Consumption; its early and remediable stages

Front matter

!ipi^i!l,lJ ; iPli! 4 ll^,(J,

YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

Preface

The author, in writing the following work, has had four principal objects in view, viz., to take advantage of the growing belief of the day, that there is a stage of Phthisis in which the disease is as remediable as it is irremediable at a later period ; to write a practical work in which may be faithfully represented the actual condition of these cases when regarded in the great numbers in which they have been brought before his observation ; to treat the subject, as far as possible, on the inductive method, and on the improved physiology and pathology of the day; and to give practical effect to numerous series of special inquiries which have been made by him during the preceding seven years.

It is not important, in reference to the first, that the views differ as to the limits, characteristics, and designation of the early stage, since, when the existence of the stage shall have been well established, an agreement as to its nature will certainly follow. Numerous authorities from distant ages, both as to Phthisis in vi PREFACE.

general and the early stage in particular, are cited ; and whilst the author has not omitted to state his own views he has generally founded his observations rather upon the agreements than the disagreements of individual observers.

In seeking to make the work practical the author has entered largely into all the questions which relate to food, exertion, chmate, and others constituting hygienics, because such is in accordance with general feeling at the present time ; because this part of medical knowledge is now being placed upon the sure footing of scientific research; and because it must be through the conditions of the every-day life of the patient that medicinal and other remedial agents may influence the constitution in so chronic a disease. For the same reason minute details have been considered of great importance, since it is upon them that the efficient working of a general plan will essentially depend.

The arrangement of the work upon pli3'siological and pathological indications and the use of propositions will, it is hoped, conduce to clearness of exposition and facility of reference, whilst it may also dissociate the consideration of the treatment from that of the evidences, and cause the same conditions or remedies to he viewed under various aspects. It cannot be doubted that assigning views as to the reasons for any par-

PREFACE. vii

ticular course will be welcomed by an intelligent and inquiring Profession, wbether such views be universally or only partially allowed to be just ; and also that it may tend to promote inquiry in thoughtful minds ; but in order to summarize the whole plan of treatment the various recommendations have been collected together in one chapter and given in an empirical manner. In reference to the author's special investigations, which have been embodied in the work, it is only necessary to ask attention to the explanation offered at the end of the work, in reference to a statistical inquiry of great extent, which was completed whilst the sheets were passing through the press.

London : 16, Queen Anne Street, "VV., April, 1862.

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TABLE OP CONTENTS.

Dedication iii

Chapter I

Phthisis commonly fatal, yet curable if regarded in the early stage — Influence of Laennec's views — Tubercle a consequence and not the cause . . . . ' . 1-7

Chapter II

historical sketch as to the nature and treatment op phthisis.

The Ancients : —

Views of Hippocrates, Areteus, Galen, Aristotle, Dioscorides, and Celsus 9-13

The Middle Ages :

Views of Trallian, Paulus jEgineta, Avicenna, Forestus, Paracelsus, Oribasius, Aetius, Capivaecius, and Avenzoar 13-14

TnE Moderns to the Time of Dr. Baillie : —

Views of Bennet, Morton, Desault, Mudge, Gilchrist, Tralles, Stark, Portal, and Pearson .... 14-16 x CONTENTS.

TAGES

Views respecting Tubercle : —

Sylvius, TraBes, Clayton, Willis, Boerhaave, Keid, Sydenham, Bush, Brillouet, Badcliffe, and Simmons . .16-18

Age IS

Causes : —

Views of Sennertus, Hofmann, Huxham, Borelli, Spigelius, Van Swieten, Stahl, Sims, Avicenna, Bush, Walker, Musgrave, Withering, and De Haen 18-19

Connection with Hectic and Hemoptysis : —

Views of Bontius, Macbride, Cullen, Hofmann, Desault, Mudge, Gilchrist, Galen, and Van Swieten . 19-20

Contagion : —

Views of Sylvius, Hofmann, Desault, Van Swieten, Darwin, Morgagni, Valsalva, and Portal 20

Nature of Phthisis : —

Views of Stark, Desault, and Bush 20-21

Milk, milk and lime water, eggs, meat, fish, olive oil, mutton suet, sea voyaging, exertion in open air, horse exercise, swinging, living in cow houses, steel, hark, early abstinence, counter irritation, loud speaking, bleeding, opiates, astringents, inhalation of oxygen . . 21-23

Opinions of our Day : —

Baillie, Bayle, Laennec, Carswell, Louis, Piorry — Change of climate and cod-liver oil 23-28

Chapter IV. General Observations

Stages of the Disease — Co-existence of general and local disease — General expression of diseased action — Variations of the type of health and disease — Inquiries on 1,000 cases into temperament — The hair, eyes, complexion, habit of body and excitability .... 42-52

Chapter VI

alimentation.

Appetite : —

Inquiries on 400 cases into dislikes for acids, sugar, tea, coffee, vegetables, fruits, bread, meat, and fat — relation of dislike of acids to much perspiration and to sour perspiration — Comparison with asthma and bronchitis — Relation of dislike of sugar, tea, and coffee to much perspiration and to sour perspiration — Further inquiries on 500 cases on the distaste for fat in phthisis, bronchitis, debility, liver complaint, &c— Inquiries on distaste for meat and milk 54-64

Digestion ■ • 6 ^

Amount of Food :—

Inquiries "••

Assimilation : —

"Weight and bulk of the body— What it includes— Circumstances affecting it—Food, excretion, urine, fat . . . 65-72 xii CONTENTS.

Chapter VII. Elimination

Its action as heat regulator— Amount of perspiration— Table of inquiries into ingesta and egesta .... 74-79

Urine : —

Inquiries into quantity— Specific gravity . . . -80

Perspiration :—

Constitutional tendency — Frequency — Acidity . . . 83-86

CHAPTER XVII. Expectoration

Its nature and chief source— Cretaceous expectoration . 135-141 CHAPTER XVIII.

HAEMOPTYSIS : —

Statistics of frequency — First occurrence — Quantity — Source — Importance — Its significance as a sign — Frequency in bronchitis — Cause of frequency in phthisis . 142-150

CHAPTER XIX. Vomiting

Relation to cough and meals 151-152

Chapter XX

Relation of the lungs to the general system in phthisis — ■ Phthisis a general or a local disease — Tubercular deposition not the first stage — State of the blood — Cause of selection of the lungs ..... 153-159

Chapter XXI

the lungs. — external pulmonary evidences os phthisis. Lessened Movement oe the Chest : —

Method of observations — Difference in the sexes — Chest measurers 160-164 xiv CONTENTS.

Structure of the lungs facilitates expiration — Bronchial tubes — Air cells with their spiral arrangement — Modes of retraction of the air cells 160-172

Chapter XXII

the lungs— internal pulmonary evidences of early phthisis.

Feeble Breathing : —

Characters — Diagnosis from debility .... 173-176 Prolonged Breath Current : —

Structure of lungs opposes inspiration — Effect of tubercular deposits 176-178

"Wavy or Jerking Respiration : —

Site and conditions ....... 178-179

Dulness on Percussion :—

Unequally appreciated — Natural variations — Relation to tubercular deposits . .... 179-182

Summary of Evidences of Phthisis 182-184

Chapter XXIII

pathology of the first STAGE OF PHTHISIS AND TUBERCLE.

Bronchial Tubes— Air Vesicles 185-186

First Stage : —

Lessened vitality of air vesicles— Cause of deposition—

Dr. Flint on the besoin de rcsjrircr .... 186-189

Second Stage :— Tubercle.

Forms of tubercle described by Laenuec— Seat— Carswell, Eainey, Bokitansky, and Lebert . . . 190-192

Microscopic characters— Formation of mass of tubercles— Rainey, Ancell — Nature of tubercle — Cellular character—Granular matter — Blood origin— Amorphous and plastic characters— Prof. Alison, "Williams- Conditions not explained by the blood theory— Epithelial origin— Van der Kolk, Addison, Bennett, Bokitansky, Lebert, Gulliver, Vogel, Virchow, Walshe- Explains many facts— Selection of the apices— Carswell . .192-203

CONTENTS.

Chapter XXIV. Progress Of Tubercle

As to the tissues — As to the tubercle — Kemoval of tubercle from the lungs — Two conditions — Hall on epithelium in the sputa — Softening — Elastic tissue — Van der Kolk and Clark — Expectoration of tubercle — The arrest of tuberculisation in the lung — Obsolescence or arrest of tubercle — Cretaceous expectoration — Absorption of tubercle — Piorry

204-214

Chapter XXV

restore the bulk of the body by lessening elimination.

Inunction of oils and fats — The ancients — After the hot bath — In hot and cold countries — Analogous to the wet sheet — Mode of action is physical.— Olive oD, cod-oil, neat's-foot oil, lard — Method of inunction . Application of Cold Water, : —

Mode of action — Method of application — Salt Water

Frequency of use of flannel shirts — Excessive and defec-

. tive clothing — waterproof clothing

Exposure to the Atmosphere ... .

Food : —

Alcohols, fats, coffee . ......

Metals: zinc, iodine, iron, lead— M. Beau's practice- Acid perspiration — Remedies — Case ....

215-222 222-225

225-229 229-230

Chapter XXVI. Restore The Bulk Of The Body By Lessening Elimination

The Kidneys and Boivels : —

Drinking fluids— Thirst— Frequency of dejection . .240-243

Chapter XXVII

restore the bulk of the body by increasing the sui'ply.

Deficiency of Nitrogen in Adolescence : —

Action of nitrogenous foods —Proportion of nitrogen in bread and milk — Nitrogen in scheme of daily dietary — Effects of gluten bread, semola, and chocolate . . 244-249

Scheme of Daily Diet : —

Special articles of food — Essential characters of the dietary — Action of gelatin, tea, coffee, chocolate, fish . . 249-254

Chapter XXVIII

increase the yital actions.

General observations — Increase heat and deposits in tissues 255-257 Increase of Appetite : —

Effect of caprice and habit — Rules to regulate the administration of food 257-261

Improvement of the Digestion : —

Hyperesthesia of the stomach, acidity, remedies — Food attached to the pharynx causing cough — Foul tongue — ■ atonic dyspepsia 261-265

Chapter XXIX

increase the assimilation of food.

Exertion : —

Effect over air inspired and urea— Regulation of exertion—Kinds of exercise, athletic, running, jumping, skipping, walking 266-271

Food :—

Passive and active foods 271-274

CONTENTS. xvii

I'AGES

Relation to vital changes — Impurity of the air in towns and crowded places — Roscoe, Angus Smith, Frankland, Welsh 274-277

Pulsation : —

Relation of fulness and rapidity to vital transformation — Increase the vis & fronts and vis & tergo — Food, compressed air bath, Grindrod, McLeod . . 277-279

Temperature : —

Cold, heat ; proper degree of temperature . 279-282

Certain Intimate Chemical Changes : —

Alkali and chloride of sodium in the blood — Liebig, Fernet . ... 282-283

Chapter Xxxviii. Cod Liver Oil

Very ancient remedy — Modern use in phthisis — Dr. Do Jongh and Professor Bennett— Special inquiries upon in-patients, assigned modes of injury and improvement— Medical report — Relation to dislike for fat — Summary — Mode of action, mode of administration — DeJongh'soil . . • 338-350

Chapter XLIII

climate.

Winter Climates in Great Britain :—

Period of change from summer climate — Ventnor, Torquay, Hastings, the Channel Islands and Clifton, their general characters and meteorological conditions in January, February and March, from 1855 to 1860 395-413

Winter Climates in Foreign Countries : —

The Nile, Pau, Madeira, Algeria, Nice, Naples,

Mentone, and Kome, their general characters . 413-424

CONTENTS.

CHAPTER XLIV. Specific Conditions : — pages

Favourable and unfavourable in the lungs and the

general system . . .... 42j-432

Chapter XLV

trognosis.

General and Numerical Conditions : —

Special inquiries upon 1000 cases when in health . . 433-434

Parents : —

Mortality — Age at Death — Feeble health— Unsteady — Died of consumption — Suffered from rheumatism, asthma, liver disease, gout, fevers, ague, insanity, diabetes and scrofulous affections— Consanguinity — Age at birth of the patient — Number of children in a family — Order of patient amongst the children — Hereditary predisposition .... 434-435

Patients :—

Age — Feeble health and appetite — Dry-nursed — ■ — Perspiration — Worn flannel shirts — Had measles, scarlet fever, small-pox and hooping cough, and their effects — Scrofulous diseases — Inflammation of lung3— Fiheumatism, typhus, diarrhoea, and liver disease' — Married — Sterility — Children — Age at birth of the first child— Number of children in a family — Health of the children — Abortions — Sexual abuse — Masturbation — Emissions — Syphilis — Gonorrhoea— Led a bad life — Drank — Smoked tobacco — Late hours — Anxiety — Injurious conditions of occupation — Taken mercury — Bled at the arm — Excessive liability of females — Relation of these facts to prognosis 436-440

Chapter I. Preliminary Observations

The word consumption almost universally suggests an incurable condition, and one which proceeds slowly yet steadily to its termination, so that there is without doubt in the public mind a greater dread of it than of any other chronic disease. This is well based upon the facts of the widely spread cases of the disease, the opportunity which nearly all persons have of tracing its progress from a certain point, and the multitudes who die from it ; but on reflection it will be seen that all this may be true, and yet the inference which has been drawn may be unsound, for it only proves that consumption is not commonly cured, and not that it is incurable. Indeed, admitting as we do the general truthfulness of the received opinions, we feel assured that there are good grounds for believing both the apparently contradictory statements, viz., that consumption is commonly fatal, and yet is commonly curable ; and we do this without assuming that there has been any want of due investigation as to the nature, or of care and talent in the treatment of the disease.

In reference to the nature of the disease in past ages, we think that there are some reasons for believing that it was not precisely the same then as now, as, for example, in the inflammatory tendency which was common in the seventeenth, eighteenth, and the early part of the nineteenth century, and which is rare now ; and hence we shall not he justified in adducing former experience either in aid of, or in opposition to, the present opinion. But the most widely spread source of fallacy is the fact that neither the profession nor the public has taken cognisance of the disease in its early manifestation, but has admitted its existence only after much advance has been made, and then watching the case from that starting-point, it has been seen that the disease is almost universally fatal. If that starting-point were the earliest period at which we could become acquainted with the disease, then we think that the popular belief could not be gainsayed. Hence, the whole question turns upon that point, viz., the general recognition both by the profession and the public of the disease in its earliest manifestations.

In this view it is easy to admit that the present age might be right in believing consumption to be curable, whilst former ages were equally right in their confirmed belief of the contrary : for, until our improved means of diagnosis were discovered and widely known, and cases of the disease were brought together in large numbers for careful investigation and study, it was quite impossible either for the public or the mass of medical practitioners, to do otherwise than commence their recognition of the disease at an advanced period in its progress. Then the disease seemed involved in mystery as to its nature, and so hopeless was it in its progress that practically little attempt was made to control it ; but at present we have means of tracing conditions pre-existent to those which constituted the starting-point of former times, and, notwithstanding the disputation which still exists as to the nature of the material deposited in the lungs, which is said to be the essence of the disease, we venture to affirm that but few diseases are more clear in their nature, or more readily capable of detection in their early manifestations. It is common to speak of the mysterious character of phthisis, as though we assumed that there were other conditions of disease which were more clear, forgetting that we are unacquainted with the essential processes by which either healthy or unhealthy nutrition is carried on, and with the nature of the various conditions of disease to which we have given names. In all these instances we are acquainted with certain leading facts, whilst the minute changes which they grossly represent are hid from view ; and in like manner, and in various degrees, we possess certain powers by which we may violently arrest the processes upon which the diseased action appears to depend, but in all our duty is chiefly confined to aiding the efforts of nature. In truth we doubt, with so high an authority as Sir James Clark, if the want of success which has attended our efforts to arrest the progress of

b 2

■i PRELIMINARY OBSERVATIONS.

phthisis is greater than has attended all efforts to arrest the progress of any other disease, accompanied by an equal destruction of the organ with -which it is associated ; and it is only the great prevalence of the disease, and the vast importance of the organ affected in relation to the animal economy, which has led to the present belief of the special incurability of phthisis. It need not be affirmed that we are equally powerless to restore the structure or the function of the liver, or of any other organ on which an equal amount of injury has been inflicted.

Hence we infer that whilst the present belief may be true under existing conditions, the opprobrium which has specially been cast upon the healing art in reference to phthisis, is at least in great part undeserved ; and that now, admitting the practical incurability of the disease after it has made a certain degree of progress, it is our duty to look at the disease in its earlier aspect, and in doing so, to lay aside opinions founded upon facts belonging to a later stage, so that with unprejudiced minds we may ascertain if in that new condition we have not the materials by which the remedial art may act more effectually, and a disease which is in its nature curable.

There is one leading particular in reference to this question in which the present is less unprejudiced than former ages. From the days of Hippocrates to those of Laennec the disease was distinguished by its general symptoms almost exclusively ; but Laennec introduced a new era, in which the state of the lungs took precedence of that of the general symptoms, and tubercle came to be regarded as the essence, the mark, and the starting-point of the disease. This view was a tangible one, because the tubercle was to be seen by every observer ; and by the proposition, only tuberculous cases were regarded as phthisical, so that it was generally adopted, and has necessarily influenced the opinions of men educated in it, and who, from its recent occurrence, have lately lived, or are still living. Those who have been more recently educated, or who will hereafter enter upon the study of the subject, will probably regard this question with greater breadth and fairness.

In considering this question, it must be remarked that the tubercle is not the cause, but only one consequence of the disease. This, at the present moment, is in part practically admitted, and in other part as practically denied. It is admitted, inasmuch as there has been an attempt to assign it an origin either in the place where it is found or in the general depraved circulation ; and even to this hour the latter source is constantly referred to. But, on the other hand, the changes which occur in the deposited tubercle have been carefully watched, and the progress of destruction of the lung, with all its consequences, have been attributed to the changes which take place in the tubercle, and the tubercle has become the foundation of the disease. It must be admitted that the tubercle is almost universally regarded as the essential feature of the disease, the cause of its progress in the lungs, and the source of injury to the general system ; and the great desideratum has been its removal. The general system has been regarded in two aspects : as associated with the deposition of tubercle, and as influenced by the deposition ; and the evil has not been in regarding it in this double light, but in giving an undue prominence to the latter, when considering the relation of tubercle to phthisis. In truth, modern views have so engrossed the mind, that one condition in the progress of phthisis has (because it is always found at some period) been raised from tbe minor to the dignity of the major premiss ; and instead of the statement that all cases of tubercle (in the lungs) are phthisis, it is averred that in all cases of phthisis there is tubercle.

We venture to affirm that this consideration is worthy of careful attention in any attempt to obtain a true view of the nature of this disease.

If tubercle be due to pre-existent causes, whatever may be their nature, the disease is not in the tubercle, but in the cause of the tubercle ; and the tubercle itself is but a result — an evidence, and all the changes in the tubercle are secondary influences. It cannot be affirmed that the tubercular element of the disease possesses an innate power of destruction such as is found in the elements of cancer, for whatever may be the origin of tubercle in the lung, it is found upon free surfaces, and does not spread by extension ; whilst cancer infiltrates the tissues and has the power of extension, and consequently of displacement or destruction. Tubercle itself is a foreign but a passive agent; and all actions, of whatever kind, which proceed about it, originate and are carried on, not by the tubercle, but by the containing tissues. It is placed in the lungs, and accumulates by new deposits ; and the subsequent changes are not due to any disintegrating action in the tubercular element, but in the tissues which contain it.

Hence surely the tubercle is not the essence of the disease, but only one of the results — a result doubtless met with at some, but not at every period in the progress of each case. So long as inquirers fix their attention upon this or any other single product of the disease, they will fail to recognise its true nature ; and so long as the aim of the practical man is to find a plan whereby the tubercle may be absorbed or ejected, he also will fail. We therefore think that whilst our age has made the great advance of distinguishing more carefully those cases of wasting which are associated with a particular disease of the lungs from those due to other causes, and has therefore given to us a large group of cases of a similar character, it has greatly erred in fixing its attention upon one of the conditions of the lungs, and regarding it, not as one of many results of diseased action, but as the essence of the disease, and the prime cause of mischief. It has cast aside that minute attention to the general system which was the especial subject of observation of the fathers of medicine, and has been content to concentrate all its powers of observation upon one internal condition which has this in common with the external symptoms, viz., that both are effects of the disease, and not the disease itself. We have limited our cases to one class only, and have spent our time in determining the characteristics of that class, but have made little progress in that higher department of knowledge — the determination of the true nature of the disease.

Chapter II. Historical Sketch As To The Nature And Treatment Of Phthisis

We do not purpose in the following sketch of the opinions which have been hitherto held respecting phthisis, to enter into large detail, but we desire rather to trace the changes of opinion or the additions to the knowledge of the disease which have occurred in large reras of medical history, with a view to show the real .amount of progress which has been made since the days of the earliest records of our art. This may be in part effected by the aid of the labours of Dr. Young, to whom the profession is indebted for abstracts of the works of nearly all preceding writers on consumption — accurate, no doubt, and arranged in chronological order, but having the great defect of an absence of scientific arrangement in the direction of the present inquiry, and being consequently of comparatively little value except to the most painstaking medical reader. We think that it will suffice for our purpose if we state hi a few words the opinions which were held by the ancient physicians to the time of Galen, those found in the works of the Arabian physicians and the physicians of the middle ages, and lastly, give a short

THE ANCIENTS. 9

analysis of the views held by the moderns since the sixteenth century ; and since the advance of knowledge during those periods has not been very great, we shall avoid wearying the reader by multiplying quotations.

The leading characteristics of these seras in the knowledge of the disease may be thus epitomised. The ancients confounded phthisis with other diseases, both of the lungs and other organs, attended by wasting, but were yet well acquainted with the disease as we see it at this day. The Arabian physicians and those of the middle ages adhered to the opinion of Hippocrates and Galen, and advanced no new views of the nature of the disease ; whilst among the moderns there has been, with advance of time, a gradual limitation of the disease to a tubercular state of the lungs, attempts to describe tubercle, speculations as to its immediate origin, an examination of its relation to scrofula; a consideration as to whether phthisis be essentially a disease of the general system or of the lungs, and a desire to generalise the conditions which mark the consumptive patient. Besides these there have been in all ages disputations as to the relation of haemoptysis to phthisis, the contagious character of phthisis, and the efficiency of various remedial agents.

THE ANCIENTS.

Hippocrates (fourth and fifth centuries B.C.) describes several forms of consumption under the heads of phthisis, phthoe, and empyema, and mentions tubercle of the lungs, but he does not regard the tuberculous state of those organs as the essential condition of the disease. His description of a true phthisical case, as the disease is now regarded, is, however, very clear and decided. He includes also such diseases of the lungs as pleurisy and empyema. In a second form he also includes bronchitis, remitting during the summer ; and in a third, scrofulous diseases of the spine. In reference to the cause of the disease he considers that the first form, which includes true phthisis, arises from haemoptysis, and begins with a kind of catarrh, in which acrid matters descend from the head and cause ulceration of the lungs. He affirms that the expectoration in phthisis arises from ulcerations of the lungs, aad he describes a test for pus which has held its ground until modern days ; but expectorated matters in general were considered to descend from the head. The treatment of the disease may, in its broad outlines, be regarded as that adopted at the present day, viz., the free use of milk, whether asses', mares', goats', or cows' milk, when there was not much fever or headache, a moderate quantity of meat, fat fish, and other fats, with walking exercise for many miles daily, and the avoidance of changes of temperature.

The small portion of the works of Aretaus (second century) which has been preserved is quite inadequate to inform us as to the views of that great master of the art, but the following description of the general evidences of phthisis are as truthful and life-like as any which have been placed upon record :—

" There is present, weight in the chest (for the lungs are insensible to pain), anxiety, discomfort, loss of appetite ; in the evening coldness, and heat towards

THE ANCIENTS. 11

morning ; sweat more intolerable than the heat as far as the chest : expectoration varied as I have described." .... " Voice hoarse ; neck slightly bent, tender, not flexible, somewhat extended; fingers slender, but joints thick ; of the bones alone the figure remains, for the fleshy parts are wasted; the nails of the fingers crooked, their pulps are shrivelled and flat, for, owing to the flesh, they neither retain their tension nor rotundity ; and owing to the same cause, the nails are bent, namely, because it is the compact flesh at their points which is intended as a support to them ; and the tension thereof is like that of the solids. Nose sharp, slender; cheeks prominent and red; eyes hollow, brilliant and glittering ; swollen, pale, or livid in the countenance ; the slender parts of the jaws rest in the teeth as if smiling ; otherwise of a cadaverous aspect. So also in all other respects ; slender, without flesh ; the muscles of the arms imperceptible ; not a vestige of the mammae, the nipples only to be seen ; one may not only count the ribs themselves, but also easily trace them to their termination ; for even the articulations at the vertebra? are quite visible, and their connections with the sternum are also manifest ; the intercostal spaces are hollow and rhomboidal, agreeably to the configuration of the bone ; hypochondriac region lank and retracted ; the abdomen and flanks contiguous to the spine; joints clearly developed; prominent, devoid of flesh, so also with the tibia, ischium and humerus ; the spine of the vertebras, formerly hollow, now protrudes, the muscles on either side being wasted ; the whole shoulder blades apparent, like the wings of a bird. If in these cases disorder of the bowels supervene, they are in a hopeless state."