CHAP.
XIII.

Chronic circumscribed

for cough. Small quantities of nourishment at short intervals. 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 my 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 appeared in perfect health, embonpoint considerable, colour excellent; has had no fever for months, no cough nor expectoration; app. excellent, b. reg., ctm. reg. Chest signs: flattening of subclavian space, dulness well marked, dry cavernous blowing, imperfect pectoriloquy (no moist sounds), right subclav. as far as third rib, slightly blowing respiration, 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 :

. June, 1856. E. M., æt 15, assists her mother as national schoolmistress, no predisposition, dark hair and eyes. Ill 2 years, constant cough, lately worse, no hæmopty. Ctma. cavity in left; health established at 13, absent one year, returned lately; is fair; under treatment 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. 3 mths. Much dulness, gurgling, pectoriloquy, flattening slight, cardiac impulse communicated for 3 inches subclav. 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 hæmopty. and frequent diarrhoea, with sweats; but by November had much 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 8.134. In December expiration prolonged right apex, cough rather more troublesome.

April, 1857: during winter got on well, expectoration moderate, rather gains flesh, and has the aspect of excellent health. Lately appetite fails, and has occasional slight diarrhoea, with thirst. Hæmoptysis 3 weeks ago. Gurgling for 3 inches, left. June 1857: has reduced in weight to 8.5; the physical signs have extended to the posterior part of the apex; cough increased; vomits. Omit oil. Mist. acid hydrocyanici. August: improved, but occasional diarrhœa, requiring astringents and opium; takes oil pretty constantly. November 1857: improved; weight, 8.131; looks well, diarrhoea rarely; a dry form of crepitation over dull space, right. With the exception of occasional hæmoptysis, 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:-Cough very slight, scanty morning expectoration, is in good flesh, colour good. Ctma. regular, digestion excellent, no diarrhœa for months. Has had occasional hæmoptysis when overworked. 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 subclav., 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 occasional dry crepitation, and some blowing sounds opposite spine of scapula. right. In July, 1865, she remains in all respects

in the same state.

CHAP.

XIII.

Well de

fined ca

vity, very

W. P., æt. 36, clerk, no predisp. 13 years ago had hæmoptysis, and was under treatment for tubercle in right lung.' Is subject to dyspnoea ever since on exertion. Slight chronic, occasional cough with slight expectoration. Complains of 13 years deficient circulation in extremities. Is in fair flesh, digestion healthy. Much dulness, cavernous blowing, very distinct pectoriloquy, bruit de pot félè under right clavicle to 2nd rib; below this wavy inspn. still lower deficient resp. (as compared with opposite lung).

CHAP.
XIII.

Defined

J. H., æt. 42, tailor, no predisp. Hæmoptysis 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. blowing (no moist sds.), subclav. right, rest of lungs clear. Treated with gallic acid, hæmopty., oil, quinine, and iodine externally. Much improved after 1

cavity, frequent

slight

8 years.

health.

year.

Limited W. H., æt. 33, coachman, no predisp. Ill 7 mths. Aphocavity, nia some mths., slight cough, hard gristly expectoration, no greatly improved hæmoptys. 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:-Great 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.

Small cavity in apex, profuse hæmopty., not extended after 8 years.

Limited

cavity be

fore pu

May 1856. H. L., æt. 38, painter (mother d. of phthisis). Ill 1 year, cough slight, increasing expectoration, sweats, dyspnoea, losing flesh. Hæmoptysis pint a day for 3 days, 5 weeks ago. Cavernous cough and pectoriloquy supraclav. dexto., below this dry and tubular character of resp. Pil. conii c. morph., oil, gallic acid, iodine externally. Report 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, expiration 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 well-defined cavity in right apex, extending as far as 3rd rib anteriorly, and suprasp. fossa, base clear, tubular blowing 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 expectoration. I can thus verify the existence of a cavity for seven years.

Jane H., æt. 16, no predisp. Ctma. not appeared. Growing fast, rather gains flesh. Ill 2 years with cough, slight