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ON THE NATURE AND TREATMENT OF PULMONARY CONSUMPTION
711 CASE 13.-A gentleman aged twenty-four. Had lost a brobladder ; your finger follows, and dilates, and then the forceps on that. Manifestly this will not do for large stones, ther in consumption, and consulted Dr. Williams about himwhich mainly, thanks to lithotrity, are what we have to deal self on Dec. 23rd, 1852. In June had influenza, and since with now. Hence the applicability of the "median" is ex- then had been weak, with occasional colds. Last September, tended by making it "medio-bilateral,"and in this manner. after a chill, had pain between the shoulders, short breath, Having performed the median, as just described, up to the slight cough, and bubbling noise in chest. Symptoms impoint of opening the urethra, instead of introducing a director, proved, but pain returned in three weeks, affecting back and you introduce the two-bladed lithotome, and when it is in the left side, and was relieved by blistering and croton-oil liniment. bladder you open the blades, and two moderate incisions are Cough has continued since, and is accompanied by opaque curdy made, one right, the other left, as you draw the opened instru- or yellow expectoration. Physical signs : Slight dulness ; defiment outwards in the groove of the staff. These two opera- cient breath in upper left chest; tubular voice near spine. tions I have now performed about thirty times, and I do not Ordered oil in tonic of nitric and hydrocyanic acids, with know, after all, that there is much to choose between them tinctures of hop, henbane, and orange. and the old "lateral." To make an accurate estimate, one reSept. 23rd, 1853.-Wintered well at Torquay, taking a teaquires at least 100 cases of each operation by the same hand. spoonful of oil four times daily. Had haemoptysis to the Nevertheless, I may say a word, finally, on the principle which amount of two drachms once. Breath weak, but clearer in essentially distinguishes these operations. They are the result left chest. Dulness and tubular sounds in upper right chest.
into the
of opposite convictions respecting the hazard of the knife. There is a set of men to whom anatomy is a bugbear, and who are afraid of cutting as much as is absolutely necessary ; and there are other men less timid-mind, I don’t say less cautious, -who regard the larger, freer style of operating as better than the small or fearful style. All surgeons, of course, tend more The anatomical or less to fall into one of these two classes. school have devised a variety of median operations in order to avoid certain bloodvessels, &c., and they sacrifice space in doing so. They answer excellently well for small and mediumsized stones ; but these are or should be crushed now, and we do not want any operation for such stones. The perineal operation which offers the most room, the recto-vesical excepted, is the lateral operation. All the others named are essentially median operations. Now I am bound to say that formerly, judging theoretically, I had a leaning to the median method, being disposed to think that it would be attended with less haemorrhage than the others. But I do not find this so in practice, and I have arrived at the conclusion that there is quite as much bleeding as in the lateral operation. I attribute this to the bulb. I regard the bulb as a large artery to all intents and purposes. You cut into that spongy tissuenot in all cases, but in some,-and there is as much bleeding as if you cut the artery of the bulb, and more difficulty in controlling it. The bulb must be cut more or less in the median operation. The problem is how to get into the bladder without wounding the bulb, its artery, and the rectum ; and I believe that a well-performed lateral operation accomplishes this, where a free opening for a large stone is required, better than any other. The next lecture will relate to diseases affecting the bladder itself.
I,
ON THE NATURE AND TREATMENT OF PULMONARY CONSUMPTION AS EXEMPLIFIED IN PRIVATE PRACTICE. BY CHARLES J. B.
WILLIAMS, M.D., F.R.S.,
CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AT
BROMPTON;
AND
CHARLES THEODORE
WILLIAMS,
M.B.
OXON.,
ASSISTANT-PHYSICIAN TO THE SAME HOSPITAL.
ABSTRACTS OF ILLUSTRATIVE CASES.
(Continued from p. 615.) THE cases hitherto related contain many points of interest with regard to the development, progress, and arrest of consumptive disease ; but they have been cited chiefly on account of their remarkable duration, all of them exceeding ten years, and many exceeding twenty. It would be easy to multiply such instances, as our 500 tabulated cases, selected within the limits mentioned in a former paper (see THE LANCET for May 2nd, p. 553), include no fewer than 287 of ten years’ standing and upwards; but it would be wearisome to quote even the abstracts of such numbers. It will suffice to add, as further samples, eight more, which, with those already related, will make up twenty illustrative cases of consumption in the ordinary tuberculousjorm. Statistics will be given of the whole number hereafter; and in our next paper we propose to exemplify the other varieties of consumption, by
adducing cases of the hcemorrhagic and inflammatory forms.
Pain in left side Pau.
during last two weeks.
Ordered to winter at
Sept. 1859.-Wintered at Pau, taking the oil the first year. Afterwards moved to Bagneres de Bigorre, and lived much in the mountains, practising photography. Entirely lost cough and weakness of chest, living a great deal in the open air, and ascending mountains, both in summer and winter, without any detriment. Quite well and active in 1868, nearly sixteen years after his first symptoms. clergyman, aged twenty-five. Nov. 2nd, 1854. ago had severe inflammation of lung; but has been well and active since till twelve months ago, when he had gastric fever. Has since taken less animal food, and felt weaker. In last few months had much mental exertion in preparing for ordination, after which, three weeks ago, he brought up several mouthfuls of blood, with slight cough. Has been very weak since. Physical signs: Defective motion and breath, and moderate dulness in upper left chest; moist subcrepitus below clavicle. Tubular sounds above right CASE 14.-A
Twenty years
scapula.
June 14th, 1855.-Taken oil with acid tonic till spring. Improving in all respects. Cough slight. Nov. 5th.-Quite well all summer, except short breath, and some opaque expectoration in morning. Walks six or seven miles. Physical signs: Still deficient motion, dulness, and large tubular sounds in upper left chest, most in front; breath weak and tubular in upper right. June 17th, 1856.-Wintered at Hyeres, Rome, &c., feeling well, and using regular exercise. Physical signs: Dulness and
tubular sounds rather less marked in front; more tubular above right scapula, where there is a click on deep breath. Nov. 4th, 1858.-Has continued to take the oil in phosphoric acid tonic, and keeps up flesh and strength, doing occasional duty, but breath always short on exertion. Only occasional opaque expectoration. Physical signs: Tubular sounds loud in both upper regions, most in right, where a click is audible on deep breath. Nov. 4th, 1860.-Continued well till about a month ago, when he had an attack of fever, cough, and expectoration, and is much reduced. Physical signs: Extensive dulness and obstructed breath in left chest; only obscure crepitus in parts;. large tubular sounds above. Oil, which had been left off for some time, to be resumed, with acid and quinine; and freevesication with acetum cantharidis. June 20th, 1861.-Wintered at Torquay, taking oil, &c., and gradually recovered flesh and strength; able to ride regu-larly, but breath always short. Cough and expectoration increased since much exertion a fortnight ago. No liniment lately; only a small spot of cautery on left chest. Urine scanty. Physical signs: Extensive dulness, obstructed breath, and coarse crepitus through left chest ; cavernous in upper. Ordered, nitric acid with oil; effervescing saline at night; acet. cantharidis liniment. This attack gradually subsided, and he lived on for six years more, always taking oil and living well, except when prevented by attacks of inflammation of the lung or pleura (of which there were two or three) and hoemoptysis, of which one at Windsor, in 1865, amounted to six ounces. His recovery from these attacks was wonderful; and in a quiet way he continued to enjoy life, passing one winter at Mentone (which disagreed), two winters at Pau, and two more at Torquay. Latterly the hypophosphites of soda or lime were added to the acid mixtures taken constantly with the oil, with manifest advantage to the nourishment of his body, which was pretty stout to the last; but shortness of breath and weakness gradually increased,
712 and the
obvious in both lungs. Conto Mentone, and died there
Cough and occasional slight haemorrhage continued a month after ; but, under the oil and sulphuric-acid mixture, and external counter-irritation, great improvement took place, and early in the winter of 1867. The duration of this case (upwards 0.(thirteen years) is re- the cough ceased. Physical signs : Crepitation gradually cleared markable, considering the extent of disease even at first, but away, except in one spot, where a croak was sometimes heard. more so when its great increase in 1860, and subsequently, is Still dulness and tubular sounds. taken into account; yet, under the influence of rest and favourJune 12th, 1854.-Been taking oil and acid mixture the able climate, and with constant use of oil and tonics, and whole time. Wintered at Naples and Rome. Been free from counter-irritation, great improvement took place again and cough and haemorrhage, and greatly improved in flesh and strength. In last week only has had a cold and cough. Physical again from conditions which seemed almost hopeless. CASE 15. -A gentleman aged twenty. Brother died of signs: Still some dulness in right scapular region, but no sounds. Some catarrhal rhonchi in various parts from phthisis. Feb. 5th, 1846. Fair complexion; red hair. Well tubular till November, when he caught severe cold, and had cough ever fresh cold. 1861.-Been quite well. In Parliament since 1856. Now since, lately with much phlegm, which he has not the knack of married. expectorating. Lost much flesh and strength. Pulse frequent. 1868.-Quite well, ffteen years after the first attack. Sweats much at night. In country since Christmas; but no CASE 18.-A clergyman, aged fifty-two, first consulted Dr. better. Physical signs: Dulness and defective breath in upper right back. Collapse below right clavicle. Some dulness and Williams on July 20th, 1848. Had been subject to occasional
trary
to
signs
of cavities
advice, he
went
were
again
’
I
deficient breath below left clavicle. Liver dulness increased below ribs. Ordered mixture of nitric acid, iodide of potassium, hydrocyanic acid, and sarsaparilla. Rhubarb-and-taraxaAcetum cantharidis to chest. cum pill every night. March 20th.-Been at Clifton, and in three weeks lost cough and sweats. Is improving in flesh. Pulse still frequent. Oct. 6th, l847.-Feels quite well. Passed last winter in Cornwall. Has had no cough for three months. Breath still rather short. Slight dulness and weak breath in upper left only. Expires 276cubic inches. Height, 5 ft. 10 in. 1866.-Heard that he continued quite well, having had no return of chest symptoms - twenty years after first attack. The combination of nitric acid, iodide of potassium, and sarsaparilla was commonly used by Dr. Williams in incipient phthisis with benefit before it was superseded by cod-liver oil, the efficacy of which was obviously much greater and more
cough since he had the measles in childhood.
Has had severe chill a year and a half ago, and in last six months has lost much flesh and colour, and now sweats at night. Physical signs: Dulness and tubular sounds on both sides of upper chest, but most in right front. Ordered oil, with orange mixture, and an iodine liniment. Aug. llth.-Cough better, but in last few days has had sharp pain and great tenderness in left shoulder-joint. Ordered, iodide of potassium and colchicum with the oil. 26th.-Pain soon relieved. Cough moderate. April 14th, 1849.-Has become quite well and strong, and has gained fifteen pounds since July. Still tubular expiration at and above left scapula. 1868.-Well and active, more than twenty years since first
cough and scanty expectoration since a bad
attack.
CASE 19. -A young gentleman, aged fifteen. May llth, Maternal aunt died of phthisis. In last Christmas CASE 16.-A delicate boy, aged eight, whose father had died holidays, after a chill, had pain in right side, and some cough of phthisis, was first seen June 2Sth, 1853. Had cough since ever since. Ten weeks ago had a severe chill after playing influenza six weeks ago. Soon after was seen by Dr. West, at football; and since has suffered much from cough and weak. who found dulness and coarse crepitus in upper left. Had ness, loss of appetite and breath. Physical signs: Dulness, lost flesh, and had profuse perspirations ; but had taken oil for defective motion and breath-sound, in whole right chest; sounds at and above scapula. To take oil, with nitric a fortnight, and much improved. Physical signs: Dulness in tubular and acids in orange infusion, and use acetum with loud half of left tracheal note on hydrocyanic chest, upper percussion at the top ; large tubular breath and voice sounds also, withi cantharidis. June 16th.-Much better. Cough nearly gone. Says breath coarse crackle in parts ; large tubular sounds above is not short now. Physical signs : Still dulness and tubular The oil to be acid and acetum with tonic, continued, scapula. sounds at and above right scapula. cantharidis to be applied from time to time on left chest. Nov. 22nd, 1866.-Took oil at times for several years, and 1861.-For several years he continued delicate, requiring constant care, and always taking the oil with varied tonics; improved much in general health and strength, but always himself rather short-winded on exertion, and sometimes residing generally at Tunbridge Wells or on the south coast. found The signs of cavity became very distinct, but in two or three rather wheezy; still he has kept his terms regularly at Camyears they diminished as the general health improved; and bridge, and studied with such success that he came out senior wrangler. Has continued well till six weeks ago, now there are only dulness and tubular sounds below the clavicle and above the scapula, and weak vesicular sounds when he caught a cold, and has had slight cough since, with below. Flesh and strength now pretty good for a lad of an occasional feeling of faintness. Physical signs: Bronchosixteen. phony above right scapula; percussion- and breath-sounds till three 1883.—Continued well and active generally clear. To take oil with iron tonic. July 21st, 1868.-Continues well (eleven years since his first sympmonths ago, when he had a severe cold, with signs of bronchitis affecting the right as well as the left lung, and the large toms). Has now become Fellow of his College. tubular sounds and coarse crepitus reappeared there. After CASE 20.-A lady aged forty, who had lost a sister from repeated blistering and continued use of the oil, he gradually consumption, first consulted Dr. Williams on June 20th, 1849. recovered, and has now only moderate cough and rather short There had been slight cough and expectoration for a year and breath, but his strength is good, and he walks ten miles. Still a half, for which she had been long treated with steel, without coarse crepitus in upper left front ; dry cavernous sounds above benefit. Physical signs: Amphoric stroke and loud cavernous left scapula; large tubular sounds above right scapula, but sounds above right clavicle and scapula ; the same signs below breath quite good in other parts. clavicle, though less marked. Ordered cod-liver oil. This patient has not been seen since ; but Dr. Williams has July 13th.-Heard that she was suffering from increasing lately heard that he recovered, fifteen yem’s having elapsed weakness, diarrhoea, hoarseness, and copious expectoration. Oil had not been taken. Ordered a tonic of nitric and hydrosince his first symptoms. CASE 17. -A gentleman, aged twenty-four, first seen July 1st, cyanic acid, and tincture of orange, to be combined with oil at 1853. In April, whilst acting as officer in Militia drill, after a later date. and much improved in Nov. 20th.-Has taken oil shouting, expectorated about a dessertspoonful of blood ; and the last three months, havingregularly, lost her cough for the first time since smaller quantities, with a feeling of tightness and soreHas lost flesh and strength. in two years, and grown fat and strong. Physical signs: Dulness of the chest, and some cough. Last night brought up half ness and large and loud cavernous sounds above right scapula, Been kept low, taking acids, &c. and to a less extent below right clavicle. an ounce of bright blood, and the sputa are still deeply tinged. 1856.-General health good; no cough, but physical signs Chest feels tight. Pulse 90. Physical signs : Dulness and same. the moist crepitus at right scapula. Was cupped to eight ounces; 1868.-Alive and well, tzventy years after first symptoms. on scapula. Acetate of lead, with excess of acetic acid, and a, In this case the disease was limited to the very apex of the little opium, given every four hours, and every morning a right lung, ending in a cavity, which remained dry long after draught of sulphate of magnesia, with sulphuric acid. restoration to health. patient’s the Dark in 2nd.-Chest Pulse blood relieved. July quiet. Note.-In the abstract of Case 6, which appeared in THE sputa. Physical signs : Much less crepitus; but still dulness! and bronchophony in right scapular region. LAXCET of May 16th, there was an inaccuracy which requires
general.
right
1857.
713 correction. It is there stated that the patient ’’ spent the lastI 3ody deserve the name of tubercle, and that they may originate Mentone, where she was leeched and cauterised 18 it were by accident. Of course there is no difficulty in so fifty times." The original notes are as follows :-" Jan. 21st, wide-spread form of disease for some persons, with whom I 1864: Generally better in chest. Only occasional colds. Of have conversed on the subject, to bring forward instances of late years, leucorrhoea and uterine irritation sometimes relieved phthisis succeeding to a chronic synovitis, an abscess in the by leeches before period. Last two winters at Mentone ; had testis, or a fistula in ano, to say nothing of the many examples caustic fifty times, and better, but still cannot walk much. of a husband soon following a wife to the grave, or a sister the It appears, therefore, that there was no brother, in confirmation of the opinion that the seeds of tubercle Taken oil, &c." leeching at Mentone; and the patient’s own expression, that maybe carried by the breath. Xow, although it is no difficult the caustic was applied fifty times, was probably an exaggera- task to select instances of this nature which may tend to corroborate such a doctrine as that just mentioned, yet we must tion, and merely meant to signify a great number of times. look up our whole clinical experience in order to discover how (To be continued.) far it can be applied; and in doing so I cannot but think that this will be found quite out of harmony with the teaching which the experiments might seem to warrant. The subject is a very THE INOCULATION OF TUBERCLE IN ITS large one, and cannot be treated in a few words; it involves the whole question of what is understood by tubercle, what is RELATION TO CLINICAL EXPERIENCE. meant by local and constitutional disease, and how the term phthisis is understood by the profession. BY SAMUEL WILKS, M.D. LOND., If it should be said that the material which is found in a PHYSICIAN TO GUY’S HOSPITAL. abscess or lymphatic gland which has been the subject dried-up I of inflammation is the same material as that discovered in the THE subject of the inoculation of tubercle, originated by body in a case of consumption, I would answer, that although Villemin and other foreign experimenters, and which is now the naked eye may not perceive a distinction, yet they are to intents and different. It might, however, be said undergoing a rigid examination at the hands of such excellent all that thispurposes is assuming the very point to be determined, again observers as Mr. Simon, Dr. Andrew Clark, Dr. Sanderson, which is, whether any material accidentally produced on the and Dr. Wilson Fox, must be treated entirely on its own surface, as from injury, may not be propagated through the merits, and should in no way be prejudiced by the introduction system in a form which is usually styled tuberculous, and into it of extraneous matter. The investigations by these gen- which all admit tends only to one event. I would say a second tlemen may serve as models for the manner in which such in- time that this is the arena for the combat of the rival doctrines, and that clinical observation is opposed to the idea quiries should be undertaken, and we may hope that they may of the spread of tubercle in thisaltogether accidental manner; in fact, I be pushed still further until some definite conclusion is arrived myself know of no form of disease to which the doctrine appaat. It is quite impossible, however, to prevent the medical rently arising from the experiments mentioned would less apply mind from speculating at once upon their nature, and making than that of tuberculosis; it would much more fit the facts obthose applications of the facts which these at present seem to served concerning the growth of cancer. The question concerning the local and constitutional nature warrant. Thus already the announcement of the inoculability of any disease is as old as it is important. The tendency of all of tubercle has been sufficient to induce some in the profession clinical experience has been to favour the constitutional rather to assert their belief in the accidental character of the disease than the accidental cause of disease; whilst pure pathology known as consumption. For my own part, I think the facts has had much to advance on the other side. Thus I have on various occasions attempted to show that particular tissues of are at present too crude to allow of any deductions which can be applicable to the elucidation of the question of tuberculosis the body are liable to special changes, whilst they are at the same time insusceptible to others ; that, for example, it is not in the human subject; much less can they be taken as exemtrue, as was once supposed, that a cancer, a tubercle, or an plifying a universal law of the propagation of tubercle in the abscess can spring up de Mcwo in any part of the body. I beanimal kingdom. Since, however, there are those who have lieve that a cancer or an abscess in the lung is one of the rarest as an idiopathic affection, and that almost accepted the results already obtained as affording an explana. possible occurrences tion of the ravages of tuberculous disease in mankind, I wil’. invariably it may be shown that the seeds of the disease have been brought from a distant In the case of cancer, briefly state that at present our clinical experience present; although one cannot deny thepart. hereditary disposition to the most formidable objections to the reception of the new doctrine. disease, yet my own observations, like those of Mr. Moore, The first announcement, it may be remembered, was simply tend to prove its frequent local origin. Indeed, the example that tubercle could be inoculated. This being apparently sus- of osteoid cancer, originating in bone, and melanotic cancer, versive of the common opinion that tuberculosis was a consti- often havingits source on a pigmental mole, is sufficient to tutional disease, the further declaration that the same results show how local characters of a disease are propagated. I were attainable by the use of many animal substances was remight also mention the occasional case of epithelial elements ceived with much satisfaction, for it tended to the conclusion being discovered in solid organs which neighbour on an epithethat the effect produced was of the nature of pysemia. SubWhen, therefore, it is said that abnormal desequently, however, the elaborate researches of Dr. Wilson Fox posits on the surface tend to the formation of similar deposits and others proved that the new formations are real growths of in the of the body, we have clinical experience of the cell composition, and that truly they can be produced by the fact. Even if cancer, in its various compound forms, had been inoculation of a variety of substances into the system. The inoculated in animals, I believe we could have advanced latter, however, are more or less allied, being what are styled nothing in human pathology in opposition to the experiments. homologous elements-that is, cell formations, the result of If a local formation of a peculiar character is succeeded by inflammatory processes in different tissues of the body. I am similar formations in the organs of the body, whether these not aware that any material supposed to contain any specific are composed of nuclei or cells of cancer-the cells of pus, boneelements in its constitution has been found equally effective. tissue, or pigment,-we are not surprised at those ill-formed Both Dr. Sanderson and Dr. Wilson Fox, I believe, in con- cell-structures which are found in inflamed products being templating their experiments, see no difficulty in regarding all succeeded by like growths in the interior of the body, if the these new growths, which they have been instrumental in former be inoculated. This has yet to be proved as occurring making, as identical in composition, and thus give to them with frequency in the human body, although I think it posthe appellation of tubercle ; and they then, moreover, naturally as one or two remarkable instances coming under my divert to the domain of human pathology, and inquire whether own notice have shown, in which the question arose between we have not been too stringent in the definition of this dea pysemic process or a case of multiple growths. But, admitwhether posit, and been making distinctions where none existed ; whe- ting these facts, what concerns us here is the question ther, indeed, the crude or cheesy deposits so constantly found these inoculable deposits are deserving of the name " tubercle."" in the human subject should not all be regarded as tubercle. My own opinion is that they are not; indeed, I confess to the There need be no fear of such cautious as well as intelligent that all my teaching of late years has been towards the observers rushing into theoretical speculations whose truth overthrow of the opinion that all low-organised or caseous detheir experience might not confirm ; but yet there are those! posits are to be regarded as tuberculous, seeing that they arise persons who would at once draw an inference to the effect thatunder such a variety of circumstances, which preclude their all the amorphous and caseous deposits found in the humanLhaving anything in common.
two winters at
"
lial growth.
interior
sible,
fact
into the
of opposite convictions respecting the hazard of the knife. There is a set of men to whom anatomy is a bugbear, and who are afraid of cutting as much as is absolutely necessary ; and there are other men less timid-mind, I don’t say less cautious, -who regard the larger, freer style of operating as better than the small or fearful style. All surgeons, of course, tend more The anatomical or less to fall into one of these two classes. school have devised a variety of median operations in order to avoid certain bloodvessels, &c., and they sacrifice space in doing so. They answer excellently well for small and mediumsized stones ; but these are or should be crushed now, and we do not want any operation for such stones. The perineal operation which offers the most room, the recto-vesical excepted, is the lateral operation. All the others named are essentially median operations. Now I am bound to say that formerly, judging theoretically, I had a leaning to the median method, being disposed to think that it would be attended with less haemorrhage than the others. But I do not find this so in practice, and I have arrived at the conclusion that there is quite as much bleeding as in the lateral operation. I attribute this to the bulb. I regard the bulb as a large artery to all intents and purposes. You cut into that spongy tissuenot in all cases, but in some,-and there is as much bleeding as if you cut the artery of the bulb, and more difficulty in controlling it. The bulb must be cut more or less in the median operation. The problem is how to get into the bladder without wounding the bulb, its artery, and the rectum ; and I believe that a well-performed lateral operation accomplishes this, where a free opening for a large stone is required, better than any other. The next lecture will relate to diseases affecting the bladder itself.
I,
ON THE NATURE AND TREATMENT OF PULMONARY CONSUMPTION AS EXEMPLIFIED IN PRIVATE PRACTICE. BY CHARLES J. B.
WILLIAMS, M.D., F.R.S.,
CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AT
BROMPTON;
AND
CHARLES THEODORE
WILLIAMS,
M.B.
OXON.,
ASSISTANT-PHYSICIAN TO THE SAME HOSPITAL.
ABSTRACTS OF ILLUSTRATIVE CASES.
(Continued from p. 615.) THE cases hitherto related contain many points of interest with regard to the development, progress, and arrest of consumptive disease ; but they have been cited chiefly on account of their remarkable duration, all of them exceeding ten years, and many exceeding twenty. It would be easy to multiply such instances, as our 500 tabulated cases, selected within the limits mentioned in a former paper (see THE LANCET for May 2nd, p. 553), include no fewer than 287 of ten years’ standing and upwards; but it would be wearisome to quote even the abstracts of such numbers. It will suffice to add, as further samples, eight more, which, with those already related, will make up twenty illustrative cases of consumption in the ordinary tuberculousjorm. Statistics will be given of the whole number hereafter; and in our next paper we propose to exemplify the other varieties of consumption, by
adducing cases of the hcemorrhagic and inflammatory forms.
Pain in left side Pau.
during last two weeks.
Ordered to winter at
Sept. 1859.-Wintered at Pau, taking the oil the first year. Afterwards moved to Bagneres de Bigorre, and lived much in the mountains, practising photography. Entirely lost cough and weakness of chest, living a great deal in the open air, and ascending mountains, both in summer and winter, without any detriment. Quite well and active in 1868, nearly sixteen years after his first symptoms. clergyman, aged twenty-five. Nov. 2nd, 1854. ago had severe inflammation of lung; but has been well and active since till twelve months ago, when he had gastric fever. Has since taken less animal food, and felt weaker. In last few months had much mental exertion in preparing for ordination, after which, three weeks ago, he brought up several mouthfuls of blood, with slight cough. Has been very weak since. Physical signs: Defective motion and breath, and moderate dulness in upper left chest; moist subcrepitus below clavicle. Tubular sounds above right CASE 14.-A
Twenty years
scapula.
June 14th, 1855.-Taken oil with acid tonic till spring. Improving in all respects. Cough slight. Nov. 5th.-Quite well all summer, except short breath, and some opaque expectoration in morning. Walks six or seven miles. Physical signs: Still deficient motion, dulness, and large tubular sounds in upper left chest, most in front; breath weak and tubular in upper right. June 17th, 1856.-Wintered at Hyeres, Rome, &c., feeling well, and using regular exercise. Physical signs: Dulness and
tubular sounds rather less marked in front; more tubular above right scapula, where there is a click on deep breath. Nov. 4th, 1858.-Has continued to take the oil in phosphoric acid tonic, and keeps up flesh and strength, doing occasional duty, but breath always short on exertion. Only occasional opaque expectoration. Physical signs: Tubular sounds loud in both upper regions, most in right, where a click is audible on deep breath. Nov. 4th, 1860.-Continued well till about a month ago, when he had an attack of fever, cough, and expectoration, and is much reduced. Physical signs: Extensive dulness and obstructed breath in left chest; only obscure crepitus in parts;. large tubular sounds above. Oil, which had been left off for some time, to be resumed, with acid and quinine; and freevesication with acetum cantharidis. June 20th, 1861.-Wintered at Torquay, taking oil, &c., and gradually recovered flesh and strength; able to ride regu-larly, but breath always short. Cough and expectoration increased since much exertion a fortnight ago. No liniment lately; only a small spot of cautery on left chest. Urine scanty. Physical signs: Extensive dulness, obstructed breath, and coarse crepitus through left chest ; cavernous in upper. Ordered, nitric acid with oil; effervescing saline at night; acet. cantharidis liniment. This attack gradually subsided, and he lived on for six years more, always taking oil and living well, except when prevented by attacks of inflammation of the lung or pleura (of which there were two or three) and hoemoptysis, of which one at Windsor, in 1865, amounted to six ounces. His recovery from these attacks was wonderful; and in a quiet way he continued to enjoy life, passing one winter at Mentone (which disagreed), two winters at Pau, and two more at Torquay. Latterly the hypophosphites of soda or lime were added to the acid mixtures taken constantly with the oil, with manifest advantage to the nourishment of his body, which was pretty stout to the last; but shortness of breath and weakness gradually increased,
712 and the
obvious in both lungs. Conto Mentone, and died there
Cough and occasional slight haemorrhage continued a month after ; but, under the oil and sulphuric-acid mixture, and external counter-irritation, great improvement took place, and early in the winter of 1867. The duration of this case (upwards 0.(thirteen years) is re- the cough ceased. Physical signs : Crepitation gradually cleared markable, considering the extent of disease even at first, but away, except in one spot, where a croak was sometimes heard. more so when its great increase in 1860, and subsequently, is Still dulness and tubular sounds. taken into account; yet, under the influence of rest and favourJune 12th, 1854.-Been taking oil and acid mixture the able climate, and with constant use of oil and tonics, and whole time. Wintered at Naples and Rome. Been free from counter-irritation, great improvement took place again and cough and haemorrhage, and greatly improved in flesh and strength. In last week only has had a cold and cough. Physical again from conditions which seemed almost hopeless. CASE 15. -A gentleman aged twenty. Brother died of signs: Still some dulness in right scapular region, but no sounds. Some catarrhal rhonchi in various parts from phthisis. Feb. 5th, 1846. Fair complexion; red hair. Well tubular till November, when he caught severe cold, and had cough ever fresh cold. 1861.-Been quite well. In Parliament since 1856. Now since, lately with much phlegm, which he has not the knack of married. expectorating. Lost much flesh and strength. Pulse frequent. 1868.-Quite well, ffteen years after the first attack. Sweats much at night. In country since Christmas; but no CASE 18.-A clergyman, aged fifty-two, first consulted Dr. better. Physical signs: Dulness and defective breath in upper right back. Collapse below right clavicle. Some dulness and Williams on July 20th, 1848. Had been subject to occasional
trary
to
signs
of cavities
advice, he
went
were
again
’
I
deficient breath below left clavicle. Liver dulness increased below ribs. Ordered mixture of nitric acid, iodide of potassium, hydrocyanic acid, and sarsaparilla. Rhubarb-and-taraxaAcetum cantharidis to chest. cum pill every night. March 20th.-Been at Clifton, and in three weeks lost cough and sweats. Is improving in flesh. Pulse still frequent. Oct. 6th, l847.-Feels quite well. Passed last winter in Cornwall. Has had no cough for three months. Breath still rather short. Slight dulness and weak breath in upper left only. Expires 276cubic inches. Height, 5 ft. 10 in. 1866.-Heard that he continued quite well, having had no return of chest symptoms - twenty years after first attack. The combination of nitric acid, iodide of potassium, and sarsaparilla was commonly used by Dr. Williams in incipient phthisis with benefit before it was superseded by cod-liver oil, the efficacy of which was obviously much greater and more
cough since he had the measles in childhood.
Has had severe chill a year and a half ago, and in last six months has lost much flesh and colour, and now sweats at night. Physical signs: Dulness and tubular sounds on both sides of upper chest, but most in right front. Ordered oil, with orange mixture, and an iodine liniment. Aug. llth.-Cough better, but in last few days has had sharp pain and great tenderness in left shoulder-joint. Ordered, iodide of potassium and colchicum with the oil. 26th.-Pain soon relieved. Cough moderate. April 14th, 1849.-Has become quite well and strong, and has gained fifteen pounds since July. Still tubular expiration at and above left scapula. 1868.-Well and active, more than twenty years since first
cough and scanty expectoration since a bad
attack.
CASE 19. -A young gentleman, aged fifteen. May llth, Maternal aunt died of phthisis. In last Christmas CASE 16.-A delicate boy, aged eight, whose father had died holidays, after a chill, had pain in right side, and some cough of phthisis, was first seen June 2Sth, 1853. Had cough since ever since. Ten weeks ago had a severe chill after playing influenza six weeks ago. Soon after was seen by Dr. West, at football; and since has suffered much from cough and weak. who found dulness and coarse crepitus in upper left. Had ness, loss of appetite and breath. Physical signs: Dulness, lost flesh, and had profuse perspirations ; but had taken oil for defective motion and breath-sound, in whole right chest; sounds at and above scapula. To take oil, with nitric a fortnight, and much improved. Physical signs: Dulness in tubular and acids in orange infusion, and use acetum with loud half of left tracheal note on hydrocyanic chest, upper percussion at the top ; large tubular breath and voice sounds also, withi cantharidis. June 16th.-Much better. Cough nearly gone. Says breath coarse crackle in parts ; large tubular sounds above is not short now. Physical signs : Still dulness and tubular The oil to be acid and acetum with tonic, continued, scapula. sounds at and above right scapula. cantharidis to be applied from time to time on left chest. Nov. 22nd, 1866.-Took oil at times for several years, and 1861.-For several years he continued delicate, requiring constant care, and always taking the oil with varied tonics; improved much in general health and strength, but always himself rather short-winded on exertion, and sometimes residing generally at Tunbridge Wells or on the south coast. found The signs of cavity became very distinct, but in two or three rather wheezy; still he has kept his terms regularly at Camyears they diminished as the general health improved; and bridge, and studied with such success that he came out senior wrangler. Has continued well till six weeks ago, now there are only dulness and tubular sounds below the clavicle and above the scapula, and weak vesicular sounds when he caught a cold, and has had slight cough since, with below. Flesh and strength now pretty good for a lad of an occasional feeling of faintness. Physical signs: Bronchosixteen. phony above right scapula; percussion- and breath-sounds till three 1883.—Continued well and active generally clear. To take oil with iron tonic. July 21st, 1868.-Continues well (eleven years since his first sympmonths ago, when he had a severe cold, with signs of bronchitis affecting the right as well as the left lung, and the large toms). Has now become Fellow of his College. tubular sounds and coarse crepitus reappeared there. After CASE 20.-A lady aged forty, who had lost a sister from repeated blistering and continued use of the oil, he gradually consumption, first consulted Dr. Williams on June 20th, 1849. recovered, and has now only moderate cough and rather short There had been slight cough and expectoration for a year and breath, but his strength is good, and he walks ten miles. Still a half, for which she had been long treated with steel, without coarse crepitus in upper left front ; dry cavernous sounds above benefit. Physical signs: Amphoric stroke and loud cavernous left scapula; large tubular sounds above right scapula, but sounds above right clavicle and scapula ; the same signs below breath quite good in other parts. clavicle, though less marked. Ordered cod-liver oil. This patient has not been seen since ; but Dr. Williams has July 13th.-Heard that she was suffering from increasing lately heard that he recovered, fifteen yem’s having elapsed weakness, diarrhoea, hoarseness, and copious expectoration. Oil had not been taken. Ordered a tonic of nitric and hydrosince his first symptoms. CASE 17. -A gentleman, aged twenty-four, first seen July 1st, cyanic acid, and tincture of orange, to be combined with oil at 1853. In April, whilst acting as officer in Militia drill, after a later date. and much improved in Nov. 20th.-Has taken oil shouting, expectorated about a dessertspoonful of blood ; and the last three months, havingregularly, lost her cough for the first time since smaller quantities, with a feeling of tightness and soreHas lost flesh and strength. in two years, and grown fat and strong. Physical signs: Dulness of the chest, and some cough. Last night brought up half ness and large and loud cavernous sounds above right scapula, Been kept low, taking acids, &c. and to a less extent below right clavicle. an ounce of bright blood, and the sputa are still deeply tinged. 1856.-General health good; no cough, but physical signs Chest feels tight. Pulse 90. Physical signs : Dulness and same. the moist crepitus at right scapula. Was cupped to eight ounces; 1868.-Alive and well, tzventy years after first symptoms. on scapula. Acetate of lead, with excess of acetic acid, and a, In this case the disease was limited to the very apex of the little opium, given every four hours, and every morning a right lung, ending in a cavity, which remained dry long after draught of sulphate of magnesia, with sulphuric acid. restoration to health. patient’s the Dark in 2nd.-Chest Pulse blood relieved. July quiet. Note.-In the abstract of Case 6, which appeared in THE sputa. Physical signs : Much less crepitus; but still dulness! and bronchophony in right scapular region. LAXCET of May 16th, there was an inaccuracy which requires
general.
right
1857.
713 correction. It is there stated that the patient ’’ spent the lastI 3ody deserve the name of tubercle, and that they may originate Mentone, where she was leeched and cauterised 18 it were by accident. Of course there is no difficulty in so fifty times." The original notes are as follows :-" Jan. 21st, wide-spread form of disease for some persons, with whom I 1864: Generally better in chest. Only occasional colds. Of have conversed on the subject, to bring forward instances of late years, leucorrhoea and uterine irritation sometimes relieved phthisis succeeding to a chronic synovitis, an abscess in the by leeches before period. Last two winters at Mentone ; had testis, or a fistula in ano, to say nothing of the many examples caustic fifty times, and better, but still cannot walk much. of a husband soon following a wife to the grave, or a sister the It appears, therefore, that there was no brother, in confirmation of the opinion that the seeds of tubercle Taken oil, &c." leeching at Mentone; and the patient’s own expression, that maybe carried by the breath. Xow, although it is no difficult the caustic was applied fifty times, was probably an exaggera- task to select instances of this nature which may tend to corroborate such a doctrine as that just mentioned, yet we must tion, and merely meant to signify a great number of times. look up our whole clinical experience in order to discover how (To be continued.) far it can be applied; and in doing so I cannot but think that this will be found quite out of harmony with the teaching which the experiments might seem to warrant. The subject is a very THE INOCULATION OF TUBERCLE IN ITS large one, and cannot be treated in a few words; it involves the whole question of what is understood by tubercle, what is RELATION TO CLINICAL EXPERIENCE. meant by local and constitutional disease, and how the term phthisis is understood by the profession. BY SAMUEL WILKS, M.D. LOND., If it should be said that the material which is found in a PHYSICIAN TO GUY’S HOSPITAL. abscess or lymphatic gland which has been the subject dried-up I of inflammation is the same material as that discovered in the THE subject of the inoculation of tubercle, originated by body in a case of consumption, I would answer, that although Villemin and other foreign experimenters, and which is now the naked eye may not perceive a distinction, yet they are to intents and different. It might, however, be said undergoing a rigid examination at the hands of such excellent all that thispurposes is assuming the very point to be determined, again observers as Mr. Simon, Dr. Andrew Clark, Dr. Sanderson, which is, whether any material accidentally produced on the and Dr. Wilson Fox, must be treated entirely on its own surface, as from injury, may not be propagated through the merits, and should in no way be prejudiced by the introduction system in a form which is usually styled tuberculous, and into it of extraneous matter. The investigations by these gen- which all admit tends only to one event. I would say a second tlemen may serve as models for the manner in which such in- time that this is the arena for the combat of the rival doctrines, and that clinical observation is opposed to the idea quiries should be undertaken, and we may hope that they may of the spread of tubercle in thisaltogether accidental manner; in fact, I be pushed still further until some definite conclusion is arrived myself know of no form of disease to which the doctrine appaat. It is quite impossible, however, to prevent the medical rently arising from the experiments mentioned would less apply mind from speculating at once upon their nature, and making than that of tuberculosis; it would much more fit the facts obthose applications of the facts which these at present seem to served concerning the growth of cancer. The question concerning the local and constitutional nature warrant. Thus already the announcement of the inoculability of any disease is as old as it is important. The tendency of all of tubercle has been sufficient to induce some in the profession clinical experience has been to favour the constitutional rather to assert their belief in the accidental character of the disease than the accidental cause of disease; whilst pure pathology known as consumption. For my own part, I think the facts has had much to advance on the other side. Thus I have on various occasions attempted to show that particular tissues of are at present too crude to allow of any deductions which can be applicable to the elucidation of the question of tuberculosis the body are liable to special changes, whilst they are at the same time insusceptible to others ; that, for example, it is not in the human subject; much less can they be taken as exemtrue, as was once supposed, that a cancer, a tubercle, or an plifying a universal law of the propagation of tubercle in the abscess can spring up de Mcwo in any part of the body. I beanimal kingdom. Since, however, there are those who have lieve that a cancer or an abscess in the lung is one of the rarest as an idiopathic affection, and that almost accepted the results already obtained as affording an explana. possible occurrences tion of the ravages of tuberculous disease in mankind, I wil’. invariably it may be shown that the seeds of the disease have been brought from a distant In the case of cancer, briefly state that at present our clinical experience present; although one cannot deny thepart. hereditary disposition to the most formidable objections to the reception of the new doctrine. disease, yet my own observations, like those of Mr. Moore, The first announcement, it may be remembered, was simply tend to prove its frequent local origin. Indeed, the example that tubercle could be inoculated. This being apparently sus- of osteoid cancer, originating in bone, and melanotic cancer, versive of the common opinion that tuberculosis was a consti- often havingits source on a pigmental mole, is sufficient to tutional disease, the further declaration that the same results show how local characters of a disease are propagated. I were attainable by the use of many animal substances was remight also mention the occasional case of epithelial elements ceived with much satisfaction, for it tended to the conclusion being discovered in solid organs which neighbour on an epithethat the effect produced was of the nature of pysemia. SubWhen, therefore, it is said that abnormal desequently, however, the elaborate researches of Dr. Wilson Fox posits on the surface tend to the formation of similar deposits and others proved that the new formations are real growths of in the of the body, we have clinical experience of the cell composition, and that truly they can be produced by the fact. Even if cancer, in its various compound forms, had been inoculation of a variety of substances into the system. The inoculated in animals, I believe we could have advanced latter, however, are more or less allied, being what are styled nothing in human pathology in opposition to the experiments. homologous elements-that is, cell formations, the result of If a local formation of a peculiar character is succeeded by inflammatory processes in different tissues of the body. I am similar formations in the organs of the body, whether these not aware that any material supposed to contain any specific are composed of nuclei or cells of cancer-the cells of pus, boneelements in its constitution has been found equally effective. tissue, or pigment,-we are not surprised at those ill-formed Both Dr. Sanderson and Dr. Wilson Fox, I believe, in con- cell-structures which are found in inflamed products being templating their experiments, see no difficulty in regarding all succeeded by like growths in the interior of the body, if the these new growths, which they have been instrumental in former be inoculated. This has yet to be proved as occurring making, as identical in composition, and thus give to them with frequency in the human body, although I think it posthe appellation of tubercle ; and they then, moreover, naturally as one or two remarkable instances coming under my divert to the domain of human pathology, and inquire whether own notice have shown, in which the question arose between we have not been too stringent in the definition of this dea pysemic process or a case of multiple growths. But, admitwhether posit, and been making distinctions where none existed ; whe- ting these facts, what concerns us here is the question ther, indeed, the crude or cheesy deposits so constantly found these inoculable deposits are deserving of the name " tubercle."" in the human subject should not all be regarded as tubercle. My own opinion is that they are not; indeed, I confess to the There need be no fear of such cautious as well as intelligent that all my teaching of late years has been towards the observers rushing into theoretical speculations whose truth overthrow of the opinion that all low-organised or caseous detheir experience might not confirm ; but yet there are those! posits are to be regarded as tuberculous, seeing that they arise persons who would at once draw an inference to the effect thatunder such a variety of circumstances, which preclude their all the amorphous and caseous deposits found in the humanLhaving anything in common.
two winters at
"
lial growth.
interior
sible,
fact