CHAP. Case 3. Case 4. Case 5. of first stage: perfect recovery. v. ferri. Jane D., æt. 15. May 1861: One uncle d. phth., habitual A. H., æt. 19. Had been out of health some months in 1846; hæmopt. rather profuse, wasting, hectic, dulness under right clav. for three inches, feeble respn., succeeded by coarse respiratory tone. These signs disappeared wholly by leeching and cupping, and the health and flesh slowly and steadily recovered; no cough remained. A second attack, with cough, hæmoptysis, and fever, returned the following year, and the signs reappeared. A similar disappearance of the physical condition resulted from the use of the same means. Next year she came abroad and was under my care. I watched her through a third of these attacks, when both signs and symptoms slowly disappeared. She returned to England, and died of phthisis about three years later.* In 1856, T. Y., then æt. 17 years, had, in common with Symptoms several members of his family, a severe attack of measles. and signs This was followed by bronchitis of unusual severity; he had cough, and copious mucopurulent expectoration, had wasted considerably, but was regaining flesh. There was still some hectic sweating, and he complained of pain in the left side. The physical signs were-dulness of percussion note, well marked, rough, wavy inspiratory sound, attended with clicking at its close, for about two inches under the left clavicle. By our advice, he made a sea voyage to Australia and New Zealand, remaining abroad two years, and constantly moving about while in those countries. He rode much on horseback, was exposed to all kinds of weather, and at one time led a rough life in the bush, often, as he has told me, riding for hours in wet clothes, after swimming rivers on horseback. During this time his appetite was enormous, and I am indebted to my former teacher, Dr. Stokes, of Dublin, for the details of the early attacks in this case, which he wrote to me at the he lived chiefly on animal food, eating daily surprising quantities of beef and mutton. On his return he had grown much in height, his chest was well developed, and he was in prime muscular vigour. His general health was, in fact, most robust. On a most careful examination, his chest presented no abnormal signs whatever, and I had personal opportunities of repeatedly proving this fact. He has since then made many mountain tours on foot, and is a fine specimen of perfect health. In remarking on these cases, it may be observed, that they only prove the disappearance of both physical signs and symptoms of phthisis, the total absorption of tubercle once deposited being incapable of absolute proof. In the highly interesting case, No. 4, authenticated as it is by one of our ablest pathologists, it is probable that the physical signs were due chiefly to irritation of the lung, which accompanied the deposit of tubercle; and such an interpretation would be most in harmony with the views of Dr. Stokes. To ensure accuracy in our researches, the continuous observation of cases for consecutive years is necessary, and the above have been selected as having been under my own eye for long periods. CHAP. IX. ties as to tion of The best authorities may be said to lean towards Authorithe opinion that tubercle is capable of removal by the possi absorption. Williams* well remarks, that a proof that ble absorpthe animal matter of tubercle may be absorbed, is found tubercle. in the substitution of earthy particles for the organised Williams. tubercle. Carswell says that the important fact of Carswell. the curability of this disease has in my opinion been already settled by Lænnec.' Hardly any person is carried off by a first attack, is remarked by Laennec, Louis, and Clark. "There has been no doubt that Laennec, modern practice has proved the curability of phthisis,' Clark. said Stokes (Lectures' in 1835); and he added, it is probable that many more cases of phthisis recover * Principles of Medicine, 1856, p. 475. Louis, CHAP. IX. Latham. Cruveil hier. Conditions most favourable to the absorption of tubercle. than is supposed.' The same great teacher remarked, speaking of the first stage of tubercle, 'If the patient has had any pulmonary irritation before, and recovered from it, it is in his favour: if it be his first cr second attack, it is against him.'* Cruveilhier says, 'Ces tubercules peuvent-ils se résoudre? Nous n'en avons pas de preuve directe pour les tubercules intérieurs, mais, comme l'observe M. Dupuytren, l'analogie doit nous en convaincre. Combien, en effet, ne voyonsnous pas de tubercules extérieurs se développer à des époques variables et disparoître par l'effet des medicamens et des moyens hygiéniques, ou plutôt par les forces de la nature au moment de la révolution générale qu'amène la puberté! Pourquoi la même chose n'auroit-elle pas lieu à l'intérieur ?' The conditions most favourable to the absorption of tubercle are to be considered with a view to the prognosis. 1. The nature of the tubercle deposited. If there be evidence from physical signs that we have a case of grey, scattered tubercles, few in number, as evident by alteration in the tone and duration of the respiratory sounds and by slight dulness, we are to regard the case as favourable. 2. The absence of signs of irritation in the lung, crepitant râles, much dulness, the various rhonchi, &c. 3. Phthisis not inherited; the disease accidental; † occurring in an individual of healthy antecedents; well-made chest; no previous syphilis nor courses of mercury. See also Dr. Latham's admirable Lectures on Subjects connected with Clinical Medicine: lect. xiii. Lond. 1836. + Essai sur l'Anatomie Pathologique en général: tome i. P. 1816. 79. Paris, 'Stokes: All the cases which recovered, and they were not a few, were cases of accidental phthisis.'-MS. Notes of Lectures. 4. The constitutional disorder soon subsides. This is important; the disease may commence with very acute symptoms, which is not unfavourable, provided they decline early. 5. One lung only affected; the right the most favourable. 6. To these conditions must be added the possibility of the patient being placed in the best hygienic A concurrence of all of the above conditions is necessary to a favourable prognosis. CHAP. IX. CHAP. Deposits of CHAPTER X. ORDINARY PHTHISIS-THE FIRST STAGE SIGNS AND PROGNOSTICS. ITS HISTORY A DEPOSIT of tubercle in the lung with or without accompanying congestion of the lung tissue, is the local condition. This may consist of 1. A few tubercles scattered throughout the lung, two kinds. causing but little irritation; or not due to local disorder. 2. A deposit of aggregated tubercles, limited to one spot, generally the apex of one lung, but occasionally occupying the base. Around these there is generally found much congestion of the lung tissue, even before softening. The pleura is also generally thickened and Symptoms adherent. The more grave symptoms, even in an early stage, have reference rather to constitutional than to local disorder, but irritation of the lung begins to develop itself early. To the emaciation and fever evidencing the blood disorder which was the causative agent of the tubercle formation, we have now superadded such symptoms of local origin as cough, dry and harassing, expectoration scanty, streaks of blood, or even profuse hæmoptysis, with local pains and dyspnoea. A more decided hectic, ending in profuse sweating, may be regarded as due rather to irritation of the lung than to the tubercle. The emaciation is more rapidly progressive than in the premonitory stage. Much disorder of the digestive canal may accompany these symptoms, and nausea, thirst, anorexia and diarrhoea harass the patient; but these are chiefly found in the acute form of the disease. Gastric, |