CHAP.

XI.

21 years; duration indefinite.

sweats, which are better. Much marasmus (2). App. good, no diarrh. Chest emaciated, dulness marked, resp. of whifservation fing character, and vocal resonance both apices; has taken much oil, which begins to nauseate; to take cit. ferri. ex infus. Calumbæ; sedatives for cough. Admitted In-P. in August; gained 16lb. 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.

Very

chronic.

Chronic 1.

8 years.

W. H. M., æt. 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 mobility, flattening, very feeble resp. subclav. left; frequent slight hæmoptysis ensued; oil, and to go to country. Returned after some mths. No fever, less cough, and expectn. Recommended 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., æt. 19. 1857. No predisp.; ctma. began at 11, stopped till 14, now regular; married at 17, no ch.; cough 2 yrs., hæmoptysis at first, lately frequent; losing flesh and str., chills, night sweats, p. rapid, app. bad, vomits, b. irreg., often loose; resp. rough, tubular, exp. prolonged, vocal res. increased, dulness, slight flattening, mob. impaired at right apex. Has taken oil for 18 mths. ; ordered alkaline mixture, with gent.; acid gall.; emplast. lyttæ. 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 hæmoptysis. Lactation partial for some mths., but was obliged to give it up. Oct. 1859.-Wavy respiration left; daily hæmoptysis. Oil and quinine, with change to seaside, greatly improved her health; she regained flesh. Feb. 1860.- Scarcely any cough, hæmoptysis 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 former wavy respiration.

Dec. 1860.-Better, less cough, no fever, gains flesh. Jan. 1861. Called to see her child, æt. 2, who had cough, large abdomen, diarrh., crepitating sounds over left lung, child died convulsed 3 weeks later. May 1862.-Mother has been at Ramsgate, is much better, but looks delicate, rarely coughs, there is no crepitation at left, but harsh resp., exp. long, and dulness as before. Has taken oil, and tr., ferri sesquichloride, for months. Oct. 1863.-Has gained flesh, cough occasional 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.

CHAP.

XI.

years.

E. E., æt. 27, male. Under Dr. Cotton two years ago; Chronic 1. hæmoptysis 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 crackle, 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.

years

C. F. W., m., æt. 25, smith. Hæmoptysis 7 years ago, and Chronic 1. slight occasional ever since; cough on lying down, and in Duration 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.

CHAPTER XII.

CALCAREOUS DEPOSITS IN THE LUNG.

CHAP. THE frequency of the occurrence of calcareous deposits XII. in the lung is sufficiently proved by competent obCalcareous servers.* It is to be accepted as a proof that nature

transfor

mation of tubercle.

Authorities.

can absorb the animal portion of tubercle. This conversion 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 blackness occur in about one half of all the bodies examined at Chelsea Hospital. Rogée, § in one hundred female bodies examined at Salpêtrière over sixty years of age, found cretaceous concretions in the lung in fiftyone instances. Aretæus 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 consumption named 'phthisie calculeuse.' The fault of the older observers has been that the accompanying symptoms of phthisis were referred by them to the concretion, instead of regarding the latter as a natural attempt at cure, and a result rather than a cause. Although very

* Williams, op. cit. See also Stokes, op. cit. p. 456.

† Turnbull, An Enquiry into the Curability of Consumption, p. 87. Lond. 1859.

Maclachlan, op. cit.

$ Archives Gén. de Médecine, tome v. p. 183.

See also Cruveilhier's Transformations et Productions Organiques, vol. ii. p. 112.

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 transformation 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. Dickenson (Trans. Path. Soc. vol. xiv. p. 163). The man died of scrofulous disease of the vertebræ with psoas abscess. The mortar-like 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.

CHAP.

XII.

One half had hæmoptysis repeated several times.

With signs of the 1st stage were found 1 case

of these

These cases were characterised by the frequency of Characters hæmoptysis, the extensive portion of the lung present- cases.

M

XII.

CHAP. ing physical signs, the harshness of the respiratory sounds, and the more advanced cases by considerable flattening of the chest walls. The transformation of tubercle is, in fact, accompanied by considerable contraction 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 remain in an altered form, and without any symptoms at eighty!

Two forms.

First variety.

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 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 attacks of the tubercular disease occur, with expectoration of chalky matter, the disease advancing slowly, while the attempt at cure is being manifested.

Of the first variety, it is to be presumed that there are many instances to be met with in 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.