung, by increasing the mechanical difficulty, either of inspiration or of expiration, or of both. To those which interfere with the entrance of air, there are objections : the class which renders its exit difficult is more rational. Yet when deep voluntary inspirations can be practised in pure air, or when some of the exercises proposed are equally efficacious, and ad- ditionally recommended by their exhilarating effects on the patient, we presume there can be no question which are the more suitable. 390 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP. 3. The elimination of morbid matters from the system viE^,_L- IS of highest importance theoretically. Practically we Eiimina- are oftcn at fault, even when the indications are most morbid marked, for rehef in this direction. The pathology of matters. ^]^g present day favours the idea of matters retained or generated in the circulation, which either act as poisons to the system, or interfere with its normal actions. When we come to examine the modes of exit which are open to them, and when we analyse the secretions which they may be supposed to influence, we are com- pelled to admit our comparative powerlessness in re- moving these morbid products. The truth seems to be, that the excretions of the body are the products of the food ingested, and of the detritus of normal tissues, rather than the poisons which induce disease — if indeed any organic affection be due to a specific contamination of the blood. It is probable that two things at least are needed for the production of organic alterations — disordered blood constituents, and local impairment of some one organ whose actions are normally connected with the assi- milation of such constituents in time of health, or their ehminatioh in diseased conditions. Difficulty ^^ considering the healthy action of the secreting in altering visccra, wc are struck at once with the difficulty of of secre-^ ^ adding any constituent to the usual matters which it is tions. their office to separate from the blood. We can more easily increase the quantity than alter the quality of such separated material. Thus, diuretics will stimulate the kidney to a greater secretion of water, but the other constituents of urine are less affected by such stimuh ; and we are wholly at fault when we endea- vour to procure the elimination of other than the ordinary healthy ingredients. Unless, therefore, such poisons as we presume to exist in the blood can be converted into urea or some of the other forms of the egesta bv this organ, the proofs of their removal by DIRECT TREATMENT OF PHTHISIS : PREMONITORY STAGE. 391 tests and other modes of appreciation are exceedingly chap. difficult, if not hitherto impossible. '^^ ' The skin, in addition to its ordinary exhalation in health, may be forced to give out some of the constituents of urine ; and it is likely that as an occasional agent in the removal of matters not contained in its ordinary secretion, it is capable of affording greater relief to the system under extraordinary conditions than even the kidneys. We are led to this conclusion from the con- sideration of the natural processes of many diseases manifestly of blood origin. Thus the poisons of scar- latina, variola, rubeola, and of syphilis, seek an exit on the epithelial surface of the body. The ancients looked chiefly to the skin for elimination, and the criti- cal sweats and external abscesses of which we read were regarded as purifying processes, by which the blood was freed from contamination. The internal mucous tract, which is so clearly allied in structure and in function to the skin, is also an eliminator. The lungs perform the office of exhalants ; and, as we know, are the medium of the oxygenising changes between the atmosphere and the blood. But doubtless other matters, too subtle for our analysis, are constantly passing out of the body through this channel, which is unceasingly at work. The system, as a whole, presents an invulnerability to external agencies ; and being compelled to exist in the presence of so many poisons, atmospheric and contagious, exercises not only a re- pellent power, but is also endued with the ability to give off these noxious agents from its various emunc- tories in a harmless form. Else how should we con- tinue to exist in the midst of the various contagions to which we are daily exposed ? With every breath the subtlest elements of destruction are drawn into the interior of a sensitive membrane engaged at all times in absorptive processes, yet still we are safe ! Yet, after a due consideration of the repellent power 392 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, and the eliminative actions, we stand compelled to XXVI. ^Qnjgj. at the hnpermeability of vital processes. The agents by which we compel increased secretion address themselves to the habitual, but leave untouched the occasional products of the blood ; and while we can stimulate the former almost to an unlimited extent, the latter remain unaffected in face of our most powerful remedies. Vital chemistry is more potent than any inorganic reagent which we can bring into contact with it ; and the body returns our most active drugs un- changed through its ordinary outlets, or stores them up in its organic structures unaltered, and so httle oxy- dised that their solution is impossible. Thus, mercury, antimony, and other metallic remedies, to which we look for most active results on organic life, are found long after their administration imbedded in the viscera. We can, however, gather from a study of natural processes, that the system in its attempt to disengage itself from organic poisons, makes a violent effort, evidenced by much constitutional disturbance, and in eruptions, increase of watery secretion, and in acid and other additions to the natural constituents of per- spiration ; and by conversions into oxalic acid and urea, endeavours to throw off something offending the system. From this it is proposed to gather the indication that nature should be imitated, and that the skin should be called into eliminative activity in the threatened stage of phthisis. We have fairly stated above some of the difficulties which attend this question, and the subject has not yet been sufficiently investigated to permit of more than surmises, but it seems most likely that good may be effected by various modes of promoting elimina- tion from the skin. Amongst the means most adapted for this purpose, the hot-air bath is the most efficacious. In a short ^ TT e we hope to give it a more extended trial, but as DIRECT TREATMENT OF PHTHISIS : PREMONITORY STAGE. 393 yet only a few cases have been subjected to its full use. chap. • XXVI Through the kindness of Dr. Leared,* we have been < , — i- permitted to examine several patients who have under- 7"^?^^®^ gone prolonged courses of the Turkish bath. They were all in the stage of softening tubercle. The results may be briefly stated to be, that the progress of soften- ing was checked, the moist crepitant sounds were replaced by a dry crackle over a less extended portion of lung, and the hectic sweatings ceased. These men were exposed to a temperature of dry air at 125° to 145° for from five to eight hours daily. They were pale, but their average weight was not diminished, and excessive waste appeared to be checked. The regu- lated use of this agent may be found beneficial in the treatment of the ' premonitory stage ' of phthisis. The remedy must not be pushed so as to induce exhaustion, nor must the seclusion in hot chambers be carried to the extent used in the above cases, for the deprivation of fresh air and of light is a serious loss to the patient. As a means of eliminating through the skin, it may also be fairly doubted whether these baths can compare with brisk exercise in the open air. From personal experiments, we believe not ; and have found that aU vital processes are more increased and invigorated by muscular exertions than by the stimulant of heat applied to the inactive body. In considering the means at our disposal for removing Mercury. a supposed noxious agent from the system, at a time ° ^^^' when our theories and observations point to blood con- tamination, but not yet to established local disease, we are naturally led to notice the presumed action of such agents as mercury and iodine. Our experience would lead us to avoid the employment of these in all cases of lowered vitality. The action of mercury in breaking * For Dr. Leared's cases of phtHsis treated by the Turkish bath, see Lancet, Nov. and Dec. 1863. 394 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAP, up tissues, and, as some assert, in causing the destruction ._ . ' ^ of blood corpuscles, seems directly contrary to all the indications in such cases, and in practice it is found to depress the nutritive powers. As an alterative and absorbent, iodine has its uses in certain cases of established phthisis, but in the stage we are now con- sidering it is less serviceable ; nor after many trials can we offer any facts to prove that it possesses specific powers in arresting the blood changes which lead to tubercle. Nutritive 4. To Supply the largest amount of the most nutri- tive food which can be digested. In the majority of cases a fair average appetite is maintained in this stage, unless during the actual febrile access, and in instances of acute or continuous phthisis. With long-continued impairment of digestion, the prog- nosis in the premonitory period must be bad ; but, under ordinary circumstances, a fair amount of food can be taken. To quicken the assimilating processes, it is far better to excite by creating a demand for food from having taken exercise than to trust to a tonic. By such exercise as has been described, we can generally manage this. A steady effort must be made on the part of the patient and his friends to have frequent moderate quantities of highly nutritive diet made use of. There can be no question that the blood must be fed with all the constituents necessary for the support Milk. of the organisation. For this purpose, milk stands at the head of all other food, being easily assimilated in most cases, and containing a large quantity of nutri- tious material. Bread, with milk, eggs, and fresh meat, twice in the day, with a due admixture of green vegeta- bles at the proper season, may constitute the ordinary diet. In certain instances, however, milk may form the chief article of food, and we have witnessed cases in which seven or eight pints have been consumed in raism. DIRECT TREATMENT OF PHTHISIS : PREMONITORY STAGE. 395 the course of the day with remarkable benefit. Other chap. food was, of course, taken in less proportion ; but on . .\ L. this plan we have known twenty pounds in weight re- gained in six weeks without the administration of any medicines. To pass a large quantity of food into the blood, and thus to enforce a more frequent renewal of that fluid, is one of the objects effected by a very full milk diet. The skin and kidney functions are at the same time quickened. Even a very feeble digestion may be encouraged to take up milk in increasing quantities. With a view to encourage rapid blood alterations, ' cure da the ingestion of large quantities of grape juice has been recommended, and this mode is carried out to a very large extent in many parts of Switzerland. It is not for a moment to be supposed that persons undergoing this system consume nothing but grapes, for a tolerably liberal bread and meat diet is allowed. Good effects doubtless follow in many instances, but as a nutritive ao-ent milk must stand much hiofher. Indeed, the con stituents of grape juice are insufficient to maintain animal life. In our judgment, no better plan could be adopted in threatened phthisis than (where means and the season of the year permit) to take up a summer residence in the Pyrenees or Alps, in some of those numerous open valleys in the pure air of the middle region, where the pastures are rich, and with daily ex- ercise in proportion to strength, and gradually increased, to try the daily ingestion of large quantities of milk of the purest quality. The medicinal agents which feed the blood are not oii. to be forgotten. Cod-liver oil and iron are among the ^'^°"* chief of these. The counter-indications for these are a furred state of tongue and nausea for oil, and a febrile state for iron. But where there is exhaustion and waste of tissue without fever they are of great value, and should never be omitted. The waste of the fatty 396 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP, constituents of tlie body is well and rapidly supplied ■ ^^^- . by oil, and the known deficiency of red globules in phthisis ofiers a decided indication for the use of iron. Chalybeate waters, which contain exceedingly minute quantities of iron largely diluted, form a favourite mode of administering it. The injection of so much fluid Dangers of bcforc food has oftcu injurious effects, and we have seen ^^°°' the waste of flesh rather increase under their use. Again we have known the tubercular attack precipitated by chalybeates taken while the febrile access was marked. But with certain cautions, many cases benefit by their use, which should be under medical, and not empirical management. Of all the preparations of iron, it has appeared to us that the sesquichloride is the best, producing the characteristic eflects proposed in a shorter time, and with greater certainty than the others. It will be remarked that, in considering the treatment of this premonitory stage of phthisis, we have dwelt rather on the resources which are derived from an observance of the natural rules of health, than on those which are found in the use of drugs. In the absence of proved specifics possessing undoubted power over blood changes and the more obscure processes of nu- trition, we are compelled to assign the highest place to the means which are placed within the reach of all for the maintenance and restoration of vital functions. So long as secretion, elimination, and the normal growth of healthy tissues can be promoted by exercise, fresh air, and nutritious diet, we are bound to assign to these the highest place as restoratives. Whether the tuber- cular deposit be the residual matter of an inferior quahty of blood, an excess of crude material which the enfeebled system cannot raise into organisation, or an altered form of existing tissues, it is evident that the events on which depend the formation of a perfect blood plasma, are those to which our remedial eflbrts DIKECT TKEATMENT OF PHTHISIS : PREMONITORY STAGE. o'J must be addressed. When sucli deposit has occurred, chap. . . XXVI the local symptoms immediately rise into importance ; -- — , — 1 but up to the moment of that event, all that can enable food to be converted into healthy tissue should be dili- gently sought for and supphed. 398 ELEMENTS OF PROGNOSIS IN CONSUMPTION, CHAPTEE XXVII. TREATMENT OF THE DIFFERENT STAGES OF PHTHISIS. THE FIRST STAGE. CHAP. The local symptoms rise into importance from the -^ — 1, — i- moment that we can by physical means certify the ex- "^f^l*™^"^* istence of deposit in the lung. first stage. In Studying the earliest signs of such lesion, it will of°thr*^°° be evident that they are due to congestion of the lung, lung. The amount of deposit at this period is in ordinary cases too small to account for the extent of interfer- ence with respiratory space, which is indicated by the amount of dulness on percussion, and lessened respiration. The symptoms also, and very commonly haemoptysis to some extent, indicate considerable pul- monary congestion. It has become evident that vesi- cular portions of the lung are blocked up, and that pressure is exercised on the vessels supplying it with air and with blood. The results of local depletion evidence the same fact, for a considerable amount of dulness at the apex can be removed by leeching or cupping. It is obvious that under these circumstances the tubercle is not absorbed, and our experience tells us that the congestion can by such means be removed. While, therefore, we never forget that we are deahng with a constitutional malady with local results, our first care in this declared stage of lung disease should be to remove congestion. In every stage of tubercular disease of the lung, the pulmonary irritation has to be regarded as the cause of TREATMENT -OP TflE FIRST STAGE. 399 a large proportion of tlie symptoms. The constitu- chap. tional disorder often pauses when the local begins, and - , '-^ with the effusion of a crop of tubercles, we may find that we have in practice to oppose a localised pneu- monia. Local depletion cannot be too strongly urged Local de- as the necessary, if not the sole, mode of relief in the ^ ''*^°°' early days of a declared deposit in the lung with irri- tative fever. The common case of a florid hasmoptysis, with high pulse, a daily febrile access and sweating, where dul- ness and feeble respiration, with prolonged expiration, are ascertained to exist at one apex, ought to be actively treated by local depletion, followed by counter- irritation. A few leeches, followed by the cupping Treatment, glass over the seat of dulness, saline medicines, perfect repose, and a non-stimulant diet, offer the best chances of ensuring quiescence of the deposit which has already taken place. At this period it is vain to put in practice the system of feeding the blood which we have advo- cated in the premonitory stage. Our question is whether this local irritant shall proceed to destructive changes necessarily involving the lung, or be tranquil- lised into the condition of a foreign body tolerated in a vital structure. On this depend our hopes of chronicity, and the chances of absorption. Absorptive Absorption processes do not occur so long as local irritation re- Jent with mains. The changes for which we look in the most lo^ai irri- tatiou hopeful condition of deposited tubercle only take place when pulmonary irritation or inflammation has ceased. Cod-liver oil and iron, with tonics, cannot control or immediately alter the. deposit, nor prevent its remain- ing as a mechanical irritant. Neither can the stimulant and supporting treatment so commonly applied to every affection involving exhaustion of vital powers, be here available, or indeed be regarded as other than mis- chievous. Eegarding acute phthisis as the typical form of in- 400 ELEMENTS OF PROGNOSIS IN CONStTMPTION. CHAP. XXVII. Oil and tonics not to be used till the lung irri- tation subsides. The first pause. cipient deposit in the lung, it may be truly said that in no instance have cod-hver oil and stimulant tonics proved of service. Their use is great when the local irritation has subsided, and the constitutional ex- haustion remains as the leading condition to amend. The great error of the present day is to regard the former at least of these powerful remedies as a specific applicable to every stage, as striking at the root of the disease ; whereas all our experience goes to favour the view that the beneficial results which may fairly be traced to its use are referable to its action as a feeder of the blood, and its local effect in rendering an unorganised deposit more amenable to the vital processes which in- fluence its favourable transformation or removal. When the local irritation has subsided, and the febrile symptoms lessen, the pulse sinking to a natural standard, and the digestive system becomes improved, as evidenced by a cleaning of the tongue, oil may be commenced with the best effects. Its use is perhaps best preceded by the lighter tonics, to which an alkah may with advan- tage be added. This is better than administering at once the preparations of iron. The common mistake is to proceed to the exhibition of restoratives while an amount of irritative disturbance is going on which in- terferes with the normal nutrition of the body and with the assimilation of the constituents which we desire should obtain an entrance into the blood. At this period, when the first pause has been reached in the onset of the disease by the subsidence of local irritation, we find our patient somewhat emaciated, and the blood partially drained of some of its vital consti- tuents, the tissues flabby and scantily nourished, owing to insufficient vital changes, whilst organic life is in- vaded, as it were, only at one point. The respiratory organ is crippled but not disabled, and if we were to measure the mischief inflicted by the amount of the mechanical result, we shall find that vital capacity has TREATMENT: FIRST STAGE. 401 been diminished only by a hundredth part of its vohnne. We have abundant evidence that hfe can be well sus- tained with much less breathing-space. It is, therefore, not to this that the threatened danger is due. Could we for a time stop the movements and suspend the peculiar functions of the lung which is the seat of the deposit — could we treat it as we do an external part of the body, by rest and remedies which relieve local con- gestion, — we should find little difficulty in reducing tubercle in the lung to the inert condition of a gouty deposit in the joints. The peculiar vital endowments of the lungs which prevent this isolation and repose, and the constitutional disorder which has led to the deposit, have, therefore, to be mainly considered in directing the treatment of the first stage of phthisis. After such local irritation has subsided, we generally find that the system is in a condition to take up nutri- tive matter very actively. We often witness at this stage a rapid increase in sanguification; the patient regains weight and colour, the secretions become mode- rate, and an average of healthy function is attained much beyond that which has prevailed for many months. It is remarkable with what ease the blood may be fed, and all the natural indications are for abundant nourishment, and such assistance as we can afford by oil, iron, and tonics. We cannot speak too highly of the adjuvants of open air, full exercise, mental employment short of fatigue, the cold sponge-bath, and an abundance of the more nutri- tive articles of food. By following this method, and by the use of prolonged counter-irritation, we have seen cases of the most threatening appearance become chronic, and in some instances the physical evidence of local disease disappear. It may, perhaps, be said, that it is aiming too low to make our object the induction of a prolonged first stage. But when we remonber the few cases in which DD 402 ELEMENTS OF PEOGNOSTS IN CONSUMPTION. ^^j a perfect cure is manifested, and that tlie conditions • — ' which promote toleration and chronicity, and retard softening of the deposit, are identical with those most • favourable to its absorption, we shall be better satisfied with the position which we decide on assuming. The physician should always attempt the highest ; but his experience and his knowledge should preserve him from supposing that this is the only result to which his art may be directed. Treatment of the Stage of Softening. Treatment In SO far as remedies reduce pulmonary congestion and congestion, inflammatory action, we can control by treatment the changes which constitute the second stage of phthisis. The process of softening seems almost incapable of being originated without increased afflux of blood to the neighbouring tissues. As is well known, tubercle may soften either from its centre or periphery ; and the latter would seem to be the most frequent mode. The symptoms accompanying the change are, irritative fever, evidenced by sharp pulse, chills, sweats, &c. The local condition is indicated by much dulness of the per- cussion note, moist sounds replacing those characteristic of the first stage, and which are probably due to capillary congestion, infiltrations of the ultimate cells, and bronchial rales m the more mmute tubes, rather than to changes in the tubercle itself. These latter, indeed, cannot at this stage afibrd such intense crepitant sounds as we generally hear. A haemo- ptysis frequently marks the pidmonary congestion. These moist sounds are capable of undergoing changes, and may not only be materially lessened by local depletions, cupping, and counter-irritation, but may pass into dry crackling sounds, the latter being very valuable indications of improvement. The treatment when softening commences must, therefore, be directed to the lessening of local con- TREATMENT: SECOND STAGE. 403 gestion. A few leeclies, and the subsequent application chap. of a cupping-glass, followed by a small blister or a -UL, — '^ strong solution of iodine, will be found most useful. An open blister may be maintained with great advan- tage for some weeks. The length of time during which the second stage may be prolonged is especially worthy of note, and for the whole of the period the sounds remain crepitant. We have pointed attention to this in the chapter on the second stage. It proves that where inflammatory action can be held in check, the coalescence of softened masses of tubercle, so as to form cavities of an appreciable size, may be prevented. It is in this stage that counter-irritation is especially useful. Wlien the constitutional symptoms subside, all the methods of improving general health should be adopted, as change of air, tonics of the more active kind, cod oil, and a highly nutritive diet. During the persistence of active febrile symptoms, oiiand such remedies as oil and iron are inadmissible. With missibie a hard and rapid pulse, much heat of surface, and hectic perspirations, these preparations invariably do harm ; and it is owing to their indiscriminate adoption at this period, that in some hands they have fallen into disrepute. It is when the pulse has subsided, the daily access of chiU or flush has disappeared, and the physical signs indicate a pause in the advance of the local disease, and especially when the crepitant sounds are becoming more dry, that these feeders of the blood are of value. During the prevalence of hectic, which especially accompanies this stage, cooHng remedies are most appropriate. The carbonates of ammonia or of potash , in effervescence are best borne. A hberal allowance of coohng drinks, with lemon-juice or tamarind, gives great relief The diet should consist chiefly of milk. Diet, fruits if in season (the grape, and our English straw- berries and gooseberries), light soups, fish, and the ■when fever exists. 404 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. XXVII. Eemedies for perspi- rations. Blisters. Iodine. lighter puddings with eggs. Meat is generally little desired by the patient, and its use should not be in- sisted on. Stimulants of the stronger kind should not be given. If the patient have been accustomed to wine, claret or hock is most suitable. The use of milk with Seltzer water is very grateful. To check the excessive sweatings, various remedies have been resorted to. Of these, the best in our prac- tice have proved to be the gallic acid and the oxyde of zinc — the first more active. The sulphuric acid, with or without quinine, is also beneficial occasionally. In certain instances, where the daily hectic chill was unusually severe and amounted to a rigor, we have used quinine in full doses (gr. iij. to gr. v., 3tiis horis) with advantage. In these instances, the access came with the regularity and severity which we have only witnessed in quotidian ague. It often differs from the latter in having no sweating, the heat of surface being intense and persistent for hours, but not relieved, as in the terminal stage of the marsh fever, by copious per- spiration. The patient suffers intensely, and feels ' burnt up.' The greatest relief is experienced from daily sponging with pure vinegar, which is best done after the early morning perspu-ation, and should be followed by a change of under-clothing ; and, if able, the patient should rise from bed. Finally, it is never to be forgotten that the hectic is generally a measure of the irritation of the lung. Frequent counter-irritation cannot be too highly re- commended with a view to its diminution. The open blister, the croton hniment, the strong* solution of iodine, and the tartar emetic ointment, will all be found very serviceable. We have not found them reduce vital power, while they eminently assist in lessening the Of these, perhaps irritative cough and the sweating. * !^Iodinii5ij. Potassii lodidi ^iv. Sp. Vini rectif. ^. applied with a glass brush. Solve. To be TREATMENT : SECOJS^D STAGE. 405 the iodine solution is the best : but it cannot be pretended chap. XXVII that by its external use any specific action on the system ^^^-^-, — ^ is obtainable. The dyspnoea which is a very common symptom in Dyspncea. this stage, is also best relieved in this manner. It would seem to be due rather to congestion of the pulmonary tissue than to the amount of tubercle de- posited, for it is very capable of a certain amount of relief by external irritant applications. Another cause for dyspnoea of the spasmodic kind is occasionally present in emphysema of the lung. This is best treated by such remedies as lobelia and sulphuric ether, while in certain cases we have seen excellent results from the iodide of potassium. Cough is such an invariable concomitant of the Cough, second stage of consumption, that by its relief we not ^^^ ^^^ only alleviate the distress of the patient, but by adding to his hours of sleep, his vigour and nervous tone are greatly improved. In prescribing for this symptom, the following points should be remembered : — 1. Where the cough is dry, frequent, and irritating. Dry. its seat is often found in the pharynx and fauces, and local remedies may give greatest relief. Of these, the gargle of tannin (3SS. to §viij.) and the solution of nitrate of silver (^ss. to 5j.) are the best astringents, being generally more suitable than local demulcents. 2. Where cough is due to active irritation in the Coymter- lung, counter-irritation or local depletion is the best "^" ^ ^°^' remedy. A small blister, followed by the endermic introduction of morphia, will often reheve most effec- tually. 3. The cough for purposes of expectoration, when Onexpec- the latter is not excessive, and characteristic of a bron- chial origin, should not be suppressed by remedies. Where bronchitic irritation is manifest, the secretion Bronchial. being frothy and difiicult, and the patient has a sense 406 ELEMENTS OF PROGNOSIS IN CONSUMPTION. CHAP. 'XXVII. Sedatives best for cough of phthisis. Morphia. of tightness across tlie chest, with dyspnoea, the best remedies are counter-irritation and small doses of tar- trate of antimony with alkalies. 4. The purely phthisical cough is best treated by sedatives, and these are better given without any com- bination with expectorants. Neither from theory nor practice have we any indications for expectorant medi- cines in ordinary phthisis. The cough is due either to pulmonary or reflex irritation, or to the necessity for getting rid of secretion. For the latter variety no remedy is necessary. Cough from irritation is often due to reflex action ; and gastric disorder is a frequent cause in some in- stances, an ulcer being present in the stomach. In such circumstances food is almost sure to induce a fit, and sometimes the stomach is emptied by the same act. Again, the constant repetition of harassing cough of a nearly dry character, which is so distressing to the patient and his friends, seems caused by an altered innervation of the larynx. In both these instances we have found, after submitting many hundreds of cases to various remedies, that pure sedatives gave most relief. Morphia,* from the twelfth to one-sixth of a grain, dis- solved in a little syrup, is the very best of these ; or morphia with hydrocyanic acid, or laurel water. A smaU bhster, followed by the endermic application of morphia over the larynx, often gives much relief. The inhalation of narcotics (as Ext. Conii gr. xv., Ext. Lupuh gr. xx.) has been found very useful. The tincture of cannabis, the tincture of aconite, and * Many thousands have used the foUovping preparations : — ^ Morphiae Hydrochloratis gr. iij. Sp. Pidegii ^ss, Syrupi Limonum Jijss. M. Ft. Syrupus. One teaspoonful for a dose, ^ Mucilaginis Acacise 5 v. Morphine Hydrochloratis gr. j. Acidi Hydrocyanici diluti (P. L.) Tr\^ xviij. Syrupi Limonum Jj. M. Ft. Mist. One tahlespoonful for a dose. TREATMENT: SECOND STAGE. 407 the preparation called chlorodyne, whose proportions chap. combine those of cannabis and of morphia, are also -^ — 1^ '-^ useful. The chloric gether seems less valuable than the pure sedatives, but suits many cases. The cough which causes vomiting is often best re- Brandy. lieved by a small quantity of strong brandy-and-water. It is also occasionally mechanical, caused by distention of the stomach, oppressing the diaphragm. In such in- stance directions should be given to take a limited quan- tity of food, and not to drink much fluid at meal-times. Eemedies of the demulcent kind often give a;reat Demui- cents relief. Of these the decoction of cetraria or of the Irish moss (so-called) have proved most useful. The former especially, combined with laurel water, will re- ■ lieve many patients who cannot take morphia or opium in any form. In all cases the tendency of sedatives to disorder the stomach, by stopping the secretions, and to cause secondary nausea and headache, is to be remembered, and a night's rest is not to be purchased at this cost to the general health. When the patient is liable to be thus affected by opium, the best antidote is lemon- juice, or a small cup of strong coffee taken on waking. The combination of camphor or of ipecacuanha with opium is also well known to counteract the disagree- able secondary effects of the latter. Tonics are not so Tonics, suitable in this stage of phthisis, when symptoms of suitable. active irritation are commonly present, as in the other more quiescent periods of the disease. They are more applicable in the limited and local use, for the purpose of rallying a flagging appetite, than when given with the intention of invigorating the general health. Very minute doses of strychnia often answer the purpose admirably. We have found a simple in- fusion of gentian, made of twice the usual strength, most useful. Iron is not a good ' appetiser ; ' but the calumba with which it is often combined will by itself 408 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, answer the purpose. As a rule, the simple vegetable ^^^^^\ bitters combined with an aromatic are better than the mineral tonics, when the tone of the stomach has to be reinforced. Cavity. Stimu- lants. Counter- irritation. Treatment of the Third Stage. When cavity has formed in the lung, if it be of the circumscribed and defined form, the other portions of the lung remaining comparatively free from tubercular deposit, there is commonly a cessation of the febrile symptoms and of the constitutional disorder, and the patient has an opportunity of recovering flesh and vigour, which should be taken a,dvantage of for the administration of the more active tonics and of cod- liver oil. We have already considered this condition- in the chapter on chronic third stage, and have only to repeat that all the indications are for a highly nutri- tious diet, and a fair allowance of stimulants suited to the age and sex of the patient. During the formation of a cavity of this kind, when the prostration was so great that hfe was threatened, we have in many in- stances had to give unusual amounts of stimulants, and have seen the most marked success follow their hberal Reference is now made only to the circumscribed use. cavity ; for if tubercular mischief be extending, tliis mode of treatment can only do mischief. But, under the conditions described, the patient should live on the hio-hest kind of nom-ishment, and take plenty of wine, egg, milk, turtle, and meat. It is in this case that counter-irritation is of such marked use ; and the best of aU modes is the seton. When the cavity has been fully formed and remains stationary in its limits, as evidenced by the physical signs beneath it, and when flattening of the chest-walls is beginning to take place, a seton should be placed over the spot. If this be objected to, an issue or perpetual blister is to be maintained. We TEEATMENT : .THIRD STAGE. 409 have very many cases on record which show the utiUty chap. of this mode of treatment, and must offer our testi- , '^ mony in its favour in addition to that of many ob- servers. One of these (Stokes) we may quote : — ' The patient's best chance I beheve to be the use of the seton and traveUing.' A small continuous drain, if it does not weaken the patient, may thus be maintained for years ; and many of the longest cases which we have witnessed have been so treated. The strong solution of iodine may also Idc used with great advan- tage, and should be painted on the affected side about once in ten days. The tendency of such cavities as these is to contract; their walls become lined with a species of membrane when the tuberculous mass has been softened and re- moved ; and in course of time the excavation is greatly reduced m volume — a result which is partly due to new fibrous tissue deposited around it, to the depression of the chest- walls from atmospheric pressure, and possibly to dilatation of the surrounding healthy air-cells of tlie lung. Active exercise in the open air, and gradu- ally increased efforts to expand the lung by such exer- cises as riding, reading aloud, and occasional forced expansion, when the case has become quite chronic, are the natural modes by which we may assist the curative process. The irregular cavity, which is in fact only a breaking-down of more or less of the infiltrated pul- monary tissue, generally involves such an extent of the remaining part of the lung, that continuity of the diseased process is almost certain. The third stage of phthisis, when attained in this manner, implies dis- integration of large and irregular masses of tubercle, with all their intervening structures. 410 ELEMENTS OP PROGNOSIS IN CONSUMPTION. CHAPTEE XXVIII. CLIMATE. CHAP. XXVIII. Climate. Change of air cannot The dis- ease not local. The following are submitted as indispensable considera- tions in selecting cases for removal to a different climate : — First, — As regards the local disease. It is impossible to cure tubercular disease of the lung by any change of air. It would seem almost unneces- sary to enlarge on the subject, were it not that the public, and occasionally an over-credulous practitioner, still cling to the idea. The disorder is not local, has not been caused by irritation of the lung or air-passages, and is not susceptible of cure by merely local remedies. Therefore, warm air, dry air, or any modification of atmospheric influences, can only act by lessening the complication of irritation of the bronchial membrane, which forms a single feature of the disease. If we had to deal with a single ulcer in the pulmonary tissue, we might expect much from constantly keeping the patient in a mild atmosphere ; but we have to deal with a tubercular ulcer and a tubercular state of the system, which is a very different thing. The ulcer in the lung is composed of tubercle in the stage of softening, con- gested pulmonary tissue, the remains of old inflammatory thickening, an altered mucous membrane, and in almost aU cases a thickened pleura. To all of these, excepting the last, the entering air is applied. It is true that this necessity of enduring a constantly renewed contact CLIMATE. 411 with the atmosphere is productive of irritation in the chap. • • • • XXVIJI hnig ; but this condition is an unavoidable necessity of — , — '- the circumstances of the organ which is engaged in the diseased action. In a carefully regulated temperature, Softening . "i ~ . *■ not re- if this were the only condition requisite, we should tardea by find the process of softening retarded, and the ulcer t^er^'^" assume a chronic form. But, with the largest opportunities for observing this Hospital condition, in a hospital with a regulated mean of 63° in ^^^^^^^ every apartment inhabited by the patient, day and night, we do not find softening of tubercle or spreading de- struction of the lung arrested or controlled. The causes which influence this process are evidently those which arise from within, and do not depend on conditions external to the system. In ninety-nine cases out of the hundred, the disintegration of an old deposit is coinci- dent with a fresh deposition of tubercle in the lung, which may be viewed as identical with a renewal of the constitutional affection. After much experience, we can declare that in the cases in which softening commences while the patient is within the hospital, it does not appear to arise in any degree from exposure to atmospheric influences. If even temperature, shelter from cold and damp, and a constantly renewed air could prevent softening, here we have the experiment tried on the largest scale. And what are the results .^ A cer- tain number of our cases, with the best care, undergo this destructive change. The symptoms with which this is ushered in and accompanied, when active, are so manifestly constitutional, that we are forbidden to refer them simply to the local irritation caused by atmospheric influences. When passive, they would occur, as we know, in any climate. Again, it is notorious that cases of soften- ing tubercle with febrile symptoms invariably do badly mm air in the ' mild air ' to which it is the fashion to export ^."favour- consumptive cases. In some oi the most frequented stage of foreign residences, we have witnessed many instances of ^"^^^^^'^S' 412 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, this stage being accelerated by the very atmospheric ■ . — '" conditions which had been sought for its retardation ! We appeal to the experience of the physicians of Ma- deira, Pan, and Eome, wliether this is not true. We maintain, therefore, that it remains to be proved that mild air can retard destructive changes in tubercle. It is true that the bronchial complications which so often distress the. patient may frequently be avoided by such removal ; but are these in general the forerunners of tubercular softening ? They are the inevitable conco- mitants ; but we must deny that, excepting in rare instances, they are the pathological phenomena which induce such changes. It is true also, that if congestion of the lung be induced by cold air and exposure in a case where tubercle has remained quiescent in the lung, the latter may be called from latency into activity ; but in practice this cause is quite exceptional, and, while it is to be sedulously avoided, can never be re- garded as one of those which should occupy a foremost place in the prudent calculations and preventive mea- sures to be adopted by a careful practitioner. Good The effects of change of air on the local disease are chanee*of ofi^''^ remedial; hut this is due rather to the qualities of air due to puritv and dryness, than to hiqh temperature. This is purity and . , . dryness. 9- fact cvidcut from experience. The relaxing climates, Bad effects wherc the air is loaded with moisture, and often with air.^^ ^^^^ malarious impurities (as in Eome), tend to promote se- cretion from the bronchial membrane, and to diminish its tone, and that of the elasticity of the contractile tissue of the air-cells. The object proposed by the older physicians, and by many even at the present day, was to maintain the respiratory actions of the con- sumptive patient at the lowest possible average, and to present such a quality of air as by its warmth and moisture should be easily breathed, but should excite the vital interchanges between the atmosphere and the blood as little as possible. The pathological views CLIMATE. 413 wliicli prompted this advice were based on the hopeless chap. character of the affection, on the impossibihty of so in- - — , — -' vigorating vital processes and the pulmonary apparatus itself, that the progress of disease should be arrested ; and on the kindly necessity of rendering the remaining hours of life as easy as possible. Arguing from the point of view that all cough is the result of bronchial irritation, and all bronchial irritation is the result of cold air, it was proposed to lessen this symptom of the disease, which was often taken for the malady itself, by immuring the patient in hot rooms at home, or by sending him to a tropical climate abroad. The results are well known. The patient at home died rapidly from respiring the impure and relaxing air of heated apartments, by which the destructive changes in the lung were encouraged, and his nutrition was impaired ; while the exported victims of a theory, after experienc- ing a temporary relief, speedily declined and perished. Such extreme experiments are now seldom tried, but we still find it proposed to send patients in the stage of irritative softening to Madeira, or some analogous cli- mate, with a view to relieve local irritation by the inhalation of mild air. How little success attends this removal the practitioners of Madeira are well aware, for no winter passes in which many deaths do not occur among patients sent out in this stage. We go a step farther, and maintain that a warm. Dry, cool relaxing air is not that most adapted to relieve local ^^^l ^"^^^ irritation of the lung in consumptive cases, and that a Why? ^ pure, dry air of moderate temperature is most agree- able to the patient, and productive of the greatest amount of relief* This is a question both of theory and experiment. The results harmonise with both. An individual with a portion of lung rendered inactive * For the author's experieBce on this subject, after a residence of seven years in Italy, see The Climate of Italy with reference to the Treatment of Chronic Disease — a series of papers in the Medical Gazette, 1850-51, 414 ELEMENTS OP PEOGNOSIS IN CONSUMPTION. CHAP, by disease should surely have the remainder of the ^ ,— ; pulmonary membrane supplied with an atmosphere as perfectly adapted to the purposes of respiration as it is possible to obtain. The system is thus most fully su^d- plied with oxygen, and the vesicular structures of the lung are retained in their integrity. Eespiration should be maintained at the highest possible average, and not at the lowest. The expansion of the air-cells by active respiratory movements, and a full aerification of the remotest parts of the bronchial tree, are antagonistic both to the col- lapse of the cells which is likely to take place in tubercle, and to the further blood contamination which may occur from any impediment to breathing. These principles are well established by competent observers, and are gaining ground day by day among the Pro- fession. Experience ^y experiment also it will be found that the greatest dry, cool possiblc amouut of relief to a patient suffering from ^^^" tubercle in the lung is obtainable by free exposure (w^ith the surface well protected) to a dry, pure, and still, open air, even when of a low temperature. We have tried this in very many instances, and are in the habit of sending out the in-patients at the hospital to breathe fresh air even in winter. Of course, exposure to east winds, and the combination of wet and cold in the air, is to be avoided. It is invariably found that these patients do not cough when in the open air, even although they have just left a carefully maintained, temperature of 63°. We have sent patients to winter in the dry, pure, still air of Canada with the greatest advantage. Cough and bronchial irritation have not been increased, while the nutrition of the body has been stimulated and improved. The air of Mentone owes much of its character to this purity, and not to warmth. Shelter from currents has often been con- CLIMATE. • 415 founded with warmth, but has not the same meaning, chap. A larger quantity of heat and of vapour exhaled from .5^^^!^ the pulmonary membrane is carried off by exposure to a current of air ; but still, cold air in a sheltered place produces less of this effect. Heat which rarefies the atmosphere, and is not incompatible with much con- tained moisture, tends to relax the pulmonary mem- brane, and impede respiratory changes, as less oxygen is afforded at each inspiration. By exercise in a cool, wintry air, more carbonic acid is carried off than in summer. We shall presently show to what are due the good effects of some of these chmates so greatly praised ; but must contend that they have no direct influence on the local disease of the lung, by virtue of any so-called sedative action. In no instance should a patient he se7it abroad ivliile irritative labouring under irritative fever. This hectic condition forbids may attend on any stage of the disease. If it be removal. present in the first, we know that the constitutional disorder is still proceeding, and that the local disease will persist in spite of any removal. If it accompany the second stage, it is the index and measure of de- structive changes in the lung as well as in the tubercle, and the patient will get worse if removed. Kone of the remedial influences observed from a well-selected climate are attainable in such a case. The discomforts of travelling and the very fact of removal are prejudi- cial ; and while the patient loses health, the climate and the medical adviser lose credit. Should hectic be present in the stage of cavity, we know that, for the time at least, the system is not tolerating the cavity, but that breaking-up of the lung tissue is continuing, or a fresh deposit is taking place in some other part of the lung. Such symptoms may subside, but we should await their subsidence before advising removal. Finally, as a definite rule, in no case should a patient 416 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, be sent away for chanofe of air with sustained accelera- XXVIII. .- n ■, r—^ tion 01 pulse. In considering the cases most hkely to be benefited by removal to a foreign climate, we are therefore to be guided by the following conditions : — 1. The deposit in the lung having taken place, all activity of disease should have ceased ; and the phy- sical evidence should prove the absence of its progres- sive extension, or of irritation of the tissue of the lung. 2. The absence of febrile action is an imperative condition. If there be any daily access of chills, heats, or sweating, with high pulse, the patient should not travel. 3. The digestive system should be fairly healthy, or at least the symptoms of gastric distress, thirst, nausea, furred tongue, or diarrhcea, should not be habitually present. If these precautions are observed, the patient may often travel with advantage, even although much emaciated. The moral effects of change, and the difference in the quality and freshness of the respired air, espe- cially after confinement to the house, are often felt to be powerfully remedial ; and the languor, mental and bodily, the want of appetite, and restlessness which prevent sleep, are frequently relieved within a few days of the removal of the patient. Best of all is a long Sea voy- gea voyagc. The daily passage through fresh air, en- ^^^" suring its constant change without fatigue ; the stimu- lation of appetite which soon occurs ; the rest of body, without complete inactivity ; the novel events of a sea hfe ; the absence of the noise and impurity of atmo- sphere of the city left behind ; the tranquillising effect of a daily contemplation of the grand phenomena of nature, of the vast ocean, the sunset, and the starry heavens, invigorate and restore the patient day by day. Boating Ncxt in valuc we would place a voyage uj) the Nile, should the season admit of it. The boating life, espe- cially if a select circle of friends can be ensured on CLIMATE. 417 board, with reading, music, sketching, and daily cliani^e chap. of scene ; the tranquil, dry air ; the beautiful nights ; J^^ZIi and (for men) the power of making excursions, shoot- ing, &c. : all these form most eligible surroundings for an invaUd just escaped from the sick-room. Should the patient's health permit of it, the hfe in the desert, as on a journey from Suez to Jerusalem, is very suitable. The extreme purity and dryness of the air, and the constant exposure to sunlight and the atmosphere, if exercise be not pushed to fatigue, have been found to agree well with many persons whose Hves would have been shortened had they remained in cities. Should these more remote journeys be unat- tainable, shorter and more accessible summer travel is within the reach of many. Such places as the Py- renees, parts of Switzerland and the Tyrol, offer resorts where gentle exercise on horseback in the purest air may be daily carried out. We have often been pleased with the evident respiratory relief which we have wit- nessed in consumptive patients on attaining the upper levels in the Pyrenees and Alps. The highest regions should, however, be avoided, as the liability to chill after ascending great elevations on a sunny day is very great, and fraught with danger to the invalid. Eiver excursions are almost given up in these days of railways ; but nothing is more delightful than the survey of such scenery as the Seine, the Loire, the Ehone, in Prance, or the Ehine and Danube, afford. Open-air life without fatigue is thus ensured ; and where the more enterprising excursions are forbidden, this quiet method of passing through rich countries has many advantages. The winter chmate to be selected is, however, the Winter most important question for the invalid, where a lono- '=^™'^*'^- sea-voyage is not practicable. Acting on the views here and elsewhere put forward, we have for many years ceased to make warmth the E E 418 ELEMENTS OF PKOGNOSIS IN CONSUMPTION. CHAP, condition of climate to be recommended. The abso- t'" , . : lute winter of England is not so unsuitable to the con- sumptive invahd as has been supposed. The spring is the time of danger ; and it is with a view to avoid the ' drying east winds of that season that a removal from this island is advisable. For the winter months (December, January, Fe- bruary) a well-placed residence in many parts of Eng- land, north and south, will answer perfectly. What we desire to obtain is shelter from wind, a dry soil, with good drainage (and therefore the absence of fog), and a southern or south-western exposition, with the facility for being out of doors every, day. Many parts of the South of England meet these re- quirements ; and we need scarcely enumerate Ventnor, Torquay, Hastings, and Queenstown in Ireland, which we are inclined to recommend in the order here given. Eeiaxing j^j. of ^oo relaxing a character is found on experience to depress appetite and nervous power. Many invahds are obliged to leave the places above named, and get on better in more elevated situations where the air is bracing. For such we have known Malvern agree remarkably well. Tunbridge Wells is very suitable for a class of patients who do not bear sea-air. Jersey is a favomite residence with many who can- not bear excessive cold, and deserves to be classed with the eligible places of easy access for all. After the remarkable details which have been fur- nished by several competent observers about the Hebrides and part of the North of Scotland, proving the infrequency of phthisis among the natives, we know not why patients should not be recommended to reside there. The want of accommodation alone should prevent this. Shelter from East Winds in Spring. ^^^' This is exceedingly desirable for the consumptive CLIMATE. 419 invalid, because the intercurrent attacks of pneumonia chap. and bronchitis are thereby avoided. We have no 2]^i^ evidence that the tubercular disease is capable of being increased by exposure to cold, but we are well aware how great is the hazard of inflammatory acci- dental attacks. The absence of east wind is not attainable anywhere in Europe north of the Alps and Pyrenees. Shelter is to be had in England and elsewhere ; but the east wind blows above and around the protected locality, and its influence is felt by the fireside, and even in bed. With this fact we are all famiUar, but we are in the habit of confounding shelter with the absence of wind. The former may be had at many places of resort in England ; for the latter we must go far. The South of Spain and the South of Italy are the two European chmates most free from east wind. At Cannes, Mce, Mentone, and all along the Eiviera, the wind is ' bise,' or north-west, and similar in effects to that from the east, its stimulant, irritative qualities being well known. Shelter can be obtained along the coast, but not a perfectly uniform climate. The absence of easterly influences seems to be first felt about Pisa and at Eome : the only severe wind is the ' tramontane,' or that which blows from the north. It is stimulating and drying, but has not the pecuhar effects which we attribute to east wind, such as excessive dryness of skin, frontal distress, and general malaise, l^either does the digestive system suffer while it is prevalent, but active exercise in the open air readily restores the functions of the skin. In Madeira, at Algiers, and in Egypt, we can also, as is well known, obtain this desired absence of easterly influence. lit remains, however, to be stated that, having found shelter at home or a locality abroad in which east winds do not prevail, we may find other £ s 2 420 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, conditions and new influences capable of exercisina; -^ , -■ even more injurious effects on our patient. Ead effects The depressing effects of various climates have been climates™!! Hiuch ovcrlookcd. Exccssivc heat, or warm relaxing digestio!!. ^^^ . ^j^e prevalence of soft winds from the south and west, as the ' scirocco ' at Eome, and the general sedative influence of the calm mild climate of Madeira, and even of Pau, are well known to depress nervous power, and directly tend to disorder the digestion, pro- ducing loss of appetite, furred tongue, and constipation, the latter probably from inactivity of the liver. At Madeka especially the prejudicial effects of these symp- toms are well known to both patients and medical men, and it need scarcely be said how much vital power is depressed in the consumptive by whatever interferes with appetite and lessens the quantity of food which the patient can consume and assimilate. A prolonged residence in Eome, where the malarious element is present in the atmosphere, afforded ample Kei:ixii!g evidence of this fact. The healthy English who pass a winter there are much troubled by loss of appetite and constipation, with various symptoms of hepatic disorder; and in invalids the digestive and nervous systems are frequently disordered. Headache and lassitude interfere with the enjoyment of fresh air and exercise, which is so desirable. We have lost many patients at Madeira, whose health failed to improve owing to this cause. The comphca- tion of phthisis with irritable gastric dyspepsia is found to be aggravated by a warm, relaxing chmate ; and such individuals should be advised to seek rather the bracing, dry localities to be found at home. Above all, in summer they should leave the relaxing climate in which they have passed the winter. Fortunately, such changes are readily attainable. Those who have wintered at Eome or Pisa should go to Switzerland ; efiects. CLIMATE. 421 while a summer visit to England will be found of great chap. advantage after a winter at Madeira. xxviii. Finally, it is by the adoption of such changes of residence as, after a careful study of the individual pecuharities of each case, seem likely to improve the general health, to increase nervous tone, and to in- vigorate digestion and sanguification, that the real advantages obtainable from climates may be made available for phthisical patients. The idea of specific climatic influence as curative of consumption is to be abandoned, all individual peculiarities in each case are to be studied, and, by the indications so gathered, our advice is to be guided. The conditions influencing nutrition, and especially the purely digestive processes, are to be considered as of primary importance ; the localities requisite to ensure open-air exercise, with light and purity of atmosphere, are to be especially recommended. Damp and low situations, and miasmata from animal or vegetable impurity, are to be shunned. A tonic and bracing air is preferable to a relaxing, damp, and warm atmosphere. Extreme ranges of temperature, as likely to cause con- gestion of the bronchial membrane and of the lung, are to be avoided, but a uniformly high average is not advisable in the residence to be selected. N'or is a persistent sojourn in any one climate or locality to be recommended. The effects of mere change of air on the pulmonary membrane and on the nervous system are to be remembered ; and the patient who has passed one winter in Madeira or Algiers is more likely to benefit by a return to these localities if the intervening summer has been passed in a cool or temperate chmate, like England or Switzerland. It is never to be forgotten that the most hardy, vigorous, and long-lived races in the world, the ci- vilisers who can tolerate the greatest extremes of new 422 ELEMENTS OF PEOGNOSIS IN CONSUMPTION. CHAP, climates, and who have colonised the remotest coim- 5^Lj tries with the moral, mental, and physical constitution best fitted to work and to endure, come from these islands, and have been nursed in a temperate climate. The races which have decayed or died out, w^hose mission in the world appears to have been only temporary, and who did not, therefore, possess the elements of long endurance, were inhabitants of the relaxing climates around the Mediterranean or of the far East. The existing differences between the races of the Forth and South are equally illustrative of the influences which tend to vigour. Let the traveller contrast the inhabitants of Germany, France, or England, / with those of Spain, Portugal, or Southern Italy, and the vast difference in energy of character and in ac- complished work will be apparent. Or let us take the colonies of these countries, and compare the vitality and vigour of the United States or of Canada with the exhausted energies of the South American Eepubhcs. It may be replied, that the institutions and the rehgion of these various countries have much to say to their pre- sent condition ; and this is true. But national character and physical vigour are the primary elements out of Avhich institutions are formed, and which originated their power or their weakness. And with all history before us, including that of the Eoman Empire, which, as it became intermixed with the Eastern element, crumbled away before the energy of the Korth, we cannot avoid the conclusion that chmate has, among the many influences apparent, a place among the more important agents which give a stamp to the character and elaborate the vigour of nations. And to apply this line of thought to the practical questions daily before the physician, we cannot beheve that a disease of lowered nutrition, with consequent exhaustion of vital powers, is best treated in all instances CLIMATE. 423 by a residence in climates of the enervating and relax- chap. ing character ; while, on the other hand, we have abim- ^Pl^|!£II' dant evidence that all which is tonic and invisoratino; in external influences is productive of corresponding good in the vital system, provided that individual constitutions and requirements are carefully studied. INDEX. ABS A BSORPTION of tubercle, 115, -^ 248 opinions of authorities on, 119 cases of, 117 conditions favourable to, 120 Accidental pbtbisis, 340 Acute pbtbisis, 97 in old age, 264 — inflammatory, 98 — passive exudation, 98, 102 — Hippocratic description of, 98 analysis of 179 cases of, 103 after pregnancy, 300 Acute diseases originating phtMsis, 83 Addison's theory of tubercle, 109 Age, effects of, on diu'ation of phthi- sis, 30, 356 — a modifier of phthisis, 253 — at which phthisis is most com- mon, 253 — at which difierent varieties occur, 257 — over forty, disease chronic in, 31 — in acute phthisis, 104 — in wavy inspiration cases, 131-3 — in cases beginning at base of lung, 136 — in chronic first stage, 154 — in „ second stage, 171 — in „ third stage, 215 — in digital clubbing, 236 — over forty liable to phthisis, 254, 257 — in phthisis with rheumatism, 974 bronchitis, 288 pregnancy, 258, 302 fistula, 258, 319 • — in very profuse haemoptysis, 311- 12 — in gout with phthisis, 274 — in lactation with phthisis, 301 BEA Age, in acute diseases originating phthisis, 84 — in chronic diffiised tubercle, 179 — in 68 cases of limited cavity, 205 — in phthisis imder fifteen, 246 Ages of growth and decay liable to consumption, 254 Air, exposure to, 351 — relaxing, bad effects of, 412 — dry, cool, good effects of, 413 Alison, Dr. Scott, 123, 126, 327 Alterations in chest walls, 125, 197, 275 Amennorrhcea not a cause of phthisis, 294 Analogy of tubercle with struma, 115 Anaemia non-concurrent vrith phthi- sis, 90 Ancestors, influence of, 341 Andral on duration of phthisis, 56 Antagonism of emphysema to phthi- sis, 287 disease of heart to phthisis, 272 Aortic valve, disease of, in phthisis, 271 An-est of phthisis, 168 evidence of, 170 Bennett's cases of, 206 Quain's cases of, 210 Author's cases of, 213 Army, prevention of consumption in, 366 Asthma with phthisis, 63, 280 — alternates with phthisis, 284 Author's mode of estimating dm'ation of phthisis, 65 "RASE of lung the seat of tubercle, ^ 135,247,251 Bathing, cold, use of, 351 Beale, Dr. L., 265 Beau quoted, 255 426 INDEX BEN Bermett, Professor, views of, 41 theory of tubercle, 109 cases of arrested phthisis, 206 Blakiston, Dr., case of acute phthisis, 264 Blisters, 404 Brinton, Dr., quoted, 255 Brandy a remedy, 407 Bronchitis a supposed cause of tu- bercle, 47 — may be mistaken for tubercle, 87, 287 — combined with tubercle, 287 — chronic, in old age, 261 Butchers, exemption of, from phthi- sis, 369 pALCAEEOUS deposits in lung, ^ 160, 165 Cancer with tubercle, 239 — withered, 21 Carbonic acid, 364 Cardiac murmurs with phthisis, 84 — dilatation, 285 (See Heart, diseases of.) Cases, premonitory stage, 81 — acute phthisis, 99 — first stage, 143 — chronic first, 156-9 second, 172-6, 183-7 third, 206, 228 — digital clubbing, 239, 242 — rapid phthisis, 103 — absorption of strumous tubercle, 117 — wavy inspiration sound, 143 — strumous phthisis, 251-2 — mitral disease and phthisis, 277 — bronchitis and phthisis, 268, 290 — emphysema with tubercle, 291 — cancer with tubercle, 239 — asthma with phthisis, 291 — number of, in different forms of phthisis, 257 — of acute phthisis in old age, 264 — of senile phthisis, 267 — disease of heart with phthisis, 289 Cases of empyema, operation for, 325 pneumothoi'ax, 323 with recovery, 330 20 fatal cases of, 334 calcareous deposits in lung, 161 chronic diffused tubercle, 183 arrested phthisis, 1 73, 206 Cases of limited cavity in the lung, 217 CLO Cases of death from profuse hae- moptysis, 308 Catamenia in phthisis, 206, 297 Catarrh does not originate phthisis, 88 Causes of phthisis remote, 50 in acute disease, 83 absence of assignable, 87 Cavity in the lung, 188 rare in lower animals, 193 anfractuous, 190, 231 circumscribed, 192, 194 time in which is formed, 188 in left lung more quickly, 189 in right lung more fa- vourable, 193, 206 causes which influence, 189 systemic disorder in, 195 breaking up of, 204 shrinking of, 198, 221 state of, in pneumotho- rax, 329 cure of, 202, 223, 227 analysis of 68 cases of, 206 cases of, limited, 217 varieties of chronic form of, 261 in persons over forty- five, 256 progTiosis in, cannot be formed at once, 197 Cavities in the lung, double, 232 Change of air, 412 (See Climate.) Chemical composition of tubercle, 109 Childhood, management of, 350 Children, number of, to phthisical parents, 85 — not to be nursed by consumptive parents, 300 Chronic organic disease, considera^ tions on, 5 — first stage, 148 — second stage, 164 — third stage, 188 Christison, Dr., quoted, 255 Classification of phthisis by the au^ thor, 65 Climate, 410 Clark, Sir James, opinion of, 69 Clarke, Dr. Andrew, opinion of, 103 Clothing, 352 INDEX. 427 COM Compensatory dilatation of air-cells in phthisis, 281 Competitive examinations, 356 Conditions favourable to the absorp- tion of tubercle, 120 Congestion of the lung, important influence of, 166, 398 Consumptive not liable to take cold, 48 epidemic diseases, 152 — mothers not to nurse, 300 Contagious epidemics, result of ex- posure to, 337 Cotton, Dr., quoted, 135 Cough, remedies for, 405 Crisp, Dr., quoted, 193 Crowding, eflects of, 364 Cruveilhier on acute phthisis, 98 — on absorption of tubercle, 120 Cui-e de raisin, 395 Cysts, 23 ■r)EATHS in acute phthisis, 104 — in chronic second stage, 172 ■ — in chronic third stage, 216 — in pneumothorax, 204 Decay, period of, incident to phthisis, 259 Deformed chest uncommon in phthi- sis, 88 Degeneration of tissues with phthisis, 263 Demulcents, 407 De Mussy, Dr., views of, 273, 284 Deposits, old, break up, 261 Depletion, local, 399 Diagnosis in premonitory stage, 94 — in acute phthisis, 106 — between bronchitis and phthisis, 287 — of chronic diffused tubercle, 178 Diarrhoea, 105, 312 Diffused tubercle, 177, 165 chai'acters of, l78 age and sex in, 179 why chronic, 177 duration in cases of, 180 symptoms in cases of, 181 prognostics in cases of, 182-7 in heart disease, 182, 275 in strumous phthisis, 250 Digestion, value of sound, 151 — injured by certain climates, 420 Digital clubbing, 234, 239 duration in cases of, 237 Digital clubbing, cases of, 239, 242 in rheumatic diathesis, 276 Double disease rarely chronic, 153 Drugs injurious, 351 Duration of phthisis, 51 progTiosis founded on, 51 difficulties in ascertaining, 52 authorities on, 56 analysis of 300 cases of, dif- fering, 72 at various ages, 73 at different stages, 74 with haemoptysis, 74 Duration of laryngeal phthisis, 75 — of 3,566 cases of phthisis, 77 Duration of phthisis up to time of death in 129 cases, 78 505 males, 79 323 females, 79 in first stage (tables), 155 in wavy inspiratory sound, 130, 133 in physical signs at base, 136 important law affecting, 137 in chronic second stage, 171 in chronic diffused tubercle, 180 in dry cavity in one lung, 205 in chronic third stage, 216 in digital clubbing, 236 Duration in phthisis under fifteen, 245-7 over forty-five, 256 with rheumatism, 274 with gout, 274 with diseases of heart, 274 with bronchitis, 288 when catamenia are sus- pended, 297 with pregnancy, 300 with profuse haemoptysis, 311 Duration in fistula, with phthisis, 319 — in pneumothorax, 334 — in emphysema with tubercle, 286 Dusty occupations, 370 Dyspnoea, 181 "C]AST winds, shelter from, 418 Edinburgh Infirmary, deaths in, 255 Education, 354 Edwards', Mr. V., cases of digital clubbing, 237 428 INDEX. EFF Effusion into pleura^ causes of, in phtliisis, 324 Elimination of morLid matters, 390 Emaciation, influence of, on duration of phtMsis, 75 — meaning and uses of, 23, 40 — degrees of, 75 — slow in age, 95 — earliest symptom of phthisis, 17, 80, 262 Emphysema, 63, 280, 284 — contrasts with phthisis, 283 — with phthisis, duration of, 286 — antagonistic to tubercle, 283 Exercise, muscular, 352, 384 — of lungs useful in phthisis, 283 ■pAEMING recommended, 360 Fevers originating phthisis, 83 Eibrin, excess of, in phthisis, 272 First stage of phthisis, 108 cases of, 143, 147 its nature and results, 108 Final stage, the, 35 Fistula in ano with phthisis, 316 Flattening of chest walls, 197 in heart disease with phthisis, 275 Forms of disease transmitted, 93, 344 Form of chest in phthisis, 89 Food in childhood, 350 phthisis, 394 Functional disorder, 9 /^ASTEIC disorder in phthisis, ^^ 64, 312 may simulate phthisis, 87 in acute phthisis, 105 rare in phthisis of old age, 263 Girls, education of, 359 Glands, deposit in, often identical with tubercle, 245 Gout with phthisis, 270, 272 Greenhow, Dr., on unhealthy occu- pations, 371 Growth, period of, 30, 244, 254, 259. — stopped in strumous phthisis, 250 Guizot on transmission of moral pro- perties, 343 XT ABIT, the spare, 43 Heart the index of nervous power, 27 Heart displaced in chronic cavity cases, 197, 199, 276 in rheumatic phthisis, 275 Heart, weak in haemoptysis, 309 — disease of, with phthisis, 270, 285 — haemoptysis common in, 275 Hectic, influences of, on dm'ation, 76 Haemoptysis, 302 — a supposed cause of phthisis, 44 — very profuse, 50 cases of, 310 — ordinary profuse, 351 cases of, 311 — males more subject to, 311 — age in profuse, 249, 311 — influence on duration, 74, 139 — salutary, 308 — stage common in, 303 — treatment of, 304 — as a prognostic, 139, 307 — modes of death in, 308 — 21 fatal cases of, 307 — value of as a symptom, 137, 139 — rare in early life, 249 — profuse, 138 — slight, repeated, 139, 305 — imcommon in acute phthisis, 105, 306 — in cavity cases, 204 — in cardiac disease with phthisis, 275 — rare in age, 262 — without tubercle, 305 — relative frequency of, in stages, 307 — reaction after, rare in phthisis, 309 — influence of sex in, 310 Haemorrhage a cause of phthisis, 85 Hereditary influence, 75, 336 to different forms of disease, 60 in acute phthisis, 105 in struma and tubercle, 116 Hippocratic description of acute phthisis, 98 Horse exercise, 283, 355 Hospital cases, causes affecting, 55 TMPURITIES of atmosphere, 365 Incipient phthisis, physical signs in, 123 Indoor occupations, 366 Infancy, management of, 350 Inflammation not a cause of tubercle, 45 Insusceptibility of certain individuals to diseases, 338 Intermissions in chronic disease, 13 — described, 26 — duration of, 30 Iodine, 393 Iron, use of, 351, 395 INDEX. 429 IRO Iron, dangers of, 396 Irritative fever, 415 T .ACTATION a cause of phthisis, -^ 85, 298 — accelerates phthisis, 300 Laennec quoted, 49, 56 Larynx affected in phthisis, 75 Latent phthisis, 149 Law affecting- duration of consump- tion, 137 — of tubercle, 288 Lavs^, Dr., case of acute phthisis, 99 Laycock, Dr., quoted, 275 Leared's, Dr., cases of phthisis treated by hot air, 393 Left limg affected in heart disease, 275 in rheumatism, 275 the seat of wavy inspiration, 134 cavity forms more rapidly in, 189 less favourable seat of disease, 215 Light, influence of, 352 Locality, influence of, on phthisis, 54 Louis, law of, 48, 243 — quoted, 49, 56 Lung, its structure and fimctions, 166 — left, why affected in heart disease, 277 — right, why most commonly the seat of limited cavity, 193 lyrACLACHLAN, Dr., quoted, 254 Malaria may mask phthisis, 86 — antagonistic to phthisis, 86 — deaths from, 337 Males more phthisical at puberty, 295 _ — Tnore subject to rapid reduction of weight, 141 to profuse heemoptysis, 311 — arrest of phthisis more common in, 215 — more subject to phthisis in old age, 256 Marriage not a remedy for con- sumption, 348 Marriages of consanguinity, 344, 347 — of the phthisical, 348 Menstruation in phthisis, 293-8 — prognostics from, 298 Mercury in phthisis, 393 Mild air, when unfavourable, 411 PNE Milk, use of, in phthisis, 394 JMitral valve diseased in phthisis, 271 Moral traits transmitted, 341 Morbid conditions coexistent with tubercle, 49 Morphia, formulas for, 406 'M'ATUIIE competent to cure, 16 Natural processes, a guide to treatment, 36 — groups of phthisis, 67 Negative attitude of phthisis, 88 Nightingale, Miss, quoted, 366 Non-concurrents with phthisis, 88, 89 Nutritive food, use of, 394 QCCUPATIONS of 5,214 phthi- sical patients, 367 — influence of, on consumption, 336, 363 — choice of, 360 Oil, use of, 351, 395 — when inadmissible, 403 Operation for fistula, 318, 320 Ordinary phthisis, 122 Organic disease influenced by trans- mission, 343 Origin of tubercle, 45 Overwork, 372 PERFORATION of pleiu-a, 326 Perspirations, remedies for, 404 Phthisis a disease of the system, 38 — originating in acute diseases, 83 j — ordinary, 108 — history and signs, 122 — without tubercle, 261 — of old age descriljed, 262 — preventible in the army, 366 Physical signs in incipient phthisis, 123 at base of lung, 135 localisation of, 165 in rheumatic phthisis, 276 in diffused tubercle, 178 in circumscribed cavity, 194, 198, 228 in irregular cavities, 233 in strumous phthisis, 249 in rheumatic heart disease and phthisis, 275 in emphysema with phthisis, 285 Pleurisy in phthisis, causes of, 328 Pneumonia, acute, 18 — analogy of, with tubercle, 20 430 IlfDEX. PNE Pneumonia, spontaneous cures of, 20 — does not originate tubercle, 46 — partial, at base, 137 Pneumonic phthisis, 261 Pneumothorax, 204, 321 — twenty cases of death from, 204, 334 — prognosis in, 324, 326 — authorities on, 334 Post-mortem appearances in senile phthisis, 264 in healed cavity, 228 in shrinking cavity, 210 Posture, effects of, 367 Predisposition to emphysema and tubercle, 287 — relative, to rheumatism and tuber- cle, 272 {See Hereditary.) Pregnancy in phthisis, 63, 293, 299 latent during, 298 fatal after, 299 Premonitory stage of phthisis, 80 Prevention of phthisis, 346 Preventive treatment of phthisis, 350 Privations a cause of phthisis, 374 Products of disease added to blood, 8 Profession, choice of, 360 Prognosis founded on diu-ation, 51 — in premonitory stage, 95 — in acute phthisis, 106 — in first stage, 141 — in second stage, 182 — in third stage, 228 — in strumous phthisis, 243 — in rheumatism, gout, phthisis, 276 — in disease of heart, with phthisis, 277 — in bronchitis, vdth tubercle, 291 — in pregnancy, with phthisis, 301 — in haemoptysis, 302, 311 — in gastric symptoms, with phthi- sis, 315 — in fistula, with phthisis, 319 — in phthisis of the aged, 268 — in phthisis, with emphysema, 291 — in arrested catamenia, 297 — in pneumothorax, 335 — in calcareous deposits, 162 — in chronic diffused tubercle, 182 — in circumscribed cavity, 228 — in double cavities, 232 — in compensatory dilatation of cells, 282 Prolific tendency in the phthisical, 85 Prout's, Dr., theory of tubercle, 109 Proximate causes of tubercle, 62 Puberty, tubercle before, 243 SEX Puberty, influence of, 244, 295 — management of, 354 Pulse, the ' dial of the nervous sys- tem,' 27 — the measure of local disease in senile phthisis, 262 QUAIN, Dr., cases of arrest of phthisis, 173, 210 J^AISIN, cure de, 395 Rachitis a non-concurrent with phthisis, 88 Peaction after haemorrhage rare in phthisis, 309 Reactions of systemic disorder, 14 Resistance of the system, 16 in acute disease, 18 Relaxing climates, bad effects of, 420 Recovery from phthisis possible, 61 Respiration, exercise of, 388 Rigaud on digital clubbing, 234 Remissions of symptoms, 24 Rheumatism, with phthisis, 270 — a cause oi^ phthisis, 83 — characters of, in phthisis, 270 — table of cases of, 271 Right limg, comparative frequency of disease in, 135, 206 recoveries more frequent at, 135, 215 more common seat of limited cavity, 193 Roger quoted, 255 Rokitansky's theory of tubercle, 109 gEA-VOYAGE, good effects of, 416 Secondary disorders in phthisis, 7, 12, 14, 32 time of occurrence, 33 rare in old age, 263 prove fatal, 12 Secretion diminished in chronic dis- ease, 28 Sedatives, use of, 406 Senile phthisis, 256, 261 Sex, influence of, on acute phthisis, 103 on wavy inspiratory sound, on tubercle, beginning at base, 136 on reduction of weight, 141 on profuse haemoptysis, 311 on arrest of phthisis, 215 of, on chronic first stage, 154 INDEX. 431 SEX Sex, influence on chronic second stage, 171 on chronic third stage, 216 ■ on diffused tubercle cases, 179 on dry cavity cases, 205 on digital clubbing, 236 on phthisis under fifteen, 245 on phthisis over forty-five, 256 on phthisis, with rheuma- tism, 274 on fistula, with phthisis, 319 on senile phthisis, 264 on pneumothorax, 334 Sexual transmission of disease, 92, 346 Signs {See Physical Signs.) Skin diseases uncommon in phthisis, 89 — healthy action of, necessary to health, 369 — remedies directed to, 391 Sounds become dry, 169 Spare habit, the, 43 Specific treatment of phthisis, 376 S,pecialism, mistakes about, 35 Spirometer experiments, 135 Stages of phthisis, divisions into in- sufiicient, 61 — time in which reached in 172 cases, 104 Stage, premonitory, 80 — first, 115 — second, 164 — third, 188 — with wavy inspiration, 133 — in persons over forty-five, 256 — in phthisis, with rheumatism, gout, 275 — in phthisis, with bronchitis, 288 ■ — in phthisis, with pregnancy, 300 with disease of heart, 275 with amennorrhcBa, 296 with fistula, 318 — in physical signs at base, 135 — in chronic diffused tubercle, 179 — influence of, on duration, 73 — the final, of chronic disease, 35 Standard Ofiice, deaths in, 255 Stokes, Dr., quoted, 125, 135 Stimulants, use of, 358 Struma, external, imcommon in phthisis, 88 — can be artificially induced, 337 Struma, analogy with phthisis, 115 Strumous deposits, 63, 165 TAB Strumous deposits can be absorbed, 22, 248 — phthisis, 243 average duration of, 247 three varieties of cases, 249 cases of, 251 Suppuration of glands rare in phthisis, 246 Susceptibility to disease, what, 339 Symptoms before physical signs, 39 Systemic disorder, importance of, 168, 195 ^ System, resistance of, 6 — lowered state of, its uses, 10 Syncope, death from, 310 T^ABLE of 300 cases of phthisis of differing duration, 72 — of 3,566 cases, duration of, 77 — of duration up to time of death, 78 — of in 505 males, 79 — of in 323 females, 79 — of cases arising from acute diseases, 83 — of — of pregnancy and phthisis, — of — of lactation 85 — of number of children to phthi- sical parents, 85 — of age and sex in rapid phthisis, 104 — of strumous affections in phthi- sis, 88 — of sexual transmission of disease, 92 — of time in which each stage was reached, 105 — of earliest physical signs in 80 cases, 123 — of age and sex in wavy inspira- tion cases, 131 — of duration in 132-3 — of localisation of 134 — of age and sex in disease com- mencing at the base, 136 — of reduction of weight in 28 cases, 140 — of age and sex in 286 first stage cases, 154 — of duration 155 — of age, sex, and duration in second stage, 171-2 — of age, sex, in diffused tubercle cases, 179 432 INDEX. TAB TaWe of duration, in diffused tuber- cle cases, 180 — of age and sex and duration in 68 cases of limited cavity, 205 — of in cases of chronic third stage, 215 — of duration 216 — of age and sex in digital club- bing, 236 — of Mr. Edwards, of 237 — of duration of cases of 237 — of age and sex in 285 cases of phthisis under fifteen, 246 — of duration in cases of strumous phthisis, 247 — of stage, duration, and sex in cases over forty-fi-ve, 256-7 — of different varieties of phthisis at different ages, 257 — of rheumatism, gout, diseased heart, with phthisis, 274 — of age and stage in phthisis, with bronchitis, 288 — of state of catamenia in phthisis, 296 — of ages in cases of phthisis, with pregnancy, 801 — of age, sex, and duration of cases of fistula, 319 — of results of operation for fistula, 319 — of 50 cases of very profuse haemoptysis, 310 — of 351 cases of profuse haemop- tysis, 311 — of occupations in 5,214 cases of phthisis, 367 Temperaments, influence of, 152 Temperature, effects of, in hospital cases, 411 Temporary crepitant sounds, 195 Theories of tubercle, 109 Thompson, Dr. E. S., 126 Tobacco, 359 Tonics, when unsuitable, 407 Tubercle capable of absorption, 21, 110, 115 — not a local disease, 38 — varieties of, 59, 108, 164 — localisation of, 59, 135 — theories of, 109 — destructive changes in, 110 — chemical changes in. 111 — in masses, 124, 189 WOR Tubercle at base of lung, 135 — in bone, brain, peritoneum, 167 — in organs other than lungs, 49 — infiltration of, in lower animals, 193 — in subjects imder fifteen, 245 — chemical composition of, 109 Transmission of disease not limited to parents, 341 Travelling, use of, 361 Trousseau on digital clubbing, 234 — on the mode of propagation of fevers, 339 Treatment of phthisis, preventive, 363 specific, 376 direct, 382 — of the premonitory stage, 382 first stage, 398 — for perspirations, 404 — for cough, 405 — of the second stage, 402 third stage, 408 Tumours uncommon in phthisis, 89 Turkish bath in phthisis, 393 "TTALVULAE, disease in phthisis, ^ 84, 271 Varieties of phthisis, ages in, 257 Ventilation, 352, 363 Vomiting, 315 "V^TALLS of chest, changes in, 125 ^ * Walshe, Dr., quoted, 135 Walton, Izaac, quoted, 152 Wasting in phthisis, earliest symp^ torn, 80 — rapid, 140 Wavy inspiratory sound, 125 authorities on, 126 origin of, 127 value of, 130 Wavy inspiratory sound, cases of, 131-2-3, 143, 147 Weaning period dangerous, 301 Weight, influence of rapid reduction of, 140 — increase of, 28 Wells, Mr. Spenser, quoted, 339 Williams, Dr., on duration of phthi- sis, 56 on absorption of tubercle, 119 on phthisis in age, 255 Winter climate, 417 Workmen, children of, 362 PKINTED 3T SPOTIISWOODE AND CO., NEW-SIBEET SQUAEE, LONDON. 39 rATEiixosTEii Row, E.G. 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