Cancerous and other intra-thoracic growths : their natural history and diagnosis being the substance of the Lumleian lectures delivered before the Royal College of Physicians of London

Front matter

I

^rmnkb to the Tibrarp

CANCEEOUS

Section I. Oanceeous Deposits Disseminated Through The

LUNGS.

Cancerous deposits in tlie form of minute tubercular bodies scattered over tlie pleurae or tlirough. tlie lungs are not infrequently met with, associated witli other forms in some other part of the chest. Less often, however, do we meet with mOiary cancer either as a primary disease of the lungs or unassociated with some other form of intra-thoracic cancer. Where the cachexia is strong, and especially where the disease has already existed some time in one or more localities as a local affection, we occasionally find it developed by a rapid and almost simultaneous deposit throughout the system in the form of minute cancerous granules scattered over the most varied surfaces and through almost all the tissues of the body. Many of these cases have been characterised by all the symptoms of acute febrile disturbance, sucli as we find in connection witli general acute tuberculosis. But, altliough as a strictlyprimary affection of either lungs or pleura, miliary cancer may be rare, it is not infrequently met with, associated with the earliest and sometimes the only symptoms of thoracic disease, and sometimes proves to be really the only form of cancerous disease within the chest. The following case will illustrate this remark.

Case 1. Disseminated miliary cancer of lungs y ^c, — A. L — , a servant girl, 15 years of age, was admitted into St. Thomas's Hospital under my care on the 25th April, 1865. The history that was obtained of her previous health was that till three months previously she had been quite well. She had then suffered from debility and swelling of the hands and lower extremities. These symptoms were relieved by rest and medical treatment ; but she had never regained her usual health and strength. The catamenia had not yet appeared. On her admission she was feverish, and had a hectic flush on her face ; the pulse was quick, and she complained of thirst. The right leg was a httle swollen, and there was a line of redness and tenderness extending from the knee to the groin. The respiration was quickened, and she had . some cough with sHght mucous expectoration ; but she had had no hgemoptysis. On examining the chest, the respiration appeared to be somewhat harsh in both apices, but the percussion-note was normal. There was a good deal of dry rhonphus heard in various parts. After slight superficial suppuration over the right knee, the swelling and inflammatory blush of the thigh clisappeared, and the constitutional disturbance subsided. Her tongue became clean and the appetite good. On the 22nd May it was observed that, the hepatic region was enlarged, and both lobes of the liver could be distinctly felt some way below the ribs. On the right side, where the enlargement was greatest, there jvas pain and tenderness on pressure, and the superficial veins were enlarged. The bowels were loose, and there was no icterus. Her appetite was tolerable, pulse 80, and there was no longer any general constitutional disturbance, nor any cough. The hepatic enlargement, however, continued steadily to increase ; and on the 2nd of June had extended to the umbili-

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cus. The pulse was tlien 120, and tlie tongue, dry, with anorexia and looseness of bowels. The thoracic symptoms had returned ; the cough, became very troublesome, and was attended, by more or less of simple mucous expectoration.; The respiration was hurried and shallow, and she complained of dyspnoea. There was, however, no dulness on percussion of the chest to be detected anywhere, but a good deal of ditFiised rhonchus and loose mucous crepitation. She died on the 17th June, having complained piuch of dyspnoea for some days before death, as well -as of uneasiness of the abdomen. She had become much emaciated, having had much diarrhoea and entire anorexia. . Post-mortem examination. — Both lungs were congested, and contained scattered throughout numerous small round whitish bodies closely resembling miliary tubercles. At the anterior edge of the right lung there was also a mass of yellow, tissue, somewhat soft, about the size of a cherry. The right lung contained a patch of pulmonary apoplexy. The heart and its valves were healthy. The peritoneum contained some serous fluid, and some shreds and filaments of partly organised lymph. The liver was greatly enlarged, weighing 7 lbs. 12 oz. Its tissue was very fatty, and the anterior part of tlie rigbt lobe wbicli projected beyond tlie ribs presented an irregular rounded protuberance. There was also a large tumour attached to the posterior and inferior part of the right lobe, which pushed the greater part of the liver forwards. Upon cutting into the liver, other tumours were found in its substance, which were either of a pale yellow colour or stained greenish from bile, or in other instances blood-stained. They w6re rather softer than the ordinary liver consistence, but nowhere pulpy or exuding milky juice. There was an enlarged gland about the size of a walnut adhering to the posterior part of the liver, presenting the same physical characters as the liver-tumours ; also similar enlarged glands in front of the lumbar vertebrge. The spleen was rather large, and contained a few small yellowish nodules similar to the liver-tumours. The stomach and intestines were healthy. The kidneys presented several small white masses in their cortical substance, like miliary tubercles ; they were otherwise healthy ; the bladder was healthy; the uterus and ovaries small as in infancy. Portions of the tumours in the liver,

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of the enlarged glands, and of the deposits in the lungs and kidneys, were examined microscopically, and were all found to present similar appearances ; consisting mainly of a cell-growth, the cells being tolerably large, with a clear well-developed outline, varying greatly in shape, many presenting angular forms, some fusiform, and like broken fibres. They were mostly nucleated, the nuclei not being very large, but distinct, and often containing a nubleolus. These cells for the most part did not contain any fat-globules, whereas the ordinary liver- structure was loaded with oil. The appearances here described were most distinctly seen in the lymphatic glands, but were also sufficiently characteristic in the other parts to justify the conclusion that the various deposits were all of the same nature.

When first seen, there was every reason for supposing that in this young girl the symptoms referable to the chest depended on the presence of scattered tubercles. The age, the previous history of ill-health, and the non-appearance of the catamenia and hectic aspect, together with the general febrile disturbance, all seemed to pomt to tubercular disease. All this, however, was probably due in great measure to tlie constitutional disturbance excited by tlie local inflammation of the knee and thigb, as all tlie main symptoms disappeared on tbe subsidence of tlie local inflammation. Tbere was no return of the thoracic symptoms till after the manifestation of extensive hepatic disease. That this was malignant in its nature, no doubt was entertained during life ; but when, as the hepatic enlargement increased, the constitutional derangement became increasingly severe, and the thoracic symptoms returned, there was nothing in their character to distinguish them from the like symptoms which had formerly existed, and had entirely disappeared. Nor was there anything in the physical signs at all distinctive. It is, however, worthy of note, that the hurried respiration and the dyspnoea were much more marked symptoms in the latter stage than in the earher. But these are among the most characteristic symptoms of acute miliary tubercle ; and in the present instance much of the dyspnoea was in all probability due to the pressure exercised by the enlarged liver and its encroachment on the thoracic cavity. Viewing also the ■eneral state of constitutional exhaustion, there

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did not seem to be anything that could with confidence be considered as in any way specially ■eferable to the presence of the miliary cancerous deposits in the lungs. These, however, were very numerous and scattered throughout both lungs; and their microscopic characters and identity of structure, with the deposits in the liver and elsewhere, leave no doubt as to their true nature.

Recurrent signs of bronchial h-ritation without any sufficient assignable cause, Dr. Stokes thinks, are characteristic of disseminated cancer, and may often form sufficient ground for the diagnosis. This is a point to which I shall probably have occasion again to revert, because I have seen reason to believe that such signs of bronchial irritation may attend any form of cancer within the thorax.

A very interesting case of primary miliary cancer of the lungs is recorded by Dr. Hilton Fagge in the eighteenth volume of the ' Transactions ' of the Pathological Society. The subject was a man 60 years of age, who was admitted into Guy's Hospital under the care of Dr. Wilks. He had been liable to winter-cough for some years, and had been obliged to leave work for seven weeks before bis admission, owing to debility and shortness of breath. He was a fine, well-built man, witli a well-formed chest. When first examined in the hospital, he was sitting propped up in bed, quite unable to he down, and had some dyspnoea. The heart's sounds were perfectly normal, and the anterior surface of the chest fairly resonant ; but there was dulness oyer each posterior base. The expiratory murmur was prolonged and loud at each apex, where slight sibilant rales were heard. Posteriorly, at the bases, sibilant and subcrepitant rales were heard, with shght bronchophony, especially on the left side. The legs were oedematous and the urine exalbuminous.

The case was regarded as one of capillary bronchitis, with more or less of pneumonia, and he was cupped and took a saline mixture with small doses of antimony. The following day he appealed to be reheved, but his face was dusky and his heart irregular. The subsequent day he died suddenly, after passing a very restless

night. ^ .

Each pleural cavity was found to contam a large quantity of clear transparent flmd of a

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brownisli colour. In the pleural merabrane were found a few minute plates, the cancerous nature of wliicb was doubtful. The lungs were studded with small cancerous deposits, looking very hke tubercles, but larger than the ordinary kind of tubercle. The two lungs were affected in exactly the same way and to the same degree. The apices were nearly free, containing only a very few of these deposits. The lungs themselves felt bulky and firm, and resisted section more than lungs affected with pneumonic consolidation or miliary tubercle. The appearance of the cut surface was pecuHar. A few of the cancerous masses were as large as hemp-seeds, and looked quite white and like small tumours ; but most of them were much smaller and closely set together. Similar small tubercle-like deposits were found in the heart and pericardium, and a few in the liver.

In this instance, as in my own case already given, we see how remarkably little tendency there appears to be to pneumonic inflammation as the direct result of cancerous deposits in the lungs. The symptoms, indeed, were those of capillary bronchitis, with more or less of pneumonia; but the immediate cause of death ap-

22 CANOEEOUS DEPOSITS DISSEMINATED pears to have been passive effusion into the pleura, as the result of the general debility and cachexia — and the actual condition of the lungs not such as characterises inflammation resulting from miliary tubercle.

There can be no doubt, as the reporter observes, that the lungs were the primary seat of the cancer ; and that a point of great interest in the case is, that the apices were much less thickly studded with the cancerous deposits than other parts of the lungs. Other instances, however, of disseminated cancer, afford no evidence for believing that the apices are less liable to cancerous deposits than other parts of the lungs. Thus, in a well-marked instance of primary cancer of the lung recorded by Dr. Quain,* both lungs throughout were studded with small hard masses, varying from the size of a pea to that of a walnut ; and such pleuritic adhesions as existed were connected with the lower lobes. The symptoms during life were those of tubercular disease, with pleuritic effusion of the right side, which, after death, was found distended by three pints of sanguineo-serous fluid. On the other hand, Dr. Sievekingt reports a case of

* ' Trans. Patli. Soc.,' vol. iii, p. 251. t Ibid., vol. i, p. 195.

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cancer of the stomacli witli secondary melanotic deposits confined to the apices of tlie lungs. In this instance, the only positive sign elicited by percussion was dulness of the left subclavicular region ; and the chief symptom referable to the lungs, urgent dyspnoea.

In most points of view, we find tubercle to contrast with cancer, rather than to present any afiinity. The mode of development and growth appears to be essentially different ; but, as regards the affinity of cancer for one part of the lungs rather than another, there is nothing, I think, to show that in this respect it stands in any antagonism to tubercle.

I have not myself met with any example of the coexistence of tubercle and cancer. There is sufficient evidence that the two may coexist ; but none, I think, to prove that this coexistence is anything more than a coincidence. It may not always be easy to distinguish the two from their microscopic characters alone ; but there can be no reasonable doubt as to many of the cases cited in proof of the coexistence. Lebert states that he has never met with the supervention of cancer in the course of phthisis, and believes that it must be very rare ; whilst

Eokitansky tliinks it more usual for cancer to follow tubercle, than the reverse. He, however, thinks that the two have no real relation beyond that of coincidence. Dr. Quain's case, related to the Pathological Society, and recorded in the third volume of the ' Transactions' of that society, appears to be an unquestionable instance. A large firm carcinomatous tumour occupied the mediastinum, and encroached on the right lung. It extended deep into the structure of the lung, but did not reach as high as the clavicle. The upper lobe was studded with tubercles, the left lung being healthy. On examining by the microscope the encephaloid mass and the tubercular deposit, the distinctions appeared to be well marked and decisive. This, however (with the exception, perhaps, of Pollock's case*), appears to be the only unquestionable example among the forty-three which form the basis of my remarks. There are two others in which the real nature of the so-called tubercles was doubtful.

Another of the rarer forms of diffused cancerous deposit in the lungs that I am able to illustrate from my own practice offers an example

* ' Trans. Patli. Soc.,' vol. iii, p. 254.

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of primary cancer in wliicli the growths had in most instances undergone more or less disintegration and consequent contraction of the central portions, so as to afford a close resemblance to the appearances presented by obsolescent tubercle or a hob-nailed liver. The details of the post-mortem examination, and the microscopical appearances of the deposits, are given by Dr. Bristowe.

Case 2. — Eliz. Wilkinson, aged 36, a servant, was admitted into hospital June 1st, 1858. She stated that for six months she had had cough, but no hgemoptysis ; that the catemenia had been absent three months ; and that since then she had had leucorrhoea. Although much emaciated, she had never been laid up till her admission. Three months previously, while drawing a hard cork, she felt a sharp pain in the left side ; and to this she attributed her illness, having had shortness of breath ever smce. She had not had any palpitation, nor any swelling of the extremities. There was considerable lateral curvature of the spine. There was dulness on percussion under the right clavicle, with large and fine crepitation. Respiration was

CANCEROUS DEPOSITS DISSEMHSTATED harsli under the left clavicle. She had some mucous expectoration. Vocal resonance was not much increased. She had slight febrile disturbance and fleeting pains in the limbs. The treatment consisted of tonics, with expectorants, sedatives at night, and cod-liver oil; subsequently, antispasmodics, and liquor vesicatorius to the left side, which became very painful. She had much irritability of the stomach before death, which took place on July 10th, 1858, apparently from exhaustion.

Post-mortem examination, July 12. — The heart and pericardium were healthy. Both pleura presented numerous firm cellular adhesions. The right lung was large ; the left was small and misshapen, to accommodate itself to the distorted spine and contracted side. The whole surface of both lungs was remarkably fissured; and often the fissures were so deep as to give the lung a hob-nailed appearance. On section, the lungs were found studded with patches of greyish- white material, rather firm, but yielding, on pressure, large quantities of creamy juice. The sectional surface of these patches varied from an inch and less in extent, differing in shape, and for the most part distinctly margi-

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nated, but giving clear indications tbat the material liad infiltrated ratlier than displaced the lung-tissue. The fissures in. the lung corresponded to the centres of these deposits. In some parts, the cancer, instead of forming distinct masses, infiltrated the lung-tissue without destroying it, giving the appearance of purulent infiltration. The lung-tissue between the masses was crepitant and tolerably healthy. The bronchial tubes contained a good deal of muco-purulent fl.uid. The pulmonary arteries and veins, and the bronchial glands, were healthy.

The liver was large, pale, and for the most part healthy. It presented, however, three or four masses of cancer, of about the size of a horsebean, two of which reached the surface. The left kidney was increased in size, and congested, but healthy ; of the right, no trace could be found. The left Fallopian tube formed an elongated cyst, the interior of which was sacculated and rugous, and contained clear fluid. The microscopic appearances were those of cancer. "Where degeneration had occurred, numerous compound granular cells were seen. Pearly patches, seen here and there, contained earthy matter, wliicli, wlien acted on by acetic acid, evolved bubbles of gas.

Here, again, notwitbstanding tbe extent to wbicb tbe lungs were implicated by tbe cancerous growtbs, we bave it stated tbat tbe intermediate lung-tissue was bealtby. Nor can we, I tbink, refer tbe old firm pleuritic bands to tbe consequences of tbe cancerous disease. Tbey were more probably due to former pleuritic attacks, associated witb tbe abnormal state of tbe tboracic organs from distorted spine. But tbe abundant muco-purulent secretion in tbe broncbi sbows bow generally, not to say invariably, tbe pulmonary mucous membrane is affected by all otber morbid conditions of tbe lungs. As regards tbe diagnosis, I must confess tbat I was unable to refer tbe pulmonary symptoms during life to any otber cause tban tubercle and tbe deranged circulation consequent on tbe spinal disease. I was not, bowever, fully satisfied as to tbe existence of tubercle. Tbe constitutional condition did not barmonise witb tbis view of tbe case.

Tbe bronchial tubes, altbougb so very generally impbcated in tbe progress of cancer originating in otber parts of tbe lung, especially in tbe me-

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diastinum and broncliial glands, are believed to be very rarely, if ever, tlie original seat of tlie disease. It would, liowever, appear tliat tlie broncliial tubes may be tlie cbannels by wMch cancerous germs are transmitted to distant parts of the lungs. Dr. Moxon lias related an interesting example of tbis, in wliicli tbe germs of epithelial cancer affecting tbe tracliea were carried along the bronchi, and deposited in the centre of the lobules of the lung, where they gave rise to small rounded firm growths, which presented in very characteristic form the "bird'snest" capsules of the epithelial cancer of the oesophagus and trachea, whence they appeared to have come.

Of the scirrhous or fibro-cancerous variety of the disease, my notes afibrd me two examples, implicating mainly the bronchial tubes and their investing tissue, running along their course, and encroaching on and diminishing their calibre. The interlobular septa and the investing pleural membrane were also the seat of similar disease. In the first of these cases the pulmonary disease was unquestionably secondary to the cancer of the stomach. All the symptoms were such as might fairly be referred either directly to the disease of the stomacli and allied organs, or to the constitutional derangement and exhaustion resulting from the general dyscrasia. Thechronic cough of which the man had for some years been the subject presented nothing unusual in its character, was not a prominent symptom during the time that he was in the hospital, and was not associated with any physical signs leading to the suspicion that the lungs were the seat of the very remarkable kind and amount of disease discovered after death. Especially is it to be observed, that there was no marked dyspnoea, and no true febrile disturbance.

Case 3.— W. H— , a gardener, sixty-eight years of age, was admitted into hospital on June 16th, 1859. He stated that he had been ill six months ; that previously he had had good health, with the exception of a chronic cough which he had had for some years. He complained chiefly of epigastric pain and distension, increased by taking food. For some time his appetite had been poor, and he had lost flesh rapidly. Only within the last day or two had there been any vomiting. The urine was abundant, and free from

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albumen ; bowels regular ; no febrile disturbance. His aspect was anaemic and somewhat cacliectic ; the tongue red and furred in patches. On examining the abdomen several tumours were observed in the abdominal integuments, one immediately above the umbilicus, which, he affirmed, had been there for many years, and which appeared to be attached to the sheath of the rectus muscle. He emaciated rapidly after his admission, having frequent vomiting and much epigastric pain, and subsequently jaundice.

The post-mortem examination was made by Dr. Bristowe, and the following is his detailed description of the appearances presented by the lungs. The body was extremely emaciated and deeply jaundiced. There was a milk-patch on the front of the heart ; otherwise the pericardium was healthy. The heart was healthy, but flabby. The valves were competent ; but there was a Httle earthy deposit in the right angle of the mitral valve, and a little along the attached margin of the aortic, but sufficient, in connexion with one curtain, to render it somewhat rigid generally. The pleurae were free from adhesions, and their parietal portions were generally liealtliy; the diapliragmatic surface of each was studded here and there with projecting lenticular patches of white cancer from a quarter of an inch in diameter downwards ; and a group of similar formations, in an area equal to that of a five- shilling-piece, was seated over the central portion of the left seventh rib, which in this situation, and for about an inch of its length, was destroyed by cancerous infiltration. The lungs were somewhat large and heavy, and presented a very remarkable appearance. The general surface was congested, but thinly covered by what looked at first sight like a leprous eruption. This consisted of flat whitish circular patches, from half an inch in diameter downwards, which had coalesced in many places, and formed sinuous patches or bands of various extent. The patches were pretty equally diffused over the entire surface of both lungs, and were so flat and little elevated as scarcely to be perceptible to the touch, or even the sight, except by their whiteness and opacity. It frequently seemed, too, that the edges were a little better defined than the central portions. In a very few instances, the central portion of a patch was elevated into a hemispherical tubercle.

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On cutting into tlie lungs, they were found generally though sparely crepitant ; but on close examination they were clearly ascertained to be studded rather thickly with cancerous material, which, however, was yariously and somewhat peculiarly arranged. 1. In many parts, but by no means uniformly so, it existed in the form of scirrhous infiltration running along the bronchial tubes and vessels of the lung, surrounding them, apparently, in the first instance; then incorporating their parietes ; and finally encroaching on and diminishing their calibre, though in no case distinctly obliterating them. The larger trunks were generally unafi"ected, or afi'ected only in an early stage ; the tertiary and subsequent divisions were those most obviously diseased. Constrictions arising in the manner indicated were discovered in both arteries and veins, but there were no nodulated or papillary growths in their channels. In those tubes in which the disease was most marked, the mucous membrane was opaque, tJiich, and wrinJded. 2. Numerous very distinct but thin bands (from half a line in thickness downwards) of scirrhus were found intersecting the lung-tissue in various directions. By tracing and examining them, it

CANCEEOTJS DEPOSITS DISSEMINATED was rendered obvious tliat tliey were tlie result of cancerous growth along tlie septa separating the lobules from one another; and that they were, therefore, of the same nature as, and had originated in similar tissues to, the patches upon the surface of the lung. 3. Besides the above, there were numerous spots, from the size of a lobule downwards, in which the tissue of the lung was more or less solid, and infiltrated with malignant growth. But it seemed clear that all these were secondary to the formations previously described, and due, as it were, to their outgrowth into neighbouring tissues. Many of them were subjacent to the superficial patches, and had obviously sprung from them. The relations of those seated in the substance of the lung were necessarily less distinct; but there was sufficient reason to regard them as having a similar dependence on more central scirrhous tracts. A few of the bronchial glands were the seat of scirrhous infiltration. There was extensive ulcerated scirrhus of the stomach, with peritoneal cancer extending along the capsule of Glisson into the liver, and causing obstruction of the bile-ducts ; but all other organs, as well thoracic as abdominal, were healthy.

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Altliougli, as has been stated, cancer affecting tlie bronchi, either primarily or independently of other parts of the thoracic organs, is, to say the least, extremely rare, if it ever occurs, cancerous vegetations from the inner surface or the tubes occur sufficiently often to give special aspects to the case, and sometimes to facilitate the diagnosis. In a case related by Dr. Peacock, considerable portions of cancerous matter, taking the form of bronchial casts, were from time to time expectorated ; and in other instances expectorated matters have shown evidence of the cancerous nature of the disease. But the amount and character of expectorated matters vary greatly in different cases. Mostly, the expectoration is simply thin frothy mucus. Viscid, glairy, red-currant jelly-like matter is by no means so common or diagnostic a sign as has been supposed of any form of intra-thoracic cancer, and certainly not of these varieties. The sputa not unfrequently are muco-purulent, but never, I believe, of the peculiar nummular character frequently seen in phthisis. Microscopic examination of the sputum would probably, in many cases, give direct evidence of the cancerous nature of the disease.

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The following case presents another example of extensive implication of tlie bronchi and connective tissue of the lungs by scu-rhous deposit, but differing very materially in its clinical aspects from case 3.

Case 4. — Secondary scirrhous or fihro-cancerous infiltration of connective tissue of lung, Sfc. ; succeeding to the removal of ^primary cancer of mamma.— Maria Thorpe, jet. 42, a cook, single, very well formed and rather stoutly built ; of healthy appearance, dark hair, and well nourished, came under my notice February 25th, 1871. Her mother is living, set. 63, and in good health. Her father died many years ago " of tumour in the throat. " Her only brother is living, and in good health. Asthma, she says, is the family complaint.

Previous history.— 'Fov four years past she has had cough in the winter, but considers herself to have been in good health till two years ago, when she first detected a swelling in the left mamma. The last two winters she had less cough than before. She never had hasmoptysis nor rheumatism, but has had epistaxis. Last July she went into St. Mary's Hospital, where the

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mammary tumour was removed by the knife. The wound healed completely and speedily, and she remained well till Christmas' last, when she had an attack of so-called bronchitis. At this time she noticed that her breath was shorter than it had ever been before, and this shortness of breath, as well as the cough, have continued ever since. She thinks she has lost flesh latterly, and has been subject to sweatings.

Present state. — The situation of the left mamma is occupied by a large indurated cicatrix, surrounded by considerable thickening and hardening of the integuments. There is some Hvidity of the edges of the cicatrix, but no ulceration. Some enlarged lymphatic glands may be traced along the edge of the pectoral muscle towards the axilla, where there are two or three enlarged glands. She complains of no pain in the diseased tissues, nor is there any tenderness. The integuments are infiltrated and hardened for some distance around the cicatrix.

She considers her cough to be somewhat better than it has been, but her breath to be even more short. She has some expectoration, not copious, and consisting for the most part of glairy mucus, mixed with some pigment and opaque mucus. Tliis was examined under tlie microscope, but revealed nothing of a special cliaracter. The thorax is ample and well formed, everywhere resonant on percussion, unless it be under the left clavicle, where there is some questionable dulness. The respiration, also, under the left clavicle is somewhat deficient ; elsewhere it is distmct and tolerably free, but everywhere mixed with sibilant and mucous rales ; sometimes there is much prolonged wheezing. The breathing is short and frequent, and the least exertion induces considerable dyspncea. The lips are slightly livid, but the general colour of the face is good. Skin soft and sweating. Pulse 100, feeble. The heart's sounds are normal. The catamenia regular. Bowels confined, tongue white, and appetite only moderate. She complains of considerable weakness. Temperature 99-6 a.m.; 99*3 p.m. She was ordered the effervescing calumba mixture, and squill and comp. ipecac, pills at night, and the ether and soda mixture occasionally for any unusual difficulty of breathing.